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The endoscopic suture method using an endoloop and several clips requires a double-channel
endoscope, which is not always available. We have previously developed a suturing
technique with a slip knot string and clips for the single-channel endoscope. This
report describes a simpler suturing method using a clip with string. In the string
clip suturing method, a clip with string (braided polyester, USP 3-0, Natsume Seisakusho
Co Ltd, Bunkyo-ku, Japan) is placed at the distal margin of the mucosal defect, followed
by insertion of an additional clip to anchor the string at another side of the margin.
The clip and string can be passed through the instrument channel (3.2 mm) of the single-channel
endoscope. Both sides of the mucosal defect can be gathered by pulling the free end
of the string. Additional endoscopic clips are placed to achieve complete closure.
Good string traction can change the field of vision from a side view to a front view
(Fig. 1; Video 1, available online at www.giejournal.org). This method is simpler than the slip knot clip suturing method and makes it easy
to close a large mucosal defect completely by use of a single-channel endoscope.
Figure 1String clip suturing method. A, Mucosal defect after duodenal endoscopic submucosal dissection (ESD). B, A clip with string is placed at the distal margin of the mucosal defect. C, A second clip is hooked onto the string. D, The second clip anchoring the string is placed at another side of the margin. E, Both sides of the mucosal defect are gathered by pulling the free end of the string,
and a third clip is placed. F, A fourth clip is placed. Good string traction can change the field of vision from
a side view to a front view. G, Additional endoscopic clips are placed to achieve complete closure. H, The string is cut with an ESD knife. I, Completion. J, Four days after ESD, all clips are still in place.
We read with interest the article by Yahagi et al1 on endoscopic string clip suturing (ESCS). ESCS is a useful suturing method. However, we previously experienced an unexpected issue with the ESCS method. The thread used for ESCS got caught between the blades of the loop cutter and could not be cut (Fig. 1). This issue may be difficult to resolve in the proximal colon.2
