Mucosal defect closure after gastric endoscopic submucosal dissection (ESD) is challenging
because of the thick mucosal and muscle layers [1]; it is particularly difficult in the gastric antrum. When a conventional endoscope
is pushed distally to access the antrum, the greater curvature is stretched. This
widens the mucosal defect and stretches the muscle layer, making closure of the defect
difficult ([Fig. 1]). Herein, we present a multibending scope technique that allows antral defect closure
using the reopenable clip-over-the-line method (ROLM) to avoid stretching the muscle
layer [2].
Fig. 1 Comparison of mucosal defect closure in the gastric antrum using: a, b a conventional upper gastrointestinal scope, which stretches the muscle layer of
the defect owing to the stretching of the greater curvature; c, d a multibending scope, which touches the greater curvature only slightly and does
not stretch the muscle layer of the defect.
A 60-mm mucosal defect was left after gastric ESD in our patient ([Fig. 2]; [Video 1]). A multibending scope (GIF-2TQ260M; Olympus) was used with the second (top) wheel
adjusted to a slightly upward position. Consequently, it was possible to confirm the
anal side of the defect edge endoscopically, without stretching the muscle layer.
Defect closure was performed using the ROLM, a defect closure technique using a line
and reopenable clip (SureClip 8 mm, 16 mm; MicroTech, Nanjing, China) [3]. First, a clip with a line secured to the tooth was placed at the anal edge of the
defect through the working channel. The line was passed through a hole in the tooth
of the next reopenable clip, before it was also introduced into the working channel.
This clip was placed on the contralateral defect edge and nearby muscle layer, with
the line tightened over the closed clip before it was deployed. The same steps were
repeated to gradually close the defect. Two ROLMs were required for complete defect
closure in this case, and the remaining line was cut with a new loop cutter (FS-5L-1;
Olympus) [4]. The patient was discharged, without experiencing any adverse events.
Fig. 2 Endoscopic images of defect closure after endoscopic submucosal dissection (ESD)
in the gastric antrum using a multibending scope showing: a appearance of the 60-mm mucosal defect after ESD with a conventional upper gastrointestinal
scope; b the same defect viewed with a multibending scope with degassing; c placement of the first clip with a line; d placement of a clip with a line previously threaded through the tooth on the contralateral
mucosal defect edge and muscle layer; e defect closure, with the muscle layer folded over, after the placement of further
clips threaded onto the line on the contralateral defect edge and muscle layer; f complete closure of the mucosal defect.
Video 1 Defect closure after endoscopic submucosal dissection in the gastric antrum with
the reopenable clip-over-the-line method using a multibending scope.
In conclusion, a multibending scope is effective for closing antral mucosal defects
because it prevents stretching of the gastric muscle layer.
Endoscopy_UCTN_Code_TTT_1AO_2AG
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