Current Opinion in Gastroenterology最新文献

Purpose of review: Pancreatic ductal adenocarcinoma (PDAC) has a dismal 13% 5-year survival rate, necessitating early detection and personalized treatment. This review evaluates whether germline genetic testing, integrated with clinical decision support (CDS) tools, is ready for widespread use in PDAC screening. We focus on its potential to identify high-risk individuals (HRIs) beyond those with strong family histories to complex risk and biomarkers, stratifying patients into low-risk and high-risk virtual populations for targeted surveillance.

Recent findings: Germline genetic testing identifies pathogenic variants linked to hereditary cancer syndromes (HCS), enabling multiorgan surveillance and precision oncology (e.g., PARP inhibitors for BRCA2 mutations). Polygenic risk scores (PRS) combined with clinical markers like new-onset diabetes (NOD) increase the positive predictive value (PPV) for PDAC (e.g., 86.7% in high-PRS quintiles). Genetic testing also adjusts for biomarker variability (e.g., CA19-9 levels via FUT2/FUT3 genotyping) and optimizes chemotherapy through pharmacogenetics, reducing toxicity. Comprehensive platforms integrating genetic, clinical, and biomarker data enhance early detection and risk stratification.

Summary: Genetic testing is ready for prime time in PDAC screening. It stratifies patients into low-risk (no surveillance) and high-risk (surveillance warranted) groups, improving early detection, outcomes, and cost-effectiveness, thus transforming PDAC prognosis through targeted intervention.

Purpose of review: To review the literature within the past 5 years on risk factors and prophylactic measures for avoiding the complications of endoscopic retrograde cholangiopancreatography (ERCP), including post-ERCP pancreatitis (PEP), post-ERCP cholangitis, bleeding, and perforation.

Recent findings: Despite advances in endoscopic technique and numerous clinical trials, complications of ERCP still occur frequently, particularly PEP. Recent findings are concentrated in the PEP domain and include the following: the discovery of pancreatic steatosis as a potential novel risk factor, machine learning models to predict PEP, combination prophylactic strategies including rectal NSAIDs, aggressive intravenous fluid hydration and pancreatic duct stents, potential novel pharmacotherapies, and enhanced endoscopic techniques for difficult biliary cannulation.

Summary: Endoscopists should be familiar with the complications of ERCP and prophylactic strategies. PEP carries a significant morbidity and economic burden, but its occurrence is par for the course when performing ERCP. Future studies should concentrate on elucidating further the pathophysiology of PEP and predicting cases that result in severe complications (severe if hospitalization was greater than 10 days along with the presence of pseudocyst, pancreatic necrosis, need for percutaneous drainage or surgery, or death).

Purpose of review: Acute endoscopic gastrointestinal perforation, a rare but potentially life-threatening complication of endoscopic procedures, presents a significant management challenge. While surgical repair has been the traditional approach, endoscopic closure offers a highly successful, less invasive alternative in select cases.

Recent findings: Successful endoscopic management hinges on prompt perforation detection, the early initiation of appropriate antibiotic therapy, and the achievement of a secure and adequate endoscopic closure utilizing well honed technical skills. We comprehensively review various endoscopic closure techniques, including standard through-the-scope clips, over-the-scope clips, dual-action clips, Mantis clips, the Overstitch system, endoscopic through-the-scope suturing systems, and the use of covered metal stents.

Summary: This review aims to equip gastroenterologists with a practical framework for the timely and effective management of acute endoscopic gastrointestinal perforations.

Purpose of review: This review aims to summarize the recent developments in hypertriglyceridemic acute pancreatitis (HTG-AP) research in China, focusing on its increasing prevalence, pathophysiology, prognosis, and novel treatment strategies, emphasizing the relevance of these findings in clinical practice and research.

Recent findings: Recent studies have highlighted a rising incidence of HTG-AP in China, especially among young males, linked to dietary and lifestyle changes. Key research has identified lipoprotein metabolism abnormalities and genetic factors as predictors of recurrence. Advances in treatment include the combination of low-molecular-weight heparin, insulin, and plasma exchange, showing improved outcomes compared to traditional methods. Additionally, the use of traditional Chinese medicine has shown promise in managing inflammation and improving patient recovery.

Summary: These findings emphasize the importance of early diagnosis, personalized treatment strategies, and integrated approaches in managing HTG-AP. Chinese research has made significant strides in understanding the pathophysiology and treatment of HTG-AP, which may influence both national healthcare strategies and global management of the condition.

Purpose of review: Accurate diagnosis of pancreatic cystic lesions (PCLs) is essential to guide appropriate management and reduce unnecessary surgeries. Despite multiple guidelines in PCL management, a substantial proportion of patients still undergo major resections for benign cysts, and a majority of resected intraductal papillary mucinous neoplasms (IPMNs) show only low-grade dysplasia, leading to significant clinical, financial, and psychological burdens. This review highlights emerging endoscopic approaches that enhance diagnostic accuracy and support organ-sparing, minimally invasive management of PCLs.

Recent findings: Recent studies suggest that endoscopic ultrasound (EUS) and its accessory techniques, such as contrast-enhanced EUS and needle-based confocal laser endomicroscopy, as well as next-generation sequencing analysis of cyst fluid, not only accurately characterize PCLs but are also well tolerated and cost-effective. Additionally, emerging therapeutics such as EUS-guided radiofrequency ablation (RFA) and EUS-chemoablation are promising as minimally invasive treatments for high-risk mucinous PCLs in patients who are not candidates for surgery.

Summary: Accurate diagnosis of PCLs remains challenging, leading to many patients undergoing unnecessary surgery. Emerging endoscopic imaging biomarkers, artificial intelligence analysis, and molecular biomarkers enhance diagnostic precision. Additionally, novel endoscopic ablative therapies offer safe, minimally invasive, organ-sparing treatment options, thereby reducing the healthcare resource burdens associated with overtreatment.

Purpose of review: Pancreatic ductal calculi (PDC) are a defining feature of chronic pancreatitis and contribute significantly to morbidity through pain and ductal obstruction. This review provides a timely update on the evolving understanding of PDC pathogenesis and highlights current and emerging strategies for their management.

Recent findings: Stone formation in chronic pancreatitis is multifactorial, involving altered pancreatic juice composition, reduced lithostatic proteins, genetic predispositions, and environmental risk factors such as alcohol and smoking. Advances in endoscopic techniques, particularly the combination of extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP), have improved ductal clearance and symptom control. Pancreatoscopy-guided lithotripsy is gaining traction in complex cases. Surgical options such as longitudinal pancreatojejunostomy and head resection remain vital in patients with extensive disease or failed endoscopic therapy, with evidence supporting superior long-term pain relief when performed early.

Summary: Management of PDC requires a multidisciplinary, personalized approach. Endoscopic therapy is the first-line intervention in most cases, while surgery offers durable benefits in select patients. Future directions include identifying biomarkers for early intervention, refining patient selection, and exploring pharmacological strategies to prevent stone formation and recurrence.

Purpose of review: This manuscript reviews recent updates on the management of pain in chronic pancreatitis, an entity that remains difficult to manage. In a time when opioid use disorder is on the rise, advanced endoscopists should be aware of the nonopioid options available to patients to help manage their pain.

Recent findings: Although there is no standardized approach in the management of pain in chronic pancreatitis, societal guidelines and recommendations have recently been updated to help guide physicians in this matter. However, the available endoscopic approaches have remained relatively unchanged in recent years. Studies are underway to determine whether one endoscopic approach is superior to another, depending on the suspected mechanism of pain.

Summary: Endoscopic management of pain in chronic pancreatitis remains challenging given the complex mechanisms at play. Surgery remains the most effective durable approach, though with significantly more morbidity and mortality compared to endoscopic options, which include endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), pancreatoscopy-directed lithotripsy, and endoscopic ultrasound-guided celiac plexus block (EUS-CPB), depending on the predominant suspected cause of pain.

Purpose of review: Idiopathic recurrent acute pancreatitis (IRAP) is a clinically relevant condition with a high likelihood of progression to chronic pancreatitis (CP) in 20-50% of patients. This review outlines the importance of early diagnosis of IRAP and potential upcoming therapies to halt disease progression. It highlights a potential therapeutic window in the natural history of IRAP.

Recent findings: Despite advancements in diagnostic modalities, identifying a definitive aetiology remains challenging in a significant proportion of cases. Current approaches emphasize structured, stepwise evaluation including metabolic, genetic, and structural factors. Emerging therapies aim to target inflammation, trypsin activation, and pancreatic fibrosis.

Summary: While diagnostic tools have improved, therapeutic options remain limited in IRAP. Early identification of modifiable risk factors, use of advanced imaging, and application of evolving treatment strategies may offer an opportunity to prevent the transition from IRAP to CP. Future research must focus on validating disease-modifying treatments and optimizing individualized management strategies.

Purpose of review: The field of inflammatory bowel disease (IBD) has been evolving at an unprecedented rate. Not only does this apply to the medical management of IBD but also to its surgical management. This review aims to highlight the major updates in the current surgical approach in Crohn's disease.

Recent findings: Surgery for Crohn's disease is no longer considered only for medically refractory disease or for disease-related complications but can rather be considered as an effective first-line treatment option. The concept of multimodal prehabilitation is becoming more solidified in Crohn's disease, as strong evidence continues to indicate its positive impact on surgical outcomes. The impact of the mesentery as well as the type of surgical anastomosis on postsurgical Crohn's disease recurrence is being closely reexamined. The optimal approach for surgical management of perianal Crohn's disease is also being redefined.

Summary: Surgery is an integral part of the care of Crohn's disease patients and keeping up with the evolving paradigm of surgery in Crohn's disease is critical for all providers taking care of Crohn's disease patients to ensure patients are getting the best care possible.