Pancreatic portal hypertension (PPH) is a distinct form of sinistral (left-sided) portal hypertension, primarily resulting from pancreatic diseases such as acute or chronic pancreatitis and pancreatic tumors. These conditions lead to splenic vein distortion, compression, and inflammatory thickening, which can progress to luminal obstruction and thrombosis. This thrombosis impairs venous return, elevates splenic vein pressure, and ultimately causes splenomegaly, hypersplenism, and left-sided portal hypertension. Current knowledge regarding the long-term prognosis of PPH is primarily derived from small-scale descriptive studies and case reports. Thus, large-scale, prospective cohort studies are needed to better characterize its natural history and outcomes. This retrospective cohort study aimed to determine the incidence of variceal bleeding (the primary complication) in patients with PPH and to identify its risk factors. A total of 207 patients diagnosed with PPH secondary to acute or chronic pancreatitis who were managed at Xijing Hospital between 2015 and 2023 were included. Demographic, clinical, laboratory, and imaging findings (e.g., thrombosis, stenosis, or occlusion of the splenic, portal, or superior mesenteric vein) were collected retrospectively. All patients were prospectively followed for the clinical endpoint of variceal bleeding. Cox proportional hazards regression analysis was performed to identify independent risk factors for variceal bleeding. The crude incidence of bleeding was 11.6

BACKGROUND:Endoscopic retrograde cholangiopancreatography (ERCP) is intricate and necessitates comprehensive training. The conventional hands-on approach in ERCP training may not be essential for improving trainee performance or ensuring procedure safety. We hypothesized that hands-off assistance would be non-inferior to hands-on assistance in terms of cannulation success by trainees during ERCP training. METHODS:A total of 770 patients with native papilla were randomized to either the hands-off (intervention, n = 389) group, where trainers offered verbal guidance via teleguidance using real-time endoscopic and fluoroscopic feeds, or the hands-on (control, n = 381) group, where trainers provided on-site verbal and restrictive hands-on assistance. Eight trainees with preliminary cannulation experience were involved. The primary outcome was the successful cannulation rate within 10 min by trainees. ITT analysis was performed and non-inferiority was established if the lower bound of the 95% confidence interval for the difference in success rates exceeded -10%. RESULTS:Cannulation success rates were nearly identical (222/389, 57.1% vs. 218/381, 57.2%; absolute difference - 0.1%, 95%CI -7.1% to 6.8%; noninferiority P = .002). There was no difference in total cannulation time and attempts between the two groups. Verbal instruction and performance scores were comparable between the two groups. The incidence of adverse events was 8.2% (32/389) vs. 9.2% (35/381) (P = .73), including pancreatitis (5.7% vs. 6.8%), bleeding (1.3% vs. 0), and cholangitis (2.1% vs. 2.6%) (all P > .05). Trainers in the hands-off group received minimal radiation exposure. CONCLUSIONS:The hands-off training showed non-inferior effectiveness and safety to the hands-on training. The alternative method can be integrated into the traditional ERCP training. Key messages What is already known on this topic: Conventional endoscopic retrograde cholangiopancreatography (ERCP) training relies heavily on direct, hands-on supervision by experienced endoscopists to guide trainees during procedures. While teleguidance (remote supervision using real-time imaging) has been proposed as a potential alternative, robust evidence comparing its effectiveness and safety to traditional hands-on assistance has been lacking. What this study adds: This randomized trial demonstrates that hands-off assistance using teleguidance is non-inferior to hands-on assistance for trainee cannulation success rates (57.2% vs. 57.1%) and overall patient safety (complication rates 8.2% vs. 9.2%). It also significantly reduces radiation exposure for trainers without increasing trainees' fluoroscopy time or compromising procedural outcomes. How this study might affect research, practice, or policy: The findings support integrating hands-off training via teleguidance into ERCP curricula, offering a viable alternative that maintains trainee performance while reducing trainer radiation risk. This approach could expand training capacity, particularly in settings with limited expert availability, and prompts further research into optimizing remote supervision for complex cases and long-term competency assessment.

OBJECTIVES:Advanced malignancies frequently cause concurrent malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO). Conventional endoscopic approaches would be duodenal stenting combined with endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD), with limited long-term efficacy. Novel therapeutic endoscopic ultrasound (EUS), known as double EUS-bypass, may offer improved outcomes. This study aimed to compare the efficacy and safety of two approaches for managing concurrent MBO and GOO. METHODS:In this retrospective cohort study, 106 patients with concurrent MBO and GOO were included between 2011 and 2025. Among them, 44 underwent double EUS-bypass, while 62 received conventional endoscopic approaches. Clinical success rate, technical success, adverse events, re-intervention rate, and long-term patency were compared. RESULTS:Technical success was achieved in 93.2% of the EUS group and 100% of the traditional group (p = 0.136). The clinical success rate was significantly higher in the EUS group (59.1% vs. 37.1%, p = 0.041), particularly in postoperative improvement on GOO (p = 0.007). Recurrence rates of MBO and GOO were significantly lower in the EUS group (p = 0.078 and p = 0.010, respectively). Notably, the re-intervention rate was markedly reduced in the EUS group (9.1% vs. 46.8%, p < 0.001). Adverse event rates, procedure duration, and hospitalization length were comparable between groups. CONCLUSIONS:Double EUS-bypass offers superior clinical outcomes and reduces the need for re-intervention in patients with concurrent malignant GOO and MBO compared to conventional endoscopic approaches.

Rationale:Anastomotic leakage (AL) remains a major surgical challenge that is difficult to address using hand-sewn closure alone. Robust, rapidly acting bioadhesive patches offer a promising alternative to conventional sutures and staples. However, the development of bioadhesive patches that achieve instantaneous wet-tissue adhesion while minimizing postoperative adhesion remains challenging. Innovative material designs and interdisciplinary translational strategies are therefore needed to advance bioadhesion technologies toward clinical application. Methods:Herein, we developed a translational asymmetric bioadhesive patch (ABP) that integrates a blood-repelling, hydrophobic, HBP oil-infused anti-adhesive top surface with a bioadhesive bottom surface capable of absorbing interfacial water. The physicochemical properties, mechanical performance, wet-tissue adhesion, and hemostatic capacity of the ABP were systematically evaluated through in vitro and in vivo assays. Its therapeutic efficacy for sutureless intestinal repair was further assessed in a rat colon defect model. Results:The ABP exhibited instantaneous and robust adhesion to various biological wet tissues (~10 times stronger than FDA-approved sealant Tisseel). The patch also showed excellent stretchability, sustaining more than 1000% strain without loss of elasticity. Moreover, ABP enables rapid hemostasis in injured tissues and achieved sutureless sealing and repair of intestinal defects in a rat colon injury model. Importantly, the asymmetric design reduced postoperative adhesions and attenuated foreign body reactions. Conclusions:The proposed ABP patch provides an effective solution for intestinal defects repair by enabling immediate wet-tissue attachment, non-invasive defect closure, and durable tissue sealing without the need for device removal. By combining strong bioadhesion with an anti-adhesive outer surface, this patch offers a promising translational platform for preventing anastomotic leakage while reducing postoperative adhesions and foreign body responses.

INTRODUCTION:Vagal nerve stimulation (VNS) holds promise for modulating inflammation and gastrointestinal function, but its efficacy as an adjunctive therapy for acute pancreatitis (AP) remains unclear. This study aimed to evaluate the efficacy and safety of transcutaneous auricular VNS (taVNS) in patients with AP. METHODS:Patients with mild AP and a PAtieNt-rePoRted OutcoMe Scale in Acute PancreatItis (an international proSpEctive cohort study) (PAN-PROMISE) score ≥ 15 were recruited from 5 tertiary hospitals in China. Patients were randomly assigned to receive taVNS or sham-taVNS plus standard care. Stimulation parameters were set as follows: pulse width 0.5 ms, frequency of 25 Hz, and amplitude ranging from 0.5 to 3.0 mA. Patients, care providers, and outcome assessors remained blinded to treatment allocation throughout the study. The primary end point was the median time to achieve a PAN-PROMISE score ≤ 6. RESULTS:A total of 60 patients were randomized. The taVNS group had a shorter median time to reach a PAN-PROMISE score ≤6 than the sham-taVNS group (3.00 vs 4.00 days, hazard ratio = 1.956, P = 0.002). The proportion of patients achieving a PAN-PROMISE score ≤ 6 within the first 3 days was significantly higher in the taVNS group than in the sham-taVNS group (50.00% vs 13.33%, P = 0.002). taVNS was associated with greater improvement in the subscales of the PAN-PROMISE, including abdominal pain, abdominal distension, and difficulty eating (all P < 0.05). By day 3, the taVNS group showed a greater reduction in C-reactive protein levels compared with the sham-taVNS group (-32.40 mg/L vs 12.75 mg/L, P = 0.005). Adverse events were mild and did not differ between the groups. DISCUSSION:In patients with mild AP, taVNS was associated with earlier symptom resolution and potential anti-inflammatory effects with a favorable safety profile.

Acute pancreatitis (AP) remains a significant clinical challenge lacking early, targeted pharmacological interventions to prevent disease progression. Dysfunctional autophagy is a central pathogenic mechanism in AP. While indomethacin (IND), a nonsteroidal anti-inflammatory drug, is known to prevent post-ERCP pancreatitis, its broader therapeutic potential and underlying mechanisms in other forms of AP are unclear. Emerging evidence suggests that IND has the potential to activate autophagy. This study aimed to investigate whether IND protects against AP by regulating autophagy. We established cerulein (CER)-induced AP models both in vivo and in AR42J cells to evaluate the protective effects of IND. Transcriptomic and pathway analyses were conducted to identify underlying signaling mechanisms. Our results demonstrate that IND alleviated CER-induced pancreatic injury, as indicated by improved histopathological scores, reduced serum amylase and lipase levels, diminished inflammatory cell infiltration, and attenuated acinar cell cytotoxicity. Mechanistically, transcriptomic and experimental data revealed that IND restored autophagy via activation of the AMP-activated protein kinase (AMPK) signaling pathway. Critically, the protective effects of IND were abolished by either the autophagy inhibitor chloroquine or the AMPK inhibitor Compound C (CC). In conclusion, our findings suggest that IND may serve as a promising therapeutic candidate for the treatment of AP.

Differentiating between benign and malignant biliary strictures is crucial yet challenging. The role of nutritional indicators in this differentiation process remains unclear. This study aimed to explore the potential of nutritional indicators for improving the diagnostic accuracy of biliary strictures. This prospective study recruited patients aged 18–80 years with suspected biliary strictures. The final diagnosis was based on pathological examination or long-term follow-up. In addition to common clinical variables, nutritional indicators, including the Global Leadership Initiative on Malnutrition (GLIM), Mini-Nutritional Assessment (MNA), Nutritional Risk Screening 2002 (NRS2002), and anthropometric measurements, were collected. Univariate and multivariate logistic regression, along with the Boruta algorithm, were used for variable selection. Multiple machine learning models were constructed. The primary outcome was defined as the differentiation of benign from malignant biliary strictures. Model performance was evaluated through metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. A total of 264 patients (106 with benign and 158 with malignant biliary strictures) were included. Through univariate and multivariate logistic regression, 7 variables related to malignant strictures were identified, including nutritional parameters such as the MNA classification. Among all 7 machine learning models, the multivariate logistic regression model demonstrated the optimal performance, with an AUC of 0.91 (95

Recent meta-analyses suggested diclofenac may be superior to indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of our study was to compare the efficacy of 100 mg rectal indomethacin versus diclofenac on PEP incidences. This multicentre, double-blinded, randomised controlled trial was conducted in nine tertiary centres in China. Patients with low and high risk for PEP and native papilla were randomly allocated (1:1) to receive 100 mg diclofenac or 100 mg indomethacin rectally before ERCP. The primary outcome was the occurrence of PEP defined by the Cotton consensus. The intention-to-treat principle was conducted for the analysis. The trial was terminated early for futility after the predetermined first interim analysis. Between June 2023 and May 2024, 1204 patients were randomised into the diclofenac group (n=600) or indomethacin group (n=604). Baseline characteristics were balanced. The primary outcome occurred in 53 patients (8.8%) of 600 patients allocated to the diclofenac group and 37 patients (6.1%) of 604 patients allocated to the indomethacin group (relative risk 1.44; 95% CI 0.96 to 2.16, p=0.074). PEP occurred in 35 (14.2%) of 247 high-risk patients in the diclofenac group and 26 (9.8%) of 266 high-risk patients in the indomethacin group (p=0.124). PEP incidences were also comparable in low-risk patients between the two groups (18/353 (5.1%) vs 11/338 (3.3%), p=0.227). Other ERCP-related complications did not differ between the two groups. Pre-procedure 100 mg rectal diclofenac was not superior to the same dose of rectal indomethacin regarding preventing PEP. These findings supported current clinical practice guidelines of 100 mg indomethacin or diclofenac for PEP prophylaxis in patients without contraindications. ClinicalTrials.gov (NCT05947461).

Background:Interval cancers are linked to a low adenoma detection rate (ADR), prompting calls for benchmark-guided ADR performance improvement. Although water exchange and a straight cap (CAP) have been reported to independently improve ADR, the effects of Daisycuff™ and Endocuff Vision® remained unknown. We hypothesized that selected cap(s) could increase ADR and related water exchange outcomes. Methods:Subjects were randomized to No cap, or CAP, Daisycuff™ and Endocuff Vision® at 7, 5 and 2 sites. The primary outcome was ADR. Outcomes were compared for No cap vs. the above randomized caps. Results:Demographic and historic data revealed adequate randomization. Despite variations in site-specific pretrial ADR, the aggregated data showed that the ADR of No cap (45.6%) exceeded the latest benchmark (35%). Each added cap increased the ADR, and the difference using Daisycuff™(52.8%) approached statistical significance (P=0.05). In the right colon, CAP and Daisycuff™ significantly increased ADR. In the left colon, Daisycuff™ significantly increased adenoma per colonoscopy. Factors that improved adenoma detection were consistent with published reports. Detection rates based on site, indication, sedation type, polyp size, shape and pathology in the No cap group were consistent with conventional data and were not influenced by the caps. Conclusions:The significantly higher right-colon ADRs with CAP and Daisycuff™ suggest potential clinical relevance for reducing interval cancers. Although water exchange with or without caps yields ADRs that surpass the benchmark, the positive findings for selected cap(s) need to be confirmed in order to enhance the options for further improvement of water exchange.

OBJECTIVE:The objective of this study was to investigate the efficacy of transcutaneous auricular vagal nerve stimulation (taVNS) in adult patients with chronic constipation. DESIGN:Consecutive patients who met the Rome IV criteria for chronic constipation were enrolled and randomly assigned to either the taVNS group or the sham-taVNS group. Treatment consisted of 30 min of therapy twice a day for 4 weeks. The primary outcome was the response rate at week 1-4, defined as the proportion of patients with a weekly complete spontaneous bowel movement (CSBM) of ≥ 3 and weekly excessive use of rescue medication ≤ 3 times. Secondary outcomes included spontaneous bowel movements, anxiety and depression scores, abdominal symptoms, and adverse events. RESULTS:The study was terminated due to lack of efficacy revealed by the interim analysis. A total of 106 patients were randomized, with 52 participants in the taVNS group and 54 participants in the sham-taVNS group. After 4 weeks of treatment, the response rates were 17% (9/52) in the taVNS group and 19% (10/54) in the sham-taVNS group. There was no significant difference between the two groups in intention-to-treat (ITT) analysis (RR 0.92, 95% CI 0.30-2.80, p = 1) or in the per-protocol (PP) analysis. No serious adverse events were reported. CONCLUSION:Our study did not support the effectiveness of 4-week 25 Hz taVNS for the treatment of adult chronic constipation patients. TRIAL REGISTRATION:clinicaltrials.gov number: NCT05723731.

Background & Aims: Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves outcomes in high-risk acute variceal bleeding but its use is limited by hepatic encephalopathy (HE). While stent diameter and post-TIPS portacaval pressure gradient (PPG) targets may influence HE risk, evidence-based standards are lacking. This study aimed to compare 8-mm vs. 10-mm diameter stents and evaluate PPG thresholds to balance HE risk and therapeutic efficacy. Methods: In this multicenter observational study, 470 patients with cirrhosis and acute variceal bleeding receiving pre-emptive TIPS (8-mm: n = 384; 10-mm: n = 86) were analyzed. Competing risks regression and restricted cubic splines were used to assess associations between stent diameter, PPG, and clinical outcomes. Results: At 1 year, 8-mm stents reduced overt HE incidence (28.9% vs. 45.4%; subdistribution hazard ratio [sHR] 0.57, 95% CI 0.40–0.82) and further decompensation (40.4% vs. 52.3%; sHR 0.68, 95% CI 0.48–0.95) compared to 10-mm stents, without increasing the risk of further bleeding (12.0% vs. 9.3%; p = 0.471) or mortality (13.3% vs. 14.0%; p = 0.813). Non-linear analysis identified a PPG range of 7–13 mmHg associated with minimized overt HE risks (sHR 1.43 for PPG <7 vs. 7–13 mmHg; 95% CI 1.01–2.01) and portal hypertensive complications (sHR 2.76 for PPG >13 vs. 7–13 mmHg; 95% CI 2.69–9.39). A significantly greater proportion of patients in the 8-mm group attained the optimal 7–13 mmHg target range compared to the 10-mm group (71.1% vs. 55.8%, p <0.001). Conclusions: Pre-emptive TIPS with 8-mm stents reduces HE and further decompensation without compromising efficacy. Immediate post-TIPS PPG measurements may aid intraprocedural decision-making, with a 7–13 mmHg range serving as a pragmatic guide for initial stent calibration in high-risk acute variceal bleeding. Impact and implications: This multicenter study of 470 patients with cirrhosis and acute variceal bleeding shows that pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) placement using 8-mm stents reduces the 1-year incidence of overt hepatic encephalopathy by 43% compared to 10-mm stents, while maintaining similar efficacy in preventing rebleeding. Non-linear analysis identified a post-TIPS portacaval pressure gradient (PPG) range of 7–13 mmHg as an optimal target, minimizing risks of both overt hepatic encephalopathy and portal hypertensive complications. A significantly higher proportion of patients achieved this PPG range with 8-mm stents. These results address a key dilemma in high-risk AVB management, demonstrating that 8-mm stents balance encephalopathy prevention with effective portal decompression. The 7–13 mmHg PPG range provides a practical intraprocedural guide for individualized TIPS calibration, helping interventional radiologists optimize shunt diameter selection.

Background:Distinguishing benign from malignant biliary strictures remains challenging. Large Language Models (LLMs) show promise in enhancing diagnostic accuracy. This study aimed to evaluate the performances of ten LLMs in the differential diagnosis of benign and malignant biliary strictures. Methods:Consecutive patients with biliary strictures undergoing endoscopic retrograde cholangiopancreatography (ERCP) at Xijing Hospital between January and December 2024 were retrospectively analyzed. Ten LLMs were systematically prompted with standardized clinical, laboratory, and imaging data. Performance was compared against tumor markers (CA19-9, CEA), a new multivariable clinical model, and ten independent pancreaticobiliary exoerienced physicians. Subgroup analyses assessed hilar (n=29) versus non-hilar strictures. Gold-standard diagnosis relied on histopathology and ≥3-month follow-up. Results:Among the 159 included patients (83 benign, 76 malignant), four LLMs (Kimi, Deepseek-R1, Claude-3.5S, Llama-3.1), the clinical model (AUC:0.83), and six physicians achieved >80% accuracy. Kimi demonstrated superior accuracy (87%), significantly outperforming 70% of physicians (7/10, p<0.01). Three other LLMs (Deepseek-R1:83%, Claude-3.5S:82%, Llama-3.1:81%) and the clinical model performed comparably to physicians (78-84%, p>0.05), collectively surpassing tumor markers (CA19-9 accuracy:66%, CEA:71%). Physicians demonstrated higher accuracy for hilar strictures (87% vs. 79% for non-hilar, p<0.001). LLMs showed similar performance across stricture locations (hilar:64-95%; non-hilar:62-88%, p>0.05). For hilar strictures, 7/10 physicians achieved significantly higher accuracy (87-90%) than 8/10 LLMs (64-84%, p<0.05). Conclusions:Using clinical, lab, and imaging data, some LLMs achieved diagnostic accuracy comparable to or exceeding clinical models and experienced physicians for differentiating benign versus malignant strictures. However, for hilar strictures, LLM performance was inferior to over half of the physicians.

Endoscopic incision (EI) combined with triamcinolone (TAA) injection has emerged as an effective method for treating benign esophageal stricture (BES). However, a single EI and TAA injection seems to be insufficient for long-term relief of BES in some patients, especially those with recurrent BES. Here, we aimed to investigate the long-term efficacy and safety of repeated EIs and TAA injections in patients with recurrent BES. Patients with recurrent BES who previously underwent endoscopic dilation or EI were enrolled in this retrospective study. All patients underwent multiple EIs and TAA injections. Patients were followed for at least 12 months. The primary outcome was the rate of re-stricture at 6 months after repeated EIs and TAA injections. The secondary outcomes included the symptom relief rate, the change in Stooler’s dysphagia score (0, normal swallowing; 1, semidry food intake only; 2, soft food intake only; 3, fluid only; and 4, no oral intake) and body mass index (BMI) at 6 months, and overall adverse events (AEs). The risk factors for 6-month re-stricture were identified using logistic regression analysis. A total of 73 patients were enrolled in this study, including 30 (41.1

Due to the common developmental origination and influences by similar unhealthy lifestyle, upper and lower gastrointestinal (GI) diseases may be closely associated. However, the evidence remains elusive. This study aims to determine the prevalence of GI endoscopic lesions and the correlations between endoscopic lesions in individuals undergoing gastroscopy and colonoscopy simultaneously. A retrospective study was conducted on 18,556 individuals who underwent simultaneous gastroscopy and colonoscopy at the Endoscopy Center of Xijing Hospital of Digestive Diseases from January 2020 to March 2023. Data on sex, age, pathological and endoscopic results were collected. The Pearson chi-square test was used to analyze the occurrence of various GI lesions among age groups and correlations between GI lesions, and logistic regression was used to determine risk factors for common upper and lower GI lesions. The mean age was 50.35 ± 12.31 years, and 55.5

IntroductionPancreatic portal hypertension (PPH) is a rare complication of acute pancreatitis (AP) that can lead to severe gastrointestinal bleeding. The risk factors associated with PPH, as well as the overall prognosis, warrant further investigation. This study aims to develop and validate a nomogram to predict PPH in patients with AP.MethodsConsecutive patients with AP from 2015 to 2023 were retrospectively included in the study. Demographic data, clinical manifestations within the first week of AP onset, and initial contrast-enhanced CT findings were used to develop the predictive model. Univariate and multivariate Cox regression analyses were performed to identify risk factors for PPH. Based on the results of the multivariate analysis, a nomogram was developed. The patients were randomly divided into training and validation sets at a 7:3 ratio. The accuracy and discriminative power of the predictive model were assessed using the area under the curve (AUC) from the receiver operating characteristic curve and the calibration curve.ResultsOf the 1473 patients with AP, 107 (7.3%) developed PPH within 6 months (range: 2–22 months) during follow-up. Multivariate regression analysis showed that body mass index (BMI) (HR, 1.10; 95% CI 1.04 to 1.16; p=0.001), moderately severe grade (HR, 9.36; 95% CI 4.58 to 19.13; p<0.001), severe grade (HR, 12.95; 95% CI 6.22 to 26.94; p<0.001), diabetes (HR, 2.26; 95% CI 1.47 to 3.47; p<0.001), acute fluid accumulation (HR, 2.13; 95% CI 1.31 to 3.47; p=0.002), and necrosis (HR, 3.64; 95% CI 2.30 to 5.78; p<0.001) were independent risk factors for PPH. A nomogram for predicting PPH was developed, with the predictive curves showing an AUC of 0.859 at 6 months and 0.846 at 9 months. In the validation set, the AUC at both time points was 0.812.ConclusionIn summary, we identified BMI, moderately severe or severe AP, diabetes, acute fluid accumulation, and necrosis as risk factors for AP-related PPH. Using the largest cohort of patients with AP to date, we developed a highly accurate nomogram with strong discriminative ability for predicting PPH. Future studies with larger sample sizes are necessary to confirm our findings and conduct external validation.