Closure of defects after gastric endoscopic submucosal dissection (ESD) can reduce
the risk of complications [1]. Although various endoscopic closure methods are proposed, mainly for the duodenum
and colon [2]
[3]
[4], closure of gastric mucosal defects is difficult because of the thick and hard wall
[5], which is one reason why a standard closure method has not yet been established.
We performed complete closure of an extremely large defect after gastric ESD using
the “accordion fold” method, a combination of dental floss-assisted and mucosal–submucosal
clipping ([Video 1]).
Video 1 Complete closure for a large defect after gastric endoscopic submucosal dissection,
using the “accordion fold” method.
A 45-year-old woman underwent gastric ESD for a large mucosal lesion (80 mm) in the
gastric fornix. A mucosal defect of approximately 100 mm remained after gastric ESD
([Fig. 1 a]). We sutured the defect using dental floss (Johnson & Johnson K.K., Tokyo, Japan)
and clips (EZ clip, HX-610-090, Olympus Medical, Tokyo, Japan; SureClip, MC Medical,
Tokyo, Japan).
Fig. 1 Endoscopic images showing steps for the “accordion fold” method. a Large mucosal defect (100 mm) immediately following gastric endoscopic submucosal
dissection (ESD). b A line of dental floss was attached to a clip. c The sides of the defect were brought closer by pulling the dental floss line that
was threaded through the clips. d Clips were used to suture the mucosa and submucosa. e Complete closure of the post gastric ESD defect by combined dental floss-assisted
and mucosal–submucosal clipping.
First, we attached dental floss to a clip ([Fig. 1 b]). It was then deployed on the anal edge of the defect. To prevent the formation
of a cavity, we placed a second clip on the submucosa in the center of the defect,
and a third clip on the oral edge, in such a way that the dental floss line was also
threaded through these two clips. The two sides of the defect were gathered together
by pulling the dental floss perorally ([Fig. 1 c]). Since the lesion was large, another clip with another dental floss line, was used
to bring the oral and anal edges closer together. Next, to reduce the size of the
defect, the two arms of additional clips were used to grip the mucosa and submucosa,
and we sutured the defect in the direction of the short axis ([Fig. 1 d]). After repeating the procedure several times, we clipped together mucosa from the
anal and oral sides of the defect, and finally we cut the dental floss. We achieved
complete closure that remained after 3 days ([Fig. 1 e]).
The “accordion fold” method can easily and completely close large defects after gastric
ESD and allow them to remain closed without dehiscence.
Endoscopy_UCTN_Code_TTT_1AS_2AZ
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