Reconstructive Endoscopic Suturing for Defect Closure After Large ≥90% Circumferential Colorectal Endoscopic Submucosal Dissection

Background and Aim: Large (≥10cm) near-circumferential and circumferential colorectal endoscopic submucosal dissection (ESD) carries substantial stricture risk, with no established prophylactic strategy. We describe a reconstructive suturing technique for immediate defect closure and report its feasibility and clinical outcomes. Methodology: Consecutive patients undergoing reconstructive endoscopic suturing after ESD of colorectal lesions ≥10 cm with ≥90% circumferential involvement were analyzed. Closure was performed in patients who consented to suturing. Primary outcomes were technical feasibility in defects elected for closure, adverse events, and symptomatic stricture requiring dilatation. Secondary outcomes included post-polypectomy syndrome, delayed bleeding, perforation, length of hospital stay, resection outcomes, and dissection speed. Results: Nineteen patients underwent suturing (median specimen length 153 mm; 36.8% fully circumferential). Technical feasibility was 100% in those elected to be closed, with a median of 11 anchors and a median suturing time of 23 minutes (IQR: 14–27). En-bloc and R0 resection were 100%. No delayed bleeding, perforation, suturing-related adverse events, or symptomatic strictures occurred during a median follow-up of 30 months (planned follow-up completed in all patients). Median hospital stay was 3 days. In a contemporary (≥2019) reference comparison, symptomatic stricture occurred in 0/19 sutured versus 8/15 (53.3%) non-sutured patients, whose lesions were larger. Conclusion: Reconstructive endoscopic suturing was feasible and safe in defects selected for closure within an exceptionally high-risk cohort and showed a promising signal against post-ESD stricture, warranting prospective multicenter validation.