title: Novel endoscopic multi-firing-clip applicator for endoscopic closure of large colonic perforations.
abstract: BACKGROUND
  Existing endoclip closure devices have difficulty in closing large colonic perforation. We developed a novel endoscopic multi-firing-clip applicator (EMFCA) system to address these limitations, and report on its initial evaluation.
  
  
  METHODS
  The functionality and efficacy of the prototype EMFCA equipped with re-openable clamp and preloaded with four clips were assessed using standardized 1.5 cm incisions created in ex-vivo porcine colonic segments. Endoscopic closure of the lacerations with two, three and four clips (n = five for each group) was followed by measurement of the leakage pressure of the three groups. Finite element analysis (FEA) was performed to validate the clip behavior and reliability during deployment.
  
  
  RESULTS
  All 15 perforations were sealed without leakage until fully distended. The leakage pressures of colonic lacerations sealed with two, three, and four clips were 26.1 ± 2.8 mmHg, 37.3 ± 7.3 mmHg and 42.3 ± 7.4 mmHg, respectively. The mean operation time to deploy one clip was 25.4 ± 5.2 seconds. On FEA, the deformation of the shape of the clip matched that of the intended design, with each clip sustaining a maximum stress of 648.5 MPa without any material failure during deployment.
  
  
  CONCLUSIONS
  These initial results confirm the efficacy of the EMFCA prototype system for endoscopic closure of colonic perforations.
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Shuchen
authors.initials: S
authors.lastname: Ge
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Chengli
authors.initials: C
authors.lastname: Song
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Shiju
authors.initials: S
authors.lastname: Yan
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Liaoyuan
authors.initials: L
authors.lastname: Ai
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Jingjing
authors.initials: J
authors.lastname: Xu
authors.affiliation: a Shanghai Institute for Minimally Invasive Therapy , University of Shanghai for Science and Technology , Shanghai , China ;
authors.forename: Mingyang
authors.initials: M
authors.lastname: Li
authors.affiliation: b Department of Endoscopy , Eastern Hepatobiliary Hospital, Second Military Medical University , Shanghai , China ;
authors.forename: Bing
authors.initials: B
authors.lastname: Hu
authors.affiliation: c Institute for Medical Science and Technology , College of Medicine, Dentistry and Nursing, University of Dundee , Dundee , UK.
authors.forename: Alfred
authors.initials: A
authors.lastname: Cuschieri
mesh_terms: D000818:Animals; D003106:Colon / Q000601:surgery*; D003113:Colonoscopy / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D007416:Intestinal Perforation / Q000601:surgery*; D061646:Operative Time; D015203:Reproducibility of Results; D013525:Surgical Instruments; D013552:Swine
keywords: Gastrointestinal perforation; endoscopic closure; multi-firing; through-the-scope clips