Scope Clip Research Articles

Over the Scope Clip (OTSC)

Over the Scope Clip (OTSC)

Over the Scope Clip (OTSC)

Over the Scope Clip (OTSC)

Transtracheal cyanoacrylate glue injection for the management of malignant tracheoesophageal fistula

Background:Malignant tracheoesophageal fistula (TEF) is a devastating complication of esophageal cancer, lung cancer, or other carcinoma associated with high mortality, short survival, and poor quality of life. Covered metallic stents placement either in trachea/esophagus or both are used for the palliative treatment. Other endoscopic modalities rarely attempted for benign and malignant TEF include use of over the scope clip, transesophageal glue injection, electrocautery, and laser.Case Description:A 56-year-old man presented with complaint of intractable cough on swallowing for last 3 months. He had completed a course of chemo-radiotherapy for carcinoma of middle one-third of the esophagus 4 months back. The upper gastrointestinal endoscopy showed a stricture with superficial ulceration at 23 cm from lower incisor in the esophagus. A small (~4 mm diameter) fistula was noted just above the stricture. Application of over-the-scope clip was failed. A hydrophilic guide wire (0.032″ diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guidewire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guidewire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, transtracheal and transesophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula was used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue. 1 mL of cyanoacrylate glue was injected while pulling the cannula out. 1 mL of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. The patient has remained asymptomatic till now.Conclusion:Transtracheal glue placement may be safer than transesophageal glue placement. This appears to be the first report of transtracheal glue injection of malignant TEF.

Cautery Is Key: A Case of Recalcitrant Gastrocutaneous Fistula (GCF) Closed by Electrocautery

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes provide durable enteral nutrition in patients unable to maintain adequate per oral intake.Conservative closure methods may prove unsuccessful and surgical closure is not without risk. Several endoscopic closure methods have been described with varying success. We describe a case of persistent GCF closed via unique methods. Case: A 53-year old female with spinal cord injury underwent PEG placement for dysphagia. Several years later, her dysphagia resolved and the PEG was removed with manual traction. She experienced daily, large volume leakage through the GCF 6 weeks after tube removal. Examination was notable for granulation tissue around the fistula. Given the failure of GCF closure with conservative measures (i.e. PPI & topical silver nitrate), an EGD was performed. The EGD revealed an 8mm diameter, 15mm deep fistula in the gastric body. Due to evident growth of gastric mucosa in the GCF, ablation of the entire tract lining was performed using the Wilson Cook 7 Fr Quicksilver probe (Effect 2, 20 Watts); subsequently 4 ECs were applied. Externally, the opening was cauterized with silver nitrate and filled with fibrin glue. The patient was NPO for 24 hours and placed on BID PPI. Two days post-procedure she continued to have drainage from the fistula site but by day 3 the drainage ceased and follow-up over the next 6 weeks confirmed successful closure of the tract. Discussion: Several endoscopic techniques have been described to treat persistent GCF. These modalities have their limitations when used alone: ECs maintain superficial grasp of the mucosa only and fibrin glue has minimal efficacy. BPC (bipolar cautrey) causes acute injury to the mucosa resulting in release of cytokines and interleukins, promoting inflammation and transforming a chronically epithelialized site into one of acute inflammation. This promotes healing via the standard pathways involved in repair of acute injuries. In our case, the delay of GCF closure by 2 days post-procedure suggests against the effectiveness of glue and clips in this patient, and rather, supports our hypothesis; BPC catalyzed an acute inflammatory state at the GCF site along with de-epithelization of the GCF tract, promoting closure. For small fistulas, cautery alone may be sufficient for healing and more cost effective than over the scope clips or endoscopic stitching techniques, although further studies will be needed to substantiate these outcomes.

Endoscopic Repair of a Recto-Vesicular Fistula

Colo-vesicular fistulae are infrequent complications of malignancy, inflammatory processes, and postoperative complications. As spontaneous closure rates are less than 2%, some form of therapy is typically required. With new advances in endoscopy, less invasive treatment options are now available for fistula closure, decreasing morbidity, and peri-operative mortality. Here we describe a unique case of endoscopic repair of a recto-vesicular fistula. 65 year-old-male with a history of hypertension, hyperlipidemia and prostate cancer status post laparoscopic radical prostatectomy, presented with fevers, and passing urine per rectum 10 days post-prostatectomy. A CT cystogram revealed a posterior bladder perforation, retro-vesicular abscess and a fistula to the rectum. The patient was initially treated conservatively with antibiotics and Foley catheter placement for 7 weeks. Although the abscess had resolved, repeat imaging continued to show a recto-vesicular fistula arising from the anterior wall of the distal rectum. Surgical approaches for repair of the fistula were discussed with the patient. Options presented included the perineal approach, which would require either gracilis interposition along with fecal diversion, or robotic-assisted abdominal repair, with omental interposition and fecal diversion. As both options would require the creation of an ostomy, the patient opted to explore less invasive options. The decision was to proceed with possible endoscopic closure. The patient underwent sigmoidoscopy 6 months postoperatively. Endoscopically, the fistula, measuring approximately 5mm in size was found along the anterior wall of the rectum, approximately 5 cm from the dentate line. The fistulous tract was denuded with a cytology brush and argon plasma coagulation. A 10 mm 12/6 over the scope clip was then applied using an anchor and cap suction technique over the rectal fistula with successful closure. Nonsurgical closure of GI defects may be desired in various situations, such as dehiscence of surgical anastomoses, perforations, or in the case above, repair of inflammatory or neoplastic fistulae. Emerging technology, such as the over-the-scope clip has been developed not only for repair of bleeding ulcers, but repair of small mural defects. In animal models, full-thickness closure of defects of as large as 27 mm have been achieved. The procedure described above represents a minimally invasive option for closure of colo-vesicular fistulae.

Mo2002 Over the Scope Clips (OTSC) Are Highly Successful in Managing High-Risk Gastrointestinal Bleeding Lesions

Mo2002 Over the Scope Clips (OTSC) Are Highly Successful in Managing High-Risk Gastrointestinal Bleeding Lesions

1050 Misplaced “Bear Claw” in a Bleeding Gastric Ulcer: What Next?

The over the scope clip (OTSC) with its large claw captures a large amount of tissue and clamp deeply below the vessel. In acute bleeding, proper deployment technique and accurate clip placement is crucial. However, when misplaced, removal of OTSC can be extremely difficult. In this case, we describe the endoscopic technique to manage a misplaced OTSC and treat a large bleeding gastric ulcer.

896 The Clinical Utility of Over the Scope Clip in the Treatment of Gastrointestinal Defects

896 The Clinical Utility of Over the Scope Clip in the Treatment of Gastrointestinal Defects

Advances on endoscopic treatment of intestinal fistulas

Intestinal fistulas are severe complications after abdominal surgical procedures. The endoscopic therapy makes it possible to close fistulas without surgical interventions. When patients achieved stabilization and had no signs of systemic sepsis or inflammation, these therapies could be conducted, which included endoscopic vacuum therapy, fibrin glue sealing, stents, fistula plug, suture, and Over The Scope Clip (OTSC). Various techniques may be combined. Endoscopy vacuum therapy could be applied to control systemic inflammation and prevent continuing septic contamination by active drainage. Endoscopic stent is placed over fistulas and gastrointestinal continuity is recovered. The glue sealing is applied for enterocutaneous fistulas, and endoscopy suture has the best results seen in fistulas <1 cm in diameter. Insertion of the fistula plug is used to facilitate fistula healing. The OTSC is effective to treat leaks with large defects. Endoscopic treatment could avoid reoperation and could be regarded as the first-line treatment for specific patients.

Endoscopic full thickness resection for gastric tumors originating from muscularis propria.

To do systematic review of current literature for endoscopic full thickness resection (EFTR) technique for gastric tumors originating from muscularis propria. An extensive English literature search was done till December 2015; using PubMed and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied. A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip (OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions (< 3 cm). EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.

S状結腸憩室穿孔・腹腔内膿瘍に対して内視鏡治療を施行した1例

S状結腸憩室穿孔・腹腔内膿瘍に対して内視鏡治療を施行した1例

Endoscopic closure with an over-the-scope clip of a duodenocolonic fistula caused by a migrated biliary stent

A 71-year-old man with diabetes, dementia, and gout presented with orange urine, nausea, and vomiting. The examination disclosed scleral icterus and jaundice. His laboratory determinations were suggestive of cholangitis: white blood count 21,500/μL, total bilirubin 21.5 mg/dL. CT of the abdomen showed the common bile duct (CBD) to be dilated up to 1.6 cm and migration of the biliary stent with the proximal end in the distal CBD, traversing through the duodenum and the distal end lying within the cecum (A). The duration of, or indication for, previous biliary stenting was not available. Endoscopy showed a straight plastic stent protruding from a bulging ampulla and penetrating the duodenal wall (B). The stent was removed with an alligator forceps, followed by ERCP with drainage of biliary sludge and pus and placement of a biliary stent. Contrast medium was injected with a sphincterotome through the duodenal opening of the fistula, which showed the fistula tract and filling of the cecum and subsequently the ascending colon without any peritoneal extravasation of contrast medium (C). The over-the scope clip (OTSC) anchor was used to retract the duodenal fistula opening, and a 12/6 gastrocutaneous OTSC was deployed for closure (D). An upper GI series was obtained the next day and showed that the OTSC was in a good position without any leak of contrast medium. The patient’s diet was advanced, and he was discharged home.

Endoscopic Management of a Gastrocolonic Fistula: A Rare Esophageal Stent Adverse Event

FigureIntroduction: A 55 year old man presented for second opinion for management of his esophageal cancer. His initial presentation was a year earlier with severe dysphagia and he was found to have esophageal adenocarcinoma with liver metastasis. He was treated with chemotherapy and underwent esophageal stent placement. He was admitted a month later with sepsis and stent migration. His stent was removed and he was eventually discharged home but started having diarrhea and became severely malnourished. He was treated with total parentral nutritional and underwent a surgical J-tube placement. He however continued to have severe diarrhea with no clear etiology so hospice was recommended. He presented to our center for a second opinion. An EGD was performed showing a gastrocolonic fistula. Given his advanced cancers and severe malnutrition, he was not a surgical candidate and was dependent on total parentral nutrition (TPN). He was offered endsoocpic repair. Methods: Repair was performed with Argon plasma coagulation ablation of the mucosa in the fistula track and multilayer closure. Closure consisted of endoscopic suturing consisting of a layer of running sutures and a second layer of interrupted suture to decrease the tension from the first layer. The colonic side was then closed with an over the scope clip placed from the colonic end. A repeat endoscopy in one week showed a small residual fistula which was again sutured and reinforced with an over the scope clip. Results: The fistula resolved. The patient gained 20 Kg in 3 months and TPN was discontinued. His diarrhea resolved. His repeat imaging and upper endoscopy 4 months later were consistent with continued closure of the fistula. He was able to resume systemic therapy for his stage 4 cancer. He initially responded to treatment. 7 months later his disease progressed including an increase in the esophageal mass and gastric wall infiltration with tumor. He became debilitated and his fistula recurred. Plans were made to attempt repair again however the patient developed urosepsis and became more debilitated and was referred to hospice. Conclusion: Gastrocolonic fistula is a rare adverse event of esophageal stenting. Endoscopic repair allowed healing of the fistula with subsequent 20 Kg weight gain, discontinuation of intravenous nutrition support and resumption of systemic chemotherapy. This minimally invasive procedure improved the patient nutritional status and quality of life until he succumbed to his disease.

Endoscopic Repair of Gastrogastric Fistulas After Roux-en-Y Gastric Bypass

Introduction: Gastrogastric fistulas are a rare complication of Roux en Y gastric bypass. Several options exist for repair. Our goal was to present our experience with the use of an over the scope clip system for endoscopic intervention. This is a retrospective review from a university hospital where three patients have undergone endoscopic repair of gastrogastric (GG) fistulas using an over the scope clip (OTSC) system developed by OVESCOTM. Case Presentations: Patient 1, a 58 yo female, presented with increased food intake. She was found to have a GG fistula 2 months post Roux en Y bypass (RNY). Her postoperative course was complicated by a left subphrenic abscess and left empyema which necessitated a VATS procedure. Two fistulas were found at EGD, one of which measured 14 mm and the other 5 mm in diameter. Two hemoclips and one OTSC (12/6 GC) were applied to the larger defect and one hemoclip was applied to the smaller defect. Repeat upper GI series one month post EGD showed failure of fistula closure. Patient 2, a 69 yo female, presented with epigastric abdominal pain and was found to have a 4 mm GG fistula 34 months post RNY. She had lost ˜118lbs since bypass. On initial repair attempt the fistulous tract appeared to have closed after APC and hemoclip placement x 2, however the fistula was again noted on repeat upper GI series 4 months later. A follow up EGD was performed with successful OTSC deployment (12/6 GC). Patient 3, a 44 yo female, presented with epigastric abdominal pain, nausea, emesis, and weight gain and was found to have a 5 mm GG fistula 66 months post RNY. She had lost ˜ 435 lbs since bypass. Successful OTSC deployment was performed (12/6 GC). The patient experienced symptom relief on follow up. Discussion: The success of gastrogastric fistula repair using an OTSC system appeared to be influenced by several factors including size, acuity, and post operative complications. Smaller fistulas were closed with greater success. The time interval between bypass and fistula development seems to have influenced success as well with fistula closure achieved in patients with a mean development interval of 50 months. Small superficial mucosal tears, with no evidence of bleeding or perforation, were noted in the proximal esophagus in both successful cases. The use of an OTSC system represents a safe, minimally invasive strategy for endoscopic closure of gastrogastric fistulas ≤5 mm.Figure 1Figure 2Figure 3

Fistulizing/Perforating IPMN: Closure Using OVESCO over the Scope Clip

Introduction: Intraductal papillary mucinous neoplasm (IPMN) is a malignant cystic neoplasm of the pancreas involving the main pancreatic duct, the branch ducts or both. We describe a rare presentation of fistulizing/perforating IPMN and treatment course Methods: A 71-year-old obese Caucasian male presented with right upper quadrant (RUQ) abdominal pain and fever. A RUQ ultrasound showed 4 mm CBD and normal gallbladder. Labs showed mild leukocytosis, anemia, total bilirubin 1.4 mg/dL, normal liver function tests and lipase 22 U/L. CT scan of abdomen and pelvis showed ill-defined low-density linear collection extending from the posterior aspect of the duodenal bulb towards pancreas with specks of air suspicious for perforated duodenal ulcer and atrophic pancreas. Pancreatic duct however was massively dilated to 8 mm. These findings were confirmed by an MRI. Results: Upper endoscopy showed fistula/perforation in the duodenal bulb with mucin extruding. A side-viewing duodenoscope showed a patulous papilla with mucin extruding confirming main-duct IPMN. With radiological and endoscopic concern for duodenal perforation and resulting complication of pseudomyxoma peritonei, the site was closed using over the scope clip (OVESCO-OTSC) successfully (image 5). CEA was 3.9 ng/ml and CA 19-9 was 2418 U/mL. Patient declined surgical intervention and was discharged home. Conclusion: IPMN first described in 1982 is a malignant cystic neoplasm of pancreas involving the main pancreatic duct, the branch ducts or both. Histologically, IPMNs are classified as intestinal type, pancreatobiliary type, oncocytic type and gastric type. Risk of invasive carcinoma is 70% with main duct involvement v/s 2-20% with branch duct. Surgery is the definitive treatment. ERCP showing patulous papilla with mucin extruding is pathognomonic for IPMN. IPMN are often asymptomatic and an incidental radiological finding. Invasion of the tumor into nearby structures with fistula formation have been infrequently reported. The rates of internal fistulization are felt to be highest into the duodenum (50%), followed by bile duct (35%) and stomach (15%). Pathogenesis of fistulization/perforation is either due to mass effect or mechanical pressure created by either direct expansion or stromal invasion of tumour. Patients can also present with pancreatitis due mucin plugs in the pancreatic ducts. This case highlights the rare presentation of fistulizing/perforating IPMN and our treatment experience.Figure 1

Eosphago-Gastro-Duodenal Stenting for Gastric Leaks Could Be More Effective Than Esophagogastric Stenting After Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is commonly used procedure for the surgical management of morbid obesity. It is safe and effective procedure but limited by a rate of gastric leak almost 5.3%. We present a case of gastric leak with fistula successfully managed by fully covered esophageal metallic stents placed in telescoping fashion between the distal esophagus and duodenal bulb bypassing the entire stomach.Figure 1Figure 261 year old female with history of morbid obesity underwent sleeve gastrectomy at outside facility. During the procedure a tear was identified which was stapled and no leak was identified after evaluation upper GI study (UGI) post operatively. On postoperative day 2, patient presented to ER with fever and abdominal pain. She underwent CT abdomen which revealed complex fluid collection anterior to stomach with a communicating fluid collection concerning for a gastric leak (GL) with possible 2 gastric fistula (GF). Patient was admitted to MICU because of sepsis and started on antibiotics. GI team was consulted for endoscopic management of GL with fistula. Patient underwent EGD, which showed 2 fistula orifices draining copious amount of debris. The 1st larger one was located at 40cm from incisor and the 2nd was at 38 cm, 0.5 cm below Z line. The larger fistula was closed by over the scope clip. A self-expandable fully covered esophageal metallic stent (FCEMS) 23 X 155 was placed across the fistulas to seal them off. No drainage was noted after the stent placement. UGI 48 hours later revealed a high-grade stricture at the distal end of stent and contrast seeping around the stent with leakage through the proximal GF. Patient underwent repeat EGD under fluoroscopy; stent was partially migrated into the stomach and touching mucosa causing stent obstruction. Therefore, stent was repositioned and another FCEMS was placed in a telescoping fashion bypassing the entire gastric sleeve and distal end of the stent was beyond the pylorus but within the duodenal bulb. Patient was kept NPO and had repeat UGI in 4 weeks time, which revealed contrast passing through the stents with out any leak. Patient underwent EGD, which showed stents are in place in a telescoping fashion bypassing the gastric sleeve. The stents were successfully removed. Repeat UGI after stent removal was negative for gastric leak. Patient was started on oral diet and tolerated it well. Bypassing the entire stomach by endoscopically placing esophago-gastric-duodenal stent is likely to have better success rate of gastric fistula closure then esophago-gastric stents.

Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery

Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients. The current literature was reviewed and the results are reported within the context of own experience. The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing. The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.

Gastrotomy Healing After Transgastric Peritoneoscopy: A Randomized Study in a Pig Model.

Reliable closure and infection prevention are the main barriers for implementation of pure transgastric peritoneoscopy. The primary aim of this study was to assess healing of over the scope clip (OTSC) closed gastrotomies. Pure transgastric peritoneoscopy was performed in 7 pigs. The pigs were randomized to 14 or 28 postoperative days (POD) of follow-up. Decontamination of the access route was performed before instrumentation. A full necropsy was performed. Closure was evaluated with histopathological examination of excised gastrorrhaphies. Three pigs were allowed 14 POD of follow-up, and 4 pigs were allowed 28 POD of follow-up. Survival was achieved in 6 of the 7 animals; 1 pig was euthanized due to diffuse peritonitis. Based on our definition, full-thickness healing had only been achieved in a single pig allowed 28 POD. With respect to clinical relevancy, full-thickness healing was deemed achieved in 4 of 6 pigs completing follow-up and in all pigs allowed and surviving 28 POD. Access required repeated punctures and the use of several endoscopic instruments. Full-thickness healing of the gastrotomy was only found in a single case when adhering to the per protocol definition. Endoscopic ultrasonography-guided access was difficult. It lacks reproducibility and needs refinement. Despite a combined decontamination regimen, infectious complications still occurred.

Sleeve Gastrectomy Leaks: The Way we Treat it

endoscopic clips and endoscopic suturing are new techniques not part of the algorithm that are becoming more widely used with positive results [10-13]. When other conservative methods have failed, RYGB or Roux-en-Y fistula jejunostomy have also been proposed as alternative treatments for non-healing gastric leaks [9,14-17]. With the increasing experience of surgeons performing LVSG and treating complications, Nedelcu has recently proposed an algorithm for treatment based on size of the leak and stenosis of the sleeve [18]. The aim of this study was to review our experience and outcomes of LVSG treatment and design an algorithm of successful treatment. Approval for this study was granted by the Banner Health institutional review board. Patients were identified from the authors’ prospectively maintained bariatric database. All patients between 2012 and 2014 were reviewed, and 11 patients were identified and treated at our institution. Data collected included patient demographics, operative, endoscopic and medical interventions, and follow-up outcomes. Patient demographics included age, sex, body mass index (BMI), co-morbidities, number of days from initial surgery until recognition of leak. Operative data included location of initial surgical intervention, need for repeat interventions and type, placement of feeding jejunostomy tube. Endoscopic interventions included use of OVESCO ® over the scope clip, Boston Scientific fully covered WallFlex™ esophageal stent, Apollo Over Stitch™. Post-operative data included need for multiple interventions, nutritional support, and number of days until resolution of leak. During the study period from 2012-2014, 556 patients underwent LVSG for the treatment of morbid obesity. We identified a total of 8 LVSG leaks (1.4%). Three patients did not have initial surgery at our institution and were transferred from an outside hospital for further treatment.

Su1516 Treatment Failure and Delayed Complication Due to Shedding of the Over-the Scope Clip: Experience in Three Cases

The over the scope clip (OTSC) was designed to close acute perforations, fistulas, and to provide hemostasis. Small case series suggest a high rate of treatment success but it has not previously been emphasized that delayed shedding of the clip can lead to secondary treatment failure and perforation. Our experience: Case #1 was a 73-year-old man with hematochezia. Colonoscopy showed a bleeding diverticulum in the sigmoid colon that did not respond to use of standard clips, injection with epinephrine and banding.