“Loop-10” line-assisted clip closure method: closure of perforation in re-do peroral endoscopic myotomy

Post written by Marc Julius Navarro, MD, from the Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan, and the Institute of Digestive and Liver Diseases, St. Luke’s Medical Center, Quezon City, Philippines.


In this video, we highlight how the “Loop-10” line-assisted clip closure method presented to be a feasible and effective method in achieving complete and sustained closure of unintentional mucosal perforation during re-do esophageal peroral endoscopic myotomy.

We also show how we performed the method through preparation of the materials needed, construction of the first endoscopic clip with Loop-10, proper closure technique, and removal of the support thread.

Complete closure of a mucosal defect is essential, especially when a full-layer resection is intentionally performed or when we encounter unintentional tissue perforation.

However, a standard method for closing a large mucosal defect has yet to be established. Based on our clinical experience, it is technically demanding to use endoscopic clips solely to close a large tissue defect. The line-assisted clip closure technique has been reported to be able to overcome technical difficulties. In principle, by pulling a thread anchored to the first clip, the succeeding clips can be efficiently and effectively applied to approximate mucosal edges with adequate tissue traction.

Yet, the remaining issue seen in the line-assisted clip closure method is the detachment of the line upon completion of the defect closure. Some authors reported the use of these accessories in order to detach to the line: endoscope surgical scissors, loop cutter, and argon plasma coagulation probe. These accessories are not widely and readily available in some centers and will add to procedure expense.

To solve the remaining issue regarding detachment of the thread in line-assisted closure, we developed the Loop-10 closure technique.

In summary, this new Loop-10 closure technique follows the principle of the line-assisted clip closure method. It provides adequate traction and lift for a more accessible mucosal approximation. This technique can be applied to close large mucosal defects.

It also solves the remaining issue encountered in the line-assisted clip closure method regarding detachment of the thread after complete closure of the defect. Lastly, this technique is easily reproducible using materials that are widely and readily available.


Unintentional mucosal perforation at the level of gastroesophageal junction: submucosal tunnel view and luminal view.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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