LAUSR

Closure of defects after gastric endoscopic submucosal dissection (ESD) can reduce the risk of complications [1]. Although various endoscopic closure methods are proposed, mainly for the duodenum and colon [2–4], closure of gastric mucosal defects is difficult because of the thick and hard wall [5], which is one reason why a standard closure method has not yet been established. We performed complete closure of an extremely large defect after gastric ESD using the “accordion fold” method, a combination of dental flossassisted and mucosal–submucosal clipping (▶Video 1). A 45-year-old woman underwent gastric ESD for a large mucosal lesion (80mm) in the gastric fornix. A mucosal defect of approximately 100mm remained after gastric ESD (▶Fig. 1 a). We sutured the defect using dental floss (Johnson & Johnson K.K., Tokyo, Japan) and clips (EZ clip, HX-610-090, Olympus Medical, Tokyo, Japan; SureClip, MC Medical, Tokyo, Japan). First, we attached dental floss to a clip (▶Fig. 1b). It was then deployed on the anal edge of the defect. To prevent the formation of a cavity, we placed a second clip on the submucosa in the center of the defect, and a third clip on the oral edge, in such a way that the dental floss line was also threaded through these two clips. The two sides of the defect were gathered together by pulling the dental floss perorally (▶Fig. 1 c). Since the lesion was large, another clip with another dental floss line, was used to bring the oral and anal edges closer together. Next, to reduce the size of the defect, the two arms of additional clips were used to grip the mucosa and submucosa, and we sutured the defect in the direction of the short axis (▶Fig. 1d). After repeating the procedure several times, we clipped together mucosa from the anal and oral sides of the defect, and finally we cut the dental E-Videos