An ultra-minimally invasive attempt: endoscopic hand-suturing for delayed anastomotic fistula after low rectal cancer surgery

A case description A delayed anastomotic fistula after low rectal cancer surgery is defined as a defect occurring more than 30 days postoperatively, forming a fistulous communication with adjacent structures.[ 1​ ] [ ​2​ ] Anastomotic fistulas are associated with higher rates of permanent stoma and functional impairment[ 2​ ] [ ​3​ ] and can significantly reduce patients’ quality of life.[ 4​ ] We report a novel endoscopic hand-suturing (EHS) technique for managing delayed anastomotic fistulas after low rectal cancer surgery. A 60-year-old man underwent ultra-low anterior resection (ULAR) for a malignant rectal tumour located 3 cm from the anal verge. The postoperative TNM stage was T1N0M0, and no adjuvant therapy was administered. The perioperative course was uneventful, and the diverting ileostomy was reversed as scheduled. One year after surgery, the patient presented with low-grade fever, localized lower abdominal pain, and tenesmus. Imaging and endoscopic evaluation ([ Fig. 1 ]) revealed a mucosal defect measuring 1.0×0.6 cm at the anastomosis, consistent with a delayed anastomotic fistula without urethral involvement. After being fully informed of the condition and associated risks, the patient elected to undergo EHS in combination with antibio-tic therapy. Under endoscopic guidance, purulent secretions and necrotic tissue around the fistula were debrided, followed by suturing using our previously reported original suturing device.[ 5​ ] The suture was secured to the mucosa by knotting the tail end, allowing fixation during tightening ([ Fig. 2 ]). After continuous suturing, the suture was tightened and fixed with titanium clips, achieving complete fistula closure ([ Fig. 3a, b ], [ Video 1 ]). The patient was discharged on postoperative day 2 without adverse events. Follow-up colonoscopy at 3 months confirmed complete fistula closure ([ Fig. 3c ]), and the patient remained asymptomatic. Fig. 1 Delayed anastomotic fistulas after ultra-low anterior resection: ( a ) an endoscopic view showing a mucosal defect (arrow) around the anastomosis; ( b ) the fistula with purulent discharge, surrounded by erythematous and edematous mucosa. Fig. 2 An endoscopic hand-suturing device: ( a ) absorbable barbed suture with a needle (VLOCL0803; Covidien, Mansfield, MA, USA) used for endoscopic suturing, with the suture tail knotted (arrow); ( b ) endoscopic suturing using the custom-designed needle holder to manipulate the suture (entrusted manufacturer: Vedkang, Jiangsu, China); ( c ) the knot at the suture tail (arrow) secures the suture during tightening, preventing slippage. Fig. 3 Endoscopic hand-suturing closure of the fistula: ( a ) after completing suturing and tightening the suture, the remaining suture tail was secured with a titanium clip. ( b ) The fistula was completely closed after suturing. ( c ) Follow-up colonoscopy at 3 months showed healed fistula and spontaneous detachment of the titanium clip. Video 1 Endoscopic hand-suturing for closure of a delayed anastomotic fistula after ultra-low anterior resection. Download Video Endoscopic management of postoperative rectal anastomotic fistulas remains exploratory. This case demonstrates the safety and feasibility of EHS as a novel treatment option for delayed anastomotic fistulas following ULAR. Endoscopy_UCTN_Code_TTT_1AQ_2AG Publication History Received: 14 April 2026 Accepted after revision: 29 May 2026 Article published online: 30 June 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany