Although post-gastric endoscopic submucosal dissection (ESD) bleeding is reduced by
defect
closure [1]
[2]
[3], there is no convenient and secure mucosal inverted closure method that enables
early
wound healing through sustained closure. We previously reported on post-ESD closure
using jumbo
grasping forceps (FG-47L-1; Olympus, Tokyo, Japan) [4]; however, one problem was the poor maneuverability of the grasping forceps.
Subsequently, we used EndoGrip grasping forceps (EndoGrip, AG-5039-2323; AGS MedTech,
Tokyo,
Japan) ([Fig. 1]), which allows closure while inverting the mucosa. EndoGrip has two advantages:
1)
small, sharp teeth at the tip and sharp claws in the arms that enable secure fold-and-drag
maneuvers; and 2) good rotatability that provides easy maneuverability. We introduce
a novel
closure technique using EndoGrip forceps and endoclips.
Fig. 1 Photographs of the EndoGrip grasping forceps (AG-5039-2323; AGS MedTech, Tokyo, Japan),
which has small, sharp teeth at the tip and sharp claws in the arms that enable secure
fold-and-drag maneuvers, as well as having good rotatability that provides easy
maneuverability; the claw length is 1.5 mm, with an opening width of 8.3 mm.
A 68-year-old man who was taking aspirin presented with a large early gastric cancer
located
on the lesser curvature in the angle. After standard ESD had been performed, a 38-mm
defect
remained ([Fig. 2]
a). After written informed consent had been obtained, the defect
was closed using the following steps ([Fig. 3]; [Video 1]). The EndoGrip was inserted into an endoscope with dual working channels (GIF-2TQ260M,
Olympus), and one edge of the mucosal defect was grasped ([Fig. 2]
b). The grasped edge was dragged to the opposite edge of the
mucosal defect, the EndoGrip was reopened, and the other side of the mucosa was grasped
([Fig. 2]
c). An endoclip (EZ Clip, HX-610-090L; Olympus) was inserted
into the second channel of the endoscope, and the clip was pressed against the mucosa
and closed
while pulling the EndoGrip ([Fig. 2]
d,e). This procedure was repeated until the defect was
completely closed ([Fig. 2]
f). Further endoclips were added in any gaps. The closure time
was 31 minutes, and sustained closure was confirmed on postoperative days 3 and 7
([Fig. 4]).
Fig. 2 Endoscopic images of the closure procedure showing: a a 38-mm defect after standard endoscopic submucosal dissection; b the grasping forceps that had been inserted through one channel of a dual-channel
endoscope being used to grasp one edge of the mucosal defect; c the grasped edge being dragged to the opposite edge of the mucosal defect, where
the forceps is slowly reopened to grasp the other side of the mucosa; d an endoclip that had been inserted through the second channel of the endoscope being
pressed against the mucosa and closed while pulling on the forceps; e the first two endoclips in place as the procedure is repeated along the entire defect
length; f the completely closed defect.
Fig. 3 Schema of the procedure. Source: Davinch Medical Illustration Office.
Fig. 4 Endoscopic appearance on the 3rd and 7th postoperative days showing continued sustained
closure, with all clips remaining in place.
Video showing the EndoGrip forceps being used to close an artificial gastric defect.
Source for graphical illustrations: Davinch Medical Illustration Office.Video 1
The ease of maneuverability and high grasping strength of the EndoGrip simplify the
technique of mucosal inverted gastric closure.
Endoscopy_UCTN_Code_TTT_1AO_2AO
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