Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips

A 74-year-old man was referred for ER of a 30-mm sessile polyp in the third portion of the duodenum occupying one-half circumference of the duodenal lumen (Fig. 1). The polyp was removed by EMR in a piecemeal fashion aided by the avulsion technique. At the end of the procedure, 2 sets of X-Tacks followed by 4 endoclips were successfully placed to achieve defect closure. The stepwise application of the X-Tack device is demonstrated in Video 1 (available online at www.giejournal.org). Follow-up endoscopy performed after 4 months showed 1 set of residual X-Tacks near the postpolypectomy scar. Two single tacks were found separately situated within the duodenal mucosa (Fig. 2). An attempt to remove the single tack by grasping with a rat tooth forceps met significant resistance; thus, it was left in situ. The scar otherwise appeared healthy with no evidence of residual polyp or recurrence.

A 70-year-old man underwent ESD of a 45-mm sessile polyp in the proximal ascending colon on the fold distal to the ileocecal valve (Fig. 3). The polyp was successfully removed in en bloc fashion, and defect closure was achieved by using 1 set of X-Tack and 9 endoclips. Follow-up colonoscopy after 4 months showed a healthy-appearing scar with no residual clips or X-Tacks near the scar site (Fig. 4).

A 53-year-old woman underwent a rectal ESD of a 15-mm flat polyp surrounded by scars from a previous polypectomy attempt with a previously placed tattoo proximally and distally (Fig. 5). Two sets of X-Tacks and 3 endoclips were placed at the end of the resection, resulting in complete closure of the mucosal defect. Colonoscopy performed after 6 months showed a clean-based scar with no evidence of residual tissue or recurrence. Two sets of residual X-Tacks were seen situated at the periphery of the scar, but no endoclips were seen. We found the X-Tacks to be grouped (Fig. 6), and attempts to remove them with a standard biopsy forceps were unsuccessful.

A 36-year-old woman underwent hybrid ESD for removal of a 30-mm nongranular lateral spreading lesion at the hepatic flexure (Fig. 7). After the resultant piecemeal ER, 2 X-Tack devices and 6 endoclips were placed, resulting in complete closure of the mucosal defect. At 6-month follow-up, a 10-mm residual tissue was seen at the scar site. This was removed by underwater EMR. At follow-up, 1 set of the X-Tack was seen in a group, and 2 single tacks were found situated inside the mucosa adjacent to the scar (Fig. 8). None of the endoclips were found during the follow-up procedure.

A 70-year-old woman underwent piecemeal EMR of a 50-mm sessile polyp located in the third portion of the duodenum occupying 60% of the circumference of the duodenal lumen (Fig. 9). Two X-Tack systems and 6 endoclips were successfully placed, with complete closure of the defect after mucosal resection. Follow-up endoscopy was performed after 9 months. This revealed 1 residual X-Tack that was grouped and a single tack near the postmucosectomy scar (Fig. 10). The other X-Tack system and the endoclips were not found. Several attempts to remove the X-Tacks using biopsy forceps were made but were unsuccessful. A 3-mm residual tissue noted near the scar site was removed with hot biopsy forceps.

All patients described had no abdominal pain or bleeding after the ER and defect closure. This case series demonstrates the outcomes of defect closure using the X-Tack system with endoclips at 4, 6, and 9 months after ER (Table 1). The X-Tack system with endoclips facilitated the closure of large mucosal defects, especially in lesions in difficult locations. In some cases, a large number of endoclips were used to achieve a high-quality closure (no exposed submucosal tissue) to reduce the risk of delayed bleeding. During the follow-up period, we observed that the X-Tacks either fell off or were grouped or situated as a single piece in the mucosa where initially placed. None of the endoclips were seen at the follow-up. We attempted to remove the remaining X-Tacks with standard biopsy forceps and rat-tooth forceps, but both devices were unsuccessful in removing the retained tacks without unscrewing them counterclockwise. We believe that the X-Tacks seen in the group will eventually fall off with the repetitive pulling forces of food or feces. An intact suture grouping the X-Tacks is likely the important factor in them falling off by themselves. However, the single tacks that were buried inside the mucosa will likely stay indefinitely. This may be because the X-Tacks were either screwed deeply in the subepithelial layer or deeper during the index procedure or there was early disconnection before all tacks were dislodged from the tissue as a group.

In conclusion, although the novel X-Tack system is a promising device to aid the effective closure of large mucosal defects, further studies are needed to assess the long-term outcomes of this novel system.