Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video)

Abstract Background and Aims Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported but none have been established for clinical use because of technical complexity and requirement for expensive equipment. Therefore, the technical feasibility of a new ligation using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed. Methods Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. Results The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 (interquartile range [IQR], 2.8–3.8) cm, and the complete ligation rate was 88.5% (23/26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21/22). The median duration of ligation procedure was 20 (IQR, 16–24) minutes. The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (p = 0.0269). Conclusions Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.