Endoscopic complete closure of duodenal mucosal defects using a clip with a looped thread after endoscopic resection

Closure of mucosal defects after endoscopic resection of superficial nonampullary duodenal tumors is important to reduce the risk of delayed bleeding and perforation [1]. Therefore, we developed a new closure method using a clip with a looped thread ([Video 1]).

Video 1 Mucosal closure after endoscopic resection of a duodenal tumor using a clip with a looped thread.

Video herunterladen

An 84-year-old man had a flat elevated 35-mm lesion in the second portion of the duodenum ([Fig. 1a, b, c]). A biopsy revealed it was an adenoma; therefore, we performed piecemeal endoscopic mucosal resection using a gastroscope (GIF-H290T; Olympus, Tokyo, Japan) with an endoscopic cap (TOP Endoscopic Hood; TOP, Tokyo, Japan) and bipolar snares (BSDA-217, BSDES-127: diameter 10, 26 mm, resp.; Zeon Corporation, Tokyo, Japan) ([Fig. 2]). There were no adverse events; however, closure of the mucosal defect after endoscopic resection was difficult using only clips because the mucosal defect was large ([Fig. 3 a]). Therefore, we attempted endoscopic closure as follows. First, a looped nylon suture was tied to a clip (HX-610-090; Olympus) mounted on an applicator (HX-110LR; Olympus). The clip was then retracted into the applicator and inserted into the accessory channel before being placed on the proximal side of the defect ([Fig. 3 b]). Another clip was used to anchor the suture to the distal normal mucosa ([Fig. 3 c]), and additional clips were placed to achieve complete closure ([Fig. 3 d, e]). The nylon suture was cut using scissor forceps (FS-3L-1; Olympus), and complete closure was achieved without delayed adverse events.

Fig. 1 Endoscopic images showing a flat elevated lesion in the second portion of the duodenum. a, b In white light. c In chromoendoscopy.

Fig. 2 The specimen was resected by piecemeal endoscopic mucosal resection.

Fig. 3 How to perform endoscopic closure assisted by a clip with a looped thread. a Large mucosal defect. b The clip with a looped nylon suture is placed on the proximal side of the mucosal defect. c Another clip is used to anchor the line to the normal mucosa distal to the mucosal defect. d Additional clips are placed. e Complete closure is achieved.

Various procedures for mucosal closure exist, such as a simple closure technique using clips, clips with a string [2], endoloop [3], or over-the-scope clip [4]. This is a modified method of traction using a clip with a looped thread during colorectal endoscopic submucosal dissection [5], and is similar to using clips with a string [2]. In this method the thread does not have to be placed in the accessory channel, so the gastroscope is maneuverable. Furthermore, dual-accessory channel endoscopes and other expensive devices are not required.

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• References

• 1 Tsutsumi K, Kato M, Kakushima N. et al. Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials. Gastrointest Endosc 2021; 93: 367-374.e3
• 2 Nishizawa T, Akimoto T, Uraoka T. et al. Endoscopic string clip suturing method: a prospective pilot study (with video). Gastrointest Endosc 2018; 87: 1074-1078
• 3 Ye LP, Mao XL, Zheng HH. et al. Safety of endoscopic resection for duodenal subepithelial lesions with wound closure using clips and an endoloop: an analysis of 68 cases. Surg Endosc 2017; 31: 1070-1077
• 4 Tashima T, Ohata K, Sakai E. et al. Efficacy of an over-the-scope clip for preventing adverse events after duodenal endoscopic submucosal dissection: a prospective interventional study. Endoscopy 2018; 50: 487-496
• 5 Indo N, Anami T, Asaji N. et al. Easy and effective counter-traction using a clip with a looped thread for colorectal endoscopic submucosal dissection. Endoscopy 2019; 51: E233-E234