Courses

The third course reviewed the problems still limiting the clinical use of NOTES: route selection, transgastric access, reliable closure and prevention of complications. Practical sessions included endoscopic resection and submucosal dissection, while robotics and new instruments were discussed as ways to overcome the limitations of the flexible endoscope. The programme also broadened into therapeutic endoscopy, with Barrett ablation, ERCP, EUS and endoluminal obesity treatment. The issue captures a transition: NOTES remained the central idea, but it was already generating techniques that would later develop clinical indications of their own.

More than 150 specialists focused on the technical limitations still holding NOTES back: safe access, orientation inside the cavity, closure and suturing. Different closure and anchoring systems were compared, alongside single-port surgery, robotics and experimental work in animal models. Sessions also covered dissection, endoscopic resection, anastomosis and obesity. The second day clearly widened the scope towards therapeutic endoscopy, including EUS as a rescue route when ERCP was not possible. The question was no longer a single procedure, but which tools were required for flexible endoscopy to work safely beyond the gastrointestinal lumen.

The fifth edition coincided with WIDER’s transition from laboratory work to clinical application. The meeting distinguished experimental from clinical NOTES and discussed POEM and new endoscopic suturing platforms able to approximate tissue in a more surgical way. Other sessions covered submucosal and full-thickness resection, thoracic applications, cholangioscopy, drainage and obesity. Training was itself a major subject, particularly the need to combine endoscopic and surgical skills. At CosmoCaixa the team presented its full-thickness colonic tumour resection with endoscopic closure, a case that embodied the move from animal experimentation to a carefully selected patient.

The sixth course broadened the medical agenda to POEM, colorectal natural-orifice approaches, endoscopic suturing, robotics and obesity surgery. Full-thickness resection, perforation closure, submucosal dissection, new operating platforms and EUS-guided procedures were all discussed. The WIDER team arrived with accumulating clinical experience in transmural resection and experimental work on anastomosis and access beyond the digestive lumen. The issue shows a clear shift: NOTES still provided the conceptual framework, but many of the solutions developed around access, closure and navigation were becoming part of a wider therapeutic endoscopy rather than remaining tied to the idea of scarless surgery.

The seventh edition concentrated heavily on advanced endoscopic resection, from EMR and ESD to deeper dissection and full-thickness resection. Perforation closure, transanal access and hybrid endoscopic-laparoscopic strategies were discussed alongside POEM and therapeutic EUS after failed ERCP. The programme also covered pancreatobiliary disease, obesity and robotics. A significant change in emphasis is visible in the debate: proving that a NOTES procedure could be performed was no longer enough. Techniques had to be compared with established endoscopic and surgical alternatives in terms of morbidity, complexity and real benefit for selected patients.

Under the theme “New Times”, the eighth edition showed how techniques that had developed around NOTES were becoming independent fields. POEM and LECS sat alongside advanced endoscopic resection, therapeutic EUS, closure of perforations and fistulas, haemostasis and endoscopic obesity treatment. The scientific activity recorded for the same period also includes EUS-guided drainage, endoscopic treatment of Bouveret syndrome and new approaches to complications after resection. The course compared endoluminal endoscopy, laparoscopy and cooperative procedures around a more clinical question: which approach was genuinely less invasive, and in which patients did replacing or complementing surgery offer an advantage.

The ninth course consolidated interventional endoscopy as the central theme. Sessions covered ESD, mucosal and full-thickness resection, suturing and perforation closure, pancreatic interventions and drainage, Barrett therapy and bariatric and metabolic endoscopy. POEM remained prominent, while EUS was increasingly presented as a therapeutic rather than purely diagnostic tool. The boundaries between NOTES, endovisceral surgery and transluminal surgery were also revisited. The issue shows how concepts born in the experimental programme — creating access, closing defects, working through tunnels and connecting structures — were becoming procedures with clinical indications of their own.

The tenth-anniversary issue also works as a review of a decade of change. POEM, STER, endoscopic suturing, therapeutic EUS and endoluminal surgery appear as part of the technological ecosystem that grew around NOTES. Full-thickness resection, drainage, new closure devices, reflux treatment and obesity were discussed alongside increasingly complex procedures performed from inside the digestive lumen. The question of who should perform them led to a recurring concept: a digestive interventionist combining endoscopic and surgical skills. Live transmissions from Vall d’Hebron brought that discussion back to real cases and to the technical difficulties of each approach.

The eleventh course focused on techniques increasingly close to routine clinical practice: POEM, therapeutic EUS, stent-created anastomoses, perforation closure, advanced resection and endoscopic obesity treatment. Sessions also covered biliary drainage, new materials, management of surgical complications and procedures transmitted live from Vall d’Hebron. Clinical NOTES sat alongside therapeutic endoluminal endoscopy and minimally invasive surgery, showing how far the meeting’s original boundaries had expanded. The issue also records a practical discussion about patient selection, safety, management of complications and cost-effectiveness: innovation was being judged not only by novelty but against existing alternatives.

The twelfth edition approached minimally invasive surgery from a clearly multidisciplinary perspective. Full-thickness resection, ESD, POEM and G-POEM, EUS-guided biliary and gallbladder drainage, endoscopic treatment of fistulas and perforations, and complications of bariatric surgery all featured prominently. Complex ERCP, new stents and suturing methods were also discussed. The volume of EUS-related material shows how echoendoscopy had moved from diagnosis towards the creation of therapeutic access and drainage routes. Robotics was presented as the next step in integrating imaging, navigation and intervention, anticipating the multifunctional room introduced by WIDER the following year.

The thirteenth edition incorporated the new Artis Pheno facilities into the course itself. Topics included duodenal and full-thickness resection, new suturing methods, POEM and STER, clinical NOTES, therapeutic EUS, drainage and hybrid procedures. Artificial intelligence received dedicated attention for lesion detection and characterisation, optical prediction of histology and support during polypectomy — a subject that had barely appeared in earlier editions. Live transmissions showed how three-dimensional radiological imaging and endoscopy could operate in the same room. The issue therefore captures a meeting speaking as much about navigation, robotics and AI as about the natural-orifice access routes from which WIDER had started.

The fourteenth edition, held in hybrid format after the 2020 interruption, shows how far the field had moved from the early courses. Artificial intelligence has its own session, covering lesion detection and characterisation, navigation and robotic platforms; the programme also reviews G-POEM for gastroparesis, ESD and full-thickness resection, new suturing methods, optical precision surgery and magnetic approaches to hybrid procedures. EUS is now fully therapeutic, with biliary and pancreatic drainage, LAMS, gastrojejunostomy, treatment of pancreatic necrosis and EUS-guided ablation. Other sessions address POEM and reflux, colorectal surgery, endoscopic obesity treatment and the impact of COVID-19 on colorectal cancer screening. The seventh edition of Digestive Endoscopy Terminology, with Armengol-Miró among its editors, is also presented. The issue portrays an endoscopy much broader than the original NOTES concept: less concerned with proving a route of access and more with combining imaging, navigation, suturing and minimally invasive therapy to solve concrete clinical problems.