Using a through-the-scope tack and suture system in patients with gastrointestinal wall defects: an alternative option beyond endoscopic clipping

We read with great interest the case series from the USA of 53 patients undergoing through-the-scope suturing (TTSS) to achieve endoscopic mucosal defect apposition [1]. Technical and clinical success rates were 96.2 % and 92.4 %, respectively. The investigators reported that TTSS was both feasible and safe, and adds to the armamentarium of endoscopic closure devices.

There is increasing interest in the TTSS technology as a good option for patients with gastrointestinal wall defects, particularly in selected patients who definitively require closure which cannot be sufficiently achieved with standard endoclips [2] [3] [4]. However, there are still some issues that need further investigation. 1) The authors did not report closure times using TTSS with and without additional through-the-scope clips, which may carry a longer procedure time compared with simple endoscopic clipping. 2) There were no methods of cost analysis. A major limitation of the device may be the cost especially in cases where multiple devices are required (mispositioning of one of the four tacks would require use of additional suturing devices for effective closure), as this not only prolongs procedure time but also adds to the time and costs of anesthesia. 3) Complications during the application of the TTSS device and after treatment were not defined? 4) The authors report the procedural characteristics and clinical outcomes in detail; however, these data are difficult to interpret without a reference for comparison.

The results are very encouraging, but it is critical that TTSS is fully and seriously evaluated in order to identify the most suitable patients. From a societal standpoint, global adoption of this novel technology will require both availability and a robust cost-effectiveness profile. Time will tell. Retrospective studies have their limitations and there is urgent need for a large prospective study to further confirm the efficacy and safety of TTSS compared with standard endoscopic clipping for gastrointestinal wall defect closure.

Publication History

Article published online:
27 September 2023

• References

• 1 Krishnan A, Shah-Khan SM, Hadi Y. et al. Endoscopic management of gastrointestinal wall defects, fistula closure, and stent fixation using through-the-scope tack and suture system. Endoscopy 2023; DOI: 10.1055/a-2019-3652.
• 2 Bi D, Zhang LY, Alqaisieh M. et al. Novel through-the-scope suture closure of colonic endoscopic mucosal resection defects. Gastrointest Endosc 2023; DOI: 10.1016/j.gie.2023.02.031.
• 3 Farha J, Ramberan H, Aihara H. et al. A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study. Endoscopy 2023; DOI: 10.1055/a-1970-5528.
• 4 Albéniz E. Further new evidence regarding clipping following colorectal endoscopic mucosal resection. Endoscopy 2021; 53: 1160-1161