Introduction
There are several methods for preventing delayed bleeding (DB) after gastric endoscopic
submucosal dissection (ESD), such as the coagulation plus clipping method and the closure
method; however, they have not been able to completely prevent DB [1]
[2]
[3]. It was hypothesized that DB could be completely prevented through a combination of
advanced closure with a coagulation and clipping method. Prevention of DB with this
coagulation, clipping and closure (CCC) method is reported here.
Gastric ESD was performed for an 83-year-old man classified as having a high risk of DB
due to oral administration of rivaroxaban and prasugrel. The ulceration followed gastric ESD
(30 mm in diameter) in the lesser curvature of the upper body of the stomach. First, a
coagulation procedure was performed after lesion resection, targeting vessels primarily at the
margin of the ulcer base ([Fig. 1]
a). Next, perforator vessels emerging between the muscle
layers and the surrounding muscle layer were clipped using 16-mm or 11-mm reopenable clips
while sufficient air was suctioned ([Fig. 1]
b). As a result, the muscle layer folded. This procedure,
inspired by the Origami method [4], reduces the size of the mucosal defect ([Fig. 2]
a). Finally, complete closure of the residual mucosal defect
was achieved using the dead space–eliminating technique with anchor pronged clips [5] ([Fig. 1]
c, [Fig. 2]
b, and [Video 1]).
Fig. 1 Coagulation, clipping and closure method for preventing delayed bleeding after gastric
endoscopic submucosal dissection. a First, a coagulation
procedure was performed after lesion resection, targeting vessels primarily at the margin
of the ulcer base. b Next, perforator vessels emerging between
the muscle layers and the surrounding muscle layer were clipped using 16-mm or 11-mm
reopenable clips (SureClip; Micro-Tech Co. Ltd, Nanjing, China) while sufficient air was
suctioned. c Complete closure of the residual mucosal defect was
achieved using the dead space-eliminating technique with anchor pronged clips (MANTIS
clip; Boston Scientific, Marlborough, Massachusetts, United States).
Fig. 2 Condition after endoscopic submucosal dissection (ESD). a The
muscle layer is folded using 16-mm or 11-mm reopenable clips. b
The ulceration was completely closed using a coagulation, clipping and closure
method.
Application of the coagulation, clipping and closure method.Video 1
Bleeding from perforator vessels may occur in areas where wound closure has dehisced;
however, it is believed that this type of DB can be prevented by preemptively coagulating and
clipping perforator vessels at the base of the ulcer. Preemptively folding the rigid gastric
muscular layer, which is prone to dehiscence, using clips may be an effective procedure for
preventing subsequent dehiscence.
The CCC method may help reduce risk of DB after gastric ESD; however, further evaluation
with a larger number of cases is required to validate its effectiveness.
Bibliographical Record
Satoshi Abiko, Haruhiro Inoue, Kei Ushikubo, Kazuki Yamamoto, Yohei Nishikawa, Ippei Tanaka, Naoya Sakamoto. Coagulation, clipping and closure method: New combined approach to prevent delayed bleeding after gastric endoscopic submucosal dissection. Endosc Int Open 2025; 13: a25499969.
DOI: 10.1055/a-2549-9969
