Search, coagulation, and clipping with the shrink method to minimize ulcer base and prevent delayed bleeding after gastric endoscopic resection

Introduction

Although the search, coagulation, and clipping (SCC) technique has been shown to be more effective than the post-endoscopic submucosal dissection (ESD) coagulation method in reducing delayed bleeding (DB) after gastric ESD [1], it does not entirely eliminate risk of DB. Applying large-sized clips during clipping may reduce the size of the mucosal defect, which could potentially promote ulcer healing and thereby lead to more efficient prevention of DB. Prevention of DB using the SCC with the shrink (SCC-S) method is reported here.

Case report

Gastric ESD was performed on a 78-year-old woman classified as having an intermediate-risk of DB due to gastric antrum and tumor diameter of 30 mm. The ulceration followed gastric ESD in the lesser curvature of the gastric antrum ([Fig. 1] a). Initially, coagulation was performed following lesion removal, with a focus on cauterizing vessels located mainly along the edge of the ulcer base ([Fig. 2] a). Subsequently, perforating vessels situated between the muscle layers were clipped using mainly 16-mm reopenable clips, while maintaining adequate suction to reduce luminal pressure ([Fig. 2] b, [Fig. 2] c).

Fig. 1 Condition after endoscopic submucosal dissection (ESD). a The ulceration followed gastric ESD in the lesser curvature of the gastric antrum. b After applying the search, coagulation, and clipping with the shrink method, the mucosal defect was effectively reduced and the ulcer base shrank to half its original size.

Fig. 2 Search, coagulation, and clipping with the shrink method. aFirst, a coagulation procedure was performed after lesion resection, targeting vessels primarily at the margin of the ulcer base. b,c Subsequently, perforating vessels situated between the muscle layers were clipped using mainly 16-mm reopenable clips (SureClip; Micro-Tech Co. Ltd, Nanjing, China), while maintaining adequate suction to reduce luminal pressure.

This Origami method [2]-inspired maneuver folded the muscle layer inward, effectively reducing the mucosal defect and shrinking the ulcer base to half its original size ([Fig. 1] b and [Video 1]). After about 2 months, the ulcer was completely cured ([Fig. 3]).

Video herunterladen

Video showing application of the search, coagulation, and clipping with the shrink method.Video 1

Fig. 3 Follow-up endoscopy. After about 2 months, the ulcer was completely cured.

The reopenable clips, which have been empirically found to have a stronger grasping force than the hemostatic clips (HX-610–135, Olympus Optical) previously used in the conventional SCC method [1], are potentially less likely to dislodge. Therefore, they may be more effective in preventing DB. Several closure methods exist to prevent DB after gastric ESD [3] [4], but performing closure in all cases is time-consuming and costly. Given that low- and intermediate-risk patients account for nearly 90% in the BEST-J study [5], the simpler and more cost-effective SCC-S method may be a reasonable option for these groups.

Contributorsʼ Statement

Satoshi Abiko: Conceptualization, Writing - original draft. Yukiko Okada: Supervision. Kazuki Yamamoto: Supervision. Yohei Nishikawa: Supervision. Ippei Tanaka: Supervision. Haruhiro Inoue: Supervision. Naoya Sakamoto: Supervision.

Conflict of Interest

Haruhiro Inoue is an advisor for Olympus Corporation and Top Corporation. He has also received educational grants from Olympus Corporation and Takeda Pharmaceutical Co. The other authors declare no conflicts of interest for this article.

Acknowledgement

We thank Yuta Tamaru, Kei Ushikubo, Kohei Shigeta, Mayo Tanabe, Nikko Theodore Valencia Raymundo, and Manabu Onimaru in the Digestive Diseases Center, Showa Medical University Koto Toyosu Hospital, for his kind support and advice. We are very grateful to the wonderful staff in the endoscopic room, outpatient care, and ward of Showa Medical University Koto Toyosu Hospital.

• References

• 1 Azumi M, Takeuchi M, Koseki Y. et al. The search, coagulation, and clipping (SCC) method prevents delayed bleeding after gastric endoscopic submucosal dissection. Gastric Cancer 2019; 22: 567-575
• 2 Masunaga T, Kato M, Sasaki M. et al. Modified double-layered suturing for a mucosal defect after colorectal endoscopic submucosal dissection (Origami method) (with video). Gastrointest Endosc 2023; 97: 962-969
• 3 Sugimoto S, Nomura T, Temma T. et al. Closure of gastric mucosal defects using the reopenable-clip over the line method to decrease the risk of bleeding after endoscopic submucosal dissection: a multicenter propensity score-matched case-control study (with video). Gastrointest Endosc 2025; 102: 37-46
• 4 Goto O, Morita Y, Takayama H. et al. Endoscopic hand suturing has the potential to reduce bleeding after gastric endoscopic submucosal dissection in patients on antithrombotic agents: Multicenter phase II study. Dig Endosc 2025; 37: 266-274
• 5 Hatta W, Tsuji Y, Yoshio T. et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut 2021; 70: 476-484

Publikationsverlauf

Eingereicht: 04. September 2025

Angenommen nach Revision: 22. Oktober 2025

Artikel online veröffentlicht:
25. November 2025