Lariat hooking method as an easy and quick preparation of clip-and-thread technique for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) for neoplastic lesions of the gastrointestinal tract is widely accepted as a minimally invasive treatment. Against this backdrop, the effectiveness of countertraction in ESD has been reported for difficult cases, and among various devices, the threaded clip technique is frequently used as a simple and inexpensive method.^1-3 However, ligating threads is a very detailed process and sometimes requires time and effort. In this report we describe an easy and quick way, the lariat hooking method (LHM), to ligate thread to the clip (Video S1). LHM requires only a reopenable clip with some gap between the arms (StellaClip; HOYA, Tokyo, Japan) and a thread tied in the lariat style. To attach the thread to the clip, insert the clip into the lariat, open the clip, hook the proximal thread between the arms of the clip, and close the clip lightly (Fig. 1). After these procedures, grasp the edge of the lesion using the clip tied to the thread and release the clip as usual. The advantage of this method is not only its simplicity, but also the reliability that the thread is firmly ligated directly to the main body of the clip, not the clip arm. When a thread is ligated to the arm of a clip as a conventional method, the traction force to pull the thread is transmitted to only one arm of the clip, resulting in the clip acting in the direction of opening, sometimes causing the clip to come off. However, LHM applies traction force in the same direction as the direction of the clip, allowing the lesion to be tensioned more consistently (Fig. 2). Thus, LHM is considered to be an effective method to prepare the clip-and-thread in a short time and at the same time to perform ESD with stable countertraction.

Authors received samples of re-openable clips from HOYA Corp. C.T. is employed by HOYA Corp.