Multi-degree-of-freedom articulating forceps for closure of a large mucosal defect after endoscopic submucosal dissection in a porcine model. The multi-degree-of-freedom articulating forceps is a commercially available flexible device with bending articulation and rotating function. Adding forward and backward action, it is 3DUF. This articulating forceps is mainly used to provide active traction through a double-channel therapeutic endoscope during ESD by grasping and pulling up a mucosal flap toward luminal side. The grasping site can be actively changed as needed. We developed a novel closure technique for post-ESD mucosal defects using this articulating forceps. Grasping an edge of the mucosal defect with the articulating forceps and pulling it up toward the luminal cavity allows for linearization of the defect and submucosal layer-to-layer apposition, which enables easy and tight defect closure. This video demonstrates ESD of the 50 mm tentative lesion and closure of the mucosal defect using the multi-DUF articulating forceps. After submucosal injection and circumferential mucosal incision, the mucosal flap was grasped with the articulating forceps and pulled up to the luminal cavity by bending the articulation. Strong traction force was applied to the front side submucosal tissues. The traction force was applied precisely to the submucosal tissue being dissected by changing the grasping site. By adjusting the bend angle and protrusion length of the forceps and adding rotation as needed, the dissection plane could be maneuvered to the best position for incision. Very efficient submucosal dissection was possible under the traction produced by the articulating forceps. After completion of ESD, closure of a 55 mm post-ESD defect was performed using the same multi-DUF articulating forceps used for ESD. Similar to traction-assisted ESD using the articulating forceps, the edge of the mucosal defect was grasped by the forceps and tinted by bending it at the articulation. Tinting the mucosal defect allows to create a beak-shaped edge. This facilitates clip closure by making the width of the mucosal defect less than the opening width of the clip while preventing mucosal intrusion into the defect being closed. For the second clipping, the first clip was grasped and pulled up to the luminal cavity to create a beak-like shape. In the middle portion, which has the highest risk of separation, the defect was linearized with submucosal layer-to-layer apposition by pulling up one side of the defect edge with the articulating forceps. Traction is applied to the mucosa while bringing both sides of the defect closer together. This helps to achieve submucosal layer-to-layer apposition and prevents pocket formation within the defect. More secure closure was achieved by maneuvering the linearized defect with the articulating forceps into the grip of the opening clip using the full degree of freedom. When placing the very front clip, the defect edge was pulled proximally by bending the forceps downward to linearize the remaining defect. A total of 7 clips were used to achieve complete closure. The total procedure time including ESD and closure was 43.6 minutes. This still image shows the closed defect obtained by cutting open the colon after procedures. Submucosal layer-to-layer apposition was confirmed from the mucosal edge facing the luminal cavity throughout the defect. Even when we tried to pull the closure apart by hand, the closed defect did not open easily. The multi-degree of freedom articulating forceps seamlessly supported ESD and tight layer-to-layer closure with endoclips without changing the scope and instrument. Submucosal layer-to-layer apposition using the articulating forceps allowed for secure and tight closure of large mucosal defects after ESD.

articulating forceps

endoscopic submucosal dissection

porcine model

closure technique

layer-to-layer apposition