Which endoscopic device and technique should be used to remove esophageal clips, and what are the recommended procedural steps?

Endoscopic Removal of Esophageal Clips

Use dedicated clip-removal forceps (rat-tooth or alligator-jaw forceps) passed through the working channel of a standard gastroscope to grasp and extract esophageal clips; if clips are embedded or difficult to grasp, consider using a snare or biopsy forceps as alternative retrieval tools.

Primary Removal Technique

Equipment Selection

• Rat-tooth forceps or alligator-jaw grasping forceps are the preferred instruments for clip removal, passed through the working channel of a therapeutic gastroscope (≥2.8 mm channel diameter preferred for larger forceps). 1
• Standard biopsy forceps can serve as an alternative for smaller or loosely attached clips, though they provide less secure grip. 2
• Polypectomy snares may be used for clips that are partially detached or have exposed edges that can be encircled. 2

Procedural Steps

• Position the endoscope to provide optimal visualization of the clip, ensuring adequate working distance (typically 2-4 cm from the clip). 1
• Grasp the clip firmly at its central hinge point or at one arm using the forceps; avoid grasping only the tip, which may cause the clip to slip. 2
• Apply steady traction while maintaining visualization; rotate the clip gently if resistance is encountered to disengage tissue caught between the arms. 1
• Withdraw the clip into the working channel or alongside the endoscope if it cannot be fully retracted; use a protective overtube if sharp edges pose mucosal injury risk during withdrawal. 1

Important Clinical Considerations

Timing of Removal

• Through-the-scope clips (TTSC) typically fall off spontaneously within 7-14 days and rarely require removal. 1
• Over-the-scope clips (OTSC) remain in place longer (weeks to months) and more commonly require endoscopic removal if causing symptoms or obstructing subsequent procedures. 1, 3
• Clips placed for perforation closure should remain in situ for at least 2-4 weeks to allow adequate healing before attempting removal. 1

Potential Complications During Removal

• Mucosal injury or bleeding can occur if clips are embedded in granulation tissue; have hemostatic clips or coagulation forceps immediately available. 1
• Re-opening of previously closed defects is a risk if clips were placed for perforation or leak closure; ensure adequate healing time has elapsed and consider contrast imaging before removal. 1
• Clip fragmentation may occur with forceful traction; if a clip breaks, retrieve all fragments to prevent downstream obstruction or perforation. 2

When Removal Is Difficult

Embedded Clips

• If clips are deeply embedded in scar tissue or granulation, use argon plasma coagulation or hot biopsy forceps to ablate surrounding tissue before attempting removal. 2
• Consider endoscopic submucosal dissection techniques with a needle-knife to free clips that are completely incorporated into the mucosa. 2

Alternative Extraction Methods

• Endoscopic suturing devices (such as the X-Tack system) can be used to create traction on embedded clips by suturing adjacent tissue and pulling the clip into a more accessible position. 4
• Balloon dilation proximal to the clip may help dislodge clips that are causing stricture, though this carries perforation risk and should be performed cautiously. 1

Special Situations

Clips Causing Obstruction

• If clips are causing dysphagia or preventing passage of the endoscope, attempt removal under fluoroscopic guidance to better visualize the clip position and surrounding anatomy. 1
• Consider placement of a guidewire past the clip before removal attempts to maintain luminal access if the clip is at a stricture site. 1

Failed Endoscopic Removal

• If endoscopic removal fails after multiple attempts, surgical consultation should be obtained, as thoracotomy or thoracoscopy may be required for clip extraction. 1
• Fully covered self-expanding metal stents (SEMS) can be placed temporarily to bypass symptomatic clips that cannot be removed, though this is a temporizing measure only. 1, 5

Post-Removal Care

• Perform careful inspection of the removal site for bleeding, mucosal injury, or evidence of underlying pathology that was obscured by the clip. 1
• Monitor patients for at least 2 hours post-procedure for signs of bleeding, perforation, or chest pain. 1
• If clips were placed for previous perforation or leak, consider water-soluble contrast study after removal to confirm complete healing and absence of recurrent defect. 1