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CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1805037
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“Tip-in clip anchoring” as a Novel Adjunct to Complete String Clip Suturing-Assisted Closure of a Large Endoscopic Submucosal Dissection Defect

Vincent Zimmer 
1   Department of Medicine, Knappschaftsklinikum Saar GmbH, Püttlingen, Germany
2   Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
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Keywords

endoscopic submucosal dissection - coronary heart - bleeding

A 49-year-old female patient was referred for resection of an elevated 25-mm antral lesion ([Fig. 1A]). Mucosal biopsies indicated low-grade dysplasia. The patient was on chronic medication with the P2Y12 inhibitor clopidogrel due to coronary heart, and a switch to acetylsalicylic acid was not possible due to salicylate intolerance. The patient underwent en bloc endoscopic submucosal dissection (ESD; high-grade dysplasia, R0), using a combination of the pocket creation method and clip-with-line traction ([Fig. 1B]). To allow for clopidogrel maintenance and reduce risks of post-interventional bleeding, clip closure of the defect was aimed at relying on what has been designated as string clip suturing. While the string clip was successfully applied in the middle, further clipping was limited by slipping of the re-openable clip due to tissue tension. Therefore, small holes were created with the knife some millimeters from the edge ([Fig. 1C]). After tipping in the branches for anchoring, the clip could be released with full closure of the dehiscence with an uncomplicated further clinical course ([Fig. 1D]).

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Fig. 1 (A) Gastroscopy indicated an estimated 25-mm elevated lesion with a biopsy diagnosis of low-grade adenoma. (B) Uncomplicated en bloc endoscopic submucosal dissection (ESD) using a combined strategy of the pocket creation method and clip-with-line traction, yielding en bloc resection of a high-grade adenoma. (C) Creation of small holes some millimeters from the wound edge using the ESD knife (DualKnife, Olympus). (D) “Tipping in” the branches of the clip in an anchoring manner, facilitating ESD defect closure.

Learning Points

  1. ESD defect closure may be cumbersome, and some tricks have been developed with the string clip suturing method probably attaining great popularity and dissemination.

  2. Nonetheless, the gastric mucosa is quite thick and often fibrotic, complicating and sometimes defying clip closure.

  3. The presented “tip-in clip anchoring” technique may represent another option for defect closure.[1]


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Conflict of Interest

None declared.


Address for correspondence

Vincent Zimmer, MD
Department of Medicine II, Saarland University Medical Center
Kirrberger Str. 100, 66421 Homburg
Germany   

Publication History

Article published online:
20 May 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Zoom Image
Fig. 1 (A) Gastroscopy indicated an estimated 25-mm elevated lesion with a biopsy diagnosis of low-grade adenoma. (B) Uncomplicated en bloc endoscopic submucosal dissection (ESD) using a combined strategy of the pocket creation method and clip-with-line traction, yielding en bloc resection of a high-grade adenoma. (C) Creation of small holes some millimeters from the wound edge using the ESD knife (DualKnife, Olympus). (D) “Tipping in” the branches of the clip in an anchoring manner, facilitating ESD defect closure.