Endoscopic closure may be a viable first-line approach for select iatrogenic colonic perforations.

• No difference in treatment success between endoscopic closure and surgery (RR 1.00, 95% CI 0.94-1.06).
• Endoscopy was generally used for smaller, immediately recognized injuries, while surgery was preferred for larger, delayed presentations.
• In ideal candidates (perforations <2 cm with no peritonitis), endoscopy could shorten hospital stays.