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The search, coagulation, and clipping method is reported to be significantly better than the existing approache in the prevention of delayed bleeding after gastric endoscopic submucosal dissection (ESD). However, it does not completely prevent post-ESD bleeding [1]. Another method combines the use of polyglycolic acid (PGA) sheets and fibrin glue to reduce the risk of delayed bleeding after gastric ESD [2], but a multicenter, prospective, randomized controlled study showed that use of PGA sheets alone was not effective in preventing delayed bleeding in patients at high risk for such bleeding [3]. We hypothesized that delayed bleeding could be prevented by combining the use of PGA sheets and fibrin glue with a modified search, coagulation, and clipping method that accommodates patients at high risk of delayed bleeding. Here we report on the prevention of delayed bleeding using this new combined approach. First, a coagulation procedure was performed after lesion resection, mainly in the vessels at the margin of the ulcer base. Then, perforator vessels emerging between muscle layers were actively sought and clipped using hemoclips. Because perforator vessels may also be present in carbonized areas of the ulcer base, clipping was also actively performed in such areas; this constituted the modification of the search, coagulation, and clipping method (▶Fig. 1). Subsequently, several large and small PGA sheets were placed (based on the size of the ulcer base), using methods proposed by Kobayashi et al. [4] and Takimoto et al. [5], respectively. Finally, fibrin glue was sprayed (▶Fig. 2). All these steps constitute the polyglycolic acid sheets, fibrin glue, and modified search, coagulation, and clipping method (PMSCC) method. ▶Video 1 shows application of the PMSCC method in a 74-year-old man classified as having high risk of delayed bleeding because of oral warfarin administration. The ulceration followed gastric ESD (40 mm in diameter) in the posterior wall of the lesser curvature of the middle body of the stomach. We implemented the PMSCC method in nine patients at high risk of delayed bleeding. None of the nine patients experienced delayed bleeding. Although bleeding may be observed from perforator vessels in areas where PGA sheets are peeled off [3], we believe that if perforator vessels at the base of ulcers are clipped in advance then such delayed bleeding may be prevented.

Combination of search, coagulation, clipping, and polyglycolic acid sheet to prevent delayed bleeding after gastric endoscopic submucosal dissection