New ligation technique using a double loop clip without adhesive for ulceration following endoscopic submucosal dissection of the colon

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video)

BACKGROUND AND AIMS

Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported, but none have been established for clinical use because of technical complexity and the need for expensive equipment. Therefore, the technical feasibility of a new ligation method using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed.

METHODS

Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using the D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.

RESULTS

The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 cm (interquartile range [IQR], 2.8-3.8 cm), and the complete ligation rate was 88.5% (23 of 26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21 of 22). The median duration of the ligation procedure was 20 minutes (IQR, 16-24 minutes). The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (P = .0269).

CONCLUSIONS

Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.