BACKGROUND:Endoscopic closure techniques are essential for management of endoscopic defects and help prevent delayed bleeding and perforation. The SutuArt endoscopic hand-suturing system (EHS) is an innovative method for defect closure, but clinical data remain limited. METHODS:In a multicenter European registry study, all procedures using EHS from 14 centers were evaluated. The primary endpoint was technical success, defined as complete defect closure without additional closure techniques. Secondary endpoints were in-hospital clinical success (absence of post-interventional complications); overall defect closure rate (closure achieved with additional devices) and procedure time. RESULTS:Between February 2023 and January 2026, 338 procedures were included. Indications comprised 240 ESD (Endoscopic Submucosal Dissection), 32 EID (Endoscopic Intermuscular Dissection), 41 G-POEM (Gastric Peroral Endoscopic Myotomy), 10 fistulas, 6 EMR (Endoscopic Mucosa Resection), 3 STERs (Submucosal Tunneling Endoscopic Resection), 2 NEWS (Non-exposed Endoscopic Wall inversion Surgery), 1 anastomotic leak, 1 perforation, 1 EFTR (Endoscopic Full Thickness Resection) and 1 endoscopic hemostasis. The median defect size was 35 mm (range 4-155 mm), the median suturing time was 25 minutes (range: 4-120). Technical success was 96.2% (325/338). Overall defect closure rate was 96.7% (327/338). In-hospital clinical success was 97.9% (331/338). Defect size did not predict suturing time in the global size-time model, indicating that procedural complexity was not explained by size alone. Procedure-related adverse events occurred in 5/338 (1.5%), overall AEs were 10/338 (3%). CONCLUSION:EHS demonstrated high technical and in-hospital clinical success with a low observed short-term adverse event rate. Further studies are needed to assess the performance for complex defects.

Background and Aims Ampullary laterally spreading lesions are rare premalignant neoplasms. Endoscopic papillectomy and piecemeal endoscopic mucosal resection (EMR) are established treatment options; however, achieving en bloc R0 resection in large laterally spreading lesions remains challenging. We aimed to demonstrate the feasibility of combined endoscopic submucosal dissection (ESD), pancreatobiliary diversion, and endoscopic hand suturing for treating a lateral-spreading ampullary lesion. Methods A 57-year-old woman with a 4-cm laterally spreading ampullary adenoma underwent ESD using saline immersion, tunneling, and traction techniques. Prophylactic biliary and pancreatic stents were placed, and the post-ESD defect was closed with absorbable barbed sutures using endoscopic hand suturing. Results En bloc resection was achieved without perforation or major bleeding. Total procedure time was 119 minutes. Mild postprocedural pancreatitis resolved with conservative management. Histopathology confirmed high-grade dysplastic tubulovillous adenoma with negative margins. The pancreatic stent was removed on postoperative day 5. At the 2, 6, and 12 month follow-up endoscopies, no residual or recurrent lesion, biliary stricture, delayed bleeding, or perforation was observed. Conclusions Combined ampullary ESD with prophylactic pancreatobiliary diversion and endoscopic hand suturing appears to be a feasible organ-preserving treatment strategy for selected lateral-spreading ampullary lesions.

Background and Aims Submucosal tunneling endoscopic resection (STER) is a minimally invasive technique for treating subepithelial lesions (SELs) originating from the muscularis propria. We aimed to evaluate the efficacy and safety of STER, independent predictors of procedural outcomes, and establish evidence-based patient selection criteria. Methodology A retrospective analysis was conducted on patients who underwent STER for esophageal and gastric SELs between January 2017 and December 2024. En bloc resection was defined as complete dissection of the lesion as a single piece from its site of origin within the submucosal tunnel. Piecemeal retrieval referred to fragmentation of an en bloc-dissected specimen during transluminal extraction owing to size constraints. Primary outcomes included technical success, en bloc resection rates, and complication rates. Secondary outcomes assessed factors predictive of piecemeal retrieval, procedure difficulty, and complication risk. Multivariable logistic regression and receiver-operating characteristic (ROC) analysis were performed. Results Among 150 patients, en bloc dissection within the submucosal tunnel was achieved in 100% of cases; en bloc retrieval through the lumen was achieved in 128 patients (85.33%), while 22 (14.67%) required piecemeal retrieval. Longitudinal length was the only independent predictor of piecemeal retrieval (aOR: 1.48 per 10 mm, 95% CI: 1.04-2.11, p = 0.031) and procedural difficulty (aOR = 1.07 per mm, 95% CI: 1.02-1.12, p = 0.003). Deep muscularis propria origin was the independent predictor of complication (aOR = 114.45, 95% CI: 30.13-434.71, p < 0.001). ROC analysis established optimal cut-offs: 43 mm for piecemeal retrieval (area under the curve [AUC] = 0.986), 38 mm for difficult procedures (AUC = 0.770), and 34 mm for complications (AUC = 0.739). Conclusions STER demonstrates high efficacy and safety for treating muscularis propria-originating SELs. Longitudinal length is the strongest predictor of piecemeal retrieval and procedural difficulty, while a deep-layer origin predicts complications. An internally validated, freely accessible interactive risk calculator ( https://nomosmed.streamlit.app/ ) is provided as a research prototype to support preoperative risk stratification; external multicenter validation is required before routine clinical adoption.

Background/Aims:Transoral incisionless fundoplication (TIF 2.0) has demonstrated efficacy in Western populations; however, data from Mediterranean cohorts are limited. This prospective observational study with retrospective analysis aimed to evaluate the safety and short-term efficacy of TIF 2.0 in Turkish patients with gastroesophageal reflux disease (GERD), using culturally validated questionnaires for both typical and extraesophageal symptoms. Methods:Twenty-eight patients with chronic GERD underwent TIF 2.0 between July 2023 and March 2025 at a single Turkish tertiary center. Patient data were prospectively collected at baseline and six months after the procedure. The primary outcome was composite clinical success at 6 months, defined as improvement in at least one subjective measure (>50% improvement in gastroesophageal reflux disease health-related quality of life (GERD-HRQL) or reflux symptom index (RSI) total scores) and at least one of the following: discontinuation of proton pump inhibitor (PPI) use or endoscopic healing of esophagitis. Results:All procedures were technically successful, with no serious adverse events. Mean GERD-HRQL scores decreased significantly from 27.0±10.1 to 5.0±3.9 (p<0.001), while RSI scores decreased from 16.1±9.1 to 3.9±5.1 (p<0.001). At six months, 85.7% of the patients discontinued PPI use, with the remaining patients requiring occasional use, and patient satisfaction improved from 0% to 86% (p<0.001). All patients with baseline esophagitis (n=24) exhibited complete endoscopic healing. Conclusions:As a pilot study, these preliminary findings support TIF 2.0 as a viable treatment option and provide the foundation for future multicenter trials.

Background and Aims: Laterally spreading tumors (LSTs) located in the colon and rectum are lesions with malignant potential and present significant diagnostic and therapeutic challenges, particularly when they reach large sizes. In this case, we present the treatment of a >30-cm circumferential rectal LST using multitunnel endoscopic submucosal dissection (ESD) combined with suturing. Methods: A 51-year-old female patient underwent colonoscopic evaluation, which revealed a granular-type LST extending circumferentially from the fourth centimeter of the rectum to approximately 15 cm proximally. With the patient under general anesthesia, ESD was performed using the multitunnel technique, followed by full-thickness endoscopic suturing. The procedure was successfully completed. Results: The lesion was resected en bloc (324 × 214 mm). Histopathologic examination revealed a tubulovillous adenoma with high-grade dysplasia and clear resection margins. The patient was discharged without any reported adverse events. No recurrence or stricture was observed during 24 months of follow-up. Conclusions: The multitunnel ESD and full-thickness suturing technique is an effective, safe, and function-preserving approach for large circumferential rectal LSTs. We believe that this strategy contributes to both curative resection and the prevention of adverse events such as stricture and bleeding.

Background and Aims: Epiphrenic diverticulum (ED) is a rare pulsion-type sac that typically develops secondary to esophageal motility disorders. Although surgical resection has been the standard treatment, advances in third-space endoscopy have introduced minimally invasive alternatives. We describe an endoscopic approach combining peroral endoscopic myotomy (POEM) with septotomy-free diverticulectomy and endoscopic suturing. Methods: A 65-year-old man with spastic achalasia and ED underwent selective circular myotomy using the POEM technique. The diverticulum was inverted into the lumen, its neck closed with barbed sutures at the muscular layer, and subsequently resected from the luminal side using a polypectomy snare. The mucosal defect was closed with additional suturing. Results: The procedure was completed without adverse events. Postoperatively, the diverticulum completely disappeared, and the patient's symptoms resolved. Follow-up endoscopy confirmed complete healing with no recurrence. Conclusions: This combined technique restores the tubular anatomy of the esophagus and maintains luminal patency. Septotomy-free diverticulectomy with endoscopic suturing may represent a minimally invasive and effective alternative to surgery for select patients with EDs.

Male breast cancer, comprising approximately 1% of all breast cancer cases, often leads to the exclusion of male patients as a criterion in clinical trials. While the efficacy of Cyclin-dependent kinases 4 and 6 (CDK 4/6) inhibitors has been established in metastatic hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer in women, limited data exist on their effectiveness in male patients. We aimed to evaluate the efficacy and safety of palbociclib or ribociclib in male patients with breast cancer.

Objective: Peroral endoscopic myotomy (POEM) has proven to be a successful treatment method for achalasia in both adult and pediatric patients. Yet, there is a lack of evidence for anaesthetic management of pediatric patients who underwent POEM procedure. In this study, we aim to present perioperative and postoperative management strategies for pediatric patients with achalasia from in anaesthesia aspect. Methods: Medical records were reviewed for 16 pediatric patients at a single center who underwent POEM procedure for achalasia between 2017 and 2020. Patients’ data regarding demographics, preoperative diet, body mass index, perioperative monitoring and vitals, airway management, anaesthesia maintenance, mechanical ventilation settings duration of recovery, length of stay, pain management and adverse events were evaluated. Results: The study cohort included 7 female and 9 male patients with a mean age of 5.5 years. Anaesthesia maintenance was provided with 0.8-1.2 minimum alveolar concentration sevoflurane in a 40-60% O2-air mixture, Remifentanil infusion and bolus doses of Rocuronium. The median age was 3 years for patients ventilated in pressure controlled ventilation mode and 10 years in volume controlled ventilation mode. Respiration rate and minute ventilation were adjusted to maintain end tidal carbon dioxide (ETCO2) below 45 mmHg. Needle decompression was applied for 14 patients (87.5%) for treatment of capnoperitoneum. The mean procedure duration and recovery room duration were 66 (±22.9) minutes and 62 (±21) minutes, respectively. Postoperative pain management is provided with paracetamol and tramadol in total 8 patients (50%). There was no adverse event during postoperative period and all patients discharged in a mean time of 3 days. Conclusion: POEM has demonstrated encouraging outcomes in terms of safety and effectiveness in pediatric patients. Due to challenging nature of the pediatric patients, it is important to acknowledge that the procedure requires specialized anaesthesia management. Management of perioperative complications of increased ETCO2 requires understanding the physiologic results of pneumo-mediastinum and pneumo-peritoneum. Beside the known anaesthetic management strategies, a tailored approach should be adopted for each patient. Further investigations should be conducted to develop standardized management.

Video 1Pushing the boundaries: circumferential endoscopic submucosal dissection in distal duodenum (7.58 seconds).

Endoscopic submucosal dissection (ESD) is a minimally invasive method for treatment of early gastrointestinal (GI) tumors at any site; however, duodenal ESD is technically challenging because of the anatomic features and high risk of complications, including bleeding and perforation [1]. Here, we report a case of en bloc removal of a distal duodenal polyp of 10 cm in length using ESD, followed by endoscopic closure.

Gastric cancer is one of the leading causes of cancer-related mortality worldwide. Endoscopic submucosal dissection (ESD), when indicated based on tumor size, stage, and histological characteristics, is a highly successful curative, minimally invasive, non-surgical endoscopic treatment option. However, the risk of adverse events is higher compared to traditional methods. Here, we present a case of ESD in an early-stage gastric carcinoma and endoscopic closure using a new hand-suturing system.

No data on the efficacy of cyclin-dependent kinase 4/6 inhibitors (CDKi) were presented in randomized clinical trials in patients with metastatic breast cancer (mBC) with bone marrow involvement. This study aimed to investigate the efficacy and safety of CDKi in patients with mBC with bone marrow involvement. The data of patients with bone marrow-involved hormone receptor-positive (HR+) Her2-negative mBC between 2019- 2022 who received ribociclib or palbociclib in combination with endocrine therapy (ET) were retrospectively analyzed within the thirteen centers. The median age of 23 patients included in the study was 48 (range: 29-75). Eleven (48.8%) of the patients were denovo metastatic. Eight of the patients (34.8%) received CDKi treatment in the first line, 5 (21.7%) in the second line, and 10 (43.5%) in ≥ the 3rd line. In addition to bone marrow metastasis, 39.1% of the patients had bone +/- lymph nodes, and 56.5% had bone + visceral organ metastasis. Of the patients, 15 (65.2%) received ribociclib and 8 (34.8%) received palbociclib. When the CDKi response was evaluated, 2 (8.7%) of the patients had a complete response, 11 (47.8%) had a partial response, 8 (34.8%) had stable disease, and 2 (8.7%) had progressive disease. Median follow-up was 15.1 (95% CI: 5.8-24.5) months. The progression-free survival (PFS) of patients who received CDKi in first-line was 21.3 (95% CI: 0.8-41.9) months, those who received CDKi in second-line 13.1 (95% CI: 6.9-19.3) months, and those who received CDKi in ≥3rd line 5.3 (95% CI: 3.9-6.7) months (p=0.004). CDKi dose reduction was required in 60.9% of patients. CDKi was discontinued in 2 (8.7%) patients due to cytopenias and 56.5% due to disease progression. Eleven (47.8%) patients had grade ≥3 neutropenia, and 5 (21.7%) patients had grade ≥3 thrombocytopenia. No treatment-related death was detected. It has been shown that PFS similar to those in randomized clinical studies can be achieved with CDK 4/6 inhibitors combined with ET in treating hormone receptor-positive Her2-negative bone marrow-involved metastatic breast cancer. The CDKi discontinuation associated with cytopenia was also meager showed that CDKi treatment could be safe in this patient group.

Amaç: Bu çalışmada Karayaka koyunlarının koç katım dönemi, gebeliğin 50. günü ve doğumdan sonraki 3. ayda vücut kondisyonları ve etki eden faktörlerin belirlenmesi amaçlanmıştır. Materyal ve Yöntem: Araştırmanın hayvan materyalini özel bir işletmede yetiştirilen 110 Karayaka koyunu oluşturmuştur. Farklı dönemlerdeki vücut rezervlerinin tespiti için koç katım dönemi, gebeliğin 50. günü ve doğumdan sonraki 3. ayda vücut kondisyon puanlaması verileri kullanılmıştır. Araştırma Bulguları: 3 döneme ait vücut kondisyon puanları arasındaki korelasyon katsayıları sırasıyla 0.315, 0.342 ve 0.408 olarak hesaplanmış olup istatistiksel olarak anlamlı bulunmuştur (p