Endoscopic closure technique performance for iatrogenic perforation: a systematic review and meta-analysis

Perforation is the most feared endoscopy-related adverse event. Various closure techniques are available, including through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), and over-the-scope suturing (OTSS). Given the lack of comparative performance estimates, we sought to systematically appraise TTSC, OTSC, and OTSS performance for iatrogenic perforation.

MEDLINE and Embase were independently searched between June 1947 and January 2024 for citations evaluating TTSC, OTSC, or OTSS performance. Technical success was defined as complete apposition of the borders of the defect with visual confirmation. Clinical success was defined as technical success without further intervention. Pooled estimates using random-effects modeling were generated and stratified by closure modality, location, perforation etiology, and time.

Thirty-seven citations assessing 795 perforations were included. Pooled technical and clinical success were 91.5% (95% confidence interval [CI], 87.9-94.1; I ² = 26%) and 86.3% (95% CI, 81.9-89.8; I ² = 39%). Technical success of TTSCs, OTSCs, and OTSS was 89.3% (95% CI, 82.6-93.6), 90.7% (95% CI, 86.0-93.9), and 94.9% (95% CI, 83.8-98.5; P = .53), respectively. Clinical success of TTSCs, OTSCs, and OTSS was 85.3% (95% CI, 77.9-90.6), 86.2% (95% CI, 80.4-90.5) and 94.9% (95% CI, 83.8-98.5) (P = .24). Clinical success was significantly higher for tissue resection-related perforations (P = .02) and perforations in the stomach (P < .04); no difference in clinical success was identified when stratifying by closure modality and time (all P > .05).

TTSCs, OTSCs, and OTSS are effective for iatrogenic perforation management, especially in tissue resection-related perforations and perforations in the stomach. No difference in performance was identified on the basis of closure modality or time.