Clinical Endoscopy

Review

Variety and clinical applications of endoscopic closure techniques: Osamu Goto, Eriko Koizumi; Received January 6, 2026 Accepted March 31, 2026 Published online August 19, 2026; DOI: https://doi.org/10.5946/ce.2026.010 [Epub ahead of print]

Abstract PDF: As endoscopic therapy has progressed, various endoscopic closure techniques have been developed to prevent adverse events and to facilitate complex therapeutic procedures. The development of closure techniques began in the 1970s with the introduction of clipping for mucosal defects after gastric polypectomy. Currently, these techniques are applied primarily to prevent post-procedural bleeding from mucosal defects resulting from endoscopic submucosal dissection; to repair iatrogenic perforations involving full-thickness defects; and to complete endoscopic full-thickness resection. They can be categorized into clipping, tissue apposition, suturing, and stapling, each with distinct advantages and disadvantages. Therefore, familiarity with each method and the ability to select the most appropriate technique for a given situation are essential.

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Original Articles

Endoscopic Suturing for the Prevention and Treatment of Complications Associated with Endoscopic Mucosal Resection of Large Duodenal Adenomas: Jaeil Chung, Kelly Wang, Alexander Podboy, Srinivas Gaddam, Simon K. Lo; Clin Endosc 2022;55(1):95-100. Published online March 3, 2021; DOI: https://doi.org/10.5946/ce.2020.281

Abstract PDF

Background
/Aims: Endoscopic mucosal resection (EMR) is the primary treatment for duodenal adenomas; however, it is associated with a high risk of perforation and bleeding, especially with larger lesions. The goal of this study was to demonstrate the feasibility and safety of endoscopic suturing (ES) for the closure of mucosal defects after duodenal EMR.
Methods
Consecutive adult patients who underwent ES of large mucosal defects after EMR of large (>2 cm) duodenal adenomas were retrospectively enrolled. The OverStitch ES system was employed for closing mucosal defects after EMR. Clinical outcomes and complications, including delayed bleeding and perforation, were documented.
Results
During the study period, ES of mucosal defects was performed in seven patients in eight sessions (six for prophylaxis and two for the treatment of perforation). All ES sessions were technically successful. No early or delayed post-EMR bleeding was recorded. In addition, no clinically obvious duodenal stricture or recurrence was encountered on endoscopic follow-up evaluation, and no patients required subsequent surgical intervention.
Conclusions
ES for the prevention and treatment of duodenal perforation after EMR is technically feasible, safe, and effective. ES should be considered an option for preventing or treating perforations associated with EMR of large duodenal adenomas.

Citations

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Management of non-ampullary duodenal adenomas
Gaurav B Nigam, Yash Kanani, Amol Bapaye, Pradeep Mundre
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Three-Dimensional Flexible Endoscopy Can Facilitate Efficient and Reliable Endoscopic Hand Suturing: An ex-vivo Study: Jun Omori, Osamu Goto, Kazutoshi Higuchi, Takamitsu Umeda, Naohiko Akimoto, Masahiro Suzuki, Kumiko Kirita, Eriko Koizumi, Hiroto Noda, Teppei Akimoto, Mitsuru Kaise, Katsuhiko Iwakiri; Clin Endosc 2020;53(3):334-338. Published online April 24, 2020; DOI: https://doi.org/10.5946/ce.2019.207

Abstract PDF Supplementary Material

Background
/Aims: Three-dimensional (3D) flexible endoscopy, a new imaging modality that provides a stereoscopic view, can facilitate endoscopic hand suturing (EHS), a novel intraluminal suturing technique. This ex-vivo pilot study evaluated the usefulness of 3D endoscopy in EHS.
Methods
Four endoscopists (two certified, two non-certified) performed EHS in six sessions on a soft resin pad. Each session involved five stitches, under alternating 3D and two-dimensional (2D) conditions. Suturing time (sec/session), changes in suturing time, and accuracy of suturing were compared between 2D and 3D conditions.
Results
The mean suturing time was shorter in 3D than in 2D (9.8±3.4 min/session vs. 11.2±5.1 min/session) conditions and EHS was completed faster in 3D conditions, particularly by non-certified endoscopists. The suturing speed increased as the 3D sessions progressed. Error rates (failure to grasp the needle, failure to thread the needle, and puncture retrial) in the 3D condition were lower than those in the 2D condition, whereas there was no apparent difference in deviation distance.
Conclusions
3D endoscopy may contribute to increasing the speed and accuracy of EHS in a short time period. Stereoscopic viewing during 3D endoscopy may help in efficient skill acquisition for EHS, particularly among novice endoscopists.

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Reviews

Endoscopic Full Thickness Resection for Gastrointestinal Tumors - Challenges and Solutions: Hung Leng Kaan, Khek Yu Ho; Clin Endosc 2020;53(5):541-549. Published online February 17, 2020; DOI: https://doi.org/10.5946/ce.2019.161

Abstract PDF

Standard polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection (ESD) are established techniques for the treatment of gastrointestinal tumors. However, resection of submucosal tumors via ESD often results in low rates of microscopically margin-negative (R0) resection and high rates of perforation. Endoscopic full thickness resection (EFTR) overcomes this adverse event and aids in the therapeutic management of complex tumors.
Multiple techniques for EFTR have been developed, each with its own advantages and disadvantages. Submucosal tunneling and nonexposed techniques are generally preferable, because the layer of overlying intact mucosa reduces the incidence of intraperitoneal contamination by the gastric fluid and dissemination of the tumor cells. However, adoption of EFTR by endoscopists in clinical practice remains low. The major challenge seems to be the technical difficulty in performing laparoscopic and/or endoscopic suturing using the currently available instruments.
We developed a novel robotic endoscopic platform with suturing capabilities to overcome the technical challenges of suturing. This platform allows easy maneuvering and triangulation of the instruments, thus facilitating endoscopic suturing using robotic arms. Our studies have demonstrated that this robotic endoscopic platform with suturing capabilities is an effective and safe method for performing EFTR with endoscopic suturing.

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Closing the Gaps: Endoscopic Suturing for Large Submucosal and Full-Thickness Defects: Keshav Kukreja, Suma Chennubhotla, Bharat Bhandari, Ankit Arora, Shashideep Singhal; Clin Endosc 2018;51(4):352-356. Published online March 5, 2018; DOI: https://doi.org/10.5946/ce.2017.117

Abstract PDF

This article is a systematic review of relevant literature on endoscopic suturing as a primary closure technique for large submucosal and full-thickness defects after endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). A comprehensive literature search was conducted through 2016 by using PubMed, to find peer-reviewed original articles. The specific factors considered were the procedural indications and details, success rates, clinical outcomes including complications, and study limitations. Six original articles were included in the final review: two with non-human subjects and four with human subjects. The mean success rate of endoscopic suturing was 97.4% (100% for human subjects and 95.4% for non-human subjects). The procedural time ranged from 7 to 89 min. The average size and depth of lesions were 2.71 cm (3.74 cm [human] and 1.96 cm [non-human]) and 1.52 cm, respectively. The technique itself had no reported impact on mortality. In conclusion, endoscopic suturing is a minimally invasive technique for the primary closure of defects caused by EMR, ESD, and EFTR, with a high success and low complication rate.

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