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HOME > Clin Endosc > Volume 58(4); 2025 > Article
Video of Issue Successful modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (origami method)
Teppei Masunaga1orcid, Daisuke Minezaki1orcid, Yusaku Takatori1orcid, Motohiko Kato2orcid, Naohisa Yahagi1orcid
Clinical Endoscopy 2025;58(4):620-621.
DOI: https://doi.org/10.5946/ce.2024.167
Published online: February 27, 2025

1Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan

2Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan

Correspondence: Teppei Masunaga Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan E-mail: teppei9027w@gmail.com
• Received: June 19, 2024   • Revised: July 30, 2024   • Accepted: August 1, 2024

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Closure of stomach defects after endoscopic submucosal dissection (ESD) using through-the-scope clips (TTSCs) is challenging because of thick mucosa. While some closure methods combine threads, bands, or endoloops with TTSCs, these procedures are technically complex. Modified double-layered suturing (origami method) is a simple technique requiring only TTSCs, which is reliable owing to the folding of the muscle layer without dead space.1,2 Here, we report a case in which this method achieved complete closure of a mucosal defect in the fornix after gastric ESD (Video 1).
A 67-year-old male was referred to our institution for the treatment of a 15 mm lesion in the fornix of the stomach (Fig. 1A). We performed en-bloc resection without perforation by ESD (Fig. 1B). We used a modified double-layered suturing to prevent delayed adverse events. First, with sufficient air suction, the muscle layer of the mucosal defect was gently grasped using a reopenable clip (SureClip; MicroTech) and folded (Fig. 1C, D). Subsequently, an additional clip was used to emphasize the folded muscle layers. The bed of the defect was completely inverted (Fig. 1E). Finally, the residual gaps in the mucosal defect were closed with clips, achieving complete closure (Fig. 1F). The closure time was nine minutes. Follow-up endoscopy on postoperative day 3 revealed complete closure (Fig. 1G). No delayed adverse event were observed. The pathological diagnosis was moderately differentiated-type adenocarcinoma (fundic-gland type), cT1a, with clear horizontal and vertical margins.
In the present case, we successfully closed the mucosal defect in the fornix using the origami method. This method has been used to close the thick-walled lower rectum. Thus, origami method may also be useful for the lower part of the stomach, which has a relatively thick muscle layer. It can achieve reliable closure, similar to surgical suturing, even for defects after gastric ESD.
Video 1. Modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (origami method).
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A video related to this article can be found online at https://doi.org/10.5946/ce.2024.167.
Fig. 1.
Procedure of the modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (ESD). (A) A 15 mm flat elevated lesion located in the fornix of the stomach. (B) En-bloc resection achieved by ESD. (C) Muscle layer grasped by a reopenable clip while suctioning air. (D) Folding of the muscle layer. (E) Additional clip emphasizing folded muscle layer. (F) Folded muscle causing complete closure without dead space under the mucosa. (G) Follow-up endoscopy 3 days post-operation showing maintenance of complete closure.
ce-2024-167f1.jpg
  • 1. Tanaka S, Toyonaga T, Obata D, et al. Endoscopic double-layered suturing: a novel technique for closure of large mucosal defects after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Endoscopy 2012;44 Suppl 2 UCTN:E153–E154.ArticlePubMed
  • 2. Masunaga T, Kato M, Sasaki M, et al. Modified double-layered suturing for a mucosal defect after colorectal endoscopic submucosal dissection (origami method) (with video). Gastrointest Endosc 2023;97:962–969.ArticlePubMed

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    • Feasibility of Endoscopic Closure Method Using Low Cost Clips With Thread for Post Gastric Endoscopic Submucosal Dissection: A Pilot Study
      Ryosuke Ikeda, Hiroaki Kaneko, Hiroki Sato, Yuto Matsuoka, Tomomi Hamaguchi, Aya Ikeda, Yoshihiro Goda, Soichiro Sue, Kuniyasu Irie, Shin Maeda
      JGH Open.2026;[Epub]     CrossRef
    • Endoscopic closure of Gastrointestinal defects: Devices and Techniques
      Zaheer Nabi, D. Nageshwar Reddy
      Expert Review of Gastroenterology & Hepatology.2025; 19(9): 973.     CrossRef

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      Successful modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (origami method)
      Clin Endosc. 2025;58(4):620-621.   Published online February 27, 2025
      DOI: https://doi.org/10.5946/ce.2024.167
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    Successful modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (origami method)
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    Fig. 1. Procedure of the modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (ESD). (A) A 15 mm flat elevated lesion located in the fornix of the stomach. (B) En-bloc resection achieved by ESD. (C) Muscle layer grasped by a reopenable clip while suctioning air. (D) Folding of the muscle layer. (E) Additional clip emphasizing folded muscle layer. (F) Folded muscle causing complete closure without dead space under the mucosa. (G) Follow-up endoscopy 3 days post-operation showing maintenance of complete closure.

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    Successful modified double-layered suturing for the defect after gastric endoscopic submucosal dissection (origami method)
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