**Background:** Since the introduction of diagnostic endoscopy, the field has advanced remarkably, enabling minimally invasive management of life-threatening conditions such as gastrointestinal (GI) bleeding, full-thickness injuries, morbid obesity, and achalasia. Endoscopic tissue approximation has evolved over the past 15 years, with devices ranging from through-the-scope clips to sophisticated endoscopic suturing systems. This narrative review describes currently available endoscopic tissue approximation technologies and their clinical applications.
**Methods:** The authors conducted a narrative review of all relevant and available literature on endoscopic tissue approximation devices published over the last 15 years. The review covers four main device categories: through-the-scope clips, over-the-scope clips (Ovesco), the OverStitch Endoscopic Suturing System, and the X-Tack through-the-scope suturing tool.
**Key Results:** Through-the-scope clips can be used in endoscopes with a 2.8-mm working channel and are effective as monotherapy for hemostasis. The Resolution 360 clip demonstrated 100% reliability when fired on a 10-mm gel simulating dense fibrinous tissue. The Ovesco over-the-scope clip (FDA approved 2010) was analyzed in a review of 24 publications and 466 acute injuries, achieving successful closure in 419 (90%) cases with only one reported adverse event. Through-the-scope clipping showed 100% success for perforations smaller than 10 mm. For non-acute defects, Chon et al. studied 13 patients with upper GI leaks using the OverStitch device, demonstrating 100% success in patients without prior leak management attempts (61.5% of cases), while all patients with prior failed attempts required further intervention. Mukewar et al. reviewed 56 patients undergoing fistula closure with OverStitch, reporting 100% initial technical success, with 17 (30%) requiring delayed repeat endoscopic intervention and 6 requiring surgery. Morrell et al. achieved 66% successful closure at 6 months in 97 patients with fistulas or leaks, with only 15% requiring surgery. For stent anchoring, migration rates decreased from 27–40% to 8–17% with suture fixation. Kantsevoy et al. reported no stent migration after suture fixation in 7 patients. A comparison study showed 8% vs. 27% migration rates with and without suture fixation. Ngamruengphong et al. demonstrated a decrease from 33% to 16% migration rate in 125 patients. A meta-analysis by Law et al. of 14 studies with 212 patients found a 17% migration rate after endoscopic suture fixation. In bariatric applications, Neto et al. analyzed 233 patients undergoing endoscopic sleeve gastroplasty (ESG) with mean baseline BMI of 34.7, showing weight loss of 17.1% at 6 months and 19.7% at 12 months with one bleeding complication. Sharaiha et al. studied 91 patients (mean pre-procedure BMI 40.7±7.0 kg/m²), showing 14.4% total body weight loss at 6 months, 17.6% at 12 months, and 20.9% at 24 months, with significant reductions in hemoglobin A1c, systolic blood pressure, alanine aminotransferase and serum triglycerides. Alqahtani et al. reviewed 1,000 patients (mean baseline BMI 33.3±4.5 kg/m²) with mean total weight loss of 13.7%±16.8% at 6 months, 15%±7.7% at 12 months, and 14.8%±8.5% at 18 months; complications included readmission in 24 (2.4%), severe abdominal pain in 8 (0.8%), bleeding in 7 (0.7%), with 2 (0.2%) requiring blood transfusion. Novikov et al. compared ESG, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in 278 patients (mean baseline BMI 43.82±0.5 kg/m²), finding 6-month weight loss of 14.37% for ESG vs. 23.48% for LSG and 12.68% for LAGB, with complication rates of 2.20%, 9.17%, and 8.96% respectively. For peroral endoscopic myotomy (POEM), Pescarus et al. found closure time was significantly shorter with clips (16±12 vs. 33±11 minutes) and lower cost ($1,502±849 vs. $2,521±575 USD), but the OverStitch was useful for large defects.
**Clinical Implications:** Endoscopic tissue approximation devices have expanded the range of GI conditions manageable through minimally invasive approaches, potentially reducing the need for surgical interventions. The OverStitch device provides surgical-quality suturing endoscopically, with particular utility in closing large or irregular defects, anchoring stents to prevent migration, and performing bariatric procedures like ESG. While through-the-scope and over-the-scope clips offer faster, less expensive options for smaller defects and acute perforations, suturing devices provide more robust closure for complex cases. The authors emphasize that surgeons, particularly foregut specialists, must actively participate in developing and using these technologies to maintain leadership and drive innovation. Further research is needed as these devices continue to be refined.