Post written by Zhendong Jin, MD, from the Department of Gastroenterology, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China.

A patient accepted ESD for a SMT originated from the muscularis propria layer, which was located at the anterior wall of the gastric body. In consideration of muscular injury, the large defect was closed completely. To facilitate the closure, a special metal clip was made. First, a surgical suture was tied up to one tooth of the first metal clip. Then a syringe cap was used to develop a small loop. The diameter of the loop should be no more than the width of an open metal clip. Next the first clip was fixed on the mouth side of the defect. Then one tooth of the second clip was inserted into the loop of the first clip and moved close to the anal side of the defect. The defect decreased significantly when the second clip was fixed on the anal side. And the residual incision was easily and completely closed with another 6 clips.

Successful closure of large mucosal defects is vital after endoscopic submucosal resection. However, it is difficult to close large defects just with metal clips for a single-channel endoscope. Some new traction methods have been reported to help close large defects with a single-channel endoscope, but they need special devices and some extra help. It is still a worth-studying issue how to close large defects effectively and easily with a single-channel endoscope. It will be more simpler to close large defects if specialized variable-size metal clips with loops are produced.

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