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Endoscopic closure of a large gastric mucosal defect after endoscopic submucosal dissection using a novel endoscopic string-with-knotter suture device
Complete defect closure after endoscopic submucosal dissection (ESD) could decrease delayed adverse events . Although various endoscopic instruments are used to suture post-ESD defects, such as the Overstitch device  and loop string-assisted clip device , these devices either cost a lot or require complicated manipulation. Therefore, we developed a string-with-knotter device (VDK-FH-A-11-180; Jiangsu Vedkang Medical Science and Technology Co., Changzhou, Jiangsu, China)  to easily and reliably close a gastric post-ESD defect ([Video 1]).
Video 1 Endoscopic closure of a large gastric mucosal defect after endoscopic submucosal dissection (ESD) using the novel string-with-knotter device. Three clips linked by a string are applied to the edges of the defect. The knotter device is then used to approximate the mucosal defect, tie the string, and cut the excess string. Additional endoscopic clips are placed to achieve complete closure.
A 50-year-old woman with a submucosal lesion of the gastric lesser curve ([Fig. 1 a]) was referred for endoscopic treatment. A large defect with muscle injury was left after ESD had been performed ([Fig. 1 b]), which was sutured using the string-with-knotter device. A reopenable clip with string attached was deployed on the middle of the lesser curve edge of the defect ([Fig. 1 c]). Another clip was used to pick up the string and was placed on the opposite edge of the defect ([Fig. 1 d]). The third clip was used to fix the string to the anal edge of the defect ([Fig. 1 e]). The knotter was introduced over the string to approximate the defect by gradually pulling the free end of the string ([Fig. 1 f]). Because the string passed successively through the outer plastic cylinder and the inner two steel wires ([Fig. 2 a]), when the plastic cylinder was continuously pushed by the metal sheath, advancing it towards the metal head, the string was firstly tied via the force of friction between the plastic cylinder and the metal head ([Fig. 2 b]), then excess string was cut under shear force from severe compression of the two steel wires ([Fig. 2 c]). Finally, the tied string was released as the welding site ruptured owing to the counter-force between the steel wires and the metal head ([Fig. 2 d]). Additional clips were then placed ([Fig. 1 g]), and endoscopic inspection confirmed complete defect closure ([Fig. 1 h]).
Inspired by the widely used string-clip suturing method , this novel suture device beautifully solves the difficulty in knotting and cutting the string, so may be a promising closure method for large gastrointestinal defects and perforations.
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17 February 2021 (online)
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