Post written by Yohei Minato, MD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

We modified the clip with line pulley suturing (CLiPS) technique using a plastic detachable snare. A clip with a string is placed at the distal margin of the mucosal defect. A second clip is then hooked onto the string and placed at the proximal side of the margin. Both sides of the mucosal defect are gathered by pulling the string.

Subsequently, a plastic detachable snare is inserted over the string and deployed to form a knot. The approximation of the edges achieved by this technique allowed for subsequent completion of closure with the addition of through-the-scope (TTS) clips.

We present 2 cases (stomach and colon).

Case 1

An 85-year-old man underwent endoscopic submucosal dissection (ESD) for a 10-mm early gastric cancer in the lesser curvature of the middle body. The resultant defect was approximately 3 cm. Because of slight muscular layer injury and to prevent perforation and bleeding, the defect was closed. The CLiPS technique was used to first approximate the edges of the defect before application of additional TTS clips to complete the closure. Follow-up endoscopies on postoperative day 3 confirmed sustained closure.

Case 2

An 85-year-old woman underwent ESD for an 80-mm early colorectal cancer in the cecum. The post-ESD defect required 2 iterations of the CLiPS technique. After approximation of the edges of the mucosal defect, complete closure was attained with the use of additional TTS clips.

This video article showcases the feasibility of endoscopic closure without the need for extra accessories, specialized endoscopes (such as a double-channel scope), or scope exchange.

The fundamental essence of the CLiPS technique lies in its core principle: reducing defect size through a robust approximation of the edges. What sets our technique apart is its simplicity in execution.

Schematic diagram of clip with line pulley securing technique and a plastic detachable snare. A, Mucosal defect after endoscopic submucosal dissection. B, A clip with a string is placed at the distal margin of the mucosal defect. C, A string is coming out from the instrument channel of endoscope. D, A second clip is hooked onto the string. E, A second clip is placed at the proximal side of the margin of the mucosal defect. F, A plastic detachable snare is inserted along the string through an instrument channel. G, Tighten with a plastic detachable snare, and a plastic detachable snare is deployed to form a knot. H, The string and plastic detachable snare are cut with a loop cutter. I, Additional endoscopic clips are placed to achieve complete closure.

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