Endoscopic closure is an essential procedure in gastrointestinal (GI) surgery, but currently it is difficult to close large defects endoscopically because of the lack of an appropriate device. Previously, we developed an endoscopic clipping device that has multifiring function and is equipped with an independent clamp. The goal of this study is to provide a new closure method with this device and 4S-modified Roeder (4SMR) slipknot. The feasibility of the closure method is examined by deploying two clips during one insertion onto the 4SMR slipknot to close a 5 cm full-thickness linear defect of an ex vivo porcine stomach from the center. Mechanical strengths of clip-knot closure and the slipknot as regards to tensioning forces are also evaluated. Specifically, the mechanical strength of the 4SMR slipknot is verified by mean peak forces to failure, while the knot is tensioning by 2.5, 5, 7.5, and 10 N force (n = 20 for each group), respectively. Experimental results indicate the clip-slipknot closure can withstand a distracting force of 6.3 ± 5.6 N. Tensioning force has a great influence on the mechanical strength of slipknot, with the mean peak force (tensioning force) being 7.1± 6.5, 16.3 ± 9.3, 18.9 ± 10.4, and 24.2 ± 12.0 N, respectively. The proposed closure method can be used for large defects. Tensioning force higher than 5 N is suitable to ensure a stronger 4SMR slipknot.

References

References
1.
Soetikno
,
R. M.
,
Gotoda
,
T.
,
Nakanishi
,
Y.
, and
Soehendra
,
N.
,
2003
, “
Endoscopic Mucosal Resection
,”
Gastrointest. Endoscopy
,
57
(
4
), pp.
567
579
.
2.
Maple
,
J. T.
,
Dayyeh
,
B. K. A.
,
Chauhan
,
S. S.
,
Hwang
,
J. H.
,
Komanduri
,
S.
,
Manfredi
,
M.
,
Konda
,
V.
,
Murad
,
F. M.
,
Siddiqui
,
U. D.
, and
Banerjee
,
S.
,
2015
, “
Endoscopic Submucosal Dissection
,”
Gastrointest. Endoscopy
,
81
(
6
), pp.
1311
1325
.
3.
Chuttani
,
R.
,
Barkun
,
A.
,
Carpenter
,
S.
,
Chotiprasidhi
,
P.
,
Ginsberg
,
G. G.
,
Hussain
,
N.
,
Liu
,
J.
,
Silverman
,
W.
,
Taitelbaum
,
G.
, and
Petersen
,
B.
,
2006
, “
Endoscopic Clip Application Devices
,”
Gastrointest. Endoscopy
,
63
(
6
), pp.
746
750
.
4.
Raju
,
G. S.
, and
Gajula
,
L.
,
2004
, “
Endoclips for GI Endoscopy
,”
Gastrointest. Endoscopy
,
59
(
2
), pp.
267
279
.
5.
Sedarat
,
A.
,
2015
, “
Clips for Closure of Full-Thickness Defects
,”
Tech. Gastrointest. Endoscopy
,
17
(
3
), pp.
129
135
.
6.
Magdeburg
,
R.
,
Collet
,
P.
,
Post
,
S.
, and
Kaehler
,
G.
,
2008
, “
Endoclipping of Iatrogenic Colonic Perforation to Avoid Surgery
,”
Surg. Endoscopy
,
22
(
6
), pp.
1500
1504
.
7.
Kirschniak
,
A.
,
Subotova
,
N.
,
Zieker
,
D.
,
Königsrainer
,
A.
, and
Kratt
,
T.
,
2011
, “
The Over-the-Scope Clip (OTSC) for the Treatment of Gastrointestinal Bleeding, Perforations, and Fistulas
,”
Surg. Endoscopy
,
25
(
9
), pp.
2901
2905
.
8.
Nishiyama
,
N.
,
Mori
,
H.
,
Kobara
,
H.
,
Rafiq
,
K.
,
Fujihara
,
S.
,
Kobayashi
,
M.
,
Oryu
,
M.
, and
Masaki
,
T.
,
2013
, “
Efficacy and Safety of Over-the-Scope Clip: Including Complications After Endoscopic Submucosal Dissection
,”
World J. Gastroenterol.
,
19
(
18
), pp.
2752
2760
.
9.
Kantsevoy
,
S. V.
,
Bitner
,
M.
,
Mitrakov
,
A. A.
, and
Thuluvath
,
P. J.
,
2014
, “
Endoscopic Suturing Closure of Large Mucosal Defects After Endoscopic Submucosal Dissection is Technically Feasible, Fast, and Eliminates the Need for Hospitalization (With Videos)
,”
Gastrointest. Endoscopy
,
79
(
3
), pp.
503
507
.
10.
Akimoto
,
T.
,
Goto
,
O.
,
Nishizawa
,
T.
, and
Yahagi
,
N.
,
2017
, “
Endoscopic Closure After Intraluminal Surgery
,”
Dig. Endoscopy
,
29
(
5
), pp.
547
558
.
11.
Matsuda
,
T.
,
Fujii
,
T.
,
Emura
,
F.
,
Kozu
,
T.
,
Saito
,
Y.
,
Ikematsu
,
H.
, and
Saito
,
D.
,
2004
, “
Complete Closure of a Large Defect After EMR of a Lateral Spreading Colorectal Tumor When Using a Two-Channel Colonoscope
,”
Gastrointest. Endoscopy
,
60
(
5
), pp.
836
838
.
12.
Fujii
,
T.
,
Ono
,
A.
, and
Fu
,
K. I.
,
2007
, “
A Novel Endoscopic Suturing Technique Using a Specially Designed So-Called ‘8-Ring’ in Combination With Resolution Clips (With Videos)
,”
Gastrointest. Endoscopy
,
66
(
6
), pp.
1215
1220
.
13.
Sakamoto
,
N.
,
Beppu
,
K.
,
Matsumoto
,
K.
,
Shibuya
,
T.
,
Osada
,
T.
,
Mori
,
H.
,
Shimada
,
Y.
,
Konno
,
A.
,
Kurosawa
,
A.
,
Nagahara
,
A.
, and
Otaka
,
M.
,
2008
, “
‘Loop Clip’, a New Closure Device for Large Mucosal Defects After EMR and ESD
,”
Endoscopy
,
40
(
Suppl. 2
), pp.
E97
E98
.
14.
Nishizawa
,
T.
,
Uraoka
,
T.
,
Suzuki
,
H.
,
Goto
,
O.
,
Ochiai
,
Y.
,
Fujimoto
,
A.
,
Maehata
,
T.
,
Kanai
,
T.
, and
Yahagi
,
N.
,
2015
, “
New Endoscopic Suturing Method: Slip Knot Clip Suturing
,”
Gastrointest. Endoscopy
,
82
(
3
), pp.
570
571
.
15.
Nishizawa
,
T.
,
Uraoka
,
T.
,
Sagara
,
S.
,
Suzuki
,
H.
,
Akimoto
,
T.
,
Kanai
,
T.
, and
Yahagi
,
N.
,
2016
, “
Endoscopic Slipknot Clip Suturing Method: An Ex Vivo Feasibility Study (With Video)
,”
Gastrointest. Endoscopy
,
83
(
2
), pp.
447
450
.
16.
Ge
,
S.
,
Song
,
C.
,
Yan
,
S.
,
Ai
,
L.
,
Xu
,
J.
,
Li
,
M.
,
Hu
,
B.
, and
Cuschieri
,
A.
,
2016
, “
Novel Endoscopic Multi-Firing-Clip Applicator for Endoscopic Closure of Large Colonic Perforations
,”
Minim. Invasive Ther. Allied Technol.
,
25
(
4
), pp.
188
195
.
17.
Song
,
C.
,
Ge
,
S.
,
Li
,
M.
,
Yan
,
S.
, and
Zhou
,
Y.
,
2016
, “
A Novel Endoscopic Clipping Device for Closing Gastrointestinal Perforation
,”
ASME J. Med. Devices
,
10
(
3
), p.
030905
.
18.
Kim
,
J. C.
,
Lee
,
Y. K.
,
Lim
,
B. S.
,
Rhee
,
S. H.
, and
Yang
,
H. C.
,
2007
, “
Comparison of Tensile and Knot Security Properties of Surgical Sutures
,”
J. Mater. Sci. Mater. Med.
,
18
(
12
), pp.
2363
2369
.
19.
Muffly
,
T. M.
,
Cook
,
C.
,
Distasio
,
J.
,
Bonham
,
A. J.
, and
Blandon
,
R. E.
,
2009
, “
Suture End Length as a Function of Knot Integrity
,”
J. Surg. Educ.
,
66
(
5
), pp.
276
280
.
20.
Shettko
,
D. L.
,
Frisbie
,
D. D.
, and
Hendrickson
,
D. A.
,
2004
, “
A Comparison of Knot Security of Commonly Used Hand‐Tied Laparoscopic Slipknots
,”
Vet. Surg.
,
33
(
5
), pp.
521
524
.
21.
Neyman
,
J.
, and
Pearson
,
E. S.
,
1928
, “
On the Use and Interpretation of Certain Test Criteria for Purposes of Statistical Inference—Part I
,”
Biometrika
,
20A
(
1/2
), pp.
175
240
.http://www.jstor.org/stable/2331945
22.
Sharp
,
H. T.
,
Dorsey
,
J. H.
,
Chovan
,
J. D.
, and
Holtz
,
P. M.
,
1996
, “
A Simple Modification to Add Strength to the Roeder Knot
,”
J. Minim. Invasive Gynecol.
,
3
(
2
), pp.
305
307
.
23.
Sharp
,
H. T.
,
Dorsey
,
J. H.
,
Chovan
,
J. D.
, and
Holtz
,
P. M.
,
1996
, “
The Effect of Knot Geometry on the Strength of Laparoscopic Slip Knots
,”
Obstet. Gynecol.
,
88
(
3
), pp.
408
411
.
24.
Shi
,
Q.
,
Chen
,
T.
,
Zhong
,
Y. S.
,
Zhou
,
P. H.
,
Ren
,
Z.
,
Xu
,
M. D.
, and
Yao
,
L. Q.
,
2013
, “
Complete Closure of Large Gastric Defects After Endoscopic Full-Thickness Resection, Using Endoloop and Metallic Clip Interrupted Suture
,”
Endoscopy
,
45
(
5
), pp.
329
334
.
25.
Zhang
,
Y.
,
Wang
,
X.
,
Xiong
,
G.
,
Qian
,
Y.
,
Wang
,
H.
,
Liu
,
L.
,
Miao
,
L.
, and
Fan
,
Z.
,
2014
, “
Complete Defect Closure of Gastric Submucosal Tumors With Purse-String Sutures
,”
Surg. Endoscopy
,
28
(
6
), pp.
1844
1851
.
26.
Abe
,
S.
,
Oda
,
I.
,
Mori
,
G.
,
Nonaka
,
S.
,
Suzuki
,
H.
,
Yoshianaga
,
S.
, and
Saito
,
Y.
,
2015
, “
Complete Endoscopic Closure of a Large Gastric Defect With Endoloop and Endoclips After Complex Endoscopic Submucosal Dissection
,”
Endoscopy
,
47
(
Suppl. 1
), pp.
E374
E375
.
You do not currently have access to this content.