Various ligation techniques for post-endoscopic submucosal dissection (ESD) ulceration
have recently been reported [1]
[2]
[3]
[4]
[5]; however, no technique has been established owing to the complexity involved and
the fact that an expensive device is required. We devised a new ligation technique
using a double loop clip (D-L clip) without an adhesive agent for ulceration following
ESD of the colon.
First, a standard clip (HX-610-90; Olympus, Tokyo, Japan) is attached to a rotatable
clip-fixing device. The clip is deployed, and before deployment is completed, a thread,
which is tied loosely in advance, is passed through the portion intersecting the clip
arm at the base of the clip and tied. Next, a double loop of appropriate length is
created using the remaining thread. The clip is drawn back again into the rotatable
clip-fixing device. This completes the D-L clip without the use of an adhesive agent
([Fig. 1]). The D-L clip is applied to the proximal side of the post-ESD ulcer area ([Fig. 2]). Clipping of the mucous membrane on the distal side is performed by applying a
different clip to the proximal or distal loop line in each situation. We usually pick
up the proximal loop line. A clip is then added to tighten the ligation, thereby completing
the ligation ([Video 1]).
Fig. 1 Method of making a D-L clip without an adhesive. a, b The clip is deployed, and before deployment is completed, a thread, which is tied
loosely in advance, is passed through the portion intersecting the clip arm at the
base of the clip and tied. c A double loop of appropriate length is created using the remaining thread. d This completes the D-L clip without the use of an adhesive agent.
Fig. 2 Ulceration following endoscopic submucosal dissection (ESD) of the colon (34 mm in
diameter). The D-L clip is applied to the proximal side of the post-ESD ulcer area.
Video 1 Method for making a D-L clip without an adhesive, and demonstration of the ligation
technique using the D-L clip for ulceration following endoscopic submucosal dissection
of the colon.
We previously used a single loop clip, but it was sometimes difficult to pick up the
loop line, because the loop line was crumpled. In this new technique, the weight of
the distal loop moderately extends the proximal loop line. We can easily pick up the
proximal loop line, and if we cannot pick up one loop line, we can try to pick up
the other loop line.
The ligation technique using a D-L clip without an adhesive agent is a useful technique
that is simple and cost-effective.
Endoscopy_UCTN_Code_CPL_1AJ_2AD
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