This study aimed to assess the clinical success rate of endoscopic hand suturing (EHS), defined as complete closure of the mucosal defect. While current literature supports the feasibility of closing post-ESD defects in the upper gastrointestinal tract, data regarding its application in the colorectum remain scarce. This case series assessed  the outcomes of EHS for rectal mucosal defects following ESD and for the closure of fistulous tracts. Secondary objectives included documenting intraprocedural and delayed adverse events and total procedure time.

This prospective, single-centre case series was conducted between November 2023 and October 2025 and included 12 patients meeting the following criteria: presence of a mucosal defect after rectal ESD requiring EHS, or an indication for endoscopic closure of a fistulous orifice. Data were reported descriptively using continuous quantitative variables without inferential statistical analysis.

The cohort comprised 66.6% male and 33.3% female patients, with a median age of 65.3 years (range 44–86). One patient was classified as ASA I, eight as ASA II, and three as ASA III. One patient on acetylsalicylic acid continued therapy without interruption, while another receiving a direct oral anticoagulant discontinued treatment three days prior to the procedure.

A total of 10 rectal lesions were treated, and two fistulous tracts were closed. According to the Paris classification, lesions included three 0-IIa, two 0-Is, four 0-IIa+IIc, and one 0-IIa+Is. Histology revealed eight lesions with low-grade dysplasia and one neuroendocrine tumour. Absorbable 3-0 barbed sutures mounted on 17-mm needles were used in all procedures without overtube assistance.

The overall complete closure rate was 83% (10/12). En bloc resection was achieved in 90% of ESDs, and both unsuccessful closures occurred after ESD. Fistula closure demonstrated a 100% immediate success rate; however, one case subsequently reopened, resulting in a final 50% success rate. A combined EHS-clip strategy was required in 66.6% of procedures. Intraprocedural adverse events included one perforation and one episode of bleeding not controlled with haemostatic forceps. Only one delayed bleed occurred, corresponding to the case in which suturing could not be successfully completed.

The median procedural time was 120 minutes (range 48–189), with a mean of 130 minutes.

This study suggests that EHS is both effective and safe for colorectal defect closure, achieving an 83% success rate. Published evidence supports its potential to reduce post-ESD bleeding in high-risk patients. In this series, the only perforation occurred in the sole fragmented ESD. Fistula closure achieved a 100% initial response, suggesting its potential application for other indications. Nevertheless, procedure duration remains a limiting factor, influenced by operator expertise, defect size, anatomical location, and technical complexity. The single-centre design and small sample size constitute the main limitations, underscoring the need for further research and larger multicentre studies.