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.
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.
Endoscopy_UCTN_Code_TTT_1AO_2AI
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