Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a major complication. While most reports focus on the closure of AL using over-the-scope clip (OTSC), few reports are available on the use of through-the-scope clip (TTSC). This is because TTSC is not typically designed for full-thickness closure, unlike OTSC. However, a MANTIS clip, categorized as TTSC, is indicated for full-thickness closure. A 73-year-old man diagnosed with AL 7 days postoperatively following laparoscopic LAR underwent laparoscopic drainage and ileostomy the next day. Although the drainage led to the shrinkage of the fistula, it persisted even after 2 months. Consequently, the fistula orifice was closed using a MANTIS clip under colonoscopy and radiography. Two days later, the patient was discharged. The drain was withdrawn cautiously to prevent residual fistula and removed completely on day 29. This report highlights our experience in using a MANTIS clip for AL following LAR.

Although esophageal stenting is one treatment option as a palliative treatment for tracheoesophageal fistulas, serious complications are associated with stent migration. Some reports have described stent fixation using various devices to prevent stent migration. However, these have yet to be sufficiently examined. We performed esophageal stent fixation using the MANTIS Clip (Boston Scientific), a novel re-openable endoclip. An 89-year-old man developed a tracheoesophageal fistula after radiotherapy for esophageal squamous cell carcinoma. Esophageal stenting was considered because the patient had difficulty with oral intake. However, the patient had a mild stenosis, which suggested stent migration. Therefore, we performed esophageal stent fixation by grasping the mouth side of the stent and the normal mucosa of the esophagus with the MANTIS Clip after placement of the stent. The esophageal stent closed the fistula, and the patient was able to take food orally. Upper gastrointestinal endoscopy performed 3 weeks after stenting showed residual MANTIS Clip and no evidence of stent migration. Esophageal stent fixation with MANTIS clips for tracheoesophageal fistulas may be an option to prevent stent migration.

BACKGROUND: Iatrogenic colonoscopy perforation (ICP) is a rare but most serious complication during colonoscopy investigation. However, endoscopic closure plays an important role in the dealing with ICP with the development of endoscopic techniques presently, there are still some portion of patients transferred to surgery.
METHODS: Once a perforation was detected, endoclips were used to closed the defect of the colon. Then a colonic TET was planted inside the colon. The terminal end of the TET was put proximally to or near the location of the perforation. Then gas and fluid was sucked out through the TET with a syringe every 4 h.
RESULTS: Three cases were treated with endoclip closure and colonic TET drainage. Case 1 was caused by urgent immediate perforation during routine colonoscopy, case 2 was delayed perforation after snare resection, and case 3 was ESD-related perforation. All patients got healed, no one transferred to surgery.
CONCLUSIONS: A combination of endoclip closure and colonic TET drainage might be an easy and potential method in the dealing with different types of ICP. This study may offer a novel paradigm for addressing endoscopy-related intestinal perforations.

Surgical clip migration post-laparoscopic cholecystectomy is a rare but important complication to consider in patients presenting with biliary obstruction. Titanium surgical clips are widely used in laparoscopic surgery to ligate vessels and ducts and are particularly important in laparoscopic cholecystectomy to ligate the cystic duct. More common complications associated with clips involve dislodgement, however, there are reported cases of migration into visceral structures causing an obstruction. We describe a case that demonstrated an acute migration of surgical clips into the common bile duct (CBD) within a three-week period, which occurred 32 years after laparoscopic cholecystectomy, likely attributed to erosion. On the patient\'s first presentation, she had acute pancreatitis with a CT demonstrating clips in the correct position. Three weeks later, the patient presented a second time with acute cholangitis and the repeat CT demonstrated the clips in the CBD. We hypothesize that the erosion of the bile duct is due to the pressure effects from either intra-abdominal organ movements or subtle clip movements, and eventually, persistent erosion leading to intra-ductal migration of the clips with the passage of the clips along the path of least resistance into the CBD, resulting in biliary obstruction. Management included standard treatment for biliary obstruction with intravenous broad-spectrum antibiotics and endoscopic retrograde cholangiopancreatography with excellent outcomes.

A 22-year-old female presented to our clinic with the redevelopment of compressive symptoms after undergoing right carpal tunnel release 2 years prior. During revision surgery, the application of a chitosan polysaccharide membrane wrap over the median nerve was secured with three hemoclips. Follow-up revealed that these clips traveled distally to the volar aspect of the patient\'s small finger necessitating excision. Hemoclips in hand surgery serve as a useful tool for securing constructs; however, the recommendation to use them sparingly is made because of the potential for migration and exacerbation of symptoms.

OBJECTIVE: Appendiceal stump leak rate after laparoscopic appendectomy is extremely low. Various methods are used to close the appendiceal stump. This study aimed to compare the outcome of three appendiceal stump closure methods.
METHODS: A retrospective study comparing stump closure methods and postoperative outcomes was conducted from January 2018 to June 2020. Patient data included demographics, pre-operative data, surgical technique, findings, and postoperative complications.
RESULTS: Out of 1021 appendectomy patients, 733 underwent laparoscopic appendectomy for acute appendicitis utilizing one of the three compared appendiceal stump closure methods. Consequently, 360 appendixes were ligated with one endoloop (1EL group), 300 appendixes had two endoloops (2EL group), and 73 appendixes were ligated with two endoclips (2EC group). All groups used a LigaSure for resection. The rate of postoperative intra-abdominal abscess was 1% (4 patients) in 1EL group vs. 1% (3 patients) in 2EL group vs. none in 2EC group (p = 0.43). There were no reported appendiceal stump leaks. Overall complication rates were 4% (14 patients), 3% (9 patients), and 0 (p = 0.15), and the mean operative length was 43 ± 21, 54 ± 22, and 43 ± 20 mins for the 1EL, 2EL, and 2EC, respectively (p < 0.01). Average cost of one endoloop is 110$, and one endoclip cartridge is 180$.
CONCLUSIONS: None of the methods were found clinically superior over the others. Considering the low and mild complication rate, it appears reasonable to prefer one method simply by cost. The use of a single endoloop may result in substantial cost reduction. Medical centers may advise surgeons to use a single-endoloop technique.

UNASSIGNED: This study is a prospective study to explore the therapeutic effect of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage.
UNASSIGNED: We prospectively collected and analyzed data from July 2018 to December 2020 from patients in Jinshan hospital, Fudan University, who underwent emergency endoscopy for acute severe high-risk non-variceal upper gastrointestinal hemorrhage (NVUGIB) and were treated with endoscopic purse-string sutures.
UNASSIGNED: We included 38 patients whose median age was 64 years (interquartile range: 57.2 - 71.2 years). All patients were high risk gastric ulcer larger than 1 cm, including Forrest Ia (n = 4, 10.5%), Forrest Ib (n = 13, 34.2%) and Forrest IIa (n = 21, 55.3%). All patients were treated with endoscopic purse-string sutures. The clinical success rate reached 89.5%. Three patients suffered from rebleeding within seven days, and were treated with surgery or arterial embolization, respectively, all of which successfully stopped bleeding. One patient died of myocardial infarction. All other patients were followed up for 30 days without bleeding.
UNASSIGNED: We conclude that endoscopic purse-string sutures seem to be safe and effective in the treatment of patients at high risk of ulcer bleeding.

A surgical endoclip in the cystic pedicle rarely migrates to the duodenum and is considered a rare complication of laparoscopic cholecystectomy. Duodenal adenocarcinoma endoscopically mimicking a foreign body granuloma in the background of postcholecystectomy endoclip migration has never been reported before. A 53-year-old Indian male presented with progressive weakness and melena for the last three months. He underwent laparoscopic cholecystectomy a year ago with an uneventful clinical course and post-operative recovery. A complete hemogram revealed hemoglobin of 4.5g/dL. Upper gastrointestinal endoscopy revealed a large necrotic polypoidal mass arising from the lateral wall of the first part of the duodenum. Contrast-enhanced computed tomography (CT) of the abdomen showed an impacted surgical clip into the lateral wall of the first part of the duodenum. Intraluminal extension of the surgical clip was not appreciated in the imaging. We suspected the diagnosis to be foreign body granuloma in the duodenal wall. He underwent open duodenal wedge resection. Microscopic evaluation of resected specimens revealed poorly differentiated adenocarcinoma. All the resection margins were free. He had an uneventful recovery and was discharged on the seventh post-op day. He was symptom-free and doing well on follow-up at 12 months. The purpose of reporting the case was to make the readers aware of the delayed massive upper gastrointestinal hemorrhage as a rare complication of endoclip migration (ECM) post laparoscopic cholecystectomy. In our case, the duodenal adenocarcinoma mimicked a foreign body granuloma endoscopically, and hence a possibility of duodenal adenocarcinoma as a potential delayed complication of ECM cannot be ruled out. Although rare, in case of upper gastrointestinal hemorrhage in the background of the previous history of laparoscopic cholecystectomy, endoclip migration should be kept as a differential diagnosis.

BACKGROUND: Endoscopic resection, including endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFR), was used to resect small gastric submucosal tumors (SMTs). Our team explored a method of tumor traction using a snare combined with endoclips to assist in the resection of SMTs. This study aims to explore the safety and effectiveness of the method.
METHODS: This research performed a propensity-score-matching (PSM) analysis to compare ESD/EFR assisted by a snare combined with endoclips (ESD/EFR with snare traction) with conventional ESD/EFR for the resection of gastric SMTs. Comparisons were made between the two groups, including operative time, en bloc resection rate, perioperative complications, and operation-related costs.
RESULTS: A total of 253 patients with gastric SMTs resected between January 2012 and March 2019 were included in this study. PSM yielded 51 matched pairs. No significant differences were identified between the two groups in perioperative complications or the costs of disposable endoscopic surgical accessories. However, the ESD/EFR-with-snare-traction group had a shorter median operative time (39 vs 60 min, P = 0.005) and lower rate of en bloc resection (88.2% vs 100%, P = 0.027).
CONCLUSIONS: ESD/EFR with snare traction demonstrated a higher efficiency and en bloc resection rate for gastric SMTs, with no increases in perioperative complications and the costs of endoscopic surgical accessories. Therefore, the method seems an appropriate choice for the resection of gastric SMTs.

Currently, the reports on esophageal endoscopic submucosal dissection (ESD) assisted by traction with a snare are rare. Because a snare is a commonly used endoscopic accessory and is easily available, its application in mucosal traction is worth exploring. The present study aims to evaluate the safety and effectiveness of snare-endoclip traction-assisted ESD for esophageal intraepithelial neoplasia. Cases of esophageal intraepithelial neoplasia resected using ESD in the Digestive Endoscopy Center of Guangzhou Nanfang Hospital, China from June 2013 to March 2019 were retrospectively analyzed. The procedure of snare-endoclip traction-assisted ESD was compared with nontraction-assisted ESD by using a propensity score matching analysis. Operation time, en bloc and R0 resection, intra- and postoperative complications, and surgery-related costs were mainly evaluated. Overall, 99 cases of esophageal intraepithelial neoplasia under tissue biopsy were included in the present study. Further, 22 exact matched pairs were obtained. There were no differences in en bloc and R0 resection rates, intra- and postoperative complications, and costs of disposable surgical accessories between the traction group and the nontraction group. However, median operation time showed a significant difference: traction group, 50.0 min (range, 20-100 min); nontraction group, 70.0 min (range, 35-133 min), P=0.012. In conclusion, snare-endoclip traction-assisted ESD for esophageal intraepithelial neoplasia was safe and shortened operation time in the study, thereby improving the efficiency of ESD. Despite the additional use of a snare and endoclips for traction, the total costs of endoscopic accessories seemed not to be increased.