Endoscopic fistula closure using a duodenoscope and the reopenable-clip over the line method

Closing a fistula using clips with a duodenoscope is difficult [1]. However, if a defect cannot be seen with a straight endoscope, it can sometimes be easily observed by changing to a duodenoscope. Therefore, a reliable defect closure method using a duodenoscope is desired. We devised a method called the “reopenable-clip over-the-line method” (ROLM), wherein complete closure can be achieved by placing clips on one side of the defect edge [2] [3]. Herein, we describe the first case of defect closure using ROLM with duodenoscopy.

The patient was a man in his 60s who developed a retroperitoneal abscess after acute pancreatitis; the abscess and horizontal part of the duodenum were perforated ([Fig. 1], [Video 1]). Because the perforation site was difficult to observe with a direct endoscope, we attempted to perform a simple clip closure using a wire-guided reopenable-clip closure with a duodenoscope [4]. However, separation of the wound was confirmed using fluoroscopy 2 weeks after the procedure. The fistula was closed using ROLM with a duodenoscope (JF-260V; Olympus). A clip with a line (SureClip: MicroTech; PE Line: Super X-wire 1.5, DUEL Co.) was placed on the edge of the fistula. The line was then threaded through one of the teeth of the re-openable clip, and the clip was inserted. The line was then pulled while the edge of the fistula was grasped using a clip. After confirming that the clips were brought close together, they were placed. The fistula closed completely after the procedure was repeated. Subsequently, several clips were used to hold the line in place. Finally, the line was cut using the modified locking-clip technique [5]. Complete closure of the fistula was confirmed using fluoroscopic imaging.

Fig. 1 Actual fistula closure using a duodenoscope and the ROLM. a Duodenum and retroperitoneal abscess seen on fluoroscopy. Leakage from the duodenal fistula to the retroperitoneum is seen (yellow arrow). b Endoscopic image of the fistula using a duodenoscope. c First clip with line placed at the edge of the fistula. d A re-openable with a line threaded through one tooth is placed on the defect edge. e The defect after repeated ROLM. f Fluoroscopy after ROLM fistula closure with no leakage into the retroperitoneum. Abbreviation: ROLM, reopenable-clip over-the-line method.

Video herunterladen

Defect closure using a duodenoscope and the reopenable-clip over-the-line method.Video 1

Endoscopy_UCTN_Code_TTT_1AO_2AI

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Park SW, Song TJ, Park JS. et al. Effect of prophylactic endoscopic clipping for prevention of delayed bleeding after endoscopic papillectomy for ampullary neoplasm: a multicenter randomized trial. Endoscopy 2022; 54: 787-794
• 2 Nomura T, Sugimoto S, Temma T. et al. Reopenable clip-over-the-line method for closing large mucosal defects following gastric endoscopic submucosal dissection: prospective feasibility study. Dig Endosc 2023; 35: 505-511
• 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;
• 4 Nomura T, Sugimoto S, Murabayashi T. et al. Double-wire-guided reopenable-clip closure of a mucosal defect after endoscopic papillectomy. Endoscopy 2022; 54: E141-E142
• 5 Nomura T, Sugimoto S, Kawabata M. et al. Large colorectal mucosal defect closure post-endoscopic submucosal dissection using the reopenable clip over line method and modified locking-clip technique. Endoscopy 2022; 54: E63-E64

Publikationsverlauf

Artikel online veröffentlicht:
06. Mai 2025