A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video)

Background and Aims Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME). Methods In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary end points included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure. Results All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative day 3–5 (73.8% for ESD defects vs. 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥ 5 mm (HR: 0.313, 95% CI 0.023‒0.781, P = 0.009) as the only independent advantage factor for the sustained closure. Conclusion EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥ 5 mm may achieve more reliable sustained closure.