LAUSR

The European Society of Gastrointestinal Endoscopy recommends routine clip closure for defects ≤20mm following duodenal endoscopic mucosal resection or endoscopic submucosal dissection (ESD) [1]. However, large resection sites that cannot be fully closed by this kind of clip are associated with higher adverse event rates [2]. A through-the-scope twin clip (TTS-TC) can close large wounds with a size of up to 4.8 cm via an endoscope working channel of 3.2mm [3]. We present an initial application of TTS-TC for closure of a large duodenal mucosal defect (▶Video 1). A 66-year-old man was admitted to our hospital with a 2.0 ×1.5 cm duodenal low grade tubular adenoma. We resected the lesion using ESD and chose a TTS-TC to close the 3.0×2.5 cm post-ESD mucosal defect (▶Fig. 1). First, we inserted the TTS-TC into the endoscopic channel and opened an arm on one side of the TTS-TC to clamp the oral side of the wound (▶Fig. 2 a). Then, the other arm was splayed out and pulled over the anal side of the injury (▶Fig. 2b). After ensuring that we had clamped both sides of the wound together tightly with the TTS-TC, we operated the handle to release the clip (▶Fig. 2 c). In this way, the TTS-TC transformed the large defect into a small one. Subsequently, six traditional throughthe-scope clips were applied to close the wound. It took 9 minutes in total to place all the clips and no adverse events occurred during this procedure. The patient developed mild postoperative abdominal pain for 3 days and was discharged a week later. To date, several closure techniques have proved to be effective for large post-ESD defects, such as endoscopic purse-string suture, over-the-scope clip, and the OverStitch device (Apollo Endosurgery, Austin, Texas, USA) [4]. The TTS-TC is a novel and effective device for closure of a large mucosal defect in the duodenum in a shorter time with a simpler mechanism. Further research is required to evaluate the safety and efficacy of the TTS-TC.