The occurrence of a perforation during endoscopic resection (ER) of a gastrointestinal lesion is a relatively rare but potentially life-threatening complication. It consists of a transmural defect of the gastrointestinal (GI) wall, which can lead to severe sequelae with consequent huge morbidity and mortality for the patient and a remarkable burden for the healthcare system [1]. Despite continuous improvements and innovations in techniques and devices in the last decade, perforation risk is still not negligible during advanced ER procedures such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Specifically, EMR carries a perforation risk of about 1–3%, while rates between 2% and 15%, depending on the GI tract involved, are reported by the studies on ESD [[2], [3], [4], [5], [6], [7], [8], [9]]. In addition, due to the worldwide spreading of screening programs, the increasing indications for ER of large superficial lesions in both the upper and lower GI and the growing adoption of third-space endoscopic procedures, the absolute number of perforations is globally increasing [10].

Management of perforations during ER depends on the location, severity and time of diagnosis [1]. Surgical treatment, which involves primary repair, resection, exclusion or diversion of the perforated organ, has the advantage of being definitive but involves greater invasiveness, morbidity and mortality [11]. Endoscopic treatment, which relies on techniques that close the endoluminal defect with clips, suturing devices, stents, or vacuum therapy, has the advantage of being less invasive, but requires experience and skills.

Current data, despite the lack of high-quality trials, support endoscopic closure as the primary method over surgery, the ancient standard of care, for the treatment of intraprocedural perforation during ER(12). Thus, though a multidisciplinary approach with radiologists and promptly available surgeons is still mandatory and surgical treatment remains the definitive treatment and the only option in some harmful clinical scenarios, endoscopic treatment has gained a pivotal role for the management of perforations occurring during ER. The closure of intraprocedural perforation during ER is most often feasible and allows conservative management without the need for surgery or long hospital stay [13]. Endoscopists cannot consider anymore perforation as a fearful catastrophe, which discourages them from attempting a resection, but as an accepted event they have to effectively and promptly handle. The increasing availability of novel closing devices holds the promise of improving remarkably the effectiveness and expanding the possibilities of endoscopic closure. However, current evidence is very limited and there is lack of robust studies supporting international guidelines. Our review aims to provide a general approach to the management of perforation during ER, focusing on the description, limitations, and potentialities of traditional and new closing devices.