Coagulation, clipping and closure method: New combined approach to prevent delayed bleeding after gastric endoscopic submucosal dissection

Introduction

There are several methods for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD), such as the coagulation plus clipping method and the closure method; however, they have not been able to completely prevent DB [1] [2] [3]. It was hypothesized that DB could be completely prevented through a combination of advanced closure with a coagulation and clipping method. Prevention of DB with this coagulation, clipping and closure (CCC) method is reported here.

Gastric ESD was performed for an 83-year-old man classified as having a high risk of DB due to oral administration of rivaroxaban and prasugrel. The ulceration followed gastric ESD (30 mm in diameter) in the lesser curvature of the upper body of the stomach. First, a coagulation procedure was performed after lesion resection, targeting vessels primarily at the margin of the ulcer base ([Fig. 1] a). Next, perforator vessels emerging between the muscle layers and the surrounding muscle layer were clipped using 16-mm or 11-mm reopenable clips while sufficient air was suctioned ([Fig. 1] b). As a result, the muscle layer folded. This procedure, inspired by the Origami method [4], reduces the size of the mucosal defect ([Fig. 2] a). Finally, complete closure of the residual mucosal defect was achieved using the dead space–eliminating technique with anchor pronged clips [5] ([Fig. 1] c, [Fig. 2] b, and [Video 1]).

Fig. 1 Coagulation, clipping and closure method for preventing delayed bleeding after gastric endoscopic submucosal dissection. a First, a coagulation procedure was performed after lesion resection, targeting vessels primarily at the margin of the ulcer base. b Next, perforator vessels emerging between the muscle layers and the surrounding muscle layer were clipped using 16-mm or 11-mm reopenable clips (SureClip; Micro-Tech Co. Ltd, Nanjing, China) while sufficient air was suctioned. c Complete closure of the residual mucosal defect was achieved using the dead space-eliminating technique with anchor pronged clips (MANTIS clip; Boston Scientific, Marlborough, Massachusetts, United States).

Fig. 2 Condition after endoscopic submucosal dissection (ESD). a The muscle layer is folded using 16-mm or 11-mm reopenable clips. b The ulceration was completely closed using a coagulation, clipping and closure method.

Application of the coagulation, clipping and closure method.Video 1

Bleeding from perforator vessels may occur in areas where wound closure has dehisced; however, it is believed that this type of DB can be prevented by preemptively coagulating and clipping perforator vessels at the base of the ulcer. Preemptively folding the rigid gastric muscular layer, which is prone to dehiscence, using clips may be an effective procedure for preventing subsequent dehiscence.

The CCC method may help reduce risk of DB after gastric ESD; however, further evaluation with a larger number of cases is required to validate its effectiveness.

Conflict of Interest

Haruhiro Inoue is an advisor for Olympus Corporation and Top Corporation. He has also received educational grants from Olympus Corporation and Takeda Pharmaceutical Co. The other authors declare no conflicts of interest for this article.

Acknowledgement

We thank Masachika Saino, Miyuki Iwasaki, Mayo Tanabe, Boldbaatar Gantuya, and Manabu Onimaru in the Digestive Diseases Center, Showa University Koto Toyosu Hospital, for their kind support and advice. We are very grateful to the wonderful staff in the endoscopic room, outpatient care, and ward of Showa University Koto Toyosu Hospital.

• References

• 1 Mukai S, Cho S, Nakamura S. et al. Postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method for the prevention of delayed bleeding after ESD. Surg Endosc 2013; 27: 1292-1301
• 2 Azumi M, Takeuchi M, Koseki Y. et al. The search, coagulation, and clipping (SCC) method prevents delayed bleeding after gastric endoscopic submucosal dissection. Gastric Cancer 2019; 22: 567-575
• 3 Sugimoto S, Nomura T, Temma T. et al. Closure of gastric mucosal defects using the reopenable-clip over the line method to decrease the risk of bleeding after endoscopic submucosal dissection: a multicenter propensity score-matched case-control study (with video). Gastrointest Endosc 2024; S0016-5107(24)03696-4
• 4 Yamamoto K, Inoue H, Tanaka I. et al. Closure in antireflux mucoplasty using anchor prong clips: dead space–eliminating technique. VideoGIE 2024; 9: 303-308
• 5 Masunaga T, Kato M, Sasaki M. et al. Modified double-layered suturing for a mucosal defect after colorectal endoscopic submucosal dissection (Origami method) (with video). Gastrointest Endosc 2023; 97: 962-969

Publikationsverlauf

Eingereicht: 28. Dezember 2024

Angenommen nach Revision: 27. Februar 2025

Artikel online veröffentlicht:
04. April 2025