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Nowadays, endoscopic submucosal dissection (ESD) is commonly performed for the removal of large gastrointestinal lesions. Endoscopic mucosal defect closure after ESD is vital to avoid adverse events. In recent years, many innovative instruments have emerged and proved to be beneficial. In this paper, we conducted a thorough literature review and summarized the closure methods for large‐size post‐ESD mucosal defects over decades. We separated these methods into five categories based on the operational principle: "side closure" method, "ring closure" method, "layered closure" method, "hand suturing closure" method, and "specially designed device closure" method. Side closure with clips assisted by instruments such as threads or loops is applicable for each segment of the gastrointestinal tract to prevent postoperative bleeding. If the defect tension is too large to close with the traditional side closure methods, zigzag closure and ring closure could be applied to gather the bilateral defect edges together and achieve continuous closure. In the stomach and rectum with a high risk of submucosal dead space between the submucosa and muscular layers, side closure methods with muscle layer grasping clip or layered closure methods could enable the involvement of the deep submucosa and muscle layers. The ring closure method and specially designed devices including over‐the‐scope clip, Overstitch, and X‐tack could resolve perforation effectively. Individual closure method requires endoscope reinsertion or sophisticated operation, which may be limited by the deep location and the narrow lumen, respectively. Although specially designed devices are expected to offer promising prospectives, the cost‐effectiveness remains to be a problem. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large‐teeth clips have also been developed. The over‐the‐scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip‐line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O‐ring closure, and the reopenable clip over‐the‐line method, have been developed. In recent years, techniques often utilized for full‐thickness ER of submucosal tumors have been widely used in full‐thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: A prior study using porcine colon demonstrated the feasibility of a novel injectable, temperature?responsive, and biodegradable collagen sol (ICS) that transforms from a liquid to a gel state in response to body temperature for endoscopic closure of perforation during endoscopic resection (ER). This study aims to report the acute and survival outcomes of ICS for gastric perforations during ER. Methods: In two experiments using nine live pigs under general anesthesia, four and six perforations (3‐5\xA0mm) were created using an electrosurgical knife in acute and survival experiments, respectively. ICS was delivered to the perforations using an endoscopic catheter. In Experiment 1, a leak test and histopathology were performed on all explanted stomachs after euthanization. In Experiment 2, perforation sites were assessed by gastroscopy and histopathology 7, 14 and 28\xA0days post?procedure. Results: In Experiment 1, gastroscopy confirmed complete closure of the perforations with ICS and no evidence of leak. Subsequent histopathology revealed a fixation of collagen gel (CG) as a sealant agent at the perforation sites. There were no adverse effects related with ESD or the use of ICS. In Experiment 2, histopathology revealed a fixation of CG as a sealant agent, replacement with granulation tissue and no CG; and fibrotic tissue at 7, 14 and 28\xA0days, respectively. Conclusions: This study presents a novel method using ICS, demonstrating promising efficacy and safety profile for endoscopic closure of perforations during ER. Further studies are necessary before translating to clinical use. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic submucosal dissection (ESD) poses a risk of intraprocedural perforation. We have developed a biodegradable injectable collagen sol that undergoes a liquid‐to‐gel formation in response to body temperature. Here, we investigated the feasibility of this novel collagen sol for the endoscopic closure of iatrogenic perforation holes. Methods: In two experiments, 12 and 5 colonic perforation holes (3–5 mm) were made using an ESD knife in four and three live pigs under general anesthesia, respectively. In Experiment 1, collagen sol was delivered to the perforation holes using an endoscopic catheter. When the colon was expanded by CO2 insufflation, endo‐clips were applied to the perforation holes. For Experiment 2, Collagen sol adjusted based on the Experiment 1 results was delivered to the perforation holes in the same manner. A leak test was performed for every colon after the pigs were killed, and the histology of the perforation sites was evaluated. Results: In both experiments, collagen sol was smoothly delivered to the target area and fixed as a gel on the perforation holes. Experiment 1, 83% (10/12) of the perforation holes were completely closed, and all endo‐clips were placed with composure. Experiment 2, all perforation holes were completely closed with collagen gel. There was no leak from the perforation holes. Histology revealed a fixation of the collagen gel as an embolus agent in the perforation holes. Conclusions: This novel collagen sol may be used for the endoscopic closure of intraprocedural perforation. Further studies will determine this collagen sol's clinical feasibility and safety. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation. This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing. As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the risk of perforation. In addition, the risk of peritonitis cannot be completely eliminated even if a perforation is closed successfully. Reported here are two cases of early colon cancer in which the patients sustained iatrogenic perforations of the ascending colon during conventional endoscopic mucosal resection and of the sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18 G Medicut needle. Both of these perforations were successfully treated by endoscopic clipping. In conclusion, conservative medical management may be possible in patients who have undergone successful closure of colonic perforations using endoscopic clipping. In order to perform immediate endoscopic closure, abdominal decompression has been useful to decrease patient discomfort and colonic lumen collapse. Now, CO2 insufflation is being used effectively for the prevention of pneumoperitoneum. [ABSTRACT FROM AUTHOR]