Aims The closure of mucosal defects following gastric Endoscopic Submucosal Dissection
(ESD) reduces the incidence of serious adverse events. Although several methods for
mucosal defects closure have been reported, a simple and effective technique is expected
to be established. We developed the Clip with Line Pulley Securing (CLiPS) technique,
a tightly secure and cost-effective closure technique utilizing widely available materials.
Methods A prospective study was conducted on 50 consecutive patients who underwent gastric
ESD at our hospital between October 2023 to March 2024. In the CLiPS technique, a
reopenable clip (SureClip, Microtec) with a 3-0 nylon thread (Bearon, Bearmedic) to
the tip of is placed at the distal margin of the mucosal defect. A second clip is
used to secure the same nylon thread to the opposite end. The nylon thread from the
forceps hole is passed through the small open detachable snare (Endoloop, Olympus).
While applying moderate tension to the nylon thread, the detachable snare is pushed
in as both a pusher and stopper. Subsequently, the detachable snare is released, bringing
the edges of the mucosal defect together. A loop cutter is then employed to cut the
detachable snare and nylon thread, followed by complete closure using standard clips.
Multiple CLiPS can be performed if the ulcer is large.
Results The success rate of CLiPS technique was 100% (50/50), and the complete closure rate
was 100% (50/50). The mean size of resected specimen was 33.8 mm (SD±11.6), and the
mean closure time was 17.8 minutes (SD±7.5). The median number of clips used was 9
(range 5-26), and the median number of detachable snares used was 1 (range 1-5). The
sustained complete closure rate on POD2 was 83.7% (41/49), except for one case in
which the endoscopy was not performed because the patient developed heart failure.
The delayed bleeding and perforation rate after ESD was 0% (50/50) and no complications
related to CLiPS technique were observed.
Conclusions CLiPS technique enables achieving complete closure of post-ESD mucosal defect. Sustained
defect closure may prevent delayed bleeding after gastric ESD. Prospective validation
of its usefulness in multiple organs is planned in the future.
