Response to Zhong et al.

We would like to thank Zhong et al. for their valuable comments on our report.

First, we would like to emphasize that we only use our hold-and-drag method of closure using endoclips with mantis-like claw for relatively small (≤30mm) defects after gastric endoscopic submucosal dissection [1]. The strength of this novel endoclip lies in its characteristic claws, which are sharply angled at 60° and 1.5 mm long, facilitating hold-and-drag closure. The authors raised several concerns, including dead space after closure, high tension during dragging, repositioning of the clip, and sustainability.

We agree with the contention that post-closure dead space created by a mucosal bridge may lead to early dehiscence, as shown in our previous investigations [2] [3]. We found that our method is acceptable for relatively small (≤30mm) defects, for which it does not create dead space. The method may be unsuitable for larger defects (≥30mm), in that creation of dead space is inevitable. Our previous comments have addressed and resolved this major issue [4]. The previously reported “accordion fold method” [5] or our endoscopic ligation with O-ring closure (E-LOC) procedure [2], which aims to anchor the muscle layer, may reduce formation of dead space.

Suction air control during dragging to facilitate approximation of the defect is useful in keeping the tension loose and preventing mucosal tearing. However, attempts at closure of larger defects (≥30 mm) using this technique may lead to mucosal tearing.

One of the authors’ concerns is repositioning of the clip. However, it is easy to remove the claw from the anchored mucosa endoscopically. In our presented case, the deployed endoclips maintained closure until postoperative Day 30. We believe that these claws contribute to long-lasting closure.

Finally, a large-scale study to clarify indications and limitations involving defect size, sustainability, and the application of endoscopic full-thickness resection is warranted.

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 <30mm. Endoscopy 2023; 55: E1244-1245
• 2 Kobara H, Tada N, Nishiyama N. et al. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: literature review over one decade. Dig Endosc 2023; 35: 216-231 DOI: 10.1111/den.14397. (PMID: 35778927)
• 3 Nishiyama N, Kobara H, Kobayashi N. et al. Efficacy of endoscopic ligation with O-ring closure for prevention of bleeding after gastric endoscopic submucosal dissection under antithrombotic therapy: a prospective observational study. Endoscopy 2022; 54: 1078-1084
• 4 Kobara H, Fujihara S. Advanced endoscopic gastric defect closure: preventive effects on post-endoscopic submucosal dissection bleeding. Dig Endosc 2022; 34: 483-484 DOI: 10.1111/den.14248. (PMID: 35178759)
• 5 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