There is relatively recent, but accumulating evidence, showing that the OTSC device can be used in the successful closure of moderate perforations which are too large for endo‐clips. The OTSC has also been used for hemostasis, for instance in point bleeding lesions. It may also be applied to perform full‐thickness biopsies of the lower GI tract. Specific accessories are available for each indication.

The device is front‐loaded onto the endoscope and is controlled by an extraendoscopic channel which is attached to the outside of the scope. The central grasping forceps are deployed to stabilize the tissue of choice and then suction is applied until vision is obliterated – similar to variceal banding; this is generally applied for five seconds and then the jaws of the capture clip are released. They have shape memory to oppose each other like jaws and are released to return to their original closed position when the handle is turned outside the patient (Figure 45.1). They have been used successfully in a few children to date for perforation closure and recently in our center to stop a point GI bleeding area successfully. A similar case is shown in Figure 45.2.

Various sizes are available and the 12 mm version is appropriate for most children. For perforation the jaws have sharp teeth but the hemostatic clips have more rounded teeth (Figure 45.3). An adaptation of this technique shows promise for obtaining full‐thickness biopsies for conditions such as Hirschsprung’s disease using a transanal approach (Figure 45.4).