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Endoscopic technique for closure of a large gastric tube perforation by using endoclips with line-assisted complete closure
14 December 2018 (online)
Endoscopic submucosal dissection (ESD) is an acceptable treatment for gastric tube cancer after an esophagectomy . However, treatment of lesions on the suture line is difficult and may cause perforations. It is sometimes difficult to close a large perforation with endoclips. We report an endoscopic technique that enabled the closure of a large perforation by using the line-assisted complete closure (LACC) method    .
An 87-year-old man with early gastric cancer located on the suture line of the lesser curvature of the gastric tube, after subtotal esophagectomy, underwent ESD. During ESD, severe fibrosis and staples were encountered in the submucosal layer of the suture line. To achieve en bloc resection, dissection was performed just below the staples. As a result, a large perforation occurred, exposing the mediastinum ([Fig. 1]). The perforation could not be closed with endoscopic clip placement because of its large size. Therefore, we endoscopically closed the perforation by using endoclips with LACC ([Fig. 2], [Video 1]).
Video 1 Endoscopic technique for closure of a large gastric tube perforation by using endoclips with line-assisted complete closure.
An endoclip (HX-610-090; Olympus, Tokyo, Japan) with 1-0 silk line was placed at the side of the perforation site ([Fig. 2 a], [Fig. 3 a, b]). To anchor the line, another endoclip was placed on the other side ([Fig. 2 b]). The same procedure was repeated, and a total of four endoclips were placed along the perforation line ([Fig. 2 c, d], [Fig. 3 c]). Both sides of the perforation were gathered by pulling the anchor line ([Fig. 2 e]). Additional endoclips were placed to achieve complete closure ([Fig. 2 f], [Fig. 3 d]).
After 7 days, an endoscopic examination revealed that the perforation site was filled with regenerating tissue. Therefore, we initiated oral intake, which the patient tolerated well. After 2 months, post-ESD ulcer scarring was observed.
This technique of using endoclips with LACC could be performed relatively easily and is potentially useful in closing a large perforation in the gastrointestinal tract.
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