Reply to Wu et al.

We would like to thank Wu et al. for their precise comments on our study [1]. Previous closure techniques aim to approximate the mucosal edges of the defect. However, early mucosal dehiscence caused by mucosal bridges after closure is problematic [2]. We thus introduced a novel technique, endoscopic ligation with O-ring closure (E-LOC), to prevent bleeding after gastric endoscopic submucosal dissection (ESD). The major advantage of this technique is maintenance of a durable closure for at least 3 days, as shown by the sustained closure rate of 95.8 % on postoperative day (POD) 2–3. This is explained by clip anchoring of the muscle layer in the center of the defect. Meanwhile, the loop-and-clip technique, which emerged as purse-string suture (PSS), is advantageous in terms of its simple maneuver. After PSS, mucosal dehiscence occurred in 52 % (36/69) of gastric post-ESD defects at a median of POD 3 [3]. E-LOC also differs from PSS in terms of closure. Because the closure force is concentrated on one central point in PSS, the radial force may strengthen the dehiscence force. In contrast, because E-LOC achieves layer-to-layer closure using both edges, its dehiscence force is weaker.

E-LOC has another advantage. In PSS, clips anchored around the defect tend to lie down toward the exposed muscle when snaring the endoloop, increasing the risk of residual clips below the closure site and clip-associated perforation. Use of a two-channel scope with grasping forceps is helpful. However, because E-LOC captures deployed clips in the ligation cap, the abovementioned problem can be avoided.

Disadvantages of E-LOC include the need for scope reinsertion for each O-ring use and the narrow endoscopic view due to the ligation cap.

The efficacy of gastric defect closure is controversial. Considering the closure-associated cost and time, the procedure should be limited to patients with high risk of delayed bleeding.

Publication History

Article published online:
27 October 2022

• References

• 1 Nishiyama N, Kobara H, Kobayashi N. et al. Efficacy of endoscopic ligation with O-ring closure for prevention of bleeding after gastric endoscopic submucosal dissection under antithrombotic therapy: a prospective observational study. Endoscopy 2022; DOI: 10.1055/a-1782-3448.
• 2 Kobara H, Fujihara S. Advanced endoscopic gastric defect closure: preventive effects on post-endoscopic submucosal dissection bleeding. Dig Endosc 2022; 34: 483-484
• 3 Ego M, Abe S, Nonaka S. et al. Endoscopic closure utilizing endoloop and endoclips after gastric endoscopic submucosal dissection for patients on antithrombotic therapy. Dig Dis Sci 2021; 66: 2336-2344