BackgroundA 38-year-old woman with a 32-year history of recurrent biliary stones (cholecystectomy at age 6 and open choledochotomy with 6-month T-tube indwelling at age 16) presented with 2 h of postprandial right upper quadrant pain. Laboratory tests showed mild hyperbilirubinemia (total bilirubin 24.4 μmol/L, direct bilirubin 8.4 μmol/L) and elevated alanine transaminase of 287 U/L. Abdominal CT scan revealed common bile duct (CBD) stones without pneumobilia. Her symptoms resolved spontaneously before scheduled endoscopic retrograde cholangiopancreatography (ERCP). ERCP showed compensated dilatation of the CBD without residual stones, inadvertent contrast overflowing into the duodenum, a 5-mm choledochoduodenal fistula in the proximal descending duodenum, and a slender distal CBD segment confirmed by intraductal ultrasound. The fistula, further confirmed by enhanced CT, acted as a benign physiological drainage pathway. The slender distal CBD formed a specific pressure gradient, and spontaneous stone passage was achieved via this fistula, which was the core mechanism for the patient's long-term symptom-free survival.ConclusionCholedochoduodenal fistula can, in rare circumstances, exert a protective rather than deleterious effect in patients with cholelithiasis. This case with a benign clinical course complements the clinical scenario beyond the conventional clinical paradigm that choledochoduodenal fistulas commonly require active intervention.

Background and Aims: Sessile serrated lesions (SSLs) are precancerous colorectal polyps with high malignant potential, yet their endoscopic recognition remains challenging. Most artificial intelligence (AI) models for polyp classification fail to specifically identify SSLs, often misclassifying them as hyperplastic polyps. This study aimed to develop and validate SERRATE (Sessile Serrated lesion Recognition and Risk Assessment Tool for Endoscopy), a deep learning model for distinguishing SSLs from conventional adenomas and hyperplastic polyps. Methods : We retrospectively collected colonoscopic images from 696T patients at Peking Union Medical College Hospital (January 2017-September 2024), yielding >20,000 images. The balanced training dataset comprised 1,120 SSL images, 1,697 conventional adenoma images, and 1,207 hyperplastic polyp images. A Swin Transformer model was trained using both white-light imaging and narrow-band imaging (NBI). Model performance was evaluated on a prospective internal validation cohort (300 patients, January 2025-April 2025; ClinicalTrials.gov NCT06773832) and the external POLAR dataset. Results : The optimal model utilized NBI images with 2×mucosal context expansion, achieving 82.42% accuracy in internal validation. For three-class classification (SSL vs. conventional adenoma vs. hyperplastic polyp), the model demonstrated 73.44% overall accuracy (precision 82.47%, recall 95.21%, specificity 91.21%, F1-score 82.17%) on prospective internal validation and 69.46% accuracy on external validation. For binary neoplasia detection, accuracy reached 91.07% across validation sets. Conclusions : SERRATE represents the first AI model specifically designed for SSL recognition with balanced training data. The model achieved clinically relevant performance for SSL differentiation, potentially improving colorectal cancer prevention through enhanced serrated lesion management.

BACKGROUND AND AIM:Peroral endoscopic myotomy is a standard treatment for achalasia (AC). The conventional approach involves circular muscle myotomy (CMM), but full-thickness myotomy (FTM) may offer more profound lower esophageal sphincter (LES) reduction. This randomized controlled noninferiority trial primarily determined whether FTM achieved clinical success noninferior to CMM. METHODS:This single-center, randomized noninferiority trial enrolled 69 patients with type I or II AC assigned to the FTM group (n = 34) or the CMM group (n = 35). The primary outcome was clinical success (Eckardt score ≤3) at 6 months after the procedure. A noninferiority margin of -10% was prespecified. Secondary outcomes included procedure-related metrics, safety outcomes or adverse events, physiological and anatomical outcomes, and GERD-related outcomes. RESULTS:In the intention-to-treat analysis, clinical success rates were 91.2% in the FTM group and 85.7% in the CMM group, with a group difference of 5.5% (90% CI, -7.1% to 18.1%). Because the lower CI bound (-7.1%) was above -10%, FTM was noninferior to CMM. FTM was associated with significantly higher insufflation-related events (32.35% vs 11.43%; P = .035). There was a trend toward more frequent moderate-to-severe intraoperative bleeding in the FTM group (41.18% vs 22.86%; P = .103). FTM resulted in significantly lower basal LES pressure than CMM (6.85 vs 11.70 mm Hg; P = .024). Postoperative esophagitis showed a numerical trend toward an increase in the FTM group (36.36% vs 18.18%; P = .097). CONCLUSIONS:FTM was noninferior to CMM in short-term efficacy. However, FTM was associated with a significantly higher incidence of insufflation-related events and demonstrated a potential increase in postprocedural reflux. Despite the comparable efficacy, the disadvantages in the safety of FTM limit its recommendation as a routine alternative to CMM in the management of AC.

Altered neutrophil infiltration and function are associated with the deterioration of acute pancreatitis (AP) and even AP-associated lung injury. Although CD177 is a marker of neutrophil activation, its role in AP remains largely unknown. To determine whether ablation of Cd177 could deteriorate colonic barrier dysfunction, changes in the gut microbiota, and AP-associated lung injury, Cd177 knock-out (KO), Cd177 conditional knock-out (cKO) in circulating neutrophils and pseudo-germ-free (antibiotic therapy, or ABX-treated) mouse models were used in this study. AP was induced in mice through injection of sodium taurocholate retrogradely into the pancreatic duct, then peripheral blood, pancreas, lung, colon tissues and fecal samples were collected at 24 h after induction, respectively. The mRNA and protein expression of certain genes and gut microbiota of mice were measured. Results indicated that both Cd177 KO and cKO increased serum amylase and lipase levels, exacerbated pathological damage, and impaired the integrity of the colonic mucosal barrier in AP mice, suggesting a protective role of neutrophil-derived CD177 in AP progression. In addition, ABX-treated mice alleviated AP-associated lung injury, demonstrating that gut microbiota dysbiosis may contribute to the deterioration of phenotypes. Moreover, ablation of Cd177 was associated with reduced abundance of gut microbiota species g_Atopostipes, downregulated Nos1ap expression in the lung and Sorbs1 expression in the colon, consequently aggravating the damage of colon and lung of mice with AP. It is concluded that Cd177+ neutrophils may ameliorate AP-associated lung injury through protecting colonic barrier and modulating certain gut microbiota and associated genes in mice.

Background/objective Prophylactic endoloop or hemoclip application and endoscopic mucosal resection (EMR) have been usually performed for large pedunculated colorectal polyps. However, their comparison remains unclear. This study aimed to compare the efficacy and safety of the prophylactic pretreatment and EMR in the large pedunculated polyps. Methods We reviewed 1994 pedunculated polyps detected in Peking Union Medical College Hospital from 2012 to 2024. Large pedunculated polyps (head size ≥2.0 cm) receiving EMR or prophylactic closure before polypectomy were included. Polyp morphology, endoscopic procedural variables, and adverse events were compared using propensity score matching and inverse probability of treatment weights. Logistic regression was performed to analyze the risk factors of adverse events. Results 204 pedunculated polyps undergoing prophylactic pretreatment and 262 polyps resected via EMR were included. Less clips (P = 0.002) and lower operational material-related costs (P < 0.001) presented in the prophylactic closure group than the EMR group, while the procedural time was comparable (prophylactic closure vs. EMR: median 13.0 vs. 10.0 min, P = 0.059). There were no differences in postpolypectomy bleeding (15.2% vs. 12.5%, P = 0.466) and postpolypectomy coagulation syndrome (1.5% vs. 0.7%, P = 0.509) between the two groups. Stalk width ≥0.6 cm (OR = 2.34, P = 0.02), number of hemoclips (OR = 1.44, P < 0.01), procedure time ≥10 min (OR = 2.03, P = 0.08), and malignant lesion (OR = 1.74, P = 0.08) were associated with high risks of immediate bleeding. The endoscopic procedure did not affect the risks of immediate or delayed bleeding. Conclusion The prophylactic closure with hemoclip or endoloop and conventional EMR are both effective and safe methods for large pedunculated colorectal polyps. Prophylactic closure has advantages in the hemoclips demand and average procedure costs compared to EMR.

IntroductionBenign-appearing gastrointestinal lesions may occasionally conceal malignancy and pose a diagnostic challenge. Esophageal leiomyomas are benign neoplasms; however, careful mucosal assessment remains essential to avoid missed diagnoses.Case descriptionWe report the case of a 53-year-old asymptomatic woman in whom a large esophageal leiomyoma masked a superficial esophageal squamous cell carcinoma (ESCC). Subtle mucosal irregularity detected on endoscopy prompted further evaluation with narrow-band imaging and targeted biopsies, confirming carcinoma in situ. Following multidisciplinary discussion and shared decision-making that incorporated patient preferences, selective endoscopic submucosal dissection (ESD) was performed to achieve complete resection of the carcinoma while preserving the underlying leiomyoma.ConclusionEn bloc resection was achieved without complications. Histopathology confirmed a well-differentiated superficial ESCC with submucosal invasion (>200 μm, pT1b), negative horizontal and vertical margins, and no lymphovascular invasion. After postoperative pathology review, additional surgical treatment was recommended because of the risk associated with submucosal invasion; however, the patient strongly declined surgery. Contrast-enhanced CT showed no evidence of regional lymph node metastasis, and the patient subsequently underwent radiotherapy at a local hospital. At 2-year follow-up, endoscopic re-examination showed no recurrence, and the leiomyoma remained stable in size. This case underscores the importance of careful evaluation for occult malignancy hidden behind benign-appearing lesions and demonstrates that favorable outcomes can be achieved through individualized, multidisciplinary management, including endoscopic resection, adjuvant therapy, and close surveillance.

Abstract Borderline resectable pancreatic cancer (BRPC) represents a complex clinical entity characterized by anatomical, biological, and conditional heterogeneity. Accurate assessments of resectability and the response to neoadjuvant chemotherapy (NAC) are crucial for determining surgical eligibility and improving overall survival. This review comprehensively summarizes current methods for predicting and evaluating the NAC response in patients with BRPC. A structured literature search was conducted in the PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov, focusing on imaging-based evaluations, serum and molecular biomarkers, and emerging radiomic and radiogenomic techniques. This review is a narrative synthesis of the current evidence. Imaging modalities such as contrast-enhanced computed tomography, magnetic resonance imaging, and positron emission tomography/computed tomography remain fundamental for assessing vascular involvement and the therapeutic response, whereas dynamic biomarkers, including carbohydrate antigen 19-9, circulating tumor DNA, and exosomal markers, provide complementary insights into biological activity. Radiomics-based models further increase the precision of the predictions by integrating quantitative imaging features with molecular signatures. However, despite promising advances, the current evidence is limited by heterogeneity in patient selection, small sample sizes, lack of standardized thresholds, and insufficient validation in prospective studies. A multidisciplinary strategy integrating imaging, biomarker, and clinical parameters within standardized assessment frameworks is essential for refining the resectability evaluation and guiding the personalized management of patients with BRPC.

Background:Primary hyperparathyroidism (PHPT) is an uncommon but clinically significant cause of acute pancreatitis (AP). Its clinical course and prognosis remain inadequately characterized compared to common AP etiologies. Methods:A bibliometric analysis was performed to evaluate global research trends on PHPT-associated acute pancreatitis (PHPT-AP). We conducted a retrospective cohort study at Peking Union Medical College Hospital between 2000-2025. Clinical data were compared with patients with biliary and hypertriglyceridemia-induced AP. Subgroup analyses evaluated differences between PHPT with mild/moderately severe AP and severe AP (SAP), and between AP and chronic pancreatitis (CP). Statistical analyses included logistic regression and Mann-Whitney U tests. Results:The bibliometric results revealed limited literatures but increasing attention to PHPT-pancreatitis. Our cohort showed PHPT-AP patients exhibited worse outcomes compared to non-PHPT-AP, with higher risks of SAP (OR 3.73, 95% CI 1.28-10.86, P = 0.016), intensive care unit admission (OR 3.79, 95% CI 1.17-12.32, P = 0.027), and in-hospital mortality (OR 12.76, 95% CI 1.52-107.3, P = 0.019). Serum calcium (median 4.2 mmol/L vs. 3.5 mmol/L, P = 0.015) and parathyroid hormone (median 1514.0 pg/mL vs. 312.0 pg/mL, P = 0.007) were significantly higher in PHPT-SAP. A three-phase calcium trajectory was observed in SAP: an initial hypercalcemic phase, a plateau under therapy, and eventual normalization after surgical or extracorporeal interventions. PHPT-CP was associated with longer PHPT duration, recurrent AP, and higher diabetes prevalence. Conclusion:PHPT-AP is associated with a worse prognosis and requires proactive management. Serum calcium correlates with severity and should be monitored dynamically. Early surgery or continuous veno-venous hemofiltration may be warranted in severe cases. Prolonged PHPT with recurrent AP and lifestyle risk factors may contribute to CP.

BackgroundAllgrove syndrome is a rare autosomal recessive disorder characterized by the triad of alacrima, adrenal insufficiency, and achalasia. Although corticosteroid replacement and artificial tears effectively manage adrenal insufficiency and alacrima, the optimal treatment for achalasia in this syndrome remains challenging and poorly defined.MethodsAll patients diagnosed with Allgrove syndrome were identified between 2009 and 2025 at Peking Union Medical College Hospital, which is a national rare disease center in China. Clinical characteristics and genetic mutations were collected and analyzed, and the long-term safety and efficacy of peroral endoscopic myotomy (POEM) in Allgrove syndrome were evaluated through follow-up telephone interviews. A comparison cohort of idiopathic achalasia (IAC) patients undergoing POEM, matched for follow-up duration, was enrolled to delineate disease-specific features.ResultsSeven patients were diagnosed with Allgrove syndrome at our institution over the past 16 years, and all of them had homozygous or compound heterozygous mutations in the AAAS gene. The patients presented with alacrima from infancy developed adrenal insufficiency during childhood and were diagnosed with Allgrove syndrome at a mean age of 17. Compared to 12 matched idiopathic achalasia patients, Allgrove patients exhibited a significantly earlier onset of achalasia symptoms (mean age: 12.5 vs. 33.8 years, p = 0.004), with similar intervals from symptom onset to intervention. Interestingly, despite comparable objective severity based on manometric and endoscopic assessments, Allgrove patients reported significantly lower subjective symptom scores (Eckardt score 5.3 vs. 7.6, p = 0.046). Over a median follow-up of 5.8 years, the mean Eckardt score decreased from 5.3 to 0.8 in Allgrove patients and from 7.6 to 1.9 in idiopathic achalasia patients at the last follow-up.ConclusionAllgrove syndrome should be taken into consideration in patients with early-onset achalasia. POEM provides effective and sustained symptom relief for achalasia in Allgrove syndrome, with a favorable safety profile.

Background Management of infected pancreatic necrosis (IPN) has shifted toward a minimally invasive step-up approach. Whether abdominal paracentesis drainage (APD) increases infection and leads to escalation of invasive treatments for IPN—or offers clinical benefits—remains controversial. This meta-analysis directly addresses this clinical dilemma in acute pancreatitis (AP). Methods From Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase databases up to January 2026, we included cohort studies and randomized controlled trials (RCTs) comparing APD with conventional treatment in moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP). Results Eight cohort studies and three RCTs (1,647 patients) were included, revealing a significantly lower incidence of necrosectomy in the APD group compared with the non-APD group (RR = 0.61, 95% CI: 0.49–0.77, P < 0.0001; I² = 0%; n = 890; low certainty). The APD group also showed significantly reduced need for percutaneous catheter drainage. Trial sequential analysis (TSA) further supported the above findings. Meanwhile, although there was a significant reduction in all-cause mortality, TSA suggested the available evidence remained insufficient to draw this conclusion. Conclusion APD could de-escalate the step-up approach for IPN without increasing infection risks. Large-scale RCTs are warranted to confirm the role of APD.

The diagnosis of autoimmune pancreatitis (AIP) is multidisciplinary. Pathological diagnosis is pivotal when distinguishing AIP from malignancies. In this study, we aim to compare the diagnostic performance and sample adequacy of 19-gauge endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) needles with 20-gauge endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needles in patients with suspected AIP. We conducted a single-centre, parallel-group, prospective, randomized controlled trial at Peking Union Medical College Hospital (Beijing, China). Patients with suspected AIP were enrolled between October 2018 and August 2023 and were randomly assigned to undergo tissue specimen collection using either a 19-gauge EUS-FNA needle or a 20-gauge EUS-FNB needle. The primary endpoint was the diagnostic accuracy against International Consensus Diagnostic Criteria, with secondary endpoints including histologic sensitivity, technical success rate, tissue adequacy, and adverse event rate. 46 patients were enrolled and 45 underwent EUS (FNB n = 23, FNA n = 22), amongst 42 had a final diagnosis of AIP. Diagnostic accuracy, as the primary endpoint, was 52.2

Pancreatic head-type autoimmune pancreatitis (PH-AIP) with elevated CA19-9 is sometimes difficult to distinguish from pancreatic head cancer (PHC) with elevated CA19-9. At times, IgG4 proves inadequate in offering assistance. The study aimed to elucidate the performance of CA19-9/DBil in distinguishing between the two conditions. This was a retrospective study. We collected serologic indicators from participants in PH-AIP and PHC Group. Three logistic regression equations were established ranging from non-adjustment (Model 1, only CA19-9/DBil included) to adjusting for sex, age, and CEA (Model 2 and Model 3) to explore the relationship between CA19-9/DBil and PH-AIP probability. ROC, Decision Curve Analysis (DCA), calibration curve were conducted. P for AUCs and net reclassification improvements (NRI) were computed to evaluate differences in discrimination and the improvement in risk reclassification between models. The study included 90 PHC and 35 PH-AIP patients, all with elevated CA19-9. The ORs for CA19-9/DBil in three models were similar (0.915 to 0.921). ROC revealed that Model 1 had an AUC of 0.772. The sensitivity, specificity, and accuracy at the best threshold were all > 0.7. Model 1, although simple, was not inferior in its discriminative ability compared to complex models: the difference in discrimination between Model 1 and each of two adjusted models was not statistically significant (P > 0.05, both AUC and NRI). Additionally, calibration curve and DCA suggested that Model 1 had good calibration and clinical utility. CA19-9/DBil exhibited promising diagnostic performance in differentiating between CA19-9-elevated PH-AIP and PHC.