A deviated and buried cap-mounted clip

This is the authors' abstract. We don't add key points for this paper.

A colorectal tumour in the sigmoid-descending colon junction in a 73-year-old man was observed during colonoscopy. Hybrid endoscopic submucosal dissection was performed, and endoscopic mucosal resection was attempted, but perforation occurred during resection (Figure 1A). A cap-mounted clip was used for perforation closure; however, owing to the large perforation, part of the cap-mounted clip deviated toward the mesentery (Figure 1B). This clip reduced the perforation size, and endoscopic clips were used to pull the surrounding healthy mucosa together to facilitate successful defect closure; however, the cap-mounted clip became embedded within the tissue, with computed tomography showing that it had deviated into the abdominal cavity. Conservative treatment was successful, without surgery. (A) Perforation occurred during resection. (B) Part of the cap-mounted clip had deviated toward the mesentery. Our patient had early-stage colorectal cancer with submucosal and lymphatic invasion; therefore, additional surgical resection was planned. The buried cap-mounted clip was only partially visible during preoperative marking endoscopy (Figure 2A), with intraoperative findings showing dislodgement into the abdominal cavity (Figure 2B, arrow), which was confirmed in a surgical resection specimen. Additional resection indicated no lymph node metastasis, and the patient remains under observation. (A) The buried cap-mounted clip is only partially visible on colonoscopy. (B) The cap-mounted clip had dislodged into the abdominal cavity, which was observed intraoperatively (arrow). The iatrogenic colon perforation rate during endoscopic mucosal resection is 0.58%.1 When large perforations are closed with cap-mounted clips, the use of adjunctive devices such as dual-arm tissue graspers may be considered.2 However, rare cases have been reported in which a cap-mounted clip was implanted to treat a full-thickness defect in the gastric wall after endoscopic treatment of gastrointestinal stromal tumors in the stomach.3 In cases involving large perforations, such as our case, the use of a cap-mounted clip should be accompanied by consideration of adjunctive devices, such as a dual-arm tissue grasper, to prevent clip deviation. None declared. Conceptualization: Tsuyoshi Suda; Data curation: Tsuyoshi Suda, Naohiro Ohta; Investigation: Tsuyoshi Suda, Kiichiro Kaji, Naohiro Ohta, Kuniaki Arai; Methodology: Tsuyoshi Suda, Kiichiro Kaji; Project administration: Tsuyoshi Suda; Supervision: Kuniaki Arai; Visualization: Tsuyoshi Suda; Writing—original draft: Tsuyoshi Suda; Writing—review & editing: all authors. Supplementary material is available at Journal of the Canadian Association of Gastroenterology online. None declared. Tsuyoshi Suda gave a lecture for Olympus Marketing and received an honorarium. All other authors have no conflicts of interest to declare. The data that support the findings of this study are available from the corresponding author, Tsuyoshi Suda, upon reasonable request. Written consent was obtained from the patient to publish these data.