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“Yoga in Endoscopy” refers not only to physical flexibility but also to the integration of ergonomics, posture control, breathing discipline, mental focus, and stress reduction into daily endoscopic practice. Modern therapeutic endoscopy is physically and mentally demanding, with high rates of musculoskeletal injury, fatigue, burnout, neck and back pain, thumb strain, and repetitive stress disorders among endoscopists and endoscopy staff. Yoga-based principles can improve posture awareness, spinal alignment, hand stability, breathing control, and procedural endurance during prolonged endoscopic procedures such as ESD, ERCP, POEM, and advanced EUS. Stretching exercises, core strengthening, controlled breathing, and mindfulness techniques may help reduce operator fatigue, improve concentration, and enhance procedural precision. Ergonomic optimization—including monitor height, scope handling, foot pedal positioning, and body mechanics—works synergistically with these practices. From a practical standpoint, incorporating short stretching routines before and between procedures may improve comfort and reduce cumulative occupational injury. Although evidence is still evolving, wellness-focused training is increasingly recognized as an important component of sustainable endoscopy practice. Yoga in endoscopy matters because high-quality therapeutic endoscopy depends not only on technical skill and technology, but also on the long-term physical and mental well-being of the endoscopist.

Per-rectal endoscopic myotomy (PREM) is an emerging third-space endoscopic technique developed for the treatment of Hirschsprung’s disease, particularly in selected adolescents and adults with short-segment disease or persistent obstructive symptoms after surgery. Adapted from principles of POEM, PREM involves creation of a submucosal tunnel in the rectum followed by selective myotomy of the aganglionic muscular segment to relieve functional outlet obstruction. The procedure is performed endoscopically through the rectum using submucosal injection, mucosal incision, tunneling, targeted myotomy, and mucosal closure with clips. PREM offers a minimally invasive alternative to conventional surgery and may reduce morbidity associated with transabdominal or redo surgical procedures. Early studies demonstrate improvement in constipation, bowel emptying, abdominal distension, and quality of life in carefully selected patients. From a practical perspective, patient selection is critical and requires confirmation of Hirschsprung’s disease with manometry, imaging, and histopathology. The technique demands expertise in third-space endoscopy because complications may include bleeding, perforation, infection, pneumoperitoneum, and incomplete myotomy. Long-term data remain limited. PREM is clinically important because it represents the expansion of advanced endoscopic myotomy techniques beyond the esophagus and stomach into colorectal motility disorders, potentially offering organ-preserving minimally invasive therapy for selected Hirschsprung’s disease patients.

EUS-guided portal pressure measurement and EUS-guided coiling represent important advances in interventional EUS, expanding endoscopy into the field of portal hypertension management. EUS-guided portal pressure measurement allows direct assessment of portal hemodynamics by accessing the portal and hepatic veins under real-time ultrasound guidance, providing a minimally invasive alternative to conventional transjugular hepatic venous pressure gradient (HVPG) measurement. It can be combined with EUS-guided liver biopsy and variceal evaluation during a single session, creating a comprehensive “one-stop” hepatology assessment. EUS-guided coiling is primarily used for gastric varices and difficult ectopic varices. Under Doppler guidance, metallic coils are deployed into the variceal complex to induce thrombosis and reduce blood flow. Coils are often combined with cyanoacrylate glue, where the coil acts as a scaffold that improves obliteration while reducing embolization risk. This approach is increasingly favored in recurrent or high-risk gastric variceal bleeding. Practically, these procedures require advanced expertise, Doppler proficiency, and multidisciplinary collaboration with hepatology and interventional radiology teams. Limitations include technical complexity, bleeding risk, and limited availability. Future directions include AI-assisted vascular targeting and broader integration into portal hypertension algorithms.

Contrast-enhanced EUS (CE-EUS) and EUS elastography are increasingly expanding the role of endoscopic ultrasound in hepatology by providing functional and structural assessment of focal and diffuse liver disease. CE-EUS evaluates microvascular perfusion patterns after intravenous contrast administration, improving characterization of liver lesions that may be indeterminate on conventional imaging. Malignant lesions typically show abnormal arterial enhancement and rapid washout, while benign lesions often demonstrate more homogeneous vascular behavior. CE-EUS is particularly useful for detecting small hepatic metastases, hepatocellular carcinoma, and guiding targeted tissue acquisition. EUS elastography assesses tissue stiffness and can support evaluation of liver fibrosis, portal hypertension-related changes, and focal lesion characterization. It may help differentiate malignant from benign lesions and identify fibrotic parenchymal changes when combined with EUS-guided liver biopsy. From a practical perspective, these technologies allow combined liver imaging, biopsy, and portal hypertension evaluation during a single endoscopic session. Limitations include operator dependency, lack of standardized cutoff values, limited availability, and overlap between inflammatory and malignant patterns. Current advances focus on quantitative elastography, AI-assisted image interpretation, and integration with EUS-guided portal pressure assessment. CE-EUS and elastography are important because they move EUS beyond morphology toward functional hepatobiliary imaging and precision-guided liver diagnostics.

Ulcerative colitis (UC) surveillance is shifting from random biopsy-based strategies toward targeted, high-definition mucosal assessment. High-definition colonoscopy with dye-based chromoendoscopy or virtual chromoendoscopy is now central to dysplasia detection because most neoplastic lesions in UC are visible when careful inspection is performed. Chromoendoscopy enhances subtle mucosal and vascular abnormalities, improving targeted biopsy yield while reducing dependence on extensive random biopsies. Artificial intelligence (AI) is emerging as an adjunct tool to improve dysplasia detection, lesion characterization, and inflammation assessment, particularly in high-volume surveillance practice. However, AI currently complements rather than replaces expert endoscopic evaluation. Targeted biopsies remain essential for visible lesions, while random biopsies are still considered in selected high-risk situations such as primary sclerosing cholangitis, severe tubular colon, prior dysplasia, or poor mucosal visualization. Optimal surveillance requires excellent bowel preparation, mucosal healing assessment, careful withdrawal technique, and standardized lesion description. The future of UC surveillance lies in combining high-definition imaging, virtual chromoendoscopy, AI-assisted detection, and precision-targeted biopsies to improve early dysplasia recognition while minimizing unnecessary sampling.

Endoscopic vacuum therapy (EVT) has become an important minimally invasive treatment for gastrointestinal leaks, perforations, fistulas, and anastomotic dehiscence, particularly after esophageal, gastric, and colorectal surgery. EVT works by placing a polyurethane sponge connected to continuous negative pressure either within the defect cavity or intraluminally, promoting drainage, collapse of infected cavities, granulation tissue formation, and progressive defect closure. The technique is most commonly used in esophageal anastomotic leaks, Boerhaave syndrome, post-bariatric leaks, rectal anastomotic leaks, and selected iatrogenic perforations. Placement is performed endoscopically using overtube-assisted or grasping techniques, with sponge exchanges usually required every 2–5 days until cavity resolution. Intracavitary EVT is preferred for larger collections, whereas intraluminal placement may be suitable for smaller defects. From a practical perspective, EVT is particularly valuable when there is active contamination or infected cavity formation where simple stenting alone may be insufficient. Benefits include continuous drainage, high closure rates, organ preservation, and avoidance of major surgery in selected patients. Limitations include repeated procedures, prolonged treatment duration, patient discomfort, and need for experienced multidisciplinary management. Potential complications include bleeding, stricture formation, and rare tissue erosion. EVT is increasingly important because it has shifted management of complex GI leaks from predominantly surgical rescue toward advanced endoscopic organ-preserving therapy.

The CO-Pilot concept evaluates a combined endoscopic approach for obesity by pairing gastric fundal mucosal ablation with an endoscopic bypass or sleeve-type restrictive procedure. The rationale is biologically attractive: the fundus is a major source of ghrelin and contributes to hunger and gastric accommodation, while endoscopic gastric bypass/restrictive remodeling reduces intake and alters nutrient flow. Early pilot data with fundal ablation combined with endoscopic sleeve gastroplasty suggest meaningful total body weight loss, reduced gastric accommodation, improved appetite-related behavior, and acceptable short-term safety in expert hands. Clinically, this represents a move from purely restrictive endoscopic obesity therapy toward combination metabolic endoscopy. However, it remains investigational, with small sample sizes, limited long-term durability data, and need for standardized technique, safety monitoring, and comparison with GLP-1–based therapy and bariatric surgery. Its importance lies in developing less invasive, mechanism-based obesity treatments that target both gastric volume and appetite biology.

Endoscopic balloon dilation (EBD) involves controlled radial expansion of the narrowed segment using through-the-scope balloons, typically for strictures <4–5 cm without deep ulceration, fistula, abscess, or marked inflammation. It is technically straightforward and widely practiced but often requires repeated sessions because the fibrotic ring remains structurally intact. Endoscopic stricturotomy is an advanced technique in which the stricture is incised longitudinally using an electrosurgical knife, usually along the anti-mesenteric side, to release fibrosis and enlarge the lumen. It is particularly useful in refractory, angulated, or anastomotic strictures where balloon dilation is less effective. The major difference lies in durability. Balloon dilation has higher recurrence and repeat-intervention rates, with many patients requiring re-dilation within 1–3 years. Stricturotomy appears to provide longer-lasting luminal patency with lower recurrence in selected short fibrotic strictures, although bleeding risk may be slightly higher. Both techniques require careful patient selection and exclusion of active penetrating disease before intervention.

Gastric peroral endoscopic myotomy (G-POEM) and endoscopic balloon dilation represent two endoscopic approaches for refractory gastroparesis, but they differ substantially in mechanism, durability, and clinical application. Balloon dilation targets pyloric resistance through mechanical stretching and may provide temporary symptom relief, particularly in mild pyloric dysfunction or high-risk patients unsuitable for more invasive intervention. However, response is often variable and less durable, frequently requiring repeat sessions. G-POEM has emerged as the preferred advanced endoscopic therapy for selected patients with medically refractory gastroparesis, particularly when pyloric dysfunction is suspected. The procedure involves submucosal tunneling and pyloromyotomy, improving gastric emptying by reducing pyloric outflow resistance. Clinical outcomes are generally more durable than balloon dilation, especially in diabetic and postsurgical gastroparesis. Increasing use of EndoFLIP and pyloric functional assessment may help identify optimal responders. From a practical perspective, G-POEM requires advanced third-space endoscopy expertise, structured patient selection, and multidisciplinary motility evaluation. Potential adverse events include capnoperitoneum, bleeding, mucosal injury, and delayed gastric emptying persistence despite technical success. Balloon dilation remains less invasive and technically simpler but has limited long-term efficacy. Current trends favor individualized pylorus-directed therapy guided by physiologic assessment rather than symptom severity alone. This topic is important because gastroparesis management is shifting toward mechanism-based therapeutic endoscopy with increasingly targeted pyloric interventions.

The procedure should be performed by experienced endoscopists using the shortest possible procedure time and minimal or no fluoroscopy exposure. Radiation reduction strategies include wire-guided cannulation, bile aspiration confirmation, limited fluoroscopy pulses, lead shielding, collimation, and avoidance of unnecessary radiographs. In selected expert centers, fluoroless ERCP may be feasible. Fetal risk from properly performed ERCP is generally low, but multidisciplinary coordination with obstetrics and anesthesia is essential. From a practical standpoint, the second trimester is usually preferred when feasible, although urgent therapeutic ERCP should not be delayed in severe biliary sepsis or persistent obstruction. Maternal stabilization always takes priority because fetal outcomes depend largely on maternal condition. Potential complications include post-ERCP pancreatitis, bleeding, perforation, and sedation-related fetal concerns. Current trends favor EUS-guided diagnosis before ERCP, radiation-minimizing protocols, and selective temporary biliary drainage strategies. ERCP in pregnancy is clinically important because timely biliary intervention can prevent serious maternal and fetal complications while maintaining procedural safety through careful technique and multidisciplinary care.

The decision to call the surgeon should occur early rather than after prolonged unsuccessful endoscopic attempts. Immediate surgical consultation is particularly important in large esophageal perforations, delayed recognition (>12–24 hours), extensive retroperitoneal or intraperitoneal air with sepsis, colonic perforation with fecal contamination, and perforations associated with obstructing tumors or necrotic tissue. Post-ERCP duodenal perforations require careful classification because some retroperitoneal guidewire injuries may respond to conservative management, whereas large periampullary perforations often require urgent multidisciplinary evaluation. From a practical perspective, optimal management includes immediate CO₂ insufflation cessation, broad-spectrum antibiotics, fasting, imaging assessment, and rapid multidisciplinary coordination between endoscopists, surgeons, radiologists, and intensivists. Modern endoscopic tools such as clips, over-the-scope clips, suturing devices, stents, and endoscopic vacuum therapy have reduced surgical rates in selected patients. However, delayed surgical referral remains a major cause of poor outcomes. Knowing when endoscopic rescue is no longer sufficient is a critical skill in advanced therapeutic endoscopy because timely surgery can be lifesaving in complex perforation management.

Closure of post-resection defects after EMR or ESD remains an evolving area in therapeutic endoscopy, with decisions increasingly guided by lesion location, defect size, patient risk factors, and anticipated complication risk rather than routine universal closure. Defect closure aims to reduce delayed bleeding, perforation, and post-procedural pain, particularly after large colorectal resections, duodenal EMR, or high-risk gastric and esophageal ESD. Routine closure is most strongly supported in large right-sided colonic EMR defects, duodenal resections, and patients receiving anticoagulants or antiplatelet therapy. Through-the-scope clips remain the most commonly used method, while over-the-scope clips, endoscopic suturing, endoloops, and tissue sealants are increasingly utilized for larger or complex defects. In contrast, complete closure after extensive colorectal or gastric ESD may be technically difficult, time-consuming, and not always necessary in low-risk settings.

Contrast-enhanced EUS and elastography are important adjuncts to conventional EUS, improving characterization of pancreaticobiliary and gastrointestinal lesions beyond morphology alone. Contrast-enhanced EUS assesses microvascular perfusion after intravenous contrast injection. Hypoenhancement supports pancreatic ductal adenocarcinoma, while hyperenhancement is more typical of neuroendocrine tumors or inflammatory vascular lesions, though histology remains essential when management depends on diagnosis. EUS elastography evaluates tissue stiffness, helping differentiate hard malignant lesions from softer benign or inflammatory tissue. It is useful in pancreatic masses, lymph nodes, subepithelial lesions, chronic pancreatitis assessment, and targeted tissue acquisition. These techniques can improve lesion targeting, reduce sampling error, and guide multidisciplinary decision-making. Limitations include operator dependence, overlap between inflammatory and malignant patterns, lack of universal cutoffs, and variable availability. They should complement—not replace—EUS-guided biopsy, CT/MRI, and clinical judgment. Contrast-enhanced EUS and elastography matter because they add functional information to EUS, improving diagnostic confidence in complex pancreaticobiliary and GI lesions.

X-ray-free ERCP is an evolving approach aimed at reducing or eliminating fluoroscopy exposure during biliary and pancreatic interventions. It is particularly relevant in pregnancy, critically ill patients requiring bedside procedures, pediatric ERCP, and high-volume endoscopy units where cumulative radiation exposure affects both patients and staff. Advances in wire-guided cannulation, cholangioscopy, EUS support, intraductal ultrasound, and direct endoscopic visualization have made selected fluoroless ERCP procedures increasingly feasible. In carefully selected cases, biliary cannulation, stone extraction, stent placement, and stent exchange can be performed using bile aspiration, guidewire behavior, endoscopic landmarks, and direct cholangioscopic confirmation rather than fluoroscopic imaging. EUS-guided biliary interventions are also contributing to reduced radiation dependence in complex cases. From a practical perspective, X-ray-free ERCP requires high operator expertise, excellent understanding of biliary anatomy, careful patient selection, and familiarity with wire and accessory tactile feedback. Benefits include radiation reduction and improved procedural flexibility, while limitations include inability to confirm complex ductal anatomy, retained stones, or guidewire position in difficult cases. Potential risks include misplacement, perforation, incomplete therapy, and reduced safety in inexperienced hands. X-ray-free ERCP is clinically important because therapeutic endoscopy is increasingly moving toward safer, lower-radiation, image-guided interventions.

Image-enhanced endoscopy (IEE) has become central to modern gastrointestinal mucosal evaluation, improving lesion detection, characterization, and delineation during diagnostic and therapeutic endoscopy. Narrow-band imaging (NBI) enhances visualization of superficial mucosal and vascular patterns using filtered blue and green light, making it highly useful for detecting dysplasia, early neoplasia, Barrett’s esophagus changes, colorectal polyps, and squamous lesions. Texture and Color Enhancement Imaging (TXI) is a newer modality designed to improve subtle mucosal color, brightness, and structural contrast under white-light conditions, helping identify faint lesions that may otherwise be overlooked. The emerging combination of NBI+TXI aims to integrate improved lesion detection with enhanced microvascular characterization. TXI may assist in initial lesion recognition, while NBI provides detailed optical diagnosis and margin assessment. This combined approach is particularly relevant in screening colonoscopy, early gastric cancer detection, inflammatory bowel disease surveillance, and upper GI neoplasia assessment. From a practical perspective, these technologies improve real-time optical diagnosis without dyes and can support more targeted biopsies and precise endoscopic resection planning. Limitations include learning curve, interobserver variability, and dependence on endoscopic expertise. Future directions include AI-integrated optical diagnosis and computer-assisted lesion characterization. Advanced IEE matters because modern endoscopy increasingly depends on detecting subtle early neoplasia before structural disease becomes advanced.

Pancreatoscopy has transformed the evaluation and treatment of pancreatic duct disorders by allowing direct intraductal visualization during ERCP. It is particularly valuable in difficult pancreatic duct stones, indeterminate strictures, intraductal papillary mucinous neoplasms (IPMN), and selected pancreatic duct neoplasia. Digital single-operator pancreatoscopy enables targeted biopsy, visual characterization, and intraductal lithotripsy using electrohydraulic or laser systems for impacted stones refractory to conventional therapy. Clinically, pancreatoscopy improves diagnostic precision and facilitates minimally invasive ductal therapy, especially in chronic pancreatitis. However, the procedure remains technically demanding and carries risks including pancreatitis, ductal injury, infection, and bleeding. Future advances include improved imaging resolution, AI-assisted interpretation, and dedicated therapeutic accessories. Pancreatoscopy is increasingly becoming an essential tool in advanced pancreatic endoscopy.

Complex biliary access refers to situations in ERCP where standard selective biliary cannulation is difficult, prolonged, or unsuccessful because of altered anatomy, periampullary diverticula, tumor infiltration, papillary distortion, impacted stones, surgically altered anatomy, duodenal obstruction, or challenging hilar strictures. Difficult cannulation is clinically important because repeated attempts increase the risk of post-ERCP pancreatitis, bleeding, and perforation. Modern management of complex biliary access extends beyond achieving duct entry and focuses on achieving definitive therapeutic success safely and efficiently. Advanced cannulation techniques include guidewire-assisted cannulation, double-guidewire technique, transpancreatic septotomy, needle-knife precut sphincterotomy, fistulotomy, and rendezvous procedures. In cases where conventional ERCP fails, EUS-guided biliary drainage and percutaneous approaches are increasingly integrated into therapeutic algorithms. From a practical perspective, success depends on early recognition of difficult anatomy, timely escalation to advanced techniques, appropriate accessory selection, and operator expertise. Current unmet needs include reducing cannulation-related adverse events, improving access in altered anatomy, and standardizing rescue strategies. Future directions involve AI-assisted papillary recognition, robotic ERCP, and hybrid EUS-ERCP interventions. Complex biliary access matters because successful cannulation is often the critical first step toward definitive biliary therapy and patient cure.

Robotic ERCP represents an emerging frontier in therapeutic endoscopy aimed at improving procedural precision, scope stability, ergonomics, and remote maneuverability during complex pancreatobiliary interventions. Current robotic platforms are being developed to assist with fine endoscope control, cannulation, guidewire manipulation, and therapeutic accessory deployment, particularly in technically demanding ERCP procedures such as altered anatomy, hilar strictures, difficult cannulation, and cholangioscopy-guided interventions. Potential advantages include reduction in operator fatigue, improved procedural consistency, enhanced stability during delicate maneuvers, and the possibility of integrating artificial intelligence, haptic feedback, and image-guided navigation. Robotic assistance may also facilitate telestration, remote mentoring, and future tele-endoscopy applications. Early feasibility studies suggest technical promise, but widespread adoption remains limited. Important challenges include high cost, platform complexity, limited tactile feedback, longer setup times, and the need for dedicated training. Current systems remain largely investigational and are not yet standard in routine ERCP practice. Robotic ERCP is clinically important because increasing procedural complexity in therapeutic endoscopy is driving the need for technologies that enhance precision, reproducibility, and operator performance in advanced biliary and pancreatic interventions.

Artificial intelligence (AI) is rapidly transforming capsule endoscopy by improving lesion detection, reducing reading time, and enhancing diagnostic consistency in small bowel evaluation. Modern AI systems, primarily based on deep learning and convolutional neural networks, are trained to recognize bleeding, angioectasias, ulcers, erosions, polyps, protruding lesions, and inflammatory changes with high sensitivity. This is particularly relevant because capsule studies generate thousands of images, making manual review time-consuming and operator dependent. Clinically, AI-assisted capsule reading is most useful in obscure gastrointestinal bleeding, Crohn’s disease, polyposis syndromes, and small bowel tumor detection. AI can rapidly filter normal frames, prioritize suspicious images, and support earlier diagnosis while reducing reader fatigue. Emerging platforms also attempt automated bowel cleanliness assessment and localization prediction. However, AI does not replace expert interpretation. False positives, missed subtle lesions, poor bowel preparation, and limited validation across diverse populations remain important limitations. Integration into workflow, medicolegal responsibility, and standardization are ongoing challenges. AI in capsule endoscopy is important because it shifts small bowel imaging from labor-intensive review toward faster, more standardized, and potentially more accurate diagnostic endoscopy.

EUS-guided tissue acquisition has evolved from fine-needle aspiration (FNA) toward fine-needle biopsy (FNB), with current practice increasingly favoring FNB for most solid pancreatic and gastrointestinal lesions. Needle selection depends on lesion type, location, required tissue quality, and scope position. Twenty-two gauge needles are the most versatile and widely used for pancreatic masses because they balance flexibility and tissue yield. Twenty-five gauge needles provide superior maneuverability in difficult transduodenal positions and may perform well in fibrotic pancreatic lesions. Nineteen gauge needles provide larger core samples and are useful for liver biopsy or when extensive histology is required, although they may be technically challenging in angulated positions. Modern Franseen-tip and fork-tip FNB needles have improved core acquisition and reduced dependence on rapid onsite cytology. Current trends favor fewer passes with high-quality core tissue acquisition. Optimal needle choice is increasingly driven by lesion biology and anticipated downstream molecular and therapeutic needs rather than cytology alone.

Current endoscopic bariatric and metabolic therapies (EBMT) have become important minimally invasive options for obesity and obesity-related metabolic disease, bridging the gap between lifestyle therapy, pharmacologic treatment, and bariatric surgery. The most established procedures include endoscopic sleeve gastroplasty (ESG), intragastric balloons, aspiration therapy, and endoscopic revision procedures for post-bariatric weight regain. ESG is increasingly favored because it reduces gastric volume through full-thickness endoscopic suturing without surgical resection, achieving meaningful weight loss with lower morbidity and shorter recovery than surgery. Metabolic therapies targeting the duodenum and proximal small bowel are also evolving, aiming to improve insulin resistance and type 2 diabetes through endoluminal mucosal or hormonal modulation. Endoscopic revision techniques are particularly valuable for managing dilated gastrojejunal anastomosis after gastric bypass. Successful outcomes depend on multidisciplinary care, nutritional counseling, behavioral support, and long-term follow-up. Limitations include variable durability, need for lifestyle adherence, and procedure-related adverse events. EBMT is increasingly relevant because obesity is now a major GI and systemic disease burden requiring scalable, less invasive therapeutic strategies.

The concept of “non-curative resection” remains highly relevant in T1 colorectal cancer (CRC), but its interpretation is evolving toward individualized risk stratification rather than automatic referral for surgery. After endoscopic resection, histopathologic assessment determines whether the lesion carries significant risk for residual disease or lymph node metastasis. Traditional high-risk features include poor differentiation, lymphovascular invasion, deep submucosal invasion, high-grade tumor budding, and positive or indeterminate margins. Historically, the presence of any single high-risk feature classified the resection as non-curative, prompting oncologic surgery. However, contemporary evidence suggests that not all risk factors carry equal biologic significance, and some patients—particularly elderly or comorbid individuals—may safely avoid surgery despite technically “non-curative” pathology. Modern management increasingly integrates en bloc resection quality, precise pathology, patient fitness, rectal versus colonic location, and multidisciplinary discussion. Thus, the term remains clinically important but should no longer be interpreted in an absolute binary manner. In modern endoscopic oncology, “non-curative” increasingly represents a spectrum of residual oncologic risk rather than an automatic indication for surgery.

Device-assisted enteroscopy (DAE) has become a cornerstone in the evaluation and management of obscure gastrointestinal bleeding, particularly when standard upper endoscopy and colonoscopy fail to identify a bleeding source. Obscure bleeding may present as overt bleeding with melena or hematochezia, or as occult bleeding with iron deficiency anemia. Most lesions are located within the small bowel and include angioectasias, NSAID enteropathy, small bowel tumors, ulcers, Crohn’s disease, Dieulafoy lesions, and post-surgical pathology. Capsule endoscopy is generally the first-line diagnostic investigation because of its high sensitivity for small bowel mucosal lesions, while DAE provides direct visualization, tissue acquisition, and therapeutic intervention. Common DAE platforms include double-balloon, single-balloon, and spiral enteroscopy. The choice of antegrade or retrograde approach depends on suspected lesion location and prior imaging findings. Therapeutic capabilities include argon plasma coagulation, clipping, injection therapy, dilation, polypectomy, tattooing, and foreign body retrieval. From a practical perspective, careful timing is important because diagnostic yield is highest when enteroscopy is performed close to the bleeding episode. Benefits include complete small bowel evaluation and avoidance of surgery in many patients. However, DAE is technically demanding, time-consuming, and not universally available. Potential adverse events include pancreatitis, perforation, bleeding, and sedation-related complications. Current advances include motorized spiral enteroscopy, AI-assisted capsule interpretation, and improved deep enteroscopy platforms. Device-assisted enteroscopy is clinically important because it has transformed obscure GI bleeding from a poorly localized condition into a diagnosable and increasingly treatable small bowel disorder.

Endoscopic ultrasound (EUS) is increasingly expanding the therapeutic and hemodynamic evaluation of variceal bleeding beyond conventional endoscopy, particularly in complex gastric varices, recurrent bleeding, and portal hypertensive collateral assessment. EUS allows detailed visualization of paraesophageal, paragastric, and perforating veins, helping identify the feeding vessels and collateral pathways responsible for persistent or recurrent variceal bleeding. This is especially relevant in gastric varices, where standard endoscopic visualization may underestimate the complexity of the vascular anatomy. EUS-guided therapy has evolved significantly with the use of coil embolization, cyanoacrylate injection, or combined coil-plus-glue techniques. Combined therapy is increasingly favored because coils provide a scaffold that reduces glue embolization risk while improving obliteration efficacy. Doppler assessment enables real-time confirmation of variceal flow reduction after treatment. In patients with recurrent bleeding after conventional therapy, EUS may identify residual perforators or collateral vessels not visible during standard endoscopy. Radiologic collaboration remains essential in modern portal hypertension management. Cross-sectional imaging and interventional radiology procedures such as TIPS, BRTO, and portal venous interventions are often integrated with EUS findings to guide definitive therapy. EUS is also emerging in portal pressure measurement and vascular access research. Limitations include technical complexity, bleeding risk, limited availability, and the need for advanced expertise. The role of EUS in variceal bleeding is clinically important because it is shifting endoscopy from purely luminal therapy toward precision-guided vascular intervention in portal hypertension management.

EUS-guided gastro-enterostomy (EUS-GE) has emerged as an effective minimally invasive alternative for the management of malignant gastric outlet obstruction (GOO), particularly in patients with unresectable periampullary, pancreatic, distal gastric, or duodenal malignancies. Using a lumen-apposing metal stent (LAMS), EUS-GE creates a bypass between the stomach and a jejunal loop distal to the obstruction, restoring enteral continuity without traversing the tumor itself. Compared with enteral self-expandable metal stents, EUS-GE offers more durable luminal patency with lower reintervention rates because the stent is placed away from the tumor, reducing recurrent obstruction from tumor ingrowth or overgrowth. In comparison with surgical gastrojejunostomy, EUS-GE is less invasive, associated with shorter recovery, earlier oral intake, and reduced hospital stay. Technical success and clinical success are high in experienced centers, although the procedure remains technically demanding. Key considerations include careful patient selection, cross-sectional imaging review, exclusion of distal bowel obstruction, and availability of advanced EUS expertise. Potential adverse events include stent maldeployment, perforation, bleeding, peritonitis, and infection. EUS-GE is increasingly becoming an important therapeutic option because it combines minimally invasive palliation with durable symptomatic relief in malignant GOO.

Management of pancreatic solid and cystic lesions requires a risk-stratified, multidisciplinary approach integrating high-quality imaging, EUS morphology, tissue acquisition, biologic behavior, patient fitness, and long-term malignant potential. The key clinical challenge is identifying which lesions require immediate intervention, surveillance, or no treatment at all. For solid pancreatic lesions, pancreatic ductal adenocarcinoma must always be excluded first. Any hypoenhancing solid lesion with upstream duct dilatation, distal pancreatic atrophy, vascular involvement, or jaundice should be considered malignant until proven otherwise. EUS-guided fine-needle biopsy (preferably core biopsy) is central for tissue diagnosis, molecular profiling, and treatment planning. Small nonfunctioning neuroendocrine tumors (<1–2 cm) without high-risk features may undergo surveillance, whereas symptomatic, enlarging, or high-grade lesions usually require surgical resection. Autoimmune pancreatitis must be differentiated carefully from cancer using EUS morphology, IgG4 profile, ductal imaging, and histology because inappropriate surgery remains a major pitfall. Management of pancreatic cystic lesions depends on identifying mucinous versus nonmucinous pathology and estimating malignant transformation risk. Serous cystadenomas generally require no treatment unless symptomatic or very large. Mucinous cystic neoplasms and branch-duct IPMNs require surveillance or surgery depending on mural nodules, main duct involvement, cyst growth, pancreatitis, cytology, elevated CA19-9, or worrisome imaging features. Main-duct IPMN usually warrants resection in fit patients because of substantial malignant potential. EUS-guided cyst fluid analysis, molecular markers, contrast-enhanced EUS, and through-the-needle technologies increasingly improve risk stratification. Practically, intervention should never be based on cyst size alone. Decisions must integrate age, comorbidity, surgical fitness, lesion biology, growth kinetics, and expected survival benefit. Over-treatment of indolent cysts and under-recognition of aggressive early cancer remain equally dangerous. Modern pancreatic practice increasingly relies on precision diagnostics, advanced EUS imaging, AI-supported characterization, and multidisciplinary pancreas boards to individualize management and avoid both unnecessary surgery and delayed cancer treatment.

The increasing use of high-resolution abdominal imaging has led to a growing detection of incidental pancreatic lesions, often referred to as pancreatic “incidentalomas.” These may include cystic lesions, small solid masses, focal pancreatic enlargement, ductal abnormalities, or neuroendocrine tumors identified in asymptomatic individuals. Endoscopic ultrasound (EUS) plays a pivotal role in further characterization because of its superior spatial resolution and ability to obtain tissue or fluid samples when needed. EUS is particularly valuable for differentiating benign, premalignant, and malignant lesions that may appear indeterminate on CT or MRI. In pancreatic cystic lesions, EUS helps assess mural nodules, septations, communication with the pancreatic duct, and high-risk features suggestive of malignancy. EUS-guided fine-needle aspiration or biopsy allows cytology, biochemical analysis, and increasingly molecular testing of cyst fluid or tissue. For small solid lesions, EUS is highly sensitive and may detect early pancreatic adenocarcinoma, neuroendocrine tumors, autoimmune pancreatitis, or focal chronic pancreatitis that are difficult to characterize radiologically. From a practical perspective, EUS-guided evaluation supports risk stratification and helps avoid unnecessary surgery while ensuring timely intervention for high-risk lesions. Benefits include minimally invasive diagnosis, real-time imaging, and targeted tissue acquisition. Limitations include operator dependency, uncertainty in interpreting some cystic lesions, procedural cost, and small but relevant risks such as pancreatitis, bleeding, or infection. Current trends include contrast-enhanced EUS, needle-based confocal imaging, AI-assisted cyst characterization, and molecular biomarker integration.

Endoscopic ultrasound (EUS) plays a central role in the diagnosis and staging of pancreatic cancer, particularly in assessing local tumor extent, vascular involvement, nodal disease, and tissue confirmation. Although cross-sectional imaging with pancreatic protocol CT remains the primary initial staging modality, EUS provides superior spatial resolution for small pancreatic lesions and detailed evaluation of locoregional anatomy. It is especially valuable when CT findings are equivocal, when lesions are small or isoattenuating, or when histologic confirmation is required before oncologic therapy. EUS-guided fine-needle aspiration or fine-needle biopsy allows real-time tissue acquisition with high diagnostic accuracy and has become standard practice for confirming pancreatic adenocarcinoma. Beyond diagnosis, EUS contributes significantly to T and N staging by evaluating tumor invasion into surrounding structures, regional lymph nodes, and major vessels such as the portal vein, superior mesenteric vein, and celiac axis. Accurate assessment of vascular invasion is clinically important because it directly influences surgical resectability and neoadjuvant treatment planning. EUS staging is often integrated into multidisciplinary pancreatic cancer pathways alongside radiology, oncology, and hepatopancreatobiliary surgery. Benefits include minimally invasive tissue diagnosis, high sensitivity for small lesions, and the ability to combine diagnostic and therapeutic interventions during the same session. Limitations include operator dependency, reduced accuracy after pancreatitis or biliary stenting, and limited ability to detect distant metastases compared with cross-sectional imaging. Current trends include contrast-enhanced EUS, elastography, molecular analysis from biopsy samples, and AI-assisted image interpretation.

Endoscopic submucosal dissection (ESD) for difficult colorectal lesions requires advanced technical expertise, careful strategy, and meticulous lesion assessment to achieve safe en bloc resection while minimizing complications. Difficult lesions include large laterally spreading tumors, fibrotic or recurrent adenomas, lesions involving folds or flexures, appendiceal orifice lesions, ileocecal valve lesions, rectal lesions near the dentate line, and lesions with significant submucosal fibrosis from prior intervention or inflammation. Successful colorectal ESD begins with detailed characterization using high-definition imaging, chromoendoscopy, and magnification techniques to assess invasion depth and define margins accurately. Adequate scope stability, patient positioning, optimized insufflation—preferably with CO₂—and careful electrosurgical settings are essential practical considerations. Traction methods have become particularly important in difficult ESD cases, improving visualization of the submucosal plane and reducing procedure time. Common approaches include clip-with-line techniques, rubber-band traction, multitraction systems, and gravity-assisted dissection. Pocket-creation methods and tunneling techniques can also facilitate safer dissection in fibrotic or unstable lesions. From a practical endoscopy unit perspective, appropriate case selection, dedicated accessories, experienced support staff, and readiness to manage perforation or bleeding are critical for procedural safety. Benefits of colorectal ESD include organ preservation, accurate histopathologic staging, and reduced recurrence compared with piecemeal resection. Limitations include long learning curves, prolonged procedure times, higher perforation risk, and variable availability outside tertiary centers.

Endoscopic resection has become the preferred minimally invasive treatment for selected early gastric neoplasia, offering organ preservation with excellent oncologic outcomes in carefully staged patients. It is primarily indicated for superficial gastric dysplasia and early gastric cancer with low risk of lymph node metastasis. Accurate preprocedural assessment using high-definition endoscopy, image-enhanced endoscopy, chromoendoscopy, and EUS where appropriate is essential to define lesion size, depth, ulceration status, and margins before resection. The two principal techniques are endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is generally suitable for smaller, well-circumscribed lesions, whereas ESD enables en bloc resection of larger or more complex lesions and provides superior histologic assessment of margins and invasion depth. ESD has become the standard approach for many early gastric cancers in expert centers because it improves curative resection rates and reduces local recurrence. However, it is technically demanding and associated with longer procedure times. Benefits of endoscopic resection include stomach preservation, reduced morbidity, shorter hospitalization, and improved quality of life compared with gastrectomy. Limitations include bleeding, perforation, stenosis risk, technical complexity, and the need for advanced training and structured follow-up.

Screening for gastric cancer aims to detect premalignant lesions and early-stage neoplasia before the development of advanced disease, where prognosis remains poor. Screening strategies vary globally according to regional cancer incidence, population risk, healthcare resources, and prevalence of Helicobacter pylori infection. High-risk groups include individuals from high-incidence regions, patients with extensive gastric atrophy or intestinal metaplasia, family history of gastric cancer, hereditary cancer syndromes, persistent H. pylori infection, previous gastric neoplasia, and certain autoimmune gastric disorders. Upper GI endoscopy remains the cornerstone of gastric cancer screening and surveillance because it allows direct mucosal visualization, targeted biopsy, and endoscopic treatment of early lesions. High-quality examination is essential and includes adequate mucosal cleaning, sufficient inspection time, systematic photo-documentation, and careful evaluation of subtle mucosal abnormalities. Image-enhanced endoscopy, magnification techniques, and chromoendoscopy are increasingly used to improve detection of early gastric neoplasia and characterize premalignant mucosal changes. Histologic staging systems for atrophy and intestinal metaplasia help stratify long-term cancer risk and determine surveillance intervals. From a practical perspective, screening programs are most effective when integrated with H. pylori detection and eradication strategies. Benefits include earlier diagnosis, increased eligibility for curative endoscopic resection, and improved survival. Limitations include cost, variability in endoscopic quality, low yield in low-incidence populations, and uncertainty regarding optimal surveillance intervals in some patient groups. Future directions include AI-assisted lesion detection, noninvasive biomarker development, and risk-based personalized surveillance pathways.

Endoscopic ultrasound-guided hepatic venous pressure gradient (EUS-HVPG) measurement is an emerging minimally invasive technique for direct assessment of portal hypertension. Traditionally, HVPG measurement has been performed through a transjugular radiologic approach, but EUS-guided methods now allow portal pressure assessment during the same session as diagnostic EUS, liver biopsy, or variceal evaluation. The technique is particularly relevant in chronic liver disease, cirrhosis, portal hypertension assessment, and research settings evaluating disease progression or response to therapy. The procedure is performed using a linear echoendoscope with fine-needle access to the hepatic vein and portal vein under real-time ultrasound guidance. Pressure measurements are obtained sequentially, and the gradient between portal and hepatic venous pressures reflects portal hypertension severity. Early studies suggest good technical feasibility and correlation with conventional radiologic HVPG measurements when performed in expert centers. From a practical endoscopy perspective, EUS-HVPG offers the advantage of combining hemodynamic assessment with EUS-guided liver biopsy, elastography, and variceal evaluation in a single minimally invasive session. This integrated “one-stop” approach may improve patient convenience and diagnostic efficiency. Potential benefits include avoidance of vascular catheterization through the neck and improved access in selected patients. However, limitations include limited availability, requirement for advanced EUS expertise, specialized equipment, procedural learning curve, and the need for further standardization and validation. Safety considerations include bleeding risk, vascular injury, infection, and sedation-related complications, although reported adverse events remain low in experienced hands. Future directions include broader validation studies, AI-assisted vascular targeting, and integration into comprehensive portal hypertension assessment algorithms. EUS-HVPG measurement is important because it represents a significant step toward fully endoscopic evaluation of liver disease and portal hypertension in modern hepatology practice.

Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as an important alternative to percutaneous and transjugular liver biopsy, particularly in patients undergoing concurrent EUS evaluation or requiring minimally invasive tissue acquisition. Its major indications include unexplained liver enzyme abnormalities, staging of diffuse liver disease, evaluation of fatty liver disease and fibrosis, autoimmune or cholestatic disorders, and situations where combined pancreaticobiliary and hepatic assessment is beneficial. EUS-LB is increasingly utilized in patients requiring simultaneous diagnostic endoscopy, portal hypertension evaluation, or focal lesion assessment. The technique is typically performed using linear echoendoscopes with fine-needle biopsy (FNB) needles, most commonly 19-gauge platforms designed to obtain core tissue samples with preserved architecture. Biopsy can be obtained from the left lobe through the stomach or from the right lobe through the duodenum, and many operators prefer bilobar sampling to reduce sampling variability. Modern suction and slow-pull techniques have improved specimen adequacy and diagnostic yield. Doppler imaging allows real-time avoidance of vascular structures, contributing to procedural safety. From a practical perspective, EUS-LB offers the advantage of high-quality imaging, targeted access, reduced post-procedure pain, and the ability to combine multiple endoscopic interventions during a single session. Limitations include higher procedural cost, need for sedation, technical expertise requirements, and limited availability outside advanced endoscopy centers. Potential adverse events include bleeding, infection, perforation, and rare bile leak.

Biliary and pancreatic duct strictures are common complications of chronic pancreatitis and frequently reflect progressive inflammation, fibrosis, and ductal remodeling. Careful evaluation is essential because differentiating benign inflammatory strictures from malignancy, particularly pancreatic cancer or cholangiocarcinoma, remains a major clinical challenge in longstanding chronic pancreatitis. Endoscopic therapy is the primary minimally invasive treatment approach in many patients. Pancreatic duct strictures are commonly managed with ERCP-guided pancreatic sphincterotomy, balloon dilation, stone clearance when present, and temporary pancreatic stent placement to improve ductal drainage and reduce ductal hypertension. Refractory strictures may require multiple plastic stents or fully covered metal stents in selected cases. Biliary strictures, particularly distal common bile duct compression from inflammatory pancreatic head disease, are typically treated with plastic or fully covered self-expandable metal stents depending on expected treatment duration and anatomy. From a practical endoscopy perspective, treatment should be individualized according to symptoms, ductal anatomy, stone burden, nutritional status, and surgical candidacy. Benefits of endotherapy include symptom relief, minimally invasive decompression, and postponement or avoidance of surgery in selected patients. However, repeated procedures, stent occlusion, infection, pancreatitis, and recurrence remain important limitations. Surgery continues to play a major role in extensive inflammatory head masses, multiple strictures, or failed endoscopic management. Current trends include increased use of pancreatoscopy, EUS-guided interventions, and advanced stent technologies. Management of biliary and pancreatic duct strictures is clinically important because appropriate ductal decompression can improve pain control, prevent complications, and optimize long-term outcomes in chronic pancreatitis.

Management of pancreatic duct stones in chronic pancreatitis is aimed at relieving ductal obstruction, reducing intraductal pressure, improving pain, and preserving pancreatic function where possible. Pancreatic stones are most commonly seen in longstanding calcific chronic pancreatitis and are frequently associated with ductal strictures, gland atrophy, and recurrent pain episodes. Careful patient selection is important because not all pain in chronic pancreatitis is ductal in origin, and outcomes are best when symptoms correlate with obstructive ductal disease. Endoscopic therapy is considered first-line treatment for many patients with symptomatic main pancreatic duct stones, particularly when stones are located in the head or body of the pancreas and are associated with upstream duct dilatation. ERCP with pancreatic sphincterotomy, stone extraction balloons or baskets, and pancreatic duct stenting are commonly used techniques. Large or impacted stones often require extracorporeal shock wave lithotripsy (ESWL) before endoscopic clearance. Digital pancreatoscopy-guided intraductal lithotripsy using electrohydraulic or laser systems is emerging as an important option for difficult stones in expert centers. From a practical perspective, management frequently requires multiple sessions and multidisciplinary coordination involving pain specialists, surgeons, nutrition teams, and endoscopists. Benefits of endoscopic therapy include minimally invasive duct decompression and reduced need for surgery, while limitations include stone recurrence, incomplete clearance, ductal strictures, and variable long-term pain relief. Surgical drainage procedures such as lateral pancreaticojejunostomy remain important for selected patients with extensive ductal disease or failed endotherapy. Future directions include improved pancreatoscopy platforms, AI-assisted imaging, and better pain phenotyping to identify responders to ductal intervention. Management of pancreatic stones remains clinically important because effective ductal decompression can significantly improve quality of life in carefully selected patients with chronic pancreatitis.

Endoscopists play a central role in the diagnosis and minimally invasive management of adverse events following bariatric surgery, increasingly reducing the need for reoperation in selected patients. Common complications include anastomotic leaks, fistulas, strictures, bleeding, marginal ulcers, sleeve stenosis, and weight regain after procedures such as sleeve gastrectomy or Roux-en-Y gastric bypass. Early recognition is critical because delayed diagnosis can lead to sepsis, malnutrition, prolonged hospitalization, and increased mortality. Modern therapeutic endoscopy offers multiple rescue options depending on the anatomy and type of complication. Covered self-expandable metal stents are frequently used for leaks and fistulas, while endoscopic internal drainage, vacuum therapy, clips, suturing systems, and tissue sealants are increasingly utilized in specialized centers. Balloon dilation remains the standard endoscopic treatment for postoperative strictures and sleeve narrowing. Endoscopy is also important in managing postoperative bleeding, foreign bodies, and nutritional access issues. From a practical perspective, successful management requires close collaboration between bariatric surgeons, radiologists, nutrition teams, and advanced endoscopists. Understanding altered postoperative anatomy is essential for safe intervention. Benefits of endoscopic management include organ preservation, reduced morbidity, shorter recovery, and avoidance of repeat surgery in many cases. However, limitations include technical complexity, need for repeated procedures, and variable success in chronic leaks or large fistulas. Current trends favor early endoscopic intervention, individualized multimodal therapy, and use of advanced closure technologies. Future research is focused on improved endoscopic devices, biodegradable stents, and AI-assisted leak detection. This topic is highly relevant because therapeutic endoscopy has become a key component of modern bariatric complication management, often providing effective minimally invasive solutions when surgery alone is challenging or high risk.

Bariatric and metabolic endoscopy has emerged as an important minimally invasive option for the management of obesity and obesity-related metabolic disorders, bridging the gap between lifestyle therapy, pharmacotherapy, and bariatric surgery. Indications generally include patients with obesity who have failed conservative measures, individuals unsuitable or unwilling for surgery, and selected patients requiring weight regain management after bariatric operations. Endoscopic therapies are also increasingly considered in metabolic disease management, particularly for type 2 diabetes, metabolic syndrome, and fatty liver disease associated with obesity. Common techniques include endoscopic sleeve gastroplasty (ESG), intragastric balloons, aspiration therapy, endoscopic revision of bariatric surgery, and emerging small bowel or duodenal interventions targeting metabolic pathways. ESG has gained significant attention because it reduces gastric volume through endoscopic suturing without surgical resection, offering meaningful weight loss with shorter recovery and lower procedural morbidity compared with surgery. Intragastric balloons remain useful for selected patients requiring temporary weight reduction or bridge therapy before surgery. Endoscopic revision procedures are increasingly important for managing weight regain after Roux-en-Y gastric bypass or sleeve gastrectomy. From a practical endoscopy perspective, patient selection, multidisciplinary evaluation, nutritional support, and long-term follow-up are essential for durable outcomes. Benefits include reduced invasiveness, shorter hospital stay, and repeatability, while limitations include variable long-term durability, need for lifestyle adherence, and procedure-specific adverse events such as nausea, bleeding, perforation, or device intolerance. Future directions include combination therapy with anti-obesity medications, AI-guided patient selection, and development of more durable metabolic interventions. Bariatric and metabolic endoscopy matters because obesity is now a major GI and systemic disease burden, and endoscopic therapies are becoming an integral part of modern multidisciplinary metabolic care.

Failure of endotherapy in acute variceal bleeding represents a life-threatening situation requiring rapid escalation of care, multidisciplinary coordination, and timely rescue interventions. Initial failure may occur due to uncontrolled active bleeding during endoscopy, early rebleeding after band ligation or glue therapy, poor visualization, severe portal hypertension, or advanced liver dysfunction. Immediate priorities include airway protection, hemodynamic stabilization, vasoactive therapy continuation, antibiotic prophylaxis, correction of coagulopathy where appropriate, and transfer to an experienced center if required. When standard endoscopic therapy fails, temporary rescue measures such as balloon tamponade or self-expanding esophageal metal stents can provide short-term bleeding control, particularly in massive esophageal variceal hemorrhage. Balloon tamponade is effective but carries significant risks including aspiration, ulceration, and perforation, and should only be used as a bridge to definitive therapy. Covered esophageal stents are increasingly favored in selected patients because they may provide effective compression with fewer complications. Definitive management usually involves early or salvage transjugular intrahepatic portosystemic shunt (TIPS), especially in high-risk patients with persistent or recurrent bleeding. In gastric variceal bleeding, EUS-guided coil and glue therapy is emerging as an important rescue option in expert centers. Practical decision-making depends on variceal location, liver function, portal vein anatomy, transplant candidacy, and local expertise. Limitations include limited availability of advanced rescue therapies and the high mortality associated with decompensated cirrhosis. Future directions include earlier risk stratification, EUS-guided portal interventions, and optimized pre-emptive TIPS strategies. This topic is critically important because rapid recognition of endotherapy failure and timely escalation to rescue therapy can be lifesaving in severe portal hypertensive bleeding.

Management of biliary strictures increasingly requires alternative drainage strategies when ERCP fails, is technically impossible, or is unlikely to achieve adequate biliary decompression. Common situations include surgically altered anatomy, inaccessible papilla, duodenal obstruction, hilar strictures with complex anatomy, failed cannulation, or inaccessible biliary-enteric anastomoses. In these settings, endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) have become important alternatives. EUS-guided techniques such as choledochoduodenostomy, hepaticogastrostomy, and rendezvous procedures are increasingly adopted in expert centers because they allow internal drainage without external catheters and may improve patient comfort and quality of life. PTBD remains highly effective, especially in complex hilar obstruction, but may be associated with catheter-related discomfort, infection risk, and repeated interventions. Surgical bypass is now generally reserved for selected patients with good performance status or when endoscopic and radiologic approaches are not feasible. From a practical endoscopy perspective, selection of the optimal drainage method depends on stricture location, malignant versus benign etiology, available expertise, anatomy, expected survival, and institutional resources. Dedicated accessories, lumen-apposing metal stents, and improved imaging guidance have expanded the role of EUS-BD in tertiary endoscopy units. However, these procedures require advanced training because complications such as bile leak, bleeding, perforation, stent migration, and peritonitis can occur. Current trends favor multidisciplinary decision-making and minimally invasive internal drainage approaches. Alternatives to ERCP are clinically important because timely and effective biliary decompression directly influences infection control, symptom relief, oncologic management, and overall patient outcomes in complex biliary disease.

Diagnosis of hilar biliary strictures remains one of the most challenging areas in pancreatobiliary endoscopy because differentiating malignant from benign disease often requires a combination of imaging, endoscopic sampling, and multidisciplinary assessment. Common malignant causes include hilar cholangiocarcinoma and gallbladder carcinoma, while benign etiologies include postoperative injury, primary sclerosing cholangitis, IgG4-related disease, and inflammatory strictures. Initial evaluation typically involves liver biochemistry and cross-sectional imaging with contrast-enhanced CT or MRI/MRCP to define the level, extent, vascular involvement, and biliary anatomy before any intervention. Endoscopic diagnosis is usually performed with ERCP-based tissue acquisition using brush cytology, forceps biopsy, or combined sampling techniques, although sensitivity remains modest. Cholangioscopy-directed biopsy has improved targeted tissue acquisition and visual characterization of indeterminate strictures. EUS also plays an important complementary role, particularly for assessing lymph nodes, mass lesions, vascular invasion, and obtaining fine-needle tissue sampling from accessible lesions. In selected situations, intraductal ultrasound and advanced molecular or fluorescence-based cytology techniques may increase diagnostic yield. From a practical standpoint, careful planning is essential because unnecessary contrast injection or incomplete drainage may increase the risk of cholangitis. Diagnostic strategies should be individualized according to resectability, transplant consideration, and anticipated drainage approach. Limitations include low sensitivity of conventional cytology, sampling error, and difficulty distinguishing inflammatory from infiltrative malignancy. Future directions include AI-assisted imaging interpretation, improved molecular diagnostics, and enhanced cholangioscopy platforms. Accurate diagnosis of hilar biliary strictures is crucial because treatment decisions, surgical planning, prognosis, and patient survival depend heavily on precise characterization of the lesion.

Analgesic and sedative agents are fundamental to modern gastrointestinal endoscopy, enabling patient comfort, procedural precision, and successful completion of both diagnostic and therapeutic interventions. Commonly used sedatives include benzodiazepines such as midazolam, propofol-based sedation, and adjunctive agents including opioids like fentanyl or pethidine for analgesia. The choice of agent depends on the procedure type, expected duration, patient comorbidities, airway risk, and local expertise. Diagnostic upper GI endoscopy and routine colonoscopy may require minimal to moderate sedation, whereas ERCP, EUS, ESD, and POEM frequently require deeper sedation or anesthesia support. From a practical endoscopy perspective, understanding pharmacokinetics, onset and recovery profiles, cardiorespiratory effects, and drug interactions is essential for safe sedation practice. Propofol offers rapid onset and recovery with high patient satisfaction but requires close monitoring because of the risk of respiratory depression and hypotension. Benzodiazepines provide anxiolysis and amnesia but may lead to prolonged recovery in elderly patients. Opioids improve procedural tolerance but increase the risk of hypoventilation when combined with sedatives. Reversal agents such as flumazenil and naloxone remain important safety tools. Current trends emphasize individualized, risk-adapted sedation strategies, structured monitoring protocols, and enhanced recovery pathways. Emerging areas include computer-assisted sedation systems, non-opioid analgesic approaches, and AI-supported sedation monitoring. Appropriate selection and safe administration of sedative and analgesic agents are essential because sedation quality directly influences patient safety, procedural success, and overall endoscopy unit performance.

The nurse’s role in procedural sedation has evolved from passive monitoring to an active, competency-based responsibility integrated into modern endoscopy quality and safety frameworks. The ESGE/ESGENA sedation curriculum emphasizes structured training in patient assessment, sedation pharmacology, airway monitoring, recognition of complications, recovery care, and effective team communication. Endoscopy nurses are expected to understand levels of sedation, vital sign interpretation, oxygen delivery systems, capnography principles where available, and early identification of respiratory or hemodynamic instability. In daily endoscopy practice, sedation-trained nurses play a central role in pre-procedure preparation, checklist verification, medication handling, intraprocedural monitoring, documentation, patient reassurance, and post-procedure recovery assessment. Their contribution is particularly important during advanced therapeutic procedures, elderly or frail patient management, and high-turnover endoscopy units where workflow efficiency must be balanced with patient safety. The curriculum also highlights the importance of non-technical skills such as situational awareness, escalation of concerns, crisis response, and multidisciplinary teamwork. Benefits of structured nurse-led sedation support include improved patient safety, smoother procedural flow, reduced sedation-related adverse events, and standardization of care across endoscopy units. Limitations may include variability in national regulations, differences in sedation privileges, staffing shortages, and inconsistent access to formal training programs. Future directions include simulation-based education, competency certification, and incorporation of digital monitoring technologies into nurse-led sedation practice. The topic is clinically important because high-quality sedation in modern GI endoscopy depends not only on drugs and devices, but also on well-trained nursing teams working within standardized safety frameworks.

CO₂ monitoring has become an increasingly important component of safe procedural sedation in gastrointestinal endoscopy, particularly for patients undergoing deep sedation, prolonged therapeutic procedures, or procedures with higher cardiopulmonary risk. Pulse oximetry detects oxygen desaturation, but it may identify respiratory depression late, especially when supplemental oxygen is used. Capnography or end-tidal CO₂ monitoring provides earlier recognition of hypoventilation, apnea, airway obstruction, or inadequate ventilation, allowing timely intervention before clinically significant hypoxemia develops. From a practical endoscopy perspective, CO₂ monitoring is most relevant during advanced endoscopic procedures such as ERCP, EUS, ESD, POEM, complex colonoscopy, and prolonged upper GI interventions, especially when propofol-based sedation or anesthesia support is used. Guidelines are increasingly moving toward risk-adapted monitoring, recommending capnography for deep sedation and high-risk patients rather than universally mandating it for all low-risk diagnostic procedures. Its benefits include earlier detection of respiratory compromise, improved sedation safety, and better team communication. Limitations include cost, false alarms, technical issues with sampling lines, and the need for staff training in interpretation and response. Future developments may include integrated monitoring platforms, automated alerts, and AI-supported prediction of sedation-related respiratory events. CO₂ monitoring matters because modern endoscopy is becoming more complex, and safer sedation requires earlier recognition of respiratory compromise rather than waiting for oxygen saturation to fall.

Pre-endoscopy assessment is a critical safety step that determines whether an endoscopic procedure is appropriate, optimized, and safe for the individual patient. It includes confirmation of indication, urgency, planned level of intervention, fasting status, comorbidities, airway and sedation risk, allergy history, pregnancy status where relevant, infection-control concerns, and review of medications, particularly antithrombotic and antidiabetic agents. Current practice increasingly emphasizes structured checklists, individualized informed consent, and risk stratification before diagnostic and therapeutic endoscopy. Sedation planning is especially important, as advanced procedures may require deeper sedation or anesthesia support, while frail patients, those with cardiopulmonary disease, obesity, sleep apnea, or high aspiration risk need careful evaluation. For practicing endoscopists, good pre-assessment improves procedural efficiency, prevents cancellations, reduces adverse events, and ensures that appropriate accessories, imaging, hemostatic tools, and recovery support are available. It also provides an opportunity to explain benefits, alternatives, limitations, and possible complications in a patient-centered manner. Limitations include variable implementation across units and the risk of checklist fatigue, but standardized workflows remain essential for quality assurance. Future directions include digital pre-assessment platforms, automated medication alerts, and AI-assisted risk prediction. Pre-endoscopy evaluation matters because safe and effective endoscopy begins before the scope enters the patient.