The clip-and-snare method with a pre-looping technique during gastric endoscopic submucosal dissection.

The effectiveness of the clip-and-snare method, which is a traction method used during gastric endoscopic submucosal dissection (ESD), has been reported previously [1,2]. In previous reports, an additional forceps was required to deliver the snare to an anchored clip. However, this delivery technique is difficult and risks gastric tissue injury, especially when lesions are located in the upper body. In this report, we describe a newly developed pre-looping technique as an easy and safe delivery method. A 72-year-old man underwent ESD of an upper gastric lesion. A single-channel endoscope (GIF-Q260J; Olympus Medical Systems Corporation, Tokyo, Japan) with a disposable transparentcap (D-201-11804; Olympus) on the endoscope tip was used. A mixture of saline solution, 0.4% sodium hyaluronate, and indigo carmine was injected into the submucosal layer surrounding the lesion, and a circumferential incision was made with an insulation-tipped scalpel (ITKnife2, Olympus). The endoscope was then withdrawn, and the snare was looped around the transparent cap (SD-221U-25; Olympus) from outside the endoscope (●" Fig.1). The endoscope and snare were reinserted into the lesion. Then, with a reusable clip deployment device (EZ Clip; Olympus), a hemoclip (HX-610-090; Olympus) was inserted through the endoscope channel and used to grasp the aboral side of the lesion (●" Fig.2). The pre-looped snare was then loosened from the transparent cap, with care taken not to release the hemoclip completely from its deployment device. The snare was then moved along the device toward the hemoclip (●" Fig.3). The hemoclip was grasped with the snare and released from the deployment device. Then, the appropriate tensionwas applied to the lesionwith the snare, independently of the endoscope, and the submucosal layer was successfully incised (●" Fig.4). The 7-mm adenocarcinoma was resected en bloc in 23 minutes without complications. The pre-looping technique enabled the easy and safe use of the clip-and-snare method in the treatment of an upper gastric lesion (●" Video 1).