Background:
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are advanced gastrointestinal lesion resection techniques that allow for precise resection and curative treatment while minimizing need for surgical interventions. However, both techniques carry an increased risk of bleeding and perforation. As such, endoscopic closure devices such as the traditional through-the-scope clip (TTSC) and the recently introduced through-the-scope suturing (TTSS) offer immediate closure of mucosal defects (Video). The choice of appropriate device closure depends on several factors, including defect size, location, and macroscopic appearance. Appropriate device selection and awareness of potential adverse outcomes can enhance endoscopic closure success rate and reduce complication rates. This study compares the technical success of closure devices and adverse events using traditional TTSC and newer TTSS.

Methods:
A retrospective review was conducted on patients who underwent gastrointestinal lesion resection with subsequent endoscopic closure using TTSC or TTSS. Demographic and clinical variables were systematically collected. Primary outcomes included technical success and adverse events. The secondary outcome was to compare the cost-effectiveness of these endoscopic closure techniques.

Results:
The study comprised of 122 patients with 126 TTSC closures (mean age, 64.4 years; 54.1% males) and 95 patients with 95 TTSS closures (mean age, 66.4 years; 55.8% females) (Table 1). The ascending colon was the most common site of both TTSC and TTSS closure device applications. Technical success rates were 100% for TTSC and 98.9% for TTSS, with mean defect sizes of 33.1 ± 10.1 mm and 42.1 ± 17.26 mm, respectively. Three patients (3.1%) in the TTSS group required rescue treatment with TTSC after initial technical success. Adverse events were more common in the TTSC group, with 4.8% experiencing bleeding and one case of perforation (0.8%). In contrast, the TTSS group reported one instance of self-reported bleeding that did not necessitate further intervention. The mean number of TTSS tacks varied based on defect size: 4 for defects less than 2 cm, 3.9 for defects between 2-4 cm, and 6.0 for defects greater than 4 cm (Table 2). Helix Tack system (U.S. $695/device) demonstrates cost parity with approximately 4 TTSCs (U.S. $150-$250/clip).

Conclusion:
The TTSS Helix Tack system proves to be an effective and safe method for closing large defects after gastrointestinal lesion resection. Furthermore, the Helix Tack system demonstrates cost parity with approximately 4 TTSCs. Moreover, helix tack device effectively reduces defect sizes, facilitating closure with cost-effective clips, especially in scenarios where original defects may be too large or cumbersome for primary clip closure. Further prospective comparative studies are needed.

Table 1: Baseline Characteristics

Table 2: Outcomes

Karim Badawi

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