Endoscopic clip systems for hemostasis and defect closure in gastrointestinal endoscopy

Table 4 Examples of clinical scenarios and approach to clipping

Clinical scenario	Recommended approach to clipping
Oozing ulcer-base bleeding	Optimize visualization with irrigation and/or dilute epinephrine. Apply a reopenable TTS clip to the culprit vessel. Combine with thermal or inject-and-clip therapy if the base is fibrotic. Escalate after 2-3 well-placed clips without control[8]
Hemostasis in narrow-lumen anatomy or pediatrics	Use short-stem clips (e.g., Steris, MicroTech). Maintain modest insufflation, and take small incremental grasps to avoid opposite-wall capture. Confirm blanching before clip release[17,18]
Small perforation closure	Clear the target area. Perform an edge-to-center zipper closure with high-force, reopenable TTS clips in small, perpendicular bites. Escalate early to OTSC if closure remains incomplete[78]
Closure after EMR/ESD	Perform an edge-to-center zipper closure using reopenable, rotatable, high-force clips. For wide defects, pre-approximate with MANTIS or DAT and complete with long-span clips. The ROLM technique using clip with eyelet and nylon line may aid closure of large defects[79]. Consider prophylactic closure in the duodenum or cecum. Escalate to OTSC or suturing if closure is suboptimal[7,78]
Training or general use	Prioritize reopenable, rotatable clips that tolerate multiple repositioning. Use a standardized checklist: Target centered, perpendicular approach, suction-assisted grasp, blanching confirmed before release, and adhere to stop rules[17]

TTS: Through-the-scope; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; DAT: Dual action tissue clip; ROLM: Reopenable clip-over-the-line method; OTSC: Over-the-scope clip.