Release and re-hook: a novel method with combined use of clips and nylon snare to close a colonic defect after endoscopic mucosal resection

A 67-year-old man presented to our department for a screening colonoscopy, during which a 2-cm type IIa nonpolypoid lesion was found in the ascending colon ([Fig. 1 a]). After submucosal injection (saline with methylene blue) and adequate lifting of the lesion, a single-piece endoscopic mucosal resection (EMR) was performed. The post-EMR defect consisted only of serosal lining ([Fig. 1 b]).

Fig. 1 a Sessile polyp and positive lifting sign in the ascending colon of a 67-year-old man undergoing screening colonoscopy. b Colonic wall defect after resection; only the serosal lining is left in situ. Attempts to close the defect with clips failed.

Because of its large size, attempts to close the defect with clips failed. A decision was made to close the defect with the combined use of clips and a nylon snare (HX-400U; Olympus, Tokyo, Japan). The traditional method of snaring and clipping could not be performed. Therefore, we developed a new technique.

At the patient’s bedside, the nylon snare was opened and released from its original sheath ([Fig. 2 a]). The distal loop of the snare was enlarged to facilitate re-hooking ([Fig. 2 b]). The snare was grasped with a clip (QuickClip2; Olympus) and introduced into the working channel of the endoscope ([Fig. 2 c], [Fig. 2 d]). The snare was delivered to the ascending colon ([Fig. 2 e], [Fig. 3 a]), where it was anchored with multiple clips along the edges of the defect ([Fig. 3 b]). The distal end of the snare was then re-hooked and pulled back into the original sheath ([Fig. 2 f]), enabling the closure to be completed in a “purse-string” fashion ([Fig. 3 c]). Follow-up colonoscopy at 8 weeks demonstrated a healed defect, with both the snare and clip in situ ([Fig. 3 d]).

Fig. 2 Release and re-hook method (bedside demonstration). a The snare is released in the open position from the original sheath. b The distal loop is enlarged to facilitate re-hooking of the snare. c The snare is grasped with a clip. d The snare is introduced through the working channel of the colonoscope. e Delivery of the snare. f Re-hooking of the snare.

Fig. 3 Combined use of a nylon snare and clips for closure of the colonic wall defect. a Delivery of the snare into the colonic lumen. b Anchoring the snare with clips along the edges of the defect. c The closure is done in a “purse-string” fashion. d Follow-up colonoscopy at 8 weeks shows complete healing of the defect, with both snare and clips in situ.

The application of two accessories with a single-channel endoscope is either challenging or impossible. Perforations and large mucosal defects can be closed with the combined use of clips and a nylon snare using two methods. In the “tulip-bundle” technique the snare is lassoed and tightened over a bundle of clips attached at the edges of the tear [1]. In the “purse-string” technique, the snare forms a nylon loop that is clipped around the edges of the lesion. Closure is accomplished by closing the snare [2] [3]. However, with the tulip-bundle technique, there is a risk of the snare slipping over the clips, whereas the purse-string approach requires the use of a double-channel endoscope, or the snare must be fixed externally to the scope. In addition, it can be difficult to operate a double-channel endoscope or to maintain the position of an externally fixed snare in a redundant or tortuous colon.

In sum, we believe that our release and re-hook method is a useful modification of the snare-and-clip technique and might be useful in a clinical scenario such as the one presented here.

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Competing interests: None

• References

• 1 Luigiano C, Ferrara F, Polifemo AM et al. Endoscopic closure of esophageal fistula using a novel “clips and loop” method”. Endoscopy 2009; 41: E249-E250
• 2 Zeng CY, Li GH, Zhu Y et al. Single-channel endoscopic closure of large endoscopy-related perforations. Endoscopy 2015; 47: 735-738
• 3 Matsuda T, Fujii T, Emura F et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc 2004; 60: 836-838