It is sometimes difficult to close a large perforation using endoclips and over-the-scope
clips, and surgery may be required [1]. We report a novel endoscopic technique for closure of a large perforation using
the clip-and-snare method with the prelooping technique.
A 76-year-old man with a metachronous esophageal cancer, which developed at a scar
in the cervical esophagus that resulted from a previous endoscopic submucosal dissection
(ESD), underwent a second ESD. A large perforation occurred during submucosal dissection
because of severe fibrosis associated with the previous ESD ([Fig. 1]). Closure of the perforation could not be achieved by endoscopic clip placement
because of its large size. Therefore, we endoscopically closed the perforation using
an endoclip with the clip-and-snare method and prelooping technique, as has been applied
in the traction method for ESD [2]
[3].
Fig. 1 Endoscopic view showing a large perforation (yellow arrowheads) in the cervical esophagus
during endoscopic submucosal dissection.
First, a snare (SD-210L-15; Olympus, Tokyo, Japan) was prelooped around the transparent
hood (D-201-11804; Olympus) attached to a single-channel upper gastrointestinal endoscope
(GIF-Q260J; Olympus) ([Fig. 2 a]), which was then advanced towards the mucosal defect. The anal side of the mucosal
perforation was grasped using an endoclip (HX-610-090; Olympus) passed through the
scope channel and was not released. Subsequently, the prelooped snare was loosened
from the transparent hood ([Fig. 2 b]), and the endoclip was grasped with the snare and released from the forceps ([Fig. 2 c]). The snare was pulled from the mouth, resulting in narrowing of the perforation,
which could then be closed using endoclips ([Fig. 2 d]; [Video 1]).
Fig. 2 The clip-and-snare method with prelooping technique. a A snare was prelooped around the transparent hood attached to a single-channel upper
gastrointestinal endoscope. b The prelooped snare was loosened from the transparent hood. c The endoclip that had previously been used to grasp the anal side of the mucosal
perforation was grasped with the snare. d Endoscopic view showing successful closure of the perforation.
A large esophageal perforation is closed using the clip-and-snare method with prelooping
technique.
Following this procedure, the patient developed no symptoms, except for a slight fever
and elevation of the C-reactive protein (CRP) level. An ulcer scar was observed 2
months post-ESD ([Fig. 3]).
Fig. 3 Endoscopic view 2 months later showing an ulcer scar.
This novel technique involving a device that is routinely used for endoscopic therapy
may be a helpful and easy procedure for closure of a large perforation in the digestive
tract.
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