Comments on “Novel strategy of hold-and-drag clip closure with mantis-like claw for post-gastric endoscopic submucosal dissection defect of <30 mm”

We read with great interest the article by Nishiyama et al. [1] reporting the efficacy and safety of the hold-and-drag clip closure method with mantis-like claw for a post-gastric endoscopic submucosal dissection defect of <30mm. We agree that this new method is useful for closure of an artificial gastric defect. However, we have several questions about the study.

The use of this method for endoscopic closure of large mucosal wounds may lead to submucosal dead space. Previous studies have reported that the “accordion fold” method can reduce the formation of dead space by clamping both sides and the center of the defect [2] [3]. Once dead space is formed, it may lead to slow wound healing and even chronic inflammation, increasing the risk of perforation.

In the description of the method, the authors held the edge of the defect at the distal trisection point and closed the clip. They then slowly reopened the clip to confirm that sufficient mucosa was grasped from both sides before deploying the clip. There may be an issue with this approach, as large wounds can create significant tension. Fixing one side first with high tension can lead to mucosal tearing, making the technique not as straightforward as the article suggests. Additionally, the 1.5-mm claw length may make it challenging to adjust the position during the operation. The article reports that the closure and all clips remained intact during the 30-day postoperative follow-up; it is unclear how long it takes for these clips to fall off.

In conclusion, although this study has some limitations, the hold-and-drag clip closure with mantis-like claw remains an effective method for closing large traumas after gastric surgery. However, further research with larger sample sizes is needed to determine whether this method can be applied to closure of large defects following endoscopic full-thickness resection.

Publication History

Article published online:
27 June 2024

• References

• 1 Nishiyama N, Matsui T, Nakatani K. et al. Novel strategy of hold-and-drag clip closure with mantis-like claw for post-gastric endoscopic submucosal dissection defect of <30 mm. Endoscopy 2023; 55: E1244-E1245
• 2 Ikenoyama Y, Katsurahara M, Tanaka K. et al. Complete closure of a large mucosal defect (100 mm) after gastric endoscopic submucosal dissection, using the “accordion fold” method. Endoscopy 2022; 54: E892-E893
• 3 Okubo Y, Shichijo S, Takeuchi Y. Complete closure of a large mucosal defect using clips with an elastic rubber band after endoscopic submucosal dissection. Dig Endosc 2022; 34: e48-e49 DOI: 10.1111/den.14230. (PMID: 35141968)