Gallbladder duplication is an uncommon congenital anomaly (1 out of 4,000 autopsies) that poses significant diagnostic and surgical challenges. In the present case, a 70-year-old female presented with right hypochondrial pain, dyspepsia, and nausea for one month. Ultrasound revealed a bifid gallbladder with calculi in one pouch and a normal common bile duct. Intraoperatively, two separate gallbladders were found, one positioned normally and the other intrahepatic. Laparoscopic excision of the first was completed, but conversion to open surgery was required because of the unclear anatomy and the intrahepatic location of the second. Both specimens were confirmed histologically as gallbladders with chronic cholecystitis. Recovery was uneventful, and the patient remained symptom-free at the six-month follow-up. Thus, gallbladder duplication, especially with intrahepatic positioning, can complicate a laparoscopic dissection. Preoperative imaging and intraoperative vigilance are crucial to avoiding bile duct injury.
Diverticulitis can rarely seed the portal‑mesenteric venous system, causing septic thrombophlebitis with morbidity and management uncertainty. This study systematically reviewed diverticulitis‑associated mesenteric venous thrombophlebitis to summarize its presentation, diagnostics, treatment, and outcomes. Twenty‑eight single‑patient reports met the selection criteria. The mean age was 54 years; fever and abdominal pain predominated. Contrast‑enhanced CT established the diagnosis in most patients, usually showing sigmoid diverticulitis with inferior mesenteric or portal‑mesenteric vein thrombus. Sigmoid involvement predominated, and inferior mesenteric vein involvement was common. Blood cultures were positive in 53.6% (common organisms: Bacteroides, Escherichia coli, and Klebsiella). Abscess, venous gas, and perforation were frequent. Broad‑spectrum antibiotics were universal, and anticoagulation was given in 82.1%, and surgery was performed in 53.6% for deterioration or complications. In a complete‑case comparison of 23 anticoagulated versus five non‑anticoagulated patients, times to symptom resolution, radiographic clearance, and length of stay were similar, with venous recanalization documented in 30.4% versus 20.0% and adverse events in 26.1% versus 0%, respectively. Overall, the length of stay averaged 19 days. Radiographic resolution occurred at approximately three months with venous recanalization in 28.6% of cases, and no deaths or recurrences. In conclusion, early CT, prompt antibiotics, consideration of anticoagulation for extensive or occlusive thrombosis, and selective drainage or resection appear prudent, but prospective data will be needed.
Background/Aims:Gastroesophageal reflux disease (GERD) significantly impairs quality of life. Although proton pump inhibitors are first-line therapy, a subset of patients remains refractory to medical treatment. Laparoscopic Nissen fundoplication (LNF) is considered the gold-standard surgical option; however, high-quality prospective outcome data from Southeast Asia, particularly Vietnam, remain limited. This study aimed to evaluate clinical outcomes and symptom control following LNF in patients with refractory GERD. Methods:This prospective cohort study included 61 consecutive patients with refractory GERD who underwent LNF at Can Tho General Hospital between March 2022 and September 2025. Gastroesophageal reflux disease questionnaire (GERD-Q) scores and symptom control were assessed at 1 month, 6 months, 12 months, and at the end of follow-up. Results:The mean age was 38.9±14.3 years, and 54.1% of patients were male. All procedures were completed laparoscopically, with a mean operative time of 102.3±17.4 minutes. Postoperative recovery was rapid, with early resumption of oral intake and ambulation. Postoperative complications occurred in 19.7% of patients and were limited to Clavien-Dindo grades I-II, with no mortality. GERD-Q scores decreased significantly from 14.26±1.69 preoperatively to 7.00±0.99 at 1 month and continued to decline during follow-up, reaching 5.41±1.18 at the end of the study (p<0.001). Good symptom control was maintained in 83.6-90.2% of patients across follow-up time points. Conclusions:LNF is a safe and effective treatment for refractory GERD, providing rapid recovery and durable symptom control in appropriately selected patients.
The therapeutic landscape of esophageal motility disorders has changed substantially over the past decade with the emergence of third-space endoscopy. Peroral endoscopic myotomy (POEM), initially developed as an endoscopic treatment for achalasia, has evolved into a standard therapeutic modality with excellent clinical efficacy and durable long-term outcomes. Accumulating evidence demonstrates that POEM provides clinical outcomes comparable to or superior to pneumatic dilation and laparoscopic Heller myotomy, while offering the advantages of a minimally invasive endoscopic approach. Technical refinements of POEM, including optimizing myotomy length, tailoring myotomy to disease phenotype, and implementing anti-reflux strategies, have further improved procedural safety and therapeutic outcomes. In addition, the indications for POEM have expanded beyond achalasia to selected patients with esophagogastric junction outflow obstruction and spastic esophageal motility disorders, such as distal esophageal spasm and hypercontractile esophagus. The development of diverticular POEM, including Zenker-POEM and diverticular-POEM, has also highlighted POEM's evolution from a disease-specific intervention to a versatile third-space endoscopic therapeutic platform. This review summarizes current evidence regarding the endoscopic treatment of esophageal motility disorders in the era of POEM, focusing on established indications, expanding applications, technical evolution, and future perspectives. Continued advances in endoscopic technology and physiology-guided therapeutic strategies are expected to broaden POEM's role further and expand personalized endoscopic treatment for esophageal motility disorders.
Background/Aims: Fully covered self-expandable metallic stents (FCSEMSs) are used widely for the preoperative biliary drainage of pancreatic cancer because of their low recurrent biliary obstruction (RBO) rates. On the other hand, concerns about non-RBO adverse events (AEs), such as pancreatitis, have led to ongoing debate over the optimal stent. Therefore, this study aimed to clarify the clinical outcomes of preoperative biliary drainage using plastic stents (PSs) and FCSEMSs for patients with pancreatic cancer undergoing neoadjuvant chemotherapy (NAC). Methods: This study retrospectively reviewed consecutive patients (between June 2012 and September 2024) who underwent NAC following biliary drainage using either PSs or FCSEMSs and who were followed up until the decision for or against a surgical resection was made. Results: Forty-seven patients were included (PS, n=33; FCSEMS, n=14). The RBO rate was not significantly different (39% vs. 7.1%, p=0.081), whereas the time to RBO was significantly longer in the FCSEMS group (126 days vs. not reached, p=0.046). Non-RBO AEs were observed more frequently in the FCSEMS group (15% vs. 43%, p=0.061). The rate of overall AEs, including RBO and non-RBO AEs, was similar between the two groups (45% vs. 43%, p=1.000). Subgroup analysis between the PS ≥10 Fr (n=27) and FCSEMS groups showed no significant differences. Conclusions: Large-diameter PSs may be an alternative in selected patients at high risk of non-RBO AEs, including post-ERCP pancreatitis, but attention should be paid to the risk of RBO.
Functional esophageal disorders are heterogeneous conditions characterized by esophageal symptoms without definite structural obstruction or major mucosal disease. Recent advances in high-resolution manometry, the Chicago Classification version 4.0, provocative maneuvers, timed barium esophagography, and functional lumen imaging probe have substantially changed the diagnostic approach to these disorders. Although high-resolution manometry remains the cornerstone of esophageal motility assessments, normal or borderline manometric findings do not always indicate a normal esophageal physiology. In particular, the integrated relaxation pressure has important limitations because it reflects pressure-based relaxation rather than actual esophagogastric junction opening. A functional lumen imaging probe provides complementary information by assessing esophagogastric junction distensibility and distension-induced contractile responses. This approach may reveal subtle obstructive physiology, impaired distensibility, or abnormal wall biomechanics that are not evident on conventional manometry. Emerging concepts, such as manometry-functional lumen imaging probe discordance, esophageal wall thickening-associated dysphagia, and distension-mediated obstruction, suggest that some patients previously diagnosed with functional dysphagia may have identifiable and potentially treatable physiologic abnormalities. Therefore, the evaluation of functional esophageal disorders is moving from exclusion-based diagnoses toward multimodal, symptom-oriented physiologic phenotyping.
Chronic pancreatitis is a progressive inflammatory disease in which persistent abdominal pain is the major determinant of an impaired quality of life. Although medical and endoscopic therapies are commonly applied as initial treatments, many patients eventually require surgical intervention. In addition, the optimal timing of surgery and the choice of surgical procedure are controversial. The main goals of surgical treatment in chronic pancreatitis are durable pain relief, management of disease-related complications, and preservation of pancreatic function. Surgical options include drainage procedures, resection procedures, and combined approaches, depending on the pancreatic morphology, particularly main pancreatic duct dilatation and the presence of an inflammatory mass in the pancreatic head. Duodenum-preserving pancreatic head resection procedures, such as the Beger, Frey, and Berne techniques, have shown long-term pain control comparable to that of pancreaticoduodenectomy, with advantages in postoperative recovery and quality of life in selected patients. Recent evidence also suggests that earlier surgical intervention may provide better long-term outcomes than prolonged endoscopic management. In conclusion, surgical treatment should be considered an integral component of the management of chronic pancreatitis rather than a last-resort option. Appropriate patient selection and individualized choice of surgical technique are essential to optimizing the clinical outcomes.
The diagnosis of gastroesophageal reflux disease (GERD) has evolved from a symptom-based approach to an objective test-based strategy. Lyon consensus 2.0 provides updated criteria for classifying GERD as conclusive or inconclusive and proposes differential diagnostic strategies based on prior GERD evidence and symptom presentation. Recent evidence incorporated into Lyon consensus 2.0 was reviewed with emphasis on actionable GERD, unproven versus proven GERD, updated endoscopic criteria, prolonged wireless pH monitoring, ambulatory pH-impedance monitoring, and adjunctive reflux metrics. Lyon consensus 2.0 defines actionable GERD as a condition in which objective esophageal testing supports revising, escalating, or personalizing management in symptomatic patients. Major updates include recognizing Los Angeles grade B esophagitis as conclusive evidence of GERD, preferring prolonged wireless pH monitoring for unproven GERD with typical symptoms, and use of on-therapy pH-impedance monitoring in proven GERD with persistent symptoms. The acid exposure time remains the primary reflux metric, while the number of reflux episodes and mean nocturnal baseline impedance serve as adjunctive parameters. In contrast, the postreflux swallow-induced peristaltic wave index has been retired from the core diagnostic framework. Lyon consensus 2.0 refines modern GERD diagnosis by integrating symptom phenotype, prior objective evidence, and context-specific reflux testing. Its main clinical value lies in personalizing diagnostic strategies and improving confidence in treatment-related decision-making.
Upper gastrointestinal subepithelial lesions (SELs) are detected during routine screening endoscopy and are usually identified as asymptomatic protrusions covered by normal-appearing mucosa. Although most SELs follow a benign clinical course, some lesions, including gastrointestinal stromal tumors, neuroendocrine tumors, lymphomas, and metastatic tumors, possess malignant potential and require further evaluation. Appropriate risk stratification is therefore essential to guide management. Endoscopy remains the initial diagnostic modality, while endoscopic ultrasonography (EUS) plays a central role in characterizing lesion size, layer of origin, echogenicity, and other high-risk features. Recent advances in tissue acquisition techniques, including EUS-guided fine-needle biopsy and mucosal incision-assisted biopsy, have improved diagnostic yield and histologic accuracy. Accumulating evidence from large retrospective and prospective studies indicates that most small asymptomatic SELs remain stable during long-term follow-up, whereas larger lesions, interval growth, mucosal surface changes, and suspicious EUS findings are associated with an increased risk of progression. Management strategies should be individualized according to lesion characteristics, malignant potential, and patient factors. Surveillance is generally appropriate for small lesions without high-risk features, while tissue diagnosis or resection should be considered for lesions demonstrating growth, symptoms, or imaging findings that are concerning. Advances in therapeutic endoscopy, including endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and endoscopic full-thickness resection, have expanded minimally invasive treatment options. Current international and Korean guidelines emphasize EUS-based risk assessment and selective intervention rather than routine resection of all SELs. This review summarizes the epidemiology, natural history, diagnostic approaches, management strategies, and current guideline recommendations for asymptomatic upper gastrointestinal SELs.
Since the 2020 Korean guidelines for Helicobacter pylori treatment, clarithromycin resistance rates have risen from 17.8% to 33.3%, dual-priming oligonucleotide-based polymerase chain reaction-guided tailored therapy has been adopted, and potassium-competitive acid blockers (P-CABs) have become available. This fourth revision addressed these changes. Nine key questions were addressed through systematic review and meta-analysis. Thirteen recommendations were evaluated using a modified Delphi process involving 64 experts. Twelve recommendations achieved a first-round consensus; one required revision and achieved 73.9% agreement. Key changes included: 1) a dual-pillar strategy of tailored therapy and empirical quadruple therapy; 2) restricted use of empirical clarithromycin-based triple therapy under specific conditions; 3) removal of sequential therapy; 4) use of P-CABs as alternatives to proton pump inhibitors; 5) expansion of eradication indications to include gastric cancer prevention in H. pylori gastritis and regression of hyperplastic polyps ≤10 mm; and 6) positioning of bismuth quadruple therapy as a conditionally recommended first-line empirical option, with preference for reservation as salvage therapy, and introduction of modified bismuth quadruple therapy (addition of bismuth to conventional regimens) as an additional first-line empirical option. The revised guidelines provide updated evidence-based recommendations for the diagnosis and treatment of H. pylori infection, reflecting the rapidly changing antibiotic resistance landscape and the introduction of new diagnostic and therapeutic tools in Korea. These guidelines aim to assist clinicians, patients, policymakers, and medical educators in optimizing H. pylori management. They may differ from the current medical insurance standards and will be further revised based on emerging evidence.
Despite the advances in biological and small-molecule therapies, a substantial proportion of patients with inflammatory bowel disease (IBD) experience multiple treatment failures, constituting difficult-to-treat IBD with remission rates plateauing at 30-50%. Advanced combination therapy (ACT), defined as the concomitant use of two advanced therapies with distinct mechanisms of action, has become a strategy to overcome this therapeutic ceiling. This review aims to synthesize the rationale, clinical evidence, safety profile, and practical implementation strategies of ACT in IBD. A narrative review of randomized controlled trials (RCTs), meta-analyses, and real-world observational studies evaluating ACT in IBD was performed, focusing on the mechanistic rationale, efficacy outcomes, safety data, and clinical application strategies. ACT is supported by pharmacokinetic synergy (reduced immunogenicity and improved drug exposure) and pharmacodynamic complementarity (simultaneous blockade of multiple inflammatory pathways). Proof-of-concept RCTs, including VEGA and EXPLORER, along with meta-analyses, revealed higher clinical and endoscopic remission rates with ACT than with monotherapy in refractory populations. The safety profiles are generally comparable to monotherapy, but regimen-specific heterogeneity exists. Although vedolizumab- or ustekinumab-based combinations show favorable long-term safety, regimens including natalizumab or JAK inhibitors warrant caution and close monitoring. Detailed clinical strategies include induction-bridge approaches with JAK inhibitors, safety-anchor strategies with gut-selective agents, mechanistic complementarity strategies for treatment failures, and double-indication strategies for extraintestinal manifestations. ACT is a promising rescue strategy for D2T IBD with encouraging efficacy and acceptable safety. Future research should focus on large-scale RCTs and biomarker-driven strategies to optimize patient selection and treatment protocols for ACT.
Hepatic portal venous gas (HPVG) may suggest an ominous pathology that requires immediate attention because it is frequently associated with life-threatening conditions such as mesenteric ischemia and bowel necrosis. Therefore, early recognition and accurate differential diagnosis are crucial for timely intervention. This paper presents a 78-year-old female who developed extensive HPVG with a fatal clinical course, ultimately resulting in death despite intensive medical management.
Colorectal cancer (CRC) is one of the most common malignancies worldwide and the second leading cause of cancer-related death. In South Korea, the incidence of CRC has increased alongside rapid socioeconomic development and westernized lifestyles, but it has recently shown a gradual decline, largely due to the National Cancer Screening Program (NCSP). The NCSP, first launched in 1999 and expanded in 2004 to include CRC screening, has reduced the incidence and mortality of colorectal cancer significantly, while improving the five-year relative survival rate. The Korean Colonoscopy Screening Pilot Study (K-COSPI) reported the feasibility, safety, and high acceptability of colonoscopy as a primary screening tool, suggesting the potential to transition to colonoscopy-based national screening. Nevertheless, challenges persist in increasing participation and maintaining high-quality performance because the adenoma detection rate remains a critical indicator of screening effectiveness. Continuous efforts to strengthen public awareness, enhance the quality control of colonoscopy, and develop evidence-based, risk-stratified screening strategies will be essential for sustaining and advancing this exemplary public health achievement.
Biliary tract cancer (BTC), encompassing intrahepatic and extrahepatic cholangiocarcinoma as well as gallbladder cancer, represents a heterogeneous group of malignancies characterized by an aggressive clinical course and poor prognosis. Systemic chemotherapy with gemcitabine plus cisplatin has remained the standard first-line treatment for more than a decade because most patients are diagnosed at an advanced or unresectable stage, but the associated survival benefit is limited. Recent therapeutic advances have been driven by the integration of immunotherapy and molecularly targeted approaches. Immune checkpoint inhibitors targeting programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1) have shown clinically meaningful activity, particularly in combination with cytotoxic chemotherapy, and are increasingly being incorporated into first-line treatment strategies for advanced BTC. Concurrently, comprehensive molecular profiling has revealed substantial genomic heterogeneity and identified actionable alterations, including fibroblast growth factor receptor 2 (FGFR2) fusions, isocitrate dehydrogenase 1 (IDH1) mutations, and human epidermal growth factor receptor 2 (HER2) amplification, enabling the development of precision targeted therapies for selected patient populations. Despite these advances, the therapeutic responses to immunotherapy and targeted agents remain highly variable, and robust predictive biomarkers have yet to be established. Accordingly, optimizing patient selection by integrating molecular and immunologic characteristics has become a critical objective for improving clinical outcomes. This review provides an overview of the recent progress in immunotherapy and targeted therapy for BTC, focusing on pivotal clinical trials, therapeutic efficacy, current limitations, and future perspectives for personalized treatment strategies.
