Endoscopic ligation technique with O-ring closure: improved or complicated?

Nishiyama et al. [1] recently published the results of a prospective observational study that examined the efficacy of a novel endoscopic ligation technique with O-ring closure (E-LOC) to prevent bleeding after gastric endoscopic submucosal dissection (ESD) in patients on antithrombotic therapy. The authors concluded that E-LOC may be an effective method of closing mucosal defects after gastric ESD. The procedure of E-LOC was illustrated clearly, and we would like to know more.

Compared with other methods for mucosal defect closure, E-LOC shows acceptable maneuverability and convenient availability. However, it seems that applying an O-ring might complicate the operation and prolong the procedure time, as the other elements of the procedure, which are quite similar to the routine loop-and-clips technique, could prevent post-procedure bleeding in most cases [2] [3]. It is essential to share the E-LOC technique and highlight its novelty and improvement in the discussion, which contributes to deep understanding, wide acceptance, and clinical potential. Moreover, bleeding after gastric ESD is not common where closure is not routinely recommended [4]. Doubts remain as to whether endoscopic closure of the mucosal defect could prevent post-ESD bleeding, not to mention whether a new closure method, E-LOC, could minimize the risk of bleeding. While the findings are likely to be highly impactful, further prospective studies are needed for validation of the novel technique.

We appreciate the work by Nishiyama et al. Despite the promising data, we eagerly await more statements about the advantages and disadvantages before applying E-LOC in the clinical setting.

^* Co-first authors.

Publication History

Article published online:
27 October 2022

• References

• 1 Nishiyama N, Kobara H, Kobayashi N. et al. Efficacy of endoscopic ligation with O-ring closure for prevention of bleeding after gastric endoscopic submucosal dissection under antithrombotic therapy: a prospective observational study. Endoscopy 2022; 54: 1078-1084 DOI: 10.1055/a-1782-3448.
• 2 Shiotsuki K, Takizawa K, Notsu A. et al. Endoloop closure following gastric endoscopic submucosal dissection to prevent delayed bleeding in patients receiving antithrombotic therapy. Scand J Gastroenterol 2021; 56: 1117-1125
• 3 Abe S, Oda I, Mori G. et al. Complete endoscopic closure of a large gastric defect with endoloop and endoclips after complex endoscopic submucosal dissection. Endoscopy 2015; 47: E374-E375
• 4 Oda I, Suzuki H, Nonaka S. et al. Complications of gastric endoscopic submucosal dissection. Dig Endosc 2013; 25: 71-78