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

Article information

Clin Endosc. 2024;.ce.2024.167

Publication date (electronic) : 2024 August 26

doi : https://doi.org/10.5946/ce.2024.167

Teppei Masunaga^,1, Daisuke Minezaki¹, Yusaku Takatori¹, Motohiko Kato², Naohisa Yahagi¹

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 2024 June 19; Revised 2024 July 30; Accepted 2024 August 1.

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).

Case: 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 were observed. The pathological diagnosis was moderately differentiated-type adenocarcinoma (fundic-gland type), cT1a, with clear horizontal and vertical margins.

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.

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.