Delayed bleeding after gastric endoscopic submucosal dissection (ESD) is a major complication
[1] that sometimes leads to shock, and mucosal defect closure to prevent delayed bleeding
was reported [2]. However, the thickness of the gastric mucosa and proper muscle layer makes suturing
difficult [3]. A recent study reported the closure of an intermediate-size mucosal defect post-gastric
ESD with a novel anchor-pronged clip (MANTIS Clip; Boston Scientific, Marlborough,
Massachusetts, USA) ([Fig. 1]) [4]. Here, we present the successful closure of large mucosal defect with a MANTIS Clip
after gastric ESD ([Video 1]).
Fig. 1 Novel anchor-pronged clip. The clip is re-openable and rotational.
Successful closure of large mucosal defect after gastric endoscopic submucosal dissection.Video
1
The case involved a woman in her 90s on continued low-dose aspirin therapy. A 40-mm
lesion
was identified on the posterior wall of the lower body in the stomach ([Fig. 2]
a). ESD was performed for en bloc resection, resulting in a
mucosal defect approximately 60 mm in size ([Fig. 2]
b). The pathological finding was intramucosal carcinoma with a
negative horizontal and vertical margin. The defect was closed using a similar approach
as a
mucosa-submucosa closure after colorectal ESD [5]. First, one side of the mucosa was grasped with the MANTIS Clip. The clip was then
moved
to the opposite muscle layer, opened once, and after sufficient air aspiration, the
clip was
used to grasp the muscle layer ([Fig. 2]
c, d; [Fig. 3]
a, c). After sufficient shrinkage of the mucosal defect,
complete closure without obvious dead space was achieved by adding mucosa-mucosa and
mucosa-muscle closure with normal clips (16-mm Sure Clip; Micro-Tech Co., Ltd, Nanjing,
China)
or EZ Clip (Olympus Medical Systems, Tokyo, Japan) ([Fig. 2]
e; [Fig. 3]
d–g). In total, three MANTIS Clips, six Sure Clips, and four EZ
Clips were applied. The closure time was 14 minutes. The patient was discharged according
to
schedule without experiencing delayed bleeding.
Fig. 2 Closure of a large mucosal defect after gastric endoscopic submucosal dissection (ESD).
a The lesion was diagnosed endoscopically as a 40-mm diameter IIc. Markings were placed
around it. b The mucosal defect after ESD. The diameter was estimated to be around 60 mm. c The mucosal defect was shrunk with a MANTIS Clip (mucosa-muscle closure was performed).
d The mucosal defect was further shrunk using the same method. e Complete closure was achieved by adding mucosa-mucosa and mucosa-muscle closure with
normal clips.
Fig. 3 Closing method schema. The black diagonal lines represent the course of muscle fibers.
a–c When the mucosal defect is large after ESD, grasp one side of the mucosa with a MANTIS
Clip. Then move the clip to the opposite muscle layer, open the clip once, and after
sufficient air aspiration, grasp the muscle layer. d, e When the mucosal defect is small, mucosa-mucosa closure after sufficient air aspiration
is performed with a normal clip. f, g When the mucosal defect is intermediate in size, mucosa-muscle closure after sufficient
air aspiration is performed with a normal clip.
The novel anchor-pronged clip was thought to be useful in closing even large mucosal
defects after gastric ESD.
Endoscopy_UCTN_Code_TTT_1AO_2AO
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
