ESGE Days, Milan, Italy

“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.