Commentary.

Abstract

The immersion into the submucosal layer with endoscopic submucosal dissection two decades ago led us to a new era of third-space endoscopy and endoscopic full-thickness resection, whereby many lesions, even with full-thickness muscularis propria involvement, can be safely removed endoscopically. Therefore, endoscopic recognition, characterization, and management of iatrogenic full-thickness mural defects is critical to ensure technical success and safety [1] [2]. The focus has now been increasingly shifting towards developing new devices to close progressively larger defects throughout the gastrointestinal tract. These closure tools, including through-the-scope (TTS) clipping, suture-based, or endoscopic vacuum therapy, need to be adapted to the size and location of the defects. In an experimental study [3] and in this video, Zhang et al. showed the efficacy of novel TTS twin clips (TTS-TCs) for closing wounds ≥ 25 mm, when intertwined with traditional TTS clips, functioning as coadjuvants in reducing submucosal dead space and achieving a firm closure effect. In summary, the TTS-TC holds great promise as a definitive mural closure device as it can be used in a deflated lumen, in situations where access is poor, and promptly without the need for endoscope exchange or reinsertion. Further prospective comparative studies are required to establish efficacy, safety, and cost–effectiveness.