Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported, but a ligation technique for clinical use has not been established because of the technical complexity and the need for expensive equipment. Therefore, we perform ligation using the double-loop (D-L) clips technique for cecum to upper rectal cases and endoscopic string clip suturing (ESCS) for lower rectum cases. In the current study, we prospectively assessed the technical feasibility of this novel ligation technique using the D-L clips for cecum to upper rectal cases.

Subjects were registered in this prospective study between May 2020 and September 2021. The study subjects included patients who underwent colorectal ESD in Hakodate Municipal Hospital and patients in whom the novel ligation technique was used.

A total of 33 patients were analyzed. Oral antithrombotic agents were administered to 15 (45.5%) of the 33 patients and direct oral anticoagulants (DOACs) were administered to 3 (9.1%) of the 33 patients. The rate of en bloc R0 resection was 100.0%, and the median length of resected specimens was 2.6 cm. The complete ligation rate was 97.0% (32 of the 33 patients). The median duration of ligation was 18 minutes. Post-endoscopic submucosal dissection coagulation syndrome occurred in one patient (3.0%) and there was no delayed bleeding in any of the patients. The D-L clips technique failed in one patient in whom the lesions were located at the transverse colon and there was paradoxical movement during the procedure.

This prospective feasibility study showed that our ligation technique using the D-L clips can be used for closing ulceration after colorectal ESD in cecum to upper rectal cases.