Process of wound healing of large mucosal defect areas that were sutured by using a loop clip–assisted closure technique after endoscopic submucosal dissection of a colorectal tumor

Abstract

Endoscopic submucosal dissection (ESD) is indicated for the treatment of large, superficial colorectal tumors. 1 Isomoto H. Nishiyama H. Yamaguchi N. et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2009; 41: 679-683 Crossref PubMed Scopus (151) Google Scholar , 2 Saito Y. Fukuzawa M. Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc. 2010; 24: 343-352 Crossref PubMed Scopus (427) Google Scholar , 3 Saito Y. Uraoka T. Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc. 2010; 72: 1217-1225 Abstract Full Text Full Text PDF PubMed Scopus (517) Google Scholar , 4 Niimi K. Fujishiro M. Kodashima S. et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2010; 42: 723-729 Crossref PubMed Scopus (133) Google Scholar However, as a result of ESD, large mucosal defect areas are made. Wound healing of artificial defect areas in the large intestine is thought to be influenced by exposure to stool, some types of enterobacteria, and peristaltic movement. 5 Watanabe S. Wang X.E. Hirose M. et al. Rebamipide prevented delay of wound repair induced by hydrogen peroxide and suppressed apoptosis of gastric epithelial cells in vitro. Dig Dis Sci. 1998; 43 (107-12S) Google Scholar , 6 Osada T. Watanabe S. Tanaka H. et al. Effect of mechanical strain on gastric cellular migration and proliferation during mucosal healing: role of Rho dependent and Rac dependent cytoskeletal reorganisation. Gut. 1999; 45: 508-515 Crossref PubMed Scopus (29) Google Scholar Serious adverse events such as bleeding and perforation are often associated with endoscopic resections, especially when the lesions removed are large. 7 Sano Y. Machida H. Fu K. et al. Endoscopic mucosal resection and submucosal dissection method for large colorectal tumors. Dig Endosc. 2004; 16: S88-S91 Crossref Scopus (20) Google Scholar , 8 Heldwein W. Dollhopf M. Rösch T. et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy. 2005; 37: 1116-1122 Crossref PubMed Scopus (287) Google Scholar Endoscopic clips have been used commonly for endoscopic closure of EMR defects to prevent or treat bleeding or perforation. 9 Parra-Blanco A. Kaminaga N. Kojima T. et al. Hemoclipping for post polypectomy and postbiopsy bleeding. Gastrointest Endosc. 2000; 51: 37-41 Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar , 10 Minami S. Gotoda T. Ono H. et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc. 2006; 63: 596-601 Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar They can be used when the diameter of the defect is smaller or larger than the width of the open clip. However, when the mucosal defect is larger than the diameter of the open clip, several clips are used. The first clip is attached at 1 of the edges of the defect, the second clip is attached adjacent to the first clip, the third clip is attached adjacent to the second clip, and so on until the defect is closed. However, this method is difficult, cumbersome, and not always feasible. We have designed a new closure device for large mucosal defects, named a loop clip, which makes it easy to close any mucosal defect completely when used with conventional endoscopic clips. 11 Sakamoto N. Beppu K. Matsumoto K. et al. “Loop clip”, a new closure device for large mucosal defects after EMR and ESD. Endoscopy. 2008; : E97-E98 Crossref PubMed Scopus (41) Google Scholar , 12 Mori H. Sakamoto N. Osada T. et al. The “Loop clip” is useful for closing large mucosal defects after colorectal endoscopic submucosal dissection: a preliminary clinical study. Dig Endosc. 2011; 23: 330-331 Crossref PubMed Scopus (6) Google Scholar Closure of the mucosal defect by using endoscopic clips is presumed to reduce the risk of adverse events such as bleeding and perforation. 13 Otake Y. Saito Y. Sakamoto T. et al. New closure technique for large mucosal defects after endoscopic submucosal dissection of colorectal tumors (with video). Gastrointest Endosc. 2012; 75: 663-667 Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar However, it is not clear how long these clips exert an effect on closure of mucosal defects and how the sutured defect areas heal. In this study, we analyzed the effect of closure clips on mucosal defects and the process of wound healing of sutured mucosal defects after colorectal ESD.