Table 1.

Endoscopic Devices Used in the Closure or Covering of Transmural Defects

Device/ Technique	Mechanism of action	Description	Best Use	Defect characteristics for success	Advantage(s)	Disadvange(s )
TTSC	Closure	Hemostatic clips used to approximate tissue. Defect closure is off-label use, only the Resolution 360™ Clip (Boston Scientific, Natick, Mass) is FDA approved for this application.	Acute wall defect: perforation	Location/distance from the entrance orifice: anywhere in the GI tract Size: smaller than 1 to 2 cm) Margin: non-everted regular edges Tissue quality: healthy	Ease of application	Limited to smaller defects and healthy tissue with regularmargins.
Cap mounted clips	Closure	Clips housed in distal attachment cap. Designed with internal prongs to approximate tissue for defect closure.	Acute/Chronic wall defect: perforation, leak and fistulas	Location/distance from the entrance orifice: anywhere in the GI tract Size: smaller than 3 cm Margin: non-everted or everted edges Tissue quality: healthy	Ease of application	Limited to smaller defects and healthy tissue.
Endoloop	Closure	Defects are approximated and sealed with endoloops alone or with clips. Defect closure is off-label use.	Acute wall defect: perforation	Location/distance from the entrance orifice: anywhere in the GI tract Size: between 3 to 5 cm Margin: non-everted or everted edges Tissue quality: healthy	Cheaper device for larger defects	Technically demanding Limited evidence
Endoscopic sutures	Closure	Can be used for interrupted or running full-thickness tissue apposition to close wall defects.	Acute/Chronic wall defect: perforation, leaks and fistulas	Location/distance from the entrance orifice: best for esophagus, stomach and rectum. Can be done in duodenum and colon but is challenging. Size: any size can be closed with the suture device Margin: non-everted or everted edges Tissue quality: healthy	Can be applied at complex wall defect	Technically demanding Not optimal for small spaces. Requires a double-channel endoscope
Cardiac septal occluder	Closure/ Covering	Nitinol, dumbbell shaped occluder plug with polyethylene terephthalate sewn-in patch. Defect closure is off-label use.	Chronic leaks and fistulas	Location/distance from the entrance orifice: anywhere in the GI tract Size: any size. You need to select the correct size of the device correlated to the defect size Margin: non-everted or everted edges Tissue quality: unhealthy (well-established fistula tract)	Ease of application	Limited evidence Expensive
Tissue sealants	Closure/ Covering	Can be used either by fistula embolization or Chronic fistula by submucosal injection into the edges of the fistula until the lumen is occluded. Other technique includes combining an absorbable mesh with a sealant application for larger fistula. Better results when used in conjunction with other endoscopic techniques.	Chronic fistula	Location/distance from the entrance orifice: anywhere in the GI tract Size: most effective in long narrow fistula tract. Margin: non-everted or everted edges Tissue quality: unhealthy (well-established fistula tract)	Ease of application	Rarely successful as mono-therapy Multiple sessions required Relatively expensive
Luminal Stents	Covering	Stent placement acts by covering the defect and diverting enteral contents.	Acute wall defect: perforationand leaks	Location/distance from the entrance orifice: best for esophagus and after bariatric surgery. Size: any size that the stents can cover Margin: non-everted Tissue quality: healthy or unhealthy	Ease of application Better results in upper GI tract	Only can be used in narrow lumens. Fully covered has higher chance of migration (should fixed in place) Partially covered can be difficult to remove