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A 67-year-old man presented to our department for a screening colonoscopy, during which a 2-cm type IIa nonpolypoid lesion was found in the ascending colon (●" Fig.1a). After submucosal injection (saline with methylene blue) and adequate lifting of the lesion, a single-piece endoscopic mucosal resection (EMR) was performed. The post-EMR defect consisted only of serosal lining (●" Fig.1b). Because of its large size, attempts to close the defect with clips failed. A decision was made to close the defect with the combined use of clips and a nylon snare (HX400U; Olympus, Tokyo, Japan). The traditional method of snaring and clipping could not be performed. Therefore, we developed a new technique. At the patient’s bedside, the nylon snare was opened and released from its original sheath (●" Fig.2a). The distal loop of the snare was enlarged to facilitate re-hooking (●" Fig.2b). The snare was grasped with a clip (QuickClip2; Olympus) and introduced into the working channel of the endoscope (●" Fig.2c,●" Fig.2d). The snare was delivered to the ascending colon (●" Fig.2e,●" Fig.3a), where it was anchored with multiple clips along the edges of the defect (●" Fig.3b). The distal end of the snare was then re-hooked and pulled back into the original sheath (●" Fig.2 f), enabling the closure to be completed in a “purse-string” fashion (●" Fig.3c). Follow-up colonoscopy at 8 weeks demonstrated a healed defect, with both the snare and clip in situ (●" Fig.3d). The application of two accessories with a single-channel endoscope is either challenging or impossible. Perforations and large mucosal defects can be closed with the combined use of clips and a nylon snare using two methods. In the “tulipbundle” technique the snare is lassoed and tightened over a bundle of clips attached at the edges of the tear [1]. In the “purse-string” technique, the snare forms a nylon loop that is clipped around the edges of the lesion. Closure is accomplished by closing the snare [2,3]. However, with the tulip-bundle technique, there is a risk of the snare slipping over the clips, whereas the purse-string approach requires the use of a double-channel endoscope, or the snare must be fixed externally to the scope. In addition, it can be difficult to operate a double-channel endoscope or to maintain the position of an externally fixed snare in a redundant or tortuous colon. Fig.1 a Sessile polyp and positive lifting sign in the ascending colon of a 67-year-old man undergoing screening colonoscopy. b Colonic wall defect after resection; only the serosal lining is left in situ. Attempts to close the defect with clips failed.

Release and re-hook: a novel method with combined use of clips and nylon snare to close a colonic defect after endoscopic mucosal resection