A Novel Endoscopic Technique to Close Large Post EMR Defects Using a Double Ring and Clips

Abstract

Background and Aims: Even though EMR is proven to be a safe procedure when used to remove nonpolypoid colorectal lesions, the risks of hemorrhage and perforation increase with lesions larger than 20 mm. To prevent such complications, we have previously reported a technique to close large mucosal defect produced after an EMR using the endoloop snare and metallic clip suture method. This procedure, however, requires the use of a two-channel colonoscope, which is not always available in every endoscopy unit. We have recently developed a novel and simple technique for complete closure of large mucosal defects using a stainless double-ring device that can be used to close a large defect using a conventional one-channel colonoscope. Methods: A conventional metallic clip (Boston Scientific Co., MA, USA) is placed through one hole of this double loop shape device to the periphery of the large post-resection mucosal defect. Another clip is inserted through the remaining hole of the device and clipped in the normal mucosa approximating the margins of the defect and thus obtaining a complete closure. To prevent the closure from becoming loose, a third metallic clip is placed to reinforce the suture. Results: From August 2005 to November 2005, we performed post EMR defect closure of 6 large colorectal lesions in 6 patients (mean age: 61.8 ± 4.4 years) using the previously described technique. Lesions average size was 14.7 ± 2.2 mm (12-18 mm). Locations were ascending colon (3), descending (2) and sigmoid (1). Macroscopic type was large flat (5) and sessile (1). Histopathology of the resected specimens revealed intramucosal neoplasia (5) and submucosal invasive cancer (1). All post EMR defects were successfully closed and no complications were observed. Conclusions: With this technique, large colorectal lesions, which would be otherwise be removed surgically due to the high risk of complications, can be safely resected by EMR enabling the procedure to become a day surgery.