Efficacy of Endoscopic Hand Suturing for Prevention of Adverse Events After Gastric Endoscopic Submucosal Dissection: A Multicenter Propensity Score-Matched Study

Background and study aims Post-endoscopic submucosal dissection (ESD) mucosal defects are associated with risks of delayed bleeding and perforation. This study aimed to evaluate the efficacy and safety of endoscopic hand suturing (EHS) for gastric ESD ulcers and to identify factors influencing its success and durability. Patients and methods We conducted a multicenter retrospective study using propensity score matching (1:3 ratio) at three institutions between 2020 and 2024. The EHS group (n=123) was compared with a non-EHS control group comprising both historical and contemporaneous controls (n=369). The primary endpoint was the overall incidence of post-ESD adverse events. Secondary outcomes included delayed bleeding, delayed perforation, technical success, suturing time, and dehiscence rates. Results Post-ESD adverse events were significantly lower in the EHS group compared to the non-EHS group (1.6% vs. 8.9%, P < 0.01). Specifically, delayed bleeding was markedly reduced (1.6% vs. 8.4%, P < 0.01). Exploratory analysis using the BEST-J classification showed numerically larger absolute risk reductions in the high-risk and very high-risk categories (21.5% and 40.0%, respectively). Complete closure was achieved in 124 of 131 EHS procedures (94.7%), with a median suturing time of 52.5 minutes. Although the dehiscence rate on postoperative day 5 was 27%, it did not increase the risk of delayed bleeding. Learning curve analysis showed that complete closure rates approached 100% after approximately 25 cases. Conclusions EHS was safely performed and was associated with fewer adverse events after gastric ESD. Procedural efficiency and success improved significantly with operator experience.