New methods
Clinical endoscopy
Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video)

https://doi.org/10.1016/j.gie.2020.02.015Get rights and content

Background and Aims

Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported, but none have been established for clinical use because of technical complexity and the need for expensive equipment. Therefore, the technical feasibility of a new ligation method using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed.

Methods

Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using the D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.

Results

The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 cm (interquartile range [IQR], 2.8-3.8 cm), and the complete ligation rate was 88.5% (23 of 26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21 of 22). The median duration of the ligation procedure was 20 minutes (IQR, 16-24 minutes). The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (P = .0269).

Conclusions

Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.

Introduction

Several reports have shown that inflammation after endoscopic submucosal dissection (ESD) of the colon can be alleviated by closing the ulceration after ESD.1, 2, 3, 4, 5 Although various ligation techniques for the prevention of post-ESD ulceration have recently been reported,10, 6, 7, 8, 9 there are currently no established techniques because of the complexity of the approaches and the need for expensive equipment to complete the procedure. Therefore, we have devised a new ligation method using a double-loop clips (D-L clips) technique without the need for an adhesive agent for ulceration after ESD of the colon.11 We have previously reported the usefulness of this easy-to-perform technique, which was inspired by the simple but reliable method of endoscopic sliding closure with a ring-shaped surgical thread after ESD.7 In the current study, we assessed the technical feasibility of this novel ligation technique.

Section snippets

Patients

Among 35 patients who underwent ESD of the colon in the Department of Gastroenterology at Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent closure of the post-ESD ulcer bed using the D-L clips technique were included after the exclusion of 9 patients, including 1 patient who underwent the procedure without ligation using the D-L clips technique performed by external ESD experts; 2 patients who underwent systematic hybrid ESD using a SOUTEN snare (Kaneka

Results

The median age of the patients was 71 years (interquartile range [IQR], 54-86 years), and the male/female ratio was 8:5. Oral antithrombotic agents were administered to 7 patients (26.9%). The lesion sites were cecum (5), ascending colon (5), transverse colon (8), descending colon (1), sigmoid colon (1), rectum (6). The median length of the long tumor axis was 2.3 cm (IQR, 2.0-2.4 cm), the median resected specimen length was 3.2 cm (IQR, 2.8-3.8 cm), and the median resection area was 6.9 cm2

Discussion

In this study, we investigated the feasibility of a new ligation technique using D-L clips without an adhesive agent for ulceration after ESD of the colon and found that (1) complete closure was achieved in most patients, (2) the duration of ligation was acceptable, (3) only 1 patient experienced delayed procedural adverse events, and (4) incomplete ligation was significantly more frequent in patients with the lesion site in the inferior rectal valve/anal verge area compared with the patients

Conclusions

Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, but other methods might be considered for lesions in the lower rectum.

Acknowledgments

We express our deep gratitude to Dr Soichiro Oda, Dr Akimitsu Meno, and Dr Akane Shidou in the Department of Gastroenterology at Kushiro Rosai Hospital for their kind support and advice. We are very grateful to the wonderful staff in the endoscopic room and ward of Kushiro Rosai Hospital.

References (25)

  • T. Nomura et al.

    Clip-on-clip closure method for a mucosal defect after colorectal endoscopic submucosal dissection: a prospective feasibility study

    Surg Endosc

    (2020)
  • T. Horii et al.

    Endoscopic closure method using a dental floss O-ring for mucosal defect after endoscopic resection

    Dig Endosc

    (2019)
  • Cited by (9)

    • GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020

      2021, Gastrointestinal Endoscopy
      Citation Excerpt :

      Nevertheless, a number of studies continued to demonstrate the special challenge posed by colonic locations for endoscopic closure. A feasibility study by Abiko et al77 of a clip and suture closure technique yielded mixed success, with a higher rate of incomplete ligation for lesions at the inferior rectal valve. OTSCs are considered easy to use and safe and effective for iatrogenic perforation, polypectomy, and bleeding in the upper GI tract.

    View all citing articles on Scopus

    DISCLOSURE: All authors are full-time employees of Kushiro Rosai Hospital.

    View full text