Successful Indirect Clipping for the Bleeding Source of Colonic Diverticular Hemorrhage Using a Reopenable Clip (Regrasping Technique)

CASE REPORT When repeated misfiring of clips is encountered for controlling colonic diverticular hemorrhage, it becomes difficult to achieve hemostasis, an intervention, such as transcatheter embolization procedure or surgery, is required for effective bleeding control. The usefulness of a reopenable clip (SureClip; Micro-Tech Co. Ltd, Nanjing, China) for endoscopic hemostasis has recently been reported.1–3 We report successful indirect clipping for the bleeding source of colonic diverticular hemorrhage using a reopenable clip (regrasping technique). Clips were placed directly onto the vessel if technically feasible (direct clipping). When direct placement of clips onto the vessel was not possible, the diverticulum was closed in a zipper fashion (indirect clipping).4 An 87-year-old man with a large volume of hematochezia was transported to our hospital. The transverse colon was carefully examined using an endoscope, and a large volume of blood clotting and severe active bleeding were observed (Figure 1). We performed clipping on the opposite side of the bleeding site so as not to lose it. We then identified the bleeding diverticulum, but we could not identify the bleeding vessels in the diverticulum because of the severe active bleeding (Figure 1). We then tried to perform indirect clipping using a reopenable clip for the bleeding diverticulum. The bleeding diverticulum was grasped with a reopenable clip (Figure 1) 4 times, but the bleeding could not be stopped. On the fifth attempt, the bleeding was successfully stopped (regrasping technique, Figure 2). Clips were then added to ensure hemostasis (Figure 2, Video 1).Figure 1.: Figure showing that we could identify the bleeding in the diverticulum, and we then tried to perform indirect clipping using a reopenable clip for the bleeding diverticulum. (A) The ascending colon was carefully examined using an endoscope, and a large volume of blood clotting and severe active bleeding were observed. (B) We identified the bleeding diverticulum, but we could not identify the bleeding vessels in the diverticulum because of the severe active bleeding. (C) We then tried to perform indirect clipping using a reopenable clip for the bleeding diverticulum. The bleeding diverticulum was grasped with a reopenable clip 4 times, but the bleeding could not be stopped.Figure 2.: Figure showing successful indirect clipping for the bleeding source of colonic diverticular hemorrhage using a reopenable clip (regrasping technique). (A) On the fifth attempt, the bleeding was successfully stopped (regrasping technique). (B) Clips were then added to ensure hemostasis. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Video showing successful indirect clipping for the bleeding source of colonic diverticular hemorrhage using a reopenable clip (regrasping technique).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_j996oi26"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The merit of the regrasping technique is that misfiring of clips can be decreased. The use of this technique can prevent the difficulty in achieving hemostasis caused by misfired clips, potentially reducing the need for angiography or surgery. The regrasping technique may be effective for clipping the bleeding source of colonic diverticular hemorrhage. DISCLOSURES Author contributions: S. Abiko wrote the manuscript. T. Tanaka, S. Sawaguchi, T. Yamamura, Y. Tokuchi, K. Nagai, K. Kinoshita, K. Hatanaka, Y. Yamamoto, and H. Naruse edited the manuscript. S. Abiko is the article guarantor. Acknowledgments: We are very grateful to the wonderful staff in the endoscopic room, outpatient care, and ward of Hakodate Municipal Hospital. Financial disclosure: None to report. Informed consent was obtained for this case report.