LAUSR

Recently, endoscopic string clip suturing has been reported to be a useful suturing method [1], and polyglycolic acid (PGA) sheets and fibrin glue have been used to close perforations in the colon [2, 3]. Here we report successful closure of a huge perforation during rectal endoscopic submucosal dissection (ESD) near the anastomosis site using an endoscopic string clip suturing method with the use of PGA sheets and fibrin glue. ESD was performed in a 58-year-old man with a 20-mm adenocarcinoma on the lower rectum near the anastomosis site. During ESD, we observed very strong fibrosis and performed submucosal dissection with difficulty. We had unknowingly removed both the lesion andmuscle layer. After resection of the lesion, there was a huge perforation of about 30mm (▶Fig. 1 a). We tried to close the perforation near the anastomosis site using an endoscopic string clip suturing method. Braided polyester (USP 3-0; Natsume Seisakusho Co., Ltd, Tokyo, Japan) was used as the suture thread. The site was closed using three suture clips with thread. This suture allowed the mucous membrane to be pulled to the anal side, but there were gaps left in some places, making it an incomplete suture. Several small PGA sheets (2×1 cm) were packed in a gap using the method proposed by Takimoto et al. [4]. Finally, fibrin glue was sprayed (▶Video 1, ▶Fig. 1b). Computed tomography after the procedure revealed a large amount of air behind the peritoneum (▶Fig. 1 c). The ulcer was on a healing trend after 1 week (▶Fig. 2 a). The length of hospital stay was 18 days. After about 2 months, the ulcer was completely cured (▶Fig. 2b). E-Videos