Surgical Endoscopy

, Volume 27, Issue 4, pp 1203–1210 | Cite as

Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study

  • J. MartínekEmail author
  • O. Ryska
  • I. Tuckova
  • T. Filípková
  • R. Doležel
  • S. Juhas
  • J. Motlík
  • M. Zavoral
  • M. Ryska



A safe technique is essential for successful access site closure in Natural Orifice Translumenal Endoscopic Surgery (NOTES) and for closures of iatrogenic perforations.


To compare an over-the-scope clip (OTSC) versus an endoloop + endoclips closure technique (KING closure).


40 minipigs underwent NOTES peritoneoscopy with liver biopsy. Gastrotomies and rectotomies were closed with OTSC (n = 20; 10× stomach, 10× rectum) or KING closure (n = 20; 10× stomach, 10× rectum). The animals were euthanized 28 days after the procedure. The main outcome variables were technical feasibility, effectiveness, and healing.


Stomach: All but one closure (KING) was successfully completed. The times of closure were similar between the techniques. At necropsy, all access sites were healed. In two animals (1× KING, 1× OTSC), an abscess, probably related to the closure technique, was found. Histologically, transmural healing with muscular bridging was observable in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in three pigs for KING versus seven pigs for OTSC closure (p = 0.08). Rectum: All closures were successfully completed. The times of closure were similar between the techniques. At necropsy, all closure sites had healed. Transmural healing with muscular bridging was present in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in two pigs for KING versus seven pigs for OTSC closure (p = 0.03). In one animal (OTSC), an enterocolic fistula developed in the proximity of the closure site.


OTSC and KING closure are comparable closure techniques in terms of technical feasibility and effectiveness. KING closure provides a superior histological outcome compared with OTSC closure.


NOTES Gastrotomy closure Rectotomy closure Over-the-scope clip Endoloop KING closure 



Supported by grants from Internal Grant Agency of the Czech Ministry of Health (IGA, NS9994-4) and the Academy of Sciences of the Czech Republic (institutional research plan no. AV0Z50450515).


Authors Jan Martínek J, Ondřej Ryska, Inna Tuckova, Tereza Filípková, Radek Doležel, Stefan Juhas, Jan Motlik, Miroslav Zavoral, and Miroslav Ryska have no conflicts of interest or financial ties to disclose.


  1. 1.
    Teoh AYB, Chiu PWY, Ng EKW (2010) Current developments in natural orifices transluminal endoscopic surgery: an evidence-based review. World J Gastroenterol 16:4792–4799PubMedCrossRefGoogle Scholar
  2. 2.
    Von Renteln D, Vassillou MC, Rothstein RI (2009) Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 41:1056–1061CrossRefGoogle Scholar
  3. 3.
    Hookey LC, Khokhotva V, Bielawska B et al (2009) The Queen’s closure: a novel technique for closure of endoscopic gastrotomy for natural orifice transluminal endoscopic surgery. Endoscopy 41:149–153PubMedCrossRefGoogle Scholar
  4. 4.
    Hucl T, Benes M, Kocik M et al (2010) A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure. Gastrointest Endosc 71:806–811PubMedCrossRefGoogle Scholar
  5. 5.
    Ryska O, Martinek J, Dolezel R et al (2011) Feasibility of a novel single loop and clip gastrotomy closure (King’s closure) after NOTES procedures in an experimental study. Gastroent Hepatol 65:207–210Google Scholar
  6. 6.
    Endo M, Inomata M, Terui T et al (2004) New endoscopic technique to close large mucosal defects after endoscopic mucosal resection in patients with gastric mucosal tumors. Dig Endosc 16:372–375CrossRefGoogle Scholar
  7. 7.
    Matsuda T, Fujii T, Emura F et al (2004) Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc 60:836–838PubMedCrossRefGoogle Scholar
  8. 8.
    Katsinelos P, Chatzimavroudis G, Zavos C (2009) Closure of an iatrogenic rectal perforation by using the endoloop/clips technique. Gastrointest Endosc 70:405PubMedCrossRefGoogle Scholar
  9. 9.
    Schurr MO, Hartmann C, Ho CN et al (2008) An over-the-scope clip (OTSC) system for closure of iatrogenic colon perforations: results of an experimental survival study in pigs. Endoscopy 40:584–588PubMedCrossRefGoogle Scholar
  10. 10.
    Kirschniak A, Kratt T, Stuker D et al (2007) A new over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc 66:162–166PubMedCrossRefGoogle Scholar
  11. 11.
    Donatsky AM, Andersen L, Nielsen OL et al (2012) Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study. Surg Endosc 26:1952–1962PubMedCrossRefGoogle Scholar
  12. 12.
    Voermans RP, Worm AM, van Berge Henegouwen MI et al (2008) In vitro comparison an evaluation of seven gastric closure modalities for natural orifice endoscopic surgery (NOTES). Endoscopy 40:595–601PubMedCrossRefGoogle Scholar
  13. 13.
    Dray X, Krishnamurty DM, Donatelli G et al (2010) Gastric wall healing after NOTES procedures: closure with endoscopic clips provides superior histological outcome compared with threaded tags closure. Gastrointest Endosc 72:343–350PubMedCrossRefGoogle Scholar
  14. 14.
    Jovanovic I, Zimmermann L, Fry LC et al (2011) Feasibility of endocopic closure of an iatrogenic colon perforation occurring during colonoscopy. Gastrointest Endosc 73:550–555PubMedCrossRefGoogle Scholar
  15. 15.
    Martínek J, Ryska O, Filípková T et al (2012) Natural orifice transluminal endoscopic surgery vs laparoscopic ovariectomy: complications and inflammatory response. World J Gastroenterol 18:3558–3564PubMedCrossRefGoogle Scholar
  16. 16.
    Voermans RP, Henegouwen MI, Bemelman WA et al (2011) Hybrid NOTES transgastric cholecystectomy with reliable gastric closure: an animal survival study. Surg Endosc 25:728–736PubMedCrossRefGoogle Scholar
  17. 17.
    Kirchniak A, Subotova N, Zieker D et al (2011) The over-the-scope clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc 25:2901–2905CrossRefGoogle Scholar
  18. 18.
    Voermans RP, Verdouwe F, Breedveld P et al (2011) Comparison of endoscopic closure modalities for standardized colonic perforation in a porcine colon model. Endoscopy 43:217–222PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • J. Martínek
    • 1
    Email author
  • O. Ryska
    • 2
  • I. Tuckova
    • 3
  • T. Filípková
    • 4
  • R. Doležel
    • 2
  • S. Juhas
    • 5
  • J. Motlík
    • 5
  • M. Zavoral
    • 1
  • M. Ryska
    • 2
  1. 1.Department of HepatogastroenterologyInstitute for Clinical and Experimental MedicinePrague 4Czech Republic
  2. 2.Department of Surgery, 2nd Faculty of MedicineMilitary University Hospital, Charles University in PraguePragueCzech Republic
  3. 3.Department of PathologyMilitary University HospitalPragueCzech Republic
  4. 4.Department of SurgeryDomazlice HospitalDomazliceCzech Republic
  5. 5.Institute of Animal Physiology and GeneticsAcademy of SciencesLibechovCzech Republic

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