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Double-channel double-grasper technique in over-the-scope clip deployment

Open AccessPublished:February 04, 2020DOI:https://doi.org/10.1016/j.vgie.2019.12.010

      Abbreviation:

      OTSC (over-the-scope clip)
      Endoscopic management of GI fistula and leak is increasingly used. One option is to apply over-the-scope clip (OTSC) devices to close defects.
      • Kobara H.
      • Mori H.
      • Nishiyama N.
      • et al.
      Over-the-scope clip system: a review of 1517 cases over 9 years.
      • Kirschniak A.
      • Kratt T.
      • Stüker D.
      • et al.
      A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.
      • Verlaan T.
      • Voermans R.P.
      • van Berge Henegouwen M.I.
      • et al.
      Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature.
      • Haito-Chavez Y.
      • Law J.K.
      • Kratt T.
      • et al.
      International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video).
      However, securing 2 opposing walls of a fistula and pulling them into the plastic hood can be challenging. A twin grasper and a tissue anchor are commonly used endoscopic devices to grasp tissue around the defect and pull them into the plastic hood of the OTSC before clip deployment.
      • Singhal S.
      • Changela K.
      • Papafragkakis H.
      • et al.
      Over the scope clip: technique and expanding clinical applications.
      The twin grasper and the tissue anchor both have limitations, especially when the defect is large. For example, it is often difficult and very challenging to secure the opposing walls of the defect by the twin grasper and tissue anchor because they tend to slip. While pulling the grasped walls into the plastic hood, we need to obtain an optimal amount of wall tissue.
      The amount of tissue secured by the twin grasper and tissue anchor is often limited, compared with that secured by a tissue grasper. The use of 2 tissue graspers further increases the tissue volume on either side of the fistula opening obtained during OTSC deployment. The authors present 3 consecutive cases of gastric fistula that were managed with clipping by OTSCs after using a novel double-channel and double-grasper technique (Fig. 1) (Video 1, available online at www.VideoGIE.org).
      Figure thumbnail gr1
      Figure 1Endoscopic image demonstrating the double-channel double-grasper technique: 2 graspers at the 5 o’clock and 7 o'clock locations.

      Patient 1

      A 35-year-old woman developed an 8-mm postsurgical subacute fistula at the gastroesophageal junction, which was successfully closed by an OTSC after the double-channel double-grasper technique was used (Figure 2, Figure 3, Figure 4). The 2 opposing walls of the fistula were sequentially grasped by 2 tissue graspers and then pulled into the plastic hood before OTSC deployment to close the fistula. A contrast swallow study performed the next day demonstrated no leak. The patient was discharged home after tolerating an oral diet and enjoyed an uneventful postprocedural course.
      Figure thumbnail gr2
      Figure 2Two graspers secured at the opposing walls around the fistula and pulling them into the plastic hood of the over-the-scope clipping device before clip deployment.
      Figure thumbnail gr3
      Figure 3After clip deployment, the 8-mm fistula is closed at the gastroesophageal junction.
      Figure thumbnail gr4
      Figure 4Contrast swallow study showing no leak at the gastroesophageal junction.

      Patient 2

      A 30-year-old woman developed a 12-mm subacute gastric fistula at the staple line after sleeve gastrectomy. The fistula failed to be closed by stent placement at an outside hospital. The fistula was closed with clipping (Figs. 5 and 6) and stent placement after use of the double-channel double-grasper technique. A contrast swallow study performed the next day demonstrated no leak. The patient was discharged home after tolerating an oral diet.
      Figure thumbnail gr5
      Figure 5A 12-mm gastric fistula at the staple line after sleeve gastrectomy.
      Figure thumbnail gr6
      Figure 6The gastric fistula is closed with an over-the-scope clip.

      Patient 3

      A 70-year-old man developed a 20-mm chronic gastric fistula from buried bumper syndrome. The gastric side of the fistula was closed by 2 OTSCs around a newly placed gastrostomy tube (Fig. 7) after the double-channel double-grasper technique was used. The gastric juice leakage around the PEG stoma significantly decreased to a very minimal level after endoscopic closure.
      Figure thumbnail gr7
      Figure 7Two graspers secured at the opposing walls around the fistula and pulling them into the plastic hood of the over-the-scope clipping device before clip deployment.
      The authors propose that the double-channel double-grasper technique can be used to assist optimal OTSC deployment. The limitations of this technique are these: (1) not every endoscopy unit has a double-channel endoscope, and (2) endoscope maneuverability is slightly decreased because of the increased scope diameter and flexibility. Future developments can include an added over-the-scope channel and a tissue grasper device to assist clip deployment if a single-channel endoscope is used.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      References

        • Kobara H.
        • Mori H.
        • Nishiyama N.
        • et al.
        Over-the-scope clip system: a review of 1517 cases over 9 years.
        J Gastroenterol Hepatol. 2019; 34: 22-30
        • Kirschniak A.
        • Kratt T.
        • Stüker D.
        • et al.
        A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.
        Gastrointest Endosc. 2007; 66: 162-167
        • Verlaan T.
        • Voermans R.P.
        • van Berge Henegouwen M.I.
        • et al.
        Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature.
        Gastrointest Endosc. 2015; 82: 618-628.e5
        • Haito-Chavez Y.
        • Law J.K.
        • Kratt T.
        • et al.
        International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video).
        Gastrointest Endosc. 2014; 80: 610-622
        • Singhal S.
        • Changela K.
        • Papafragkakis H.
        • et al.
        Over the scope clip: technique and expanding clinical applications.
        J Clin Gastroenterol. 2013; 47: 749-756