DDW 2026, Chicago, USA. Day 3

Brief Introduction Peroral endoscopic myotomy (POEM) has become an established treatment for achalasia with durable long-term efficacy. However, a subset of patients develop recurrent or persistent dysphagia after initial symptom improvement. At DDW 2026, emphasis was placed on the importance of structured reassessment and individualized management rather than reflexive repeat intervention. Background / Clinical Context Symptom recurrence after myotomy is clinically challenging because dysphagia may arise from multiple mechanisms beyond persistent lower esophageal sphincter obstruction. Reflux disease, structural esophageal remodeling, technical procedural factors, and altered esophageal mechanics can all contribute to persistent symptoms, making comprehensive evaluation essential before selecting further therapy. Key Points from DDW 2026 The session highlighted that treatment decisions after failed or recurrent symptoms following POEM should not rely solely on manometric abnormalities. Available therapeutic options include pneumatic dilation, repeat POEM, and laparoscopic Heller myotomy, but no single approach has demonstrated universal superiority across all clinical scenarios. Management therefore requires individualized selection based on symptom profile, anatomy, and prior procedural history. Long-term follow-up data continue to support the durability of POEM, with sustained clinical success in the majority of patients over several years. Nevertheless, gradual decline in symptom control may occur in some individuals over time, underscoring the need for ongoing surveillance and reassessment. Several mechanisms of symptom recurrence were reviewed. Gastroesophageal reflux was identified as one of the most common contributors and may present with varying degrees of esophagitis. Structural changes such as progressive esophageal dilation, sigmoid deformity, and blown-out myotomy can additionally impair esophageal emptying despite technically adequate sphincter disruption. Blown-out myotomy in particular was associated with abnormal distal esophageal distension and persistent regurgitation symptoms. Comprehensive diagnostic reassessment was strongly emphasized and typically includes high-resolution manometry, upper endoscopy, timed barium esophagram, and EndoFLIP evaluation. Concordance between impaired distensibility and manometric obstruction may support benefit from repeat intervention, whereas discordant findings may suggest reflux or alternative mechanisms better managed conservatively. Technical considerations during the index procedure were also discussed. Excessively long myotomies or extensive gastric extension may increase risks of reflux and structural complications, reinforcing the importance of balanced procedural planning and intra-procedural physiologic assessment. Clinical Interpretation These findings reinforce that recurrent dysphagia after POEM is multifactorial and requires careful physiologic and structural reassessment before additional intervention. Not all symptom recurrence reflects inadequate myotomy, and inappropriate repeat procedures may worsen outcomes in selected patients. What Is New or Practice-Changing? Practice-informing: DDW 2026 emphasized multimodal reassessment using manometry, timed barium esophagram, and EndoFLIP to guide individualized management of recurrent symptoms after POEM rather than relying on isolated diagnostic findings. Limitations / Caution Comparative long-term outcome data between repeat POEM, pneumatic dilation, and surgical revision remain limited. Emerging therapies for complications such as blown-out myotomy are still evolving and require further validation. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 highlighted that recurrent dysphagia after POEM should prompt comprehensive reassessment rather than automatic repeat intervention. Reflux, structural esophageal remodeling, and procedural factors frequently contribute to persistent symptoms alongside residual outflow obstruction. Integration of endoscopy, manometry, timed barium esophagram, and EndoFLIP may improve diagnostic accuracy and help tailor individualized management strategies in this complex patient population.

Brief Introduction Bleeding following endoscopic mucosal resection (EMR) remains one of the most important complications in therapeutic endoscopy. At DDW 2026, emphasis was placed on understanding predictors of post-EMR bleeding, differentiating immediate from delayed hemorrhage, and implementing structured preventive and management strategies to improve patient safety and outcomes. Background / Clinical Context Post-EMR bleeding may occur either during the procedure or several days after discharge, making risk assessment and follow-up planning critically important. Delayed bleeding is particularly concerning because it may present unexpectedly and require urgent intervention. Although overall incidence remains relatively low, bleeding risk increases substantially in complex lesions and high-risk patients. Key Points from DDW 2026 The presentation reviewed the multifactorial determinants of post-EMR bleeding. Important patient-related risk factors included advanced age, anticoagulant or antiplatelet therapy, cardiovascular disease, and renal impairment. Lesion-related predictors included larger lesion size, particularly ≥20 mm, flat or laterally spreading morphology, and right-sided colonic location where thinner bowel wall anatomy and increased vascularity may predispose to delayed hemorrhage. Procedural factors such as deep resection, electrocautery use, and incomplete hemostasis further contribute to bleeding risk. A major focus was individualized risk stratification using predictive models that integrate lesion characteristics, antithrombotic therapy, and comorbidities. These tools may help identify patients requiring prophylactic interventions or intensified monitoring. Careful management of anticoagulant and antiplatelet therapy was emphasized as particularly important, balancing bleeding risk against thromboembolic complications. Preventive procedural strategies included meticulous lesion assessment, controlled electrocautery use, optimal visualization, and selective prophylactic clipping, especially for large proximal colon lesions. Endoscopic therapy remains the primary management modality for active bleeding, with available options including hemoclips, argon plasma coagulation, bipolar coagulation, and epinephrine injection. Combination therapy is often preferred in complex or high-risk bleeding scenarios. The discussion also highlighted the importance of guideline-driven management pathways integrating pre-procedural assessment, intra-procedural vigilance, and post-procedure monitoring to support timely recognition and intervention. Clinical Interpretation These findings reinforce that post-EMR bleeding should be approached proactively through individualized risk assessment and targeted preventive strategies rather than reactive treatment alone. Lesion size, anatomical location, and antithrombotic exposure remain among the strongest determinants of risk. What Is New or Practice-Changing? Practice-informing: DDW 2026 emphasized integrated risk-stratified management of post-EMR bleeding using predictive models, individualized prophylactic strategies, and guideline-based endoscopic therapy. Limitations / Caution Bleeding risk prediction models vary in performance across patient populations and procedural settings. Management decisions regarding antithrombotic therapy must remain individualized and guideline-concordant. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 highlighted post-EMR bleeding as a multifactorial complication requiring careful procedural planning, individualized risk assessment, and structured follow-up. Larger lesions, right-sided colonic location, and antithrombotic therapy substantially increase bleeding risk. Preventive strategies such as selective prophylactic clipping and meticulous hemostasis may reduce complications, while endoscopic therapy remains the cornerstone of management when bleeding occurs.

Brief Introduction Esophageal dilation is a fundamental therapeutic procedure for benign and complex strictures but carries the risk of deep mural injury and perforation. At DDW 2026, emphasis was placed on the critical challenge of distinguishing deep post-dilation tears from true transmural perforation, as management decisions differ substantially and directly impact patient outcomes. Background / Clinical Context Deep mucosal disruption after dilation can appear alarming endoscopically, often mimicking perforation despite preservation of full-thickness integrity. Incorrect interpretation may result either in unnecessary invasive intervention or delayed recognition of clinically significant injury. Accurate differentiation therefore requires integration of endoscopic findings, procedural context, imaging, and clinical monitoring. Key Points from DDW 2026 The session highlighted several important risk factors for deep injury and perforation, including advanced age, radiation-induced fibrosis, anastomotic strictures, markedly narrowed luminal diameter, and prior interventions altering tissue compliance. These features increase susceptibility to uneven esophageal expansion during dilation and should influence procedural planning and escalation thresholds. Technique-related factors were also emphasized. Balloon dilation provides controlled radial force and is generally preferred for precision, whereas bougie dilation additionally exerts axial force that may increase risk in selected cases. Gradual stepwise dilation, adherence to the “rule of three,” and fluoroscopic guidance in complex anatomy remain key safety principles. A major focus was recognition of endoscopic signs suggestive of true perforation. While deep mucosal tears may expose submucosal layers, findings such as visualization of peri-esophageal fat (“fat sign”) or a deep cavity resembling a “black hole” strongly indicate full-thickness injury requiring urgent escalation. Cap-assisted reassessment and fluoroscopic contrast evaluation immediately after dilation were recommended to further assess luminal integrity before patient transfer from the procedure area. The presentation also stressed the importance of close post-procedure clinical monitoring. Symptoms including chest pain, tachycardia, fever, and subcutaneous emphysema may precede definitive imaging abnormalities. When suspicion persists, contrast esophagography and CT imaging provide complementary information regarding leaks, mediastinal air, and contained perforation. Early therapeutic re-intervention using clips, stents, or endoscopic closure techniques may be effective in selected stable patients. Clinical Interpretation These findings reinforce that deep post-dilation tears should not automatically be classified as perforations. Careful endoscopic interpretation combined with structured clinical and imaging assessment is essential to balance timely intervention against unnecessary overtreatment. What Is New or Practice-Changing? Practice-informing: DDW 2026 emphasized a structured algorithmic approach integrating endoscopic findings, fluoroscopic assessment, imaging, and clinical monitoring to improve differentiation between deep mural injury and true esophageal perforation. Limitations / Caution The discussion was largely expert- and case-based without comparative prospective outcome data. Interpretation of endoscopic findings may remain operator-dependent, particularly in complex strictures and post-radiation anatomy. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 highlighted that deep mucosal tears following esophageal dilation are relatively common and do not necessarily represent full-thickness perforation. Accurate diagnosis depends on careful recognition of specific endoscopic signs, immediate reassessment, clinical monitoring, and appropriate imaging correlation. A structured stepwise management approach may help avoid both unnecessary intervention and delayed recognition of serious injury, ultimately improving procedural safety and patient outcomes.

Brief Introduction Colonoscopy quality directly influences colorectal cancer prevention and long-term patient outcomes. At DDW 2026, the development of a national electronic health record (EHR)-based quality dashboard was presented as a scalable strategy to standardize performance measurement, automate quality tracking, and support continuous improvement across healthcare systems. Background / Clinical Context High-quality colonoscopy is strongly associated with reduced interval colorectal cancer risk and mortality. Key procedural quality indicators such as adenoma detection rate (ADR), bowel preparation adequacy, cecal intubation rate, and withdrawal time are well-established markers of examination quality. However, large-scale measurement remains challenging because manual data abstraction is labor-intensive, documentation practices vary substantially, and benchmarking across institutions is difficult. Key Points from DDW 2026 The presentation outlined a national framework designed to standardize colonoscopy quality assessment using automated EHR data extraction. The system integrates structured and unstructured clinical data, enabling scalable benchmarking across institutions and providers. Core workflow components included identification of colonoscopy procedures within EHR systems, extraction of procedural variables, analytic processing, and visualization through a user-friendly dashboard. A major focus was the use of natural language processing (NLP) to capture clinically relevant information from free-text endoscopy reports. NLP applications included extraction of polyp characteristics, procedural findings, and narrative clinical details that would otherwise remain inaccessible for large-scale analytics. This allowed conversion of unstructured documentation into standardized measurable data. Validation and reliability were emphasized as essential for clinician acceptance. Data accuracy was assessed through comparison with manual chart review, ongoing quality checks, and reproducibility testing. The dashboard additionally enabled provider-level ADR monitoring, peer benchmarking, identification of performance variability, and targeted quality improvement interventions. Large-scale implementation demonstrated the feasibility of EHR-driven quality monitoring across thousands of procedures. Benefits included standardized reporting, improved metric comparability, enhanced accountability, and the ability to perform system-wide performance analysis. Future directions discussed included incorporation of AI-driven analytics, expansion of quality metrics, and development of real-time clinical decision support systems. Clinical Interpretation These findings suggest that automated EHR-based dashboards may substantially improve the scalability and consistency of colonoscopy quality measurement. Reliable benchmarking and feedback systems could help reduce variability in procedural performance and strengthen colorectal cancer prevention efforts. What Is New or Practice-Changing? Potentially practice-informing: DDW 2026 highlighted how NLP-enabled EHR dashboards can automate colonoscopy quality assessment and support continuous system-level quality improvement at national scale. Limitations / Caution Implementation depends heavily on EHR infrastructure, documentation quality, interoperability, and continuous validation processes. Variability between healthcare systems may affect generalizability and reproducibility. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 emphasized the growing role of EHR analytics and NLP in transforming colonoscopy quality assessment from manual review to scalable automated monitoring. ADR remains the most important quality metric, but comprehensive dashboards integrating multiple procedural indicators may enable more standardized benchmarking, targeted performance feedback, and continuous quality improvement across healthcare systems.

Brief Introduction Esophageal symptom evaluation remains challenging because conventional diagnostic tools frequently fail to explain patient symptoms or demonstrate physiologic abnormalities. At DDW 2026, the concept of translational physiomechanics was presented as an emerging framework integrating biomechanics, advanced physiological assessment, and artificial intelligence to better characterize esophageal disease. Background / Clinical Context Patients with dysphagia, chest pain, and regurgitation commonly undergo endoscopy, manometry, and esophagram testing, yet many continue to have inconclusive or discordant findings. Traditional pressure-based metrics may inadequately capture the dynamic processes underlying bolus transit and symptom generation, contributing to persistent diagnostic uncertainty and frequent classification into functional disorders. Key Points from DDW 2026 The session emphasized a shift from static pressure measurements toward dynamic assessment of esophageal biomechanics and bolus transit. Esophageal emptying was conceptualized as a multistage physiological process involving compartmentalization, ampullary flow, and coordinated luminal mechanics. Advanced pressure topography and distension-based metrics now permit more detailed characterization of bolus retention and flow patterns beyond conventional high-resolution manometry (HRM). Functional Lumen Imaging Probe (FLIP) panometry was highlighted as a major advancement in esophageal diagnostics. FLIP simultaneously evaluates luminal geometry, distensibility, and contractile activity in real time during endoscopy, providing information not obtainable through pressure measurements alone. Parameters such as esophagogastric junction (EGJ) distensibility index may better identify clinically relevant obstruction and abnormal EGJ opening dynamics. The discussion also reviewed repetitive antegrade contractions (RACs), physiologic contraction patterns observed during esophageal distension. The “Rule of 6” was described as a reproducible RAC pattern reflecting coordinated neuromuscular activity and intrinsic pacing mechanisms within the esophagus. These patterns may offer new mechanistic insights into motility disorders and abnormal neural regulation. A major future direction involves combining FLIP panometry, impedance planimetry, and AI-driven analysis to develop hybrid physiologic models capable of improving diagnostic precision and personalizing therapy selection in esophageal disease. Clinical Interpretation These findings suggest that many esophageal disorders may be better understood through dynamic biomechanical assessment rather than isolated pressure measurements alone. FLIP panometry may help bridge current diagnostic gaps, particularly in patients with persistent symptoms despite inconclusive conventional testing. What Is New or Practice-Changing? Potentially practice-informing: DDW 2026 highlighted translational physiomechanics and FLIP panometry as emerging tools that may redefine classification and evaluation of esophageal motility disorders through dynamic functional assessment and AI integration. Limitations / Caution Many physiomechanical concepts and AI-driven approaches remain investigational and require further validation before widespread clinical implementation. Standardization of interpretation and integration into routine practice are still evolving. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 presented translational physiomechanics as a new framework for understanding esophageal disease by integrating biomechanics, dynamic luminal assessment, and artificial intelligence. FLIP panometry emerged as a particularly promising tool for evaluating EGJ function, esophageal distensibility, and contractile behavior beyond conventional manometry. These advances may improve diagnostic accuracy, refine motility disorder classification, and support more personalized management strategies for complex esophageal symptoms.

Brief Introduction Gastroduodenal disorders remain among the most challenging conditions in gastroenterology because symptoms frequently occur without clear structural abnormalities. At DDW 2026, the state-of-the-art discussion focused on functional dyspepsia (FD), gut–brain interaction disorders, duodenal immune activation, and the growing recognition of overlapping behavioral and motility syndromes. Background / Clinical Context Functional dyspepsia is now increasingly understood as a multifactorial disorder of gut–brain interaction rather than a purely acid- or motility-driven condition. Patients commonly present with epigastric pain, early satiety, postprandial fullness, nausea, and overlapping symptoms involving esophageal, gastric, and behavioral dysfunction. Diagnostic complexity increases further in patients with connective tissue disorders, autonomic dysfunction, rumination syndrome, or ARFID. Key Points from DDW 2026 The session emphasized that FD involves complex interactions among gut motility, mucosal immunity, microbiome alterations, visceral hypersensitivity, and central nervous system processing. Rome V criteria categorize FD into epigastric pain syndrome and postprandial distress syndrome, reflecting differing symptom patterns and potentially distinct mechanisms. Population studies continue to demonstrate that many symptomatic patients lack structural abnormalities on endoscopy, reinforcing the functional nature of the disorder. A major focus was the emerging role of duodenal dysfunction and low-grade inflammation. Meta-analytic evidence demonstrates increased eosinophils and mast cells in the duodenum of FD patients, supporting a model in which mucosal immune activation disrupts gastric accommodation, gastric emptying, and sensory signaling. Microbiome alterations and post-infectious changes, including post-COVID phenomena, were additionally discussed as contributors to symptom persistence. The presentation also highlighted the importance of recognizing overlapping gut–brain and behavioral disorders. Rumination syndrome was described as a behavioral and physiological disorder characterized by effortless regurgitation, diagnosable using combined manometry and impedance monitoring. ARFID was emphasized as increasingly prevalent among patients with DGBI, often contributing to severe weight loss, nutritional compromise, and healthcare utilization. Newly recognized motility disorders such as retrograde cricopharyngeus dysfunction and inability-to-belch syndrome were also reviewed, illustrating how advances in high-resolution impedance manometry are expanding understanding of upper GI physiology and symptom generation. Clinical Interpretation These findings support a transition from a purely structural disease model toward an integrated biopsychosocial framework for FD and related gastroduodenal disorders. Immune activation, altered motility, microbiome disruption, and behavioral factors likely interact simultaneously to drive symptom burden. What Is New or Practice-Changing? Practice-informing: DDW 2026 reinforced the emerging role of duodenal immune activation and gut–brain dysfunction in FD while highlighting the importance of recognizing overlapping disorders such as rumination syndrome and ARFID in complex upper GI presentations. Limitations / Caution Many mechanistic findings remain associative rather than causative, and targeted therapies addressing immune or microbiome pathways are still evolving. Diagnostic overlap between disorders remains substantial, making individualized assessment essential. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 highlighted the evolving understanding of functional dyspepsia and gastroduodenal disorders as multifactorial gut–brain conditions involving immune activation, microbiome alterations, motility disturbances, and psychosocial factors. Increasing recognition of duodenal eosinophilia, rumination syndrome, ARFID, and newly described motility disorders is reshaping diagnostic frameworks and therapeutic approaches. Effective management increasingly requires individualized, multidisciplinary, patient-centered care rather than reliance on structural findings alone.

Brief Introduction Metabolic surgery continues to represent the most effective and durable intervention for obesity and obesity-related metabolic disease. At DDW 2026, the discussion focused on the evolving role of bariatric surgery within chronic disease management frameworks, including perioperative pharmacotherapy, multidisciplinary care, and long-term survival benefits. Background / Clinical Context Obesity is increasingly recognized as a chronic, relapsing disease requiring sustained long-term management rather than isolated short-term intervention. While pharmacologic therapies such as GLP-1 receptor agonists have expanded treatment options, metabolic surgery continues to provide superior and more durable outcomes in weight reduction, metabolic improvement, and complication risk reduction, particularly in moderate to severe obesity. Key Points from DDW 2026 The session emphasized the substantial survival advantage associated with bariatric surgery. Large observational and real-world studies consistently demonstrate nearly a 50% reduction in all-cause mortality compared with usual care. Surgery was also associated with significant increases in life expectancy, averaging approximately 6.1 additional years overall and nearly 9.3 years in patients with type 2 diabetes. These findings reinforce the role of metabolic surgery as a disease-modifying and potentially life-prolonging therapy rather than simply a weight-loss procedure. Preoperative optimization was highlighted as another critical determinant of outcome. Achieving greater than 10% total weight loss before surgery was associated with approximately 42% reduction in postoperative mortality. Preoperative weight reduction may additionally improve operative feasibility, reduce liver size, and facilitate postoperative recovery. A major theme was the increasing integration of pharmacotherapy into perioperative obesity care. Preoperative medical therapy may optimize metabolic status and reduce operative risk, while postoperative pharmacotherapy can support further weight reduction and reduce weight regain. Emerging evidence suggests that combined medical and surgical approaches may produce superior long-term outcomes compared with either modality alone. The session also emphasized that effective obesity management requires multidisciplinary systems of care involving surgeons, obesity medicine specialists, dietitians, pharmacists, and advanced practice providers. Accredited programs such as MBSAQIP were highlighted for improving standardization, safety monitoring, and personalized treatment planning. Clinical Interpretation These findings support the concept that obesity should be managed similarly to other chronic diseases using long-term, multimodal treatment pathways. Metabolic surgery remains the central therapeutic modality for durable disease control, while pharmacotherapy and multidisciplinary support increasingly serve complementary roles. What Is New or Practice-Changing? Practice-informing: DDW 2026 reinforced the growing “treat-to-target” obesity model integrating surgery, pharmacotherapy, endoscopic therapy, and lifestyle intervention within coordinated multidisciplinary systems. Limitations / Caution Much of the survival and life expectancy data derives from observational and real-world evidence rather than randomized long-term trials. Outcomes also depend heavily on patient selection, perioperative optimization, and long-term adherence to multidisciplinary follow-up. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 emphasized that metabolic surgery remains the most effective and durable treatment for obesity, providing major benefits in long-term survival, metabolic improvement, and life expectancy. Preoperative optimization and perioperative pharmacotherapy may further enhance outcomes, particularly in high-risk patients. The evolving management paradigm increasingly integrates surgery within multidisciplinary chronic disease care models designed to provide individualized, long-term obesity management.

Brief Introduction Endoscopic bariatric therapies are rapidly evolving as minimally invasive options for obesity and metabolic disease management. At DDW 2026, major focus was placed on the growing role of endoscopic sleeve gastroplasty (ESG), emerging gastric and small bowel interventions, and the integration of endobariatric therapy into long-term multidisciplinary obesity care. Background / Clinical Context Obesity is increasingly recognized as a chronic relapsing disease requiring durable and individualized treatment strategies. Endobariatric therapies were initially positioned between pharmacologic therapy and bariatric surgery but are now expanding across a broader BMI spectrum, including patients with BMI >27 with associated comorbidities. These approaches aim to provide meaningful weight loss while minimizing invasiveness and procedural risk. Key Points from DDW 2026 ESG was highlighted as the most established and widely adopted endoscopic bariatric procedure. Using full-thickness endoscopic suturing, ESG reduces gastric volume without surgical resection and is typically performed as an outpatient procedure with low complication rates. Clinical data, including findings from the MERIT study, demonstrated approximately 50% excess weight loss at one year, with sustained benefit extending up to five years. Significant improvements in metabolic parameters such as HbA1c, insulin resistance, and blood pressure were also observed. The mechanism of ESG appears primarily related to delayed gastric emptying while preserving gastric motility and contractility, enhancing satiety without substantially worsening reflux symptoms. Baseline gastric emptying characteristics may additionally help predict treatment response and support more personalized therapy selection. Intragastric balloons remain an important non-anatomy-altering option, although weight loss durability is generally inferior to ESG, with weight regain commonly occurring after device removal. Emerging gastric therapies such as swallowable balloons, adjustable systems, novel suturing platforms, and bariatric endoscopic antral myotomy (BEAM) continue to broaden the endoscopic obesity treatment landscape. The session also reviewed small bowel–targeted metabolic therapies including duodenal mucosal resurfacing (DMR) and vapor ablation techniques designed to replicate some metabolic benefits of bariatric bypass surgery. Early studies demonstrated promising glycemic improvements and possible insulin discontinuation in selected patients with type 2 diabetes. Experimental approaches such as magnet-assisted anastomosis and electroporation were additionally presented as potential incisionless metabolic interventions for future practice. Clinical Interpretation These findings suggest that endobariatric therapy is transitioning from a niche procedural field toward an integrated component of chronic obesity and metabolic disease management. ESG currently appears to offer the strongest balance of efficacy, safety, and durability among available endoscopic options. What Is New or Practice-Changing? Potentially practice-informing: DDW 2026 reinforced the long-term durability of ESG and highlighted the expanding role of metabolic endoscopy, including small bowel therapies targeting glycemic control beyond weight reduction alone. Limitations / Caution Many emerging therapies remain investigational with limited long-term comparative data. Outcomes remain highly dependent on multidisciplinary follow-up, patient adherence, and integration with lifestyle and pharmacologic therapy. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 highlighted the rapid evolution of endoscopic bariatric therapy, with ESG emerging as the leading minimally invasive gastric remodeling procedure capable of producing durable weight loss and metabolic improvement. New gastric and small bowel–targeted interventions are expanding therapeutic possibilities, particularly for patients with obesity and type 2 diabetes. Long-term success, however, depends on integrating endoscopic therapy within a comprehensive multidisciplinary obesity management strategy.

Brief Introduction Complex gastrointestinal lesions may closely mimic neoplastic, inflammatory, or vascular disorders, creating major diagnostic and therapeutic challenges. At DDW 2026, several rare and atypical cases highlighted the importance of advanced tissue acquisition, individualized endoscopic strategies, and careful clinicopathologic correlation in achieving accurate diagnosis and optimal management. Background / Clinical Context Many uncommon gastrointestinal lesions present with nonspecific symptoms such as bleeding, dysphagia, or strictures and may resemble more common malignancies or benign conditions on routine endoscopy. Superficial biopsies are frequently non-diagnostic, emphasizing the growing role of advanced endoscopic techniques for both diagnosis and therapy. Key Points from DDW 2026 A recurrent upper GI bleeding case initially suspected to represent a subepithelial tumor was ultimately identified as a Dieulafoy lesion after removal of prior hemostatic clips exposed a prominent underlying vessel. Bipolar coagulation achieved hemostasis, while full-thickness resection was performed because of persistent concern for neoplasia. Histopathology confirmed a vascular lesion rather than tumor, underscoring the diagnostic overlap between Dieulafoy lesions and subepithelial masses. Diffuse esophageal papillomatosis was presented as a rare cause of chronic dysphagia in a young patient with extensive circumferential lesions. Given the diffuse disease burden, management relied on staged piecemeal endoscopic mucosal resection combined with cryotherapy for residual lesions, achieving symptomatic improvement while acknowledging ongoing malignant transformation risk. Additional cases demonstrated infiltrative and aggressive pathologies mimicking malignancy. Localized gastric amyloidosis presented as an irregular vascular gastric lesion highly suspicious for cancer. Endoscopic ultrasound and specialized staining confirmed isolated gastric amyloid deposition without systemic involvement. Similarly, primary esophageal melanoma presented as a pigmented obstructing lesion with subsequent metastatic progression despite intervention, highlighting the aggressive nature and poor prognosis of this rare malignancy. The session also emphasized the importance of deep tissue acquisition in persistent structural disease. In a patient with longstanding dysphagia and recurrent strictures initially attributed to candidiasis, repeated superficial biopsies failed to establish diagnosis until band-assisted endoscopic mucosal resection obtained deeper tissue confirming verrucous esophageal carcinoma. Surgical resection achieved favorable outcome in early-stage disease. Clinical Interpretation These cases reinforce that atypical gastrointestinal lesions often require escalation beyond standard biopsy techniques. Integration of advanced imaging, deep tissue sampling, endoscopic resection methods, and histopathologic expertise is essential when clinical suspicion persists despite inconclusive initial evaluation. What Is New or Practice-Changing? Practice-informing: DDW 2026 highlighted the expanding role of tailored endoscopic management and advanced tissue acquisition strategies in diagnosing rare gastrointestinal lesions that mimic more common pathology. Limitations / Caution The session was based on rare case presentations and expert procedural experience rather than comparative clinical trials. Generalizability may therefore be limited, particularly for uncommon malignancies and infiltrative disorders. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 showcased several diagnostically challenging gastrointestinal lesions where vascular, infiltrative, inflammatory, and malignant conditions closely mimicked alternative pathology. The cases emphasized the importance of maintaining diagnostic suspicion when routine biopsies are inconclusive and highlighted the growing value of advanced endoscopic techniques, deep tissue sampling, and individualized therapeutic planning to achieve accurate diagnosis and appropriate management.

Brief Introduction Barrett’s esophagus with low-grade dysplasia (LGD) represents an important premalignant stage in the progression toward esophageal adenocarcinoma. At DDW 2026, emphasis was placed on the importance of meticulous endoscopic evaluation, standardized classification systems, and structured biopsy protocols to improve early dysplasia detection and guide management decisions. Background / Clinical Context Barrett’s esophagus is defined by replacement of normal squamous epithelium with specialized columnar mucosa extending at least 1 cm above the gastroesophageal junction. Progression from non-dysplastic Barrett’s to LGD, high-grade dysplasia, and invasive adenocarcinoma occurs through a stepwise neoplastic sequence, making accurate surveillance critically important for cancer prevention. Key Points from DDW 2026 The session highlighted that high-quality endoscopic inspection remains central to detecting dysplasia. Careful mucosal cleansing, adequate insufflation, prolonged inspection time, and use of high-definition imaging were emphasized as essential techniques to improve visualization of subtle lesions. Accurate identification of anatomical landmarks, including the squamocolumnar junction and gastroesophageal junction, is equally important because errors in measurement may alter risk assessment and surveillance intervals. Standardized classification systems were reviewed as critical tools for consistent documentation and management planning. The Prague classification was emphasized for describing Barrett’s segment length, while the Paris classification was used to characterize visible lesion morphology. Associated reflux esophagitis should additionally be graded using the Los Angeles classification. A structured biopsy strategy remains essential because many dysplastic lesions are inconspicuous or completely invisible under standard imaging. The Seattle protocol using systematic four-quadrant biopsies at regular intervals significantly improves dysplasia detection. Targeted biopsies of any visible abnormality are particularly important, especially when enhanced imaging techniques such as chromoendoscopy reveal subtle mucosal or vascular irregularities suggestive of LGD. Management of confirmed LGD requires individualized decision-making. Options include continued close surveillance or endoscopic eradication therapy. Because interpretation of LGD is challenging and subject to interobserver variability, confirmation by experienced gastrointestinal pathologists and referral to specialized Barrett’s centers were strongly recommended. Clinical Interpretation These findings reinforce that successful Barrett’s surveillance depends less on technology alone and more on meticulous examination technique, standardized reporting, and disciplined biopsy protocols. Early LGD may be extremely subtle, requiring careful inspection and expertise for accurate diagnosis. What Is New or Practice-Changing? Practice-informing: DDW 2026 reinforced the importance of structured high-quality Barrett’s surveillance, advanced imaging, and expert pathological confirmation to optimize detection and management of low-grade dysplasia. Limitations / Caution The discussion primarily focused on procedural principles and expert practice recommendations rather than new comparative clinical trial data. Variability in pathological interpretation of LGD remains an important limitation in clinical practice. The available information is limited, so the interpretation should be cautious. Final Clinical Summary DDW 2026 emphasized that Barrett’s esophagus with LGD requires a highly systematic approach integrating careful endoscopic inspection, standardized classification systems, enhanced imaging, and structured biopsy protocols. Because dysplastic lesions are often subtle or invisible, prolonged examination time and expert pathological confirmation are essential. Accurate early detection allows timely intervention and may reduce progression to advanced neoplasia and esophageal adenocarcinoma.