Endoscopic treatment of gastrointestinal perforations and leaks: Why, when, and how?

Table 1 Endoscopic modalities for gastrointestinal defect closure

Endoscopic modality	Benefits	Limitations	Ideal use case
TTSC	Widely available and low-cost	Limited closure strength	Small defects
	Easy to deploy through standard endoscopes	Not suitable for large defects
	Short procedure time	Multiple clips may be required	Healthy tissue
	Multiple sizes	Spontaneous dislodgement
OTSC	Full-thickness closure and strong compression	Requires withdrawal and reinsertion	Large defects
	Durable closure with a single device	Difficult to remove	Fibrotic tissue
	Useful for larger defects		Area with easy access
Endoscopic stents	Early oral intake	Migration risk, especially SEPS	Esophagus
	Diversion of luminal contents, promoting healing	May cause pressure necrosis or ulceration
	Useful in leaks not amenable to direct closure	Need for repeat endoscopy for stent retrieval/replacement	Large defects
	Can cover large defects	Difficult use in lower GI
EVT	Highly effective for chronic leaks and large cavities	Multiple endoscopic sessions for sponge changes	Large cavities with abscess formation
	Promotes granulation tissue and healing	Patient discomfort	Patients with significant surgical risk
	Can be used when other modalities fail	Less widely available and technically demanding
Tissue adhesives	Minimally invasive and easy to apply	Limited efficacy as a stand-alone therapy	Small defects
	Useful as an adjunct to clips or stents	Variable durability	Combination with other modalities
		Limited data
Endoscopic suturing	Full-thickness, flexible, and customizable closure	Specialized equipment and advanced expertise	Large defects
			Fibrotic tissue
	Effective for larger defects	Longer procedure time	Area with easy access
	Can be combined with stents or other therapies	Limited availability and high cost	Post-ESD defects

TTSC: Through-the-scope clips; OTSC: Over-the-scope clips; GI: Gastrointestinal; EVT: Endoscopic vacuum therapy; SEPS: Self-expanding plastic stents; ESD: Endoscopic submuscoasl dissection.