“Metallic tulip bundle” technique as rescue hemostatic therapy after endoscopic mucosal resection of a gastric lesion

Excerpt

The authors present a case of a 73-year-old man with history of a Billroth II partial gastrectomy for peptic ulcer disease who was referred for resection of a sessile neoplastic superficial lesion of 12 mm in the remnant gastric corpus, whose biopsies revealed high-grade dysplasia. The patient underwent en bloc endoscopic mucosal resection after submucosal lifting with saline, indigo carmine, and 1/100,000 adrenaline solution. After resection, diffuse oozing from the scar occurred with no identifiable visible vessels after persistent irrigation of the scar with waterjet. Hence, it was decided to close the defect with hemostatic clips. The bleeding was only partially controlled after closure of the defect with 6 hemostatic clips (Fig. 1). Therefore, an over-the-scope clip (OTSC, Ovesco Endoscopy AG, Tübingen, Germany) was applied around and underneath the clips, as done in the classic tulip bundle technique (Fig. 2a). Since bleeding from one of the borders of the scar persisted, another OTSC was placed over one of the metallic rims of the first OTSC and the remaining border of the scar, enabling definite hemostasis (Fig. 2b). Histological evaluation revealed a gastrointestinal (G1) intramucosal adenocarcinoma, with free margins and no lymphovascular invasion.

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