Novel clip closure technique for a large mucosal defect with anchor-pronged clips after duodenal endoscopic submucosal dissection

Abstract

Duodenal endoscopic submucosal dissection (DESD) has a high incidence of delayed adverse events (AEs).¹ However, complete mucosal closure (CMC) can reduce the risk of AEs after DESD.² Conventional clip closure is a common technique,¹ but it poses challenges when used for CMC of large defects after DESD. This case shows a simple closure technique using anchor-pronged clips (MANTIS clip; Boston Scientific, Waltham, MA, USA) for CMC after DESD.

A 63-year-old man underwent DESD for a 40 mm flat elevated lesion in the descending duodenum (Fig. 1a). During the DESD, an intraprocedural perforation occurred, which was closed using a conventional clip (SureClip; Micro-tech, Nanjing, China). Then en bloc resection was performed on a 47 × 41 mm specimen (Fig. 1b). After resection, mucosal closure was initiated with the anchor-pronged clips for the approximately half circumferential defect (Fig. 2a,b). We grasped the oral edge of the defect using the anchor-pronged clip, allowing us to bring and grasp the opposite side (Video S1). The anchor-pronged clip closed the center of the defect (Fig. 2c), and CMC was achieved in 11 min using seven additional conventional clips (Fig. 2d). The patient was discharged 6 days later without AEs. Pathological examination revealed the lesion was an intramucosal well-differentiated adenocarcinoma with negative resection margins.

Although there are various techniques for CMC after DESD,¹ some of these methods require technical skills. Anchor-pronged clip closure is a simple technique that enables the closure of larger defects and overcomes the challenges of conventional clips during the closure procedure, such as tissue slippage when grasping the opposite side.^{3, 4} Furthermore, by applying the previously reported technique of anchor-pronged clip to grasp and suture the muscle layer, it may be possible to reduce suture-induced dead space even in the duodenum.⁵ Therefore, mucosal closure using anchor-pronged clips is a viable option for CMC of large defects after DESD.

Authors declare no conflict of interest for this article.