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Background and Aim Endoscopic closure in gastric endoscopic submucosal dissection (ESD) is useful to prevent delayed bleeding. Although several closure methods have been reported, their cost remains a significant issue. In this pilot study, we developed a low‐cost endoscopic closure (LoCC) method and evaluated its feasibility and cost‐effectiveness. Methods We retrospectively analyzed 20 gastric lesions in 18 patients who underwent ESD between September 2024 and July 2025. Mucosal defect closure was performed using the LoCC method, which involves the application of conventional clips and threads to approximate mucosal edges. The primary outcome was the complete closure rate. The secondary outcomes were closure time, number of clips used and their cost, sustained closure rate on postoperative day (POD) 1, and incidence of delayed bleeding. Results Complete closure was achieved in 90.0% (18/20) of the lesions, with sustained closure on POD1 in 85.0% (17/20). The median closure time was 17.5 min (interquartile range [IQR]: 12.3–24.0), using a median of 20 clips (IQR: 15–23), at a median cost of 131.8 United States dollars (IQR: 98.8–151.5). No cases of delayed bleeding occurred. Conclusions The LoCC method showed favorable technical feasibility and enabled cost‐efficient closure of post‐ESD ulcers compared with other closure methods. This technique achieved a high closure success rate and sustained closure rate without the need for expensive devices, suggesting that it may serve as a practical and feasible closure method in routine clinical practice.

We present the case of a 45‐year‐old man who underwent a screening total colonoscopy and developed delayed perforation after a cold snare polypectomy in the descending colon and sigmoid colon. The patient developed abdominal pain and was referred to our department for further evaluation and treatment. On clinical examination, we noted lower abdominal tenderness, mild rebound pain, and elevated levels of inflammatory markers. Abdominal contrast‐enhanced computed tomography confirmed the presence of free air in the abdomen. Since there were no signs of peritoneal inflammation and the vital signs were stable, we planned to perform endoscopic clip closure of the perforated area. The patient's symptoms improved with conservative management thereafter, including fasting, fluid replacement, and antibiotic administration. The patient was discharged on the 6th hospital day. In this case report, we discuss the usefulness of endoscopic clip closure in managing delayed perforation.

Background Endoscopic closure techniques are effective and safe in the management of transmural gastrointestinal defects. However, there is a paucity of data regarding their comparative effectiveness. This study aimed to compare the efficacy and safety of several new-generation, endoscopic closure devices in a pre-clinical model. Methods We evaluated five commercially available devices: a through-the-scope clip (TTSC), an anchor-pronged TTSC, a suturing device, helical tacking system, and over-the-scope clip. We tested closure strength using an ex-vivo porcine model. Next, live animals underwent 15 mm gastric and colonic perforations followed by immediate endoscopic closure with one of the devices. We assessed technical success, 7-day survival, time to complete closure, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) task load index. Results A total of 60 ex-vivo closures were conducted (12 per device). The suturing device achieved a higher closure strength than all other devices ( P  < 0.05 for all comparisons). Technical success was achieved in 80% of cases, and 9 of 10 animals (90%) survived to 7 days post-closure. The mean procedure time for the suturing device was longer than all other devices ( P  < 0.05 for all comparisons). The mean procedure time for the anchor-pronged TTSC was also faster than over-the-scope clip ( P  = 0.04). The total endoscopist NASA-TLX score for the suturing device and helical system were greater than all other devices ( P  < 0.05 for all comparisons). Conclusion Each closure device varies significantly in closure strength, closure time, and ease of use. Optimal device selection will depend on defect size, anatomic location, the viability of the surrounding tissue, and endoscopist/technician expertise.

Purpose The over-the-scope endoscopic suturing system (ESS) (OverStitch™) is one of the most widely utilized endoscopic suturing systems in current clinical practice; however, data on the adverse events associated with this device is scarce. Our study aims to evaluate the adverse events and complications associated with the over-the-scope ESS using the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Materials and Methods We analyzed the post-marketing surveillance data from the FDA MAUDE database for the over-the-scope ESS from January 2008 through June 2022. Results Eighty-three reports were filed from January 2008 to June 2022. Adverse events were classified as device-related complications and patient-related adverse events. Seventy-seven device-related issues and 87 patient adverse events were identified. The most common device-related issue was difficulty to remove after deployment ( n =12, 15.58%) followed by mechanical problem ( n =10, 12.99%), mechanical jam ( n =9, 11.69%), or entrapment of device ( n =9, 11.69%). Of the 87 patient-related adverse events, the most common was perforation ( n =19; 21.84%), followed by device embedded in tissue or plaque ( n =10; 11.49%), and abdominal pain ( n =8; 9.20%). Of the 19 patients who experienced perforation, two required open surgical repair and one required laparoscopic surgical repair. Conclusion The overall adverse events from the over-the-scope ESS remain acceptable as evidenced by the number of reported cases since 2008. However, it is important to note that adverse event rates might increase as the use of the device increases; therefore, it is essential for endoscopists to be aware of the potential common and rare adverse events associated with the use of the over-the-scope ESS device. Graphical Abstract

Introduction Delayed perforation (DP) remains a significant complication of colorectal endoscopic submucosal dissection (ESD). This study analyzed the risk factors, clinical course, and management for DP following colorectal ESD. Methods We retrospectively reviewed 4,632 consecutive colorectal ESD cases from 13 institutions between January 2006 and May 2024. DP cases were identified, and the incidence rate, along with patient/lesion characteristics (as tumor size, location, and severe fibrosis) were assessed. The clinical course, including onset timing, initial treatments, need for surgery, and risk factors were examined. Results DP occurred in 18 cases, with an incidence rate of 0.39% [95% confidence interval (CI): 0.24–0.62]. The mean tumor size was 49.7 ± 35.7 mm. The rates of right-sided colon lesions and severe fibrosis were observed in 77.8 and 61.2%, respectively. DP occurred on post-procedure day 1 in 55.8% of cases, day 2 in 22.2%, and on day 3 or later in 22.2%. Initial DP management included conservative treatment in five cases (27.8%), endoscopic closure in six (33.3%), and surgery in seven cases (38.9%). Among the six cases managed endoscopically, five (83.3%) were successfully managed without surgery. Finally, surgery was required in 11 cases (61.1%). Multivariate analysis (odds ratio [95%CI]) identified severe fibrosis (4.61 [1.50–14.20], p = 0.007), and long procedure time (1.01 [1.00–1.02], p = 0.042), as significant risk factors for DP, while complete closure was inversely correlated with DP risk (0.12 [0.01–0.96], p = 0.046). Conclusions This study identified DP incidence and risk factors after colorectal ESD, with some cases requiring surgery. Endoscopic treatment may prevent surgery.

Background and Study AimsPost-laparoscopic sleeve gastrectomy (LSG) fistula is a major complication, responsible for high morbidity. Endoscopic treatment represents an alternative to surgical management, with variable approaches and success rates. In this study, we aimed to evaluate the efficacy of endoscopic treatment in a tertiary care center.Patients and MethodsBetween March 2010 and March 2015, all patients referred to our center for endoscopic treatment of fistula related to laparoscopic sleeve gastrectomy were included. The primary endpoint was defined as a complete closure of the fistula without recurrence within the 2 months.ResultsA total of 26 patients were retrospectively included (73% female). The mean time between fistula diagnosis and first endoscopy was 27.4 days (± 22). Twenty-three (88.4%) patients had a complete fistula closure after endoscopic treatment. The healing delay was 76.4 days (± 42.8), and an average of 3.5 (± 1.4) endoscopic procedures were required. Clinical efficacy was 100% when the endoscopic treatment was performed within the first 3 weeks, or 70% afterwards (p = 0.046). The fistula closure rate was similar between patients with endoscopic drainage (with or without other endoscopic techniques) and patient with closing techniques alone (85.7% vs. 89.5%, respectively).ConclusionEndoscopic treatment of fistula after LSG is efficient but requires early procedures within the first 3 weeks. Endoscopic strategies involving closing procedure or drainage procedure seem to be similar, but these data must be confirmed in large prospective clinical studies.

Background: Endoscopic treatments for gastric cancers have still been progressing even after the great success of endoscopic submucosal dissection (ESD). Summary: In further advancements of ESD, safe and less-invasive procedures are challenged by managing postoperative bleeding, one of the major adverse events in ESD. Covering the mucosal defect after removal of lesions appears reasonable and effective for preventing delayed bleeding from the post-ESD ulcers. Shielding with biodegradable sheets is attempted on clinical trials, which show equivocal results. Although suturing of the mucosal rims is technically challenging, pilot studies demonstrate favorable outcomes for avoiding post-ESD bleeding even in cases at high risk. In cases after noncurative resection of ESD, the selection of patients who truly require additional gastrectomy with lymph node dissection is important to provide necessary surgery. Risk stratification of lymph node metastases and surgery has been developed, which offers tailor-made management to each patient considering the risks and benefits. In surgery, function-preserving gastrectomy to minimize the resection area in both lymphadenectomy and the primary site is clinically introduced. The sentinel node navigation surgery is promising to realize the minimally invasive gastrectomy, and it should strongly fit ESD as well as laparoscopic endoscopic cooperative surgery or endoscopic full-thickness resection, although nonexposure approaches are desirable. Key Message: Development for less-invasive managements on gastric cancer will be continued in step with the advancement of endoscopic treatments.

AimTo investigate the effectiveness of over-the-scope-clip (OTSC)-based endoscopic closure in patients with perforated peptic ulcer (PPU).MethodsOne hundred six patients diagnosed with PPU were treated with either OTSC (n = 26) or conservative treatments (n = 80), respectively. The outcome assessments included technical success rate, clinical success rate, post-treatment complications after 1 month, mortality rate, time to resume oral feeding, length of hospital stay, and the administration of antibiotics.ResultsIn the OTSC group, technical and clinical success was achieved in 100% of patients without any complications, including death, incomplete closure, duodenal obstruction, and gastrointestinal bleeding, with a median operation time of 10 min. All patients in the OTSC group were discharged, while the mortality rate in the control group was 13.8%. Subsequent surgeries were required in 30% of patients in the control group. The median times to resume oral feeding were 3.5 (interquartile range [IQR] 2.0–5.25) days in the OTSC group and 7.0 (IQR 5.0–9.0) days in the control group (p < 0.001). One month post-procedure, 30% (24/80) of patients in the control group and 0 (0/26) in the OTSC group required additional operations (p < 0.001). No significant difference was found in the length of the hospital stay and the administration of antibiotics between the two groups (p > 0.05).ConclusionsOTSC-based endoscopic technique, with a high clinical success rate and a shorter time to resume oral feeding, was effective in achieving closure of PPU with a diameter < 15 mm.

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

Background Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal (GI) lesions originating from the muscularis propria layer. Successful closure of the wall defect is a critical step. Objective The aim of this study was to evaluate the feasibility and efficacy of a novel and simplified endoscopic grasp-and-loop (GAL) closure method using an endo-loop assisted with grasping forceps for defect closure. Methods From January 2015 to March 2016, 13 patients with submucosal tumors (SMTs) originating from the muscularis propria (MP) layer underwent EFTR and were enrolled in this study. After successful tumor resection, an endo-loop was anchored onto the circumferential margin of the gastric defect with grasping forceps assistance and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated. Results Of the 13 lesions in the stomach, two were located in the greater curvature of the mid-upper body, 11 were located in the fundus. The endoscopic GAL closure method was successfully performed after EFTR in all the 13 patients without laparoscopic assistance. The mean procedure time was 43.5 min (range 20–80 min), while the GAL closure procedure took a mean of 9.4 min (range 3–18 min). The mean resected lesion size was 1.5 cm (range 0.5–3.5 cm). Pathological diagnoses of these lesions were 11 gastrointestinal stromal tumors (GISTs) and two leiomyomas. No major adverse events occurred during or after the procedure. All the patients were discharged after a mean time of 2.4 days (range 1–4 days). No residual lesion or tumor recurrence was found during the follow-up period (median, 5 months; range, 1–15 months). Conclusions The endoscopic GAL closure method is feasible, effective, and safe for closing the gastric defect after EFTR in patients.