Feasibility of Underwater Clip Closure for Large Mucosal Defects after Colorectal Endoscopic Submucosal Dissection

Abstract

Background/Aims: Clip closure of mucosal defects after colorectal endoscopic submucosal dissection (C-ESD) may decrease the incidence of delayed adverse events. The size of the defect to be closed by conventional clip is limited, however, and we sometimes encounter incomplete closure when the defect is located at the flexure. As, theoretically, underwater clip closure (UCC) could achieve complete closure despite these difficult cases, we investigated its feasibility. Methods: We retrospectively analyzed 21 patients who underwent UCC after C-ESD. The main outcome was the UCC success rate, defined as complete closure of the defect. Other outcomes were procedure time, number of clips, and the delayed adverse event rate. Results: The median resected specimen size was 31 mm (range 18–47 mm). The UCC success rate was 100%. The median procedure time was only 11 min (range 6–21 min). The median number of clips was 9 (range 5–16). No delayed adverse event occurred. Conclusion: It is feasible to use UCC to close large mucosal defects, although further studies are warranted to assess its efficacy.

Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade

“…88 These techniques are simple, shorten the procedure time, and are cost-effective. However, they seem unfavorable for lesions affecting more than half the circumference 82,87 and lesions in a thick-walled rectum. 82,89 One study revealed a moderate complete closure rate (73% [8/11]) of surgical stitch-based EHS.…”

“…9,15,16,78,[82][83][84][85][86][87][88][89][90] The mean defect size, complete closure rate, and procedure time ranged from 31.2 to 40.9 mm, 73% to 100%, and 9.6 to 18.7 min, respectively. Clip-based techniques include mucosal incision, 82 hold-anddrag closure, 83 mucosa-submucosa clips, 86 underwater clip closure, 87 and clip-on-clip closure. 88 These techniques are simple, shorten the procedure time, and are cost-effective.…”

“…Figures 1 and 2 illustrate representative clip-based techniques (hold-and-drag using repositionable clip [QuickClip Pro, HX-202UR; Olympus], 83 EPSS using detachable endoloop, 85 line-assisted complete closure, 78 mucosa-submucosa clip, 17,86 underwater clip closure, 87 and E-LOC 13 ), mechanical clipping (OTSC with clips 14,38,46 ), and surgical stitch-based techniques (OverStitch 15 and EHS 10,90 ).…”

“…Thirteen articles described colorectal closure techniques (Table 6). 9,15,16,78,[82][83][84][85][86][87][88][89][90] The mean defect size, complete closure rate, and procedure time ranged from 31.2 to 40.9 mm, 73% to 100%, and 9.6 to 18.7 min, respectively. Clip-based techniques include mucosal incision, 82 hold-anddrag closure, 83 mucosa-submucosa clips, 86 underwater clip closure, 87 and clip-on-clip closure.…”

Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta‐analysis

“…To reduce the risk of AEs, several studies have suggested prophylactic endoscopic closure of the mucosal defect after colorectal ESD 17–20 . Furthermore, in order to complete closure of large mucosal defects, a number of advanced devices and techniques have been developed 21–30 . Some other studies have indicated that endoscopic closure does not decrease the rate of AEs and may require additional operative time and an increased cost 31–34 .…”