Endoscopic closure after endoscopic mucosal resection (EMR), endoscopic submucosal dissection (EMR) or endoscopic full-thickness resection (EFTR) is necessary to eliminate serious complications. Through-the-Scope clips are usually used in treating GI bleeding and perforation for their convenience and reliable outcome, but they are not ideal when the perforation size is larger than 2 cm since their opening width is limited. Several approaches are introduced to reinforce the performance of clips in regarding gathering edges of large defect by using endoloop and clips with double-channel endoscope [1]. Recently, an innovative endoscopic suturing technique using slipknot string and clips with single-channel endoscope has been reported, which resulted in shorter procedure time [2]. However, slipknot cannot maintain for a long time when exposing to distractions due to its poor holding strength.

We have designed and fabricated an endoscopic clipping device and reported its initial ex-vivo results [3]. In this paper, a new suturing method is presented by using this device incorporated with a 4S-Modified Roeder (4SMR) knot, which enables such device to close large defect in a short time. Furthermore, the mechanical strength of 4SMR knot is also studied.

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