These are our disclosures. The most widely used endoscopic suturing device features a curved needle. In some situations, it requires the use of a traction device to facilitate suturing. The official accessory is similar to a corkscrew. This device, although quite reliable, presents with some limitations, like the difficulty to unscrew, mainly because of entrapment of the musculares mucosa. This can lead to bleeding when pulling the device out, and the possibility of suture entrapment that could lead to suture line break. Among other options of traction devices, we find a three-pronged anchoring device, single opening grasping forceps, and a double opening grasping forceps. The three-pronged anchoring device was designed initially to help in over-the-scope clip placement. This device is available in two sizes, one with longer spikes designed to be used in the stomach, and another with shorter spikes for the collar. The device with longer spikes buries deeper into the wall, making it difficult to pull the tissue into the suturing device. This was the one we used initially. A bump is felt during traction. This is probably secondary to muscularis propria release. We can see here this moment that the bump is felt. The device with shorter spikes tractions enough tissue, but no bump is felt. It also allows for a much faster operation compared to a corkscrew. This is a full suture that's performed within seconds, and the device is already released. Main limitations would be tissue release due to excessive traction. As we mentioned before, this happens only with the longer spike anchoring device due to the muscularis propria entrapment. Another problem is due to the design of the anchorage device catheter that features opening in the distal tip that improves flexibility, but could lead to suture line break if it gets entangled there. Single-opening graspers like an alligator jaw grasping forceps or a double-opening grasping forceps used in a single side could also be used. Those could be useful mainly in mucosal defects. As the forceps get into the border, it facilitates operation. Another option would be the double-opening grasper that features a sequential 90-degree opening or a more limited simultaneous opening. Those are ideal when in narrow mucosal defects with a perpendicular approach. Here we see in this model how we can trap both sides of the mucosal defect and then we perform a one-step direct suture. Again, one side, then another side. This is especially useful when the defects are not very wide. In tangential approaches, the use is much more challenging. Main limitations of these devices would be, as we mentioned, the non-perpendicular approach or when wide openings are present. In conclusion, standard corkscrew traction is useful, though there are limitations in some situations. The use of alternative traction methods could facilitate endoscopic tutoring in certain clinical situations. The three-prong anchoring devices are faster when pulling is necessary, while the grasping forceps could be useful in case of mucosal defects, especially if a perpendicular approach is found. Anyway, finding adequate indications would overcome the limitations of alternative methods.

endoscopic suturing

curved needle

three-pronged anchoring device

single-opening graspers

double-opening graspers