The 'clip-band closure' technique: a new endoscopic traction method for closure of a large ulcer.

We present the case of a 69-year-old man with a rectal granular-type laterally spreading tumor (LST) of about 50mm in diameter who underwent endoscopic submucosal dissection (ESD) using a Hybrid knife I-type (Erbe, Tübingen, Germany) at our institute (●" Fig.1). The following day, the patient developed rectal bleeding, and endoscopy revealed a large post-ESD ulcer with clots at the base (●" Fig.2a). After rinsing the clots, we decided to attempt closure of the ulcer using a new technique, which we called the ‘clip-band closure’ technique. First, a rubber band used for orthodontic treatment (5–6mm in diameter and 56.7–99.2g in strength; ORMCO Corp., Glendora, California, USA) was preloaded onto the open prongs of a Resolution clip (Boston Scientific, Natick, Massachusetts, USA). The clip with the loaded band was inserted through the working channel of the endoscope and attached to the proximal inner margin of the ulcer (●" Fig.2b). The band was then clamped again with a second clip, which was pushed towards the opposite mucosal edge distal to the ulcer where it was attached (●" Fig.2c). The same clip/band sequence was applied at two other points on the ulcer edge to further draw the ulcer margins together (●" Fig.2d). No more episodes of bleeding were recorded in the following days and 1 week later a follow-up endoscopy confirmed closure of the ulcer, with the clips and Fig.1 Endoscopic views of a rectal laterally spreading tumor (LST) in a 69-year-old man: a before endoscopic submucosal dissection (ESD); b,c during ESD.