Post written by Teppei Masunaga, MD, and Motohiko Kato, MD, PhD, from the Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Endoscopic defect closure techniques have been applied to reduce the incidence of adverse events after colorectal endoscopic submucosal dissection (ESD). This retrospective observational study aimed to evaluate the feasibility of a novel closure method, the Origami method.

As for the closure device, through-the-scope clips (TTSCs) are useful because they do not require dedicated devices, and they are easy to apply to any location, even the proximal colon. However, closure of large defects is challenging because clips are usually small and insufficient for closing mucosal defects.

In addition, closure of a large wound by simple clipping typically results in closing only the mucosal layer, creating a dead space under the mucosa, which could be unreliable. To achieve robust closure, closing all layers involving the muscle layer, such as through surgical suturing, is important.

The Origami method enables us to fold the muscle layer and get reliable closure using only TTSCs. This study was important because, to the best of our knowledge, it was the first report evaluating the feasibility of this novel closure method.

In the results of this study, the Origami method was attempted in 47 cases after colorectal ESD. Complete closure was surprisingly achieved in 94% cases, including the largest lesion of 85 mm and even lesions in the thick-walled rectum.

With the Origami method, the muscle layer is folded with reopenable clips, making a few peaks such as in origami. We speculate that folding muscle layer results in contacting serosa to serosa layers, as in surgical suturing, and makes robust closure.

This new closure method is feasible and recommended. The Origami method could achieve reliable closure of large defects in any location, including the proximal colon and thick-walled lower rectum, using only TTSCs.

Modified double-layered suturing, the Origami method. A, A 70-mm mucosal defect was observed after endoscopic submucosal dissection of the lesion on the upper part of the rectum. B, The oral side of the muscle layer of the mucosal defect was grasped using a reopenable clip along the long axis while suctioning air and releasing the tension of the muscle layer. C, The muscle layer was folded. D, The second reopenable clip grasped the anal side of the muscle layer, and another muscle was folded. E, These folded muscles were connected using a reopenable clip, and the mucosal defect was shrunk. F, The folded muscles and normal mucosa of the defect margin were connected using a reopenable clip along the long axis while paying attention not to bury the clips under the mucosa. G, Residual gaps in the defect were closed with clips, and complete closure was achieved. H, Second-look endoscopy after 2 postoperative days revealed that complete closure was retained.

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