Post written by Tatsuma Nomura, MD, from the Department of Gastroenterology, Suzuka General Hospital, Suzuka, and Shinya Sugimoto, MD, from the Department of Gastroenterology, Ise Red Cross Hospital, Ise, Japan.

A retrospective study was conducted to analyze endoscopic submucosal dissection (ESD) procedures performed between January 2012 and March 2024. Patients were classified into 2 groups: a nonclosure group, where the post-ESD mucosal defect was left open, and a reopenable-clip over-the-line method (ROLM) group, where the defect was closed using ROLM. To reduce bias, propensity score matching was applied. Following matching, 168 lesions were analyzed in each group.

ROLM demonstrated outstanding clinical performance. It achieved a 100% complete closure rate in all lesions, with a mean mucosal defect size of 45.9 mm, requiring an average of 33.2 clips and 35.6 minutes to complete the closure. Importantly, ROLM significantly reduced the post-ESD bleeding rate to 1.8% (3 of 168 lesions) compared with 7.7% (13 of 168 lesions) in the nonclosure group (P = .02).

This bleeding reduction also was observed among high-risk patients, such as those with elevated Bleeding After ESD Trend From Japan scores, where the expected bleeding risk ranges from 11.4% to 29.7%.

ESD is a minimally invasive and widely adopted technique for treating early gastric cancer. However, one of its major adverse events—post-ESD bleeding—remains a significant concern, especially in patients with high bleeding risk because of factors such as antithrombotic therapy. Although mucosal defect closure following ESD has been proposed to reduce such risks, no optimal or standardized closure method has been established. In response to this clinical gap, a novel technique called ROLM was developed and assessed for its efficacy in preventing post-ESD bleeding.

The procedure offers several advantages: It does not require endoscope reinsertion or withdrawal, does not depend on specialized equipment beyond reopenable clips and nylon line, and thus is cost-effective and scalable. Moreover, it significantly reduced the rate of antithrombotic therapy discontinuation from 82.9% in the nonclosure group to just 9.8%, minimizing the risk of thromboembolic events during the perioperative period. In addition, routine second-look endoscopy became unnecessary in most cases, further reducing costs and patient burden.

In conclusion, ROLM provides a simple, efficient, and highly effective closure method for mucosal defects after gastric ESD. Its favorable bleeding outcomes, cost-efficiency, and ease of implementation make it a promising candidate to become the standard of care in advanced endoscopic practice, especially for managing large defects and high-risk patients.

Graphical abstract

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