Today, techniques for achieving complete clip closure on the ASGE SUTAB tip of the week. To get on the same page with terminology that I'll be using, we'll use some drawings to demonstrate the principles of burying clips or filling the jaws with tissue right up to the stem, clip orientation and defect manipulation and manipulation of previously placed clips and then use photos and videos to demonstrate these principles plus closure of defects, at least some defects that are substantially wider than the clip diameter. A few principles regarding effective clip placement and the closure of EMR defects. First of all, in my opinion, it's better to do what I call bury the clip, which means that after it's been applied, if this is the clip and this is the tissue, you can't see any space between the prongs or the jaws of the clip. So this is suboptimal. I think this clip is less likely to stay on compared to a clip where there's tissue coming all the way up into the jaws, all the way up to the stem of the clip. So if we're looking down the colon at the EMR defect, the best way to bury the clips is to orient them in the up-down direction in most cases, take the lower prong, place it adjacent to the EMR defect and deflect downward. This will tilt the EMR defect toward you to allow accurate placement and to fill the prongs or jaws with tissue. Another maneuver that's also helpful later in the process, we've got multiple clips on and we may be having trouble placing the last couple of clips. We can take the scope, go proximal to the clips, bend down and pull back. And that will force the clips down into a more horizontal position, expose the remaining part of the defect and allow us to make the last placements accurately. This is a secal EMR defect and the basic approach is we're zippering, which means that we're starting at one end and headed toward the other. Notice that we've got the first clip oriented in the up-down direction. We've placed the bottom prong adjacent to the distal edge of the defect and then forced the tissue down and that turned or flipped the defect at us. Here we're maneuvering around the first clip using that bottom prong and deflecting down with the scope to get the defect to come up at us. The last minute we can push out. That helps to bury the clip. We can also suction a little bit to get tissue to come up into the clip. Now as the edges of the defect come closer together, we're gathering up more normal tissue in the closure. We may be able to space the clips a little bit farther apart and still get a nice complete closure. This is a transverse colon lesion that is longer in the longitudinal axis than it is wide in the right-left axis. The natural tendency is to orient the clips sideways from right to left in the endoscopic field because you want to be perpendicular to the long axis, but my tendency is usually still to at least start the closure with the clips in the up-down direction. It's because the shape of the colon wall, especially after the injection, is such that the tissue will come up and fill the jaws or prongs of the clip better if you have the clips oriented in the up-down direction. Here's another defect, same approach. You can see the ileocecal valve on the left. We've got the clip in the up-down orientation. We place the bottom prong at the edge of the clip and now we're pushing the wall down and getting the defect to turn towards the clip using a little bit of forward pressure and some suction right at the end to get the tissue really buried up in the prongs. Again, we're zippering. We're starting at one edge and moving toward the other edge. Same process with the second clip. We have the edge on the downside. We're pushing down. You can see the defect roll up at us. This basic approach will also work when the defect is toward the endoscopic right. It's very hard to effectively clip with the defect on the left endoscopic view or the up view, but either with the defect on the down wall or to the right, you can clip effectively. In this case where we're working more toward the right, we have the clips oriented transversely now, but perpendicular to the long axis of the defect. We're placing the prong on the right side and now we're bending the scope tip to the right to turn the defect up into the clip. Now it's a little bit oriented at 45 degrees, so we've got the bottom prong placed and bending down and right in order to turn the defect up into the clip. Either in the six o'clock or the three o'clock position, you can clip effectively. Another trick we discussed is manipulating clips we've already placed to place additional clips later in the closure. You can see we're holding several clips down, turning the defect at us and placing an additional clip. We go proximal and then bend down as we come back. This is facilitated by having that distal attachment on there. It gives you a little bit of extra length. You can see in the lower left, that clip is being held down, turns the defect at us. Now we're going to put a smaller clip in between these two. We've oriented that small clip. As we come back, we'll slip off, but it doesn't matter. We were able to accurately place the clip by manipulating previously placed clips. Here's another example of manipulating clips that have already been placed to get access to the defects. Using the scope and the cap on the end of the scope, we're deflecting clips at two o'clock and three o'clock to the right and holding down a clip that's down at five o'clock. You'll see it in a second to get accurate access to a gap between two clips. Some defects are too large to close. This one looks too big to close, probably 40 millimeters across, but in the end it is closed. How can that be achieved? There are several reported ways to close very large defects like this, but the simplest one using clips is to place a few clips in the middle of the defect, approximately in the position where these red lines are. You can place clips directly on the semicoaster. There's no problem with that. The effect of those clips will be to draw the edges of the defect closer together. The yellow arrows represent the direction the edges will move as a result of the clips placed along these red lines. If you look at the final closure, you'll see that the clips marked with arrows, following them down toward the defect, they pass right between the edges. Those are the clips that are buried in the semicoaster in the center of the defect to draw the edges together, and then the other clips are placed around those to close the defect edge to edge. Next week, closing muscle injuries that occurred during EMR on the ASGE SUTAB tip of the week.

ASGE SUTAB tip of the week

clip closure

burying the clip

manipulating the scope

closing muscle injuries