Description:
The first case shows a 61-year old man with a flat-type adenoma in the bulbus, with low-grade dysplasia in biopsies. The lesion was removed using the multi-band mucosectomy technique. The first resection, however, resulted in an 8-mm large perforation.
Here you see the flat type lesions in the bulbus and the luminal defect immediately after endoscopic resection. Since the defect was too large to approximate the edges with clips, it was decided to use the 'tulip bundle technique' to close the defect. For this technique the clips are placed at the edges of the perforation. Here you see the first and second clip being placed around the wound edges, followed by a third clip and a fourth. Then an endoloop is introduced, opened, and placed around the clips. By closing the endoloop, the clips are bundled and the wound edges are approximated.
After the procedure, watery contrast swallowing examination did not show any signs of leakage.
The patient was submitted with nil per os, a naso-gastric suction tube, and intravenous administration of PPI's and antibiotics, and discharged home after 7 days.
Histological examination of the resected specimen confirmed the presence of the inner and outer proper muscle layer.
After 1 month the defect had completely healed.
The second case shows a 71-year old mentally retarded woman with an early cancer arising in a Barrett esophagus. The lesion was resected during a piecemeal procedure using the ER-cap technique with submucosal lifting. The third resection, however, resulted in a 10-mm large perforation. Placing a stent was not considered a good option in this case, due to the wide esophagus and large defect.
Here you see the lesion and the perforation that was observed after the third resection. As in the previous case, it was decided to use the 'tulip bundle technique' to close the luminal defect. The first clip was placed at the edge of the wound, and a second clip was placed opposite from the first one. Then a third and fourth clip were placed around the defect. The clips were captured in an endoloop, and by closing the endoloop the clips were bundled. Since the endoloop ended up rather proximally on the clips, a second endoloop was introduced and placed underneath the first endoloop at the base of the clips, to ensure good approximation of the mucosa.
After the procedure, watery contrast swallowing examination did not show any signs leakage.
The patient was submitted with nil per os, a naso-gastric suction tube, and intravenous administration of PPI's and antibiotics, and she was discharged home after 6 days.
Histological examination of the resected specimen confirmed the presence of the inner and outer proper muscle layer.
After 3 months the defect had completely healed.
Based on these experiences, the 'tulip bundle technique' appears to be a useful technique to endoscopically close large luminal defects.
Contributed By:
Roos E. Pouw, MD, Academic Medical Center, University of Amsterdam, The Netherlands
