Endoscopic closure is the preferred therapy for iatrogenic gastrointestinal perforations, but real-world data, especially for the loop-and-clip technique, remain limited. This study evaluated technical success, clinical success, and adverse events, and the requirement of surgery across commonly used endoscopic closure methods.

This retrospective cohort study analyzed all patients with iatrogenic perforations during 229,712 endoscopic procedures (upper endoscopy, colonoscopy, ERCP, EUS, enteroscopy) at Asian Institute of Gastroenterology, Hyderabad, India from November 2022 to November 2024. Endoscopic closure strategy was determined by defect size, morphology, anatomical site, timing of recognition, and patient stability, with final discretion left to the endoscopist. Closure techniques included loop-and-clip, through-the-scope (TTS) clips and over-the-scope clips (OTSCs). The primary outcome was clinical  success, while secondary outcomes  included technical success, need of surgical intervention, and adverse events. 

During the study period, 82 perforations occurred (0.039% of incidence). The mean age of patients was 58.9 ± 14.9 years; and 54% were male. The most frequent organs with iatrogenic perforation were the duodenum (32.9%) and colon (29.2%). Perforation was identified intraprocedurally in 90% of cases, with early diagnosis (<12 hs)  in 3.6% and delayed diagnosis (≥ 12 hs) in 6%.  Endoscopic closure was attempted in 76 (92.6%) cases. Technical success was high across closure methods: Loop-and-clip achieved 92% (median size perforation size: 2.3 cm, range: 1-4cm), TTS 100% (median size 0.5cm, range: 0.5-1 cm), and OTSC 100% (median size: 1.5 cm, range: 1.0- 2.0 cm). Clinical success was achieved in 88.2% of attempted closures (loop-and-clip achieved 90% clinical success, TTS 94.7%, OTSC 100%). Perforation size was an independent predictor of closure failure (OR 2.87; 95%CI: 1.38-6.07). Adverse events occurred in 28% of the cohort (AGREE II), and overall mortality was 2.4%. Eight patients (9.7%) required surgery, including six after failed endoscopic closure attempts. Among the six patients in whom endoscopic closure was not attempted, conservative management was successful in 66.7% (4/6). 

Endoscopic closure showed strong technical and clinical performance across modalities. The loop-and-clip technique demonstrated high effectiveness and broad applicability, supporting its role as a practical closure method with acceptable adverse event rates.