Neurogastroenterology & Motility

Background & Aims: The association between upper gastrointestinal (GI) symptoms and delayed gastric emptying time (GET) is debated. This study utilized Body Surface Gastric Mapping (BSGM) and the 'Auckland Classification' BSGM phenotyping scheme to investigate whether symptom associations with GET vary across different mechanistic phenotypes. Methods: A pooled analysis was performed on two prospective datasets of 194 patients with chronic upper GI symptoms. Participants underwent simultaneous BSGM (Gastric Alimetry) and gastric emptying testing (breath test or scintigraphy). Validated time-of-test symptom profiling was recorded at 15-minute intervals using 0-10 Likert-type scales. Patients were classified: 'Spectral Abnormal' (abnormal electrophysiology), 'Sensorimotor' (symptoms correlate with gastric electrical amplitude), 'Continuous' (symptoms uncorrelated), and 'NA' (no phenotype). Results: In the analyzed cohort, 24% had delayed GET. Overall, delayed GET was associated with a higher total symptom burden (15.6 delayed vs. 8.8 normal, p=0.006; r=0.30, p<0.001), specifically postprandial fullness (p=0.004) and early satiation (p=0.015). However, associations varied significantly by phenotype. In the 'Sensorimotor' phenotype, nausea was associated with delayed GET (4.9 vs. 1.0, p=0.027; r=0.59, p=0.009), while total symptom burden was 23.3 vs. 8.4 (p=0.135). Conversely, patients with 'Continuous' or 'Spectral Abnormal' phenotypes, or who were unclassified, showed no symptom associations. Conclusions: Delayed GET is weakly associated with an increased burden of upper GI symptoms. However, gastroduodenal disorders are heterogeneous, such that phenotyping reveals this association to be exclusive to patients with a 'Sensorimotor' phenotype. These results could improve targeting of therapies that address gastric emptying.

Irritable Bowel Syndrome (IBS) is a highly prevalent, commonly diagnosed gastrointestinal disorder of gut-brain interaction (DGBI) that causes substantial physical, psychological, and financial burden. The role of abnormal motility and altered autonomic nervous system function, and their interplay, remains to be fully understood. Here we present a non-invasive method using body surface electrical recordings to concurrently quantify meal-response colonic motility and heart rate variability (HRV). We demonstrate the practical utility of this new technique in a pilot study comparing colonic motility and autonomic nervous system (ANS) function in IBS patients (n=14) and healthy controls (HC; n = 22). The study protocol included a 2-3 hr body-surface electrical recording with 60-90 minutes each of pre- and post- meal epochs. Colonic motility was markedly increased in the subset of IBS patients experiencing moderate-to-severe symptoms during the study, compared to IBS no or mild symptom groups and healthy controls. HRV metrics in IBS patients showed substantial baseline shifts with decreased vagal and increased sympathetic input, with blunted autonomic meal responses compared to HC. Newly introduced dynamic trajectory maps revealed pronounced colon motility-vagal dysregulation in high symptom IBS patients but not mild or no symptom groups. These results indicate altered autonomic-motility interaction as a potential mechanism of symptom genesis in IBS patients. This technology platform offers an easy-to-apply, non-invasive tool for larger scale investigations of gut and autonomic nervous system function in healthy and gastrointestinal disease cohorts.

Purpose: Modified Barium Swallow (MBS) studies utilize videofluoroscopy, a dynamic X-ray technique for evaluating swallowing anatomy and physiology. Each MBS exam typically includes multiple bolus trials, often involving different bolus consistencies. Accurate classification of bolus types is essential, as swallowing dynamics, aspiration risks, and residue levels vary with bolus consistency. In this preliminary study, we propose a deep learning-based approach for automated bolus type classification in MBS, aiming to provide a standardized and efficient framework for automated processing of swallowing assessments. Methods: A total of 206 patients (Mean +/- SD age: 60.24 +/- 9.02 years; 89.32% men) underwent MBS examinations, comprising 277 individual MBS studies. The dataset included 2,752 bolus-level video segments, categorized by bolus type as follows: 1,711 liquid (IDDSI 0-3, 62.17%), 521 pudding (IDDSI 4, 18.93%), and 520 solid boluses (IDDSI 7, cookie or cracker, 18.89%). To standardize variable video lengths for the data pipeline, each MBS video was temporally segmented into a fixed-length frame sequence, with shorter videos padded using static frames and longer videos randomly cropped to the target length. We employed an Inflated 3D convolutional neural network to develop the deep learning model. Results: Each video segment contained an average of 273.03 +/- 195.81 frames. On the independent test set, the deep learning model achieved an overall accuracy of 96.13%, and the macro F1-score was 95.05% in classifying food bolus types within MBS videos. Conclusions: The developed AI-based system demonstrated effective automated classification of food bolus types in MBS videos, representing an important step toward fully automated MBS analysis for swallowing efficiency assessment. The AI model reduces the reliance on manual labels, thereby promising to streamline clinical and research workflows.

BackgroundObjective tools for longitudinal dietary monitoring, despite its importance in the health triad of diet, sleep, and exercise, remain limited. Widely available ambulatory options include continuous glucose monitoring, which is a delayed response, and manual logging, which is rife with human error. Clinical tools such as gastric emptying scintigraphy are impractical for everyday use. High-resolution electrogastrography (HR-EGG) offers an alternative by treating gastric myoelectric activity as a biomarker of digestive state. However, its utility for ambulatory meal detection remains unclear. We hypothesize that HR-EGG and accelerometry together encode distinct postprandial gastric signatures to enable automated meal detection, and that postural context represents a relevant source of variation in signal detectability. MethodsHR-EGG and accelerometry data were collected from seven healthy adults across sixteen 150-minute meal sessions under IRB-approved protocol. Each session included a 30-minute fasted baseline, consumption of a standardized meal, and 90-minute postprandial period of sitting, walking, and lying in a randomized order. Features of the gastric slow wave, including raw and normalized bandpower, phase gradient directionality (PGD), wave direction, and wave speed, were extracted alongside triaxial accelerometer magnitude. A dilated one-dimensional convolutional network (1D CNN) was trained to classify meal consumption at five-minute resolution using leave-one-subject-out cross-validation. Postural effects on gastric myoelectric metrics were assessed using the Friedman test. ResultsThe model achieved a mean AUROC of 0.925 (95% CI: [0.857, 0.993]) and mean AUPRC of 0.824 (95% CI: [0.668, 0.980]; null model: 0.20). Feature ablation showed PGD as the most informative input ({Delta}AUPRC = -0.188), with wave propagation speed the least informative ({Delta}AUPRC = -0.105). Walking produced the highest signal-to-noise ratio (9.94 dB), lying had the most stable gastric rhythm (89.1% normogastric), and sitting demonstrated the greatest frequency instability (dominant frequency standard deviation = 0.825 cpm). ConclusionA dilated 1D CNN applied to spatiotemporal HR-EGG features enables temporally aware passive meal detection across ambulatory contexts. This study framework addresses a gap between clinical need for objective dietary monitoring and the limitations of current detection methods.

Objective To verify the reliability of a self developed bowel sound monitoring device under real biological tissue acoustic propagation conditions using a controllable sound source, and to establish quantitative evidence for its translational applicability. Methods Freshly euthanized six month old Bama miniature pigs were used as an experimental model. A high fidelity Bluetooth audio playback device was implanted into the abdominal cavity to deliver manually annotated bowel sound recordings as controllable acoustic stimuli. A self developed bowel sound monitoring device was fixed on the abdominal surface for continuous signal acquisition. Playback timestamps were defined as the ground truth, and event level matching was performed within a predefined temporal tolerance window. Four performance indicators were evaluated: (1) bowel sound acquisition and energy amplification, (2) event matching accuracy, (3) acoustic feature consistency, and (4) subjective agreement assessed by blinded auscultation from gastroenterologists with different levels of clinical experience. Results The monitoring device exhibited stable detection capability and effectively covered the full spectral range of the original signals. It significantly enhanced bowel sound energy while preserving temporal and spectral characteristics, demonstrating high consistency in time and frequency domain features. Blinded clinician assessments showed a subjective agreement rate of 88.9% between original and surface recorded bowel sound events. Conclusions Under real tissue acoustic propagation conditions, the self-developed bowel sound monitoring device reliably captures bowel sound events with high temporal accuracy, acoustic fidelity, and clinical perceptual consistency. This controllable sound source based validation provides robust technical evidence for subsequent in vivo studies and clinical translation, supporting the development of objective and continuous gastrointestinal function monitoring.

Pain in pancreatic ductal adenocarcinoma (PDAC) is associated with poor survival, but whether altered pain processing carries prognostic significance is unknown. We analyzed a prospective cohort of 143 patients with PDAC who underwent pancreatic quantitative sensory testing (PQST) after diagnosis. Patients were classified as having normal pain processing (n=84), segmental hyperalgesia (n=30), or widespread hyperalgesia (n=29). Survival was measured from the date of P-QST assessment. During follow-up, 70 deaths occurred. Widespread hyperalgesia was associated with increased mortality in unadjusted Cox analysis (HR 1.96, 95% CI 1.14,3.35) and after adjustment for age, sex, tumor stage, comorbidity, opioid treatment, and body mass index (adjusted HR 2.33, 95% CI 1.30,4.15). Segmental hyperalgesia was not associated with mortality. Kaplan Meier analysis demonstrated lower survival probability in the widespread hyperalgesia group (log rank p=0.025). These findings suggest that widespread hyperalgesia, reflecting altered central pain processing, identifies a subgroup of PDAC patients at increased risk of mortality independent of conventional clinical factors.

Aims To develop the Bowel Irrigation Questionnaire (BIQ), a patient-reported experience measure (PREM) designed to assess the user experience of transanal irrigation (TAI). Methods Statements were generated through literature review and qualitative interviews with healthcare professionals (HCPs) and product users. Statements were rated on a 6-point content validity index scale through an international three-round online Delphi survey by 20 expert panel members. Consensus attainment was defined based on percentage agreement, statements which did not meet consensus were discussed at a final international online consensus meeting. The content validity of the PREM was evaluated through cognitive interviews and the Questionnaire on Questionnaires (QQ-10). Reliability was assessed using a test-retest design, where users completed the BIQ on two occasions one week apart. Results 215 statements were generated from 9 multi-disciplinary qualitative interviews and literature review. Statements were refined to reduce repetition and ensure clarity. 73 statements grouped into 11 domains were reviewed through the Delphi survey. Following the Delphi survey and clinical consensus meeting, the preliminary BIQ consisted of 15 items. Six cognitive interviews were conducted, resulting in a finalised BIQ of 16 items. 32 product users completed both the QQ-10 and test-retest study, the results of which demonstrated good content validity and temporal stability respectively. Conclusions The Bowel Irrigation Questionnaire is a novel PREM designed to assess the user experience of TAI in both clinical and research settings. The instrument demonstrates good validity, acceptability and temporal stability, supporting its use as a reliable measure of patient experience.

BACKGROUND & AIMS Conventional reusable endoscopes incur significant expenses in the form of purchase, maintenance, reprocessing, and disinfection. Reprocessing is frequently ineffective even following the use of high-level disinfectants (HLDs). Disposable gastroscopy might be a strategy to decrease infectious outbreaks associated with reusable endoscope. The aim of this study was to analyze and evaluate the performance, efficiency and safety in gastroscopy observation and subsequent potential EMR procedure via the disposable gastroscope in a clinical setting. METHODS Patients who required gastroscopies and met the criteria were recruited to this prospective, open-label, non-inferiority study. After obtaining the written informed content, the enrolled subjects selected themselves independently to the disposable group or reusable group. The primary measure was to evaluate the acceptable image quality and whether the disposable endoscope devices could meet the basic clinical demands with a noninferiority margin of -8%. The second measures were to analyze and evaluate the image conditions, accepted endoscopic maneuverability, efficiency and safety of observation and advanced potential EMR procedure. Appropriate statistical methods were conducted via PASS software and SAS 9.4. A two-tailed P value < 0.05 was considered statistically significant. RESULTS A total of 90 individuals (the number of those in disposable group and reusable group was both 45) were recruited to this study. The success rate of acceptable image quality via photographing iconic anatomical sites between two groups was 100.0% (45/45, 95% confidence interval (CI): 0.9213,1.0000) and the lower limit of the 95%CI (-7.8654%, 7.8654%) was larger than the noninferiority margin of -8% (Newcombe-Wilson score method). Significant differences were showed in the measures of image conditions (image acquisition, image quality, brightness, contrast and sharpness) and accepted endoscopic maneuverability (endoscopy body rigidity). No significant differences were observed in the field of knob operation, sharp angle adaptability, and the auxiliary features including air supply, water supply and suction. In terms of efficiency, the total operating time, insertion time and withdrawal time were longer in the disposable group. The En-bloc resection rate of those observed polyps and required to EMR procedure due to relatively larger diameter (5mm-15mm) was the same 100% in both groups (26/26 vs 23/23, 95%CI: 0.8713,1.0000). Nevertheless, the procedure time of EMR for each polyp was significantly longer in the disposable group. This study showed no intraoperative bleeding, delayed bleeding, perforation or other study-related adverse events among 90 patients. No dramatic fluctuations in vital signs were showed in perioperative period. CONCLUSIONS In consideration of the efficiency, efficacy and safety evaluation, the disposable gastroscopes might represent an alternative to conventional reusable gastroscopes in routine examination and endoscopic mucosal resection.

Pancreatic ductal adenocarcinoma (PDAC) is characterized by a dense desmoplastic extracellular matrix (ECM) that contributes to tumor progression, therapeutic resistance, and poor patient survival. However, the relationship between in vivo imaging-derived mechanical properties, ex vivo tissue biomechanics, ECM architecture, and cellularity remains incompletely understood. Here, we combined pre-operative in vivo clinical magnetic resonance elastography (MRE) with ex vivo biomechanical testing of fresh human PDAC tissue and histopathological analyses. Nine patients undergoing pancreatic resection were prospectively enrolled. Quantitative MRE was performed pre-operatively to assess tissue stiffness through shear wave speed (c) and relative viscosity or fluidity through the loss angle ({varphi}). Fresh tumor and adjacent non-malignant tissue biopsies were subsequently analyzed ex vivo by unconfined uniaxial compression testing to determine elastic moduli and stress relaxation halftime. Histological analyses quantified collagen-rich fibrous tissue area, cell nuclei density, and nuclear morphology. Tumor tissue exhibited significantly increased stiffness and collagen fraction compared with adjacent non-malignant tissue, together with reduced cellularity, smaller nuclear area and more elongated nuclei. Ex vivo stiffness positively correlated with collagen content and negatively correlated with patient survival. Reduced stress relaxation halftime, indicative of increased tissue viscosity, was associated with lower cellularity and elongated nuclei. Importantly, pre-operative MRE parameters of the intact surrounding environment correlated significantly with ex vivo tumor mechanics, cellular organization, and survival. Specifically, a softer and less viscous surrounding environment was associated with stiffer and more viscous tumors, with lower cellularity and elongated nuclei, and poorer prognosis. These findings demonstrate that MRE-derived mechanical biomarkers reflect underlying ECM remodeling and tumor mechanobiology in PDAC. Integrating in vivo imaging with ex vivo tissue mechanics and histopathology may improve non-invasive disease characterization and support biomechanically-informed therapeutic strategies.

RationaleThere is no effective pharmacotherapy for obesity hypoventilation syndrome (OHS). Intranasal leptin augments the hypercapnic ventilatory response (HCVR), attenuates upper airway obstruction, and increases ventilation during sleep in diet-induced obese (DIO) mice. Respiratory effects of leptin can be attenuated by serotonergic antagonists. ObjectivesTo establish if serotonergic innervation of the hypoglossal motoneurons (XII MN) mediates effects of leptin on OHS. MethodsWe examined effects of intranasal leptin on the HCVR, sleep architecture, arousal latency, flow limited (obstructed) and non-flow limited breathing, genioglossus muscle (GG) activity and metabolic rate across sleep/wake states in the presence and absence of serotonergic neurons innervating XII MN in DIO Sert-flp mice expressing FlpO recombinase in the serotonergic neurons. These mice were transfected into the XII MN with retrograde adeno-associated virus carrying either FlpO-dependent caspase or control yellow fluorescent protein (YFP). Measurements and Main ResultsControl YFP virus was densely localized to the serotonergic neurons of the medullary raphe (MR), but not the dorsal raphe (DR), and these neurons were ablated by caspase. Leptin enhanced the HCVR, increased arousal latency in males, but not in females, and these effects were abolished by caspase. Neither leptin nor caspase affected sleep architecture or metabolic rate. Leptin increased GG activity awake and during NREM sleep, attenuated pharyngeal obstruction and increased minute ventilation in NREM and REM sleep. All effects of leptin were abolished by the FlpO-dependent caspase. ConclusionsLeptin treats OHS by stimulating MR serotonergic neurons, which project to XII MN and stimulate pharyngeal muscles during sleep.

Background and AimsAcute pancreatitis (AP) can lead to systemic inflammatory response (SIRS), paralytic intestinal obstruction, and in severe cases, intra-abdominal hypertension (IAH), organ failure (OF), and even death. Early magnesium sulphate (MS) catharsis treatment can relieve paralytic intestinal obstruction and IAH, thus reducing the incidence of severe acute pancreatitis (SAP) as well as mortality. Methods850 patients with AP at high risk of systemic complications (potential SAP (p-SAP)) were recruited. These p-SAP patients were categorized into two groups based on the treatment they received: the routine group (RT group, standard treatment for AP) and the MS group (early MS catharsis added to standard treatment). The final cohort had an allocation ratio of 2.5:1 (RT : MS). The primary composite endpoints were clinically finally diagnosed SAP (d-SAP) and mortality. The intensive care unit (ICU) admission, OF, inflammatory factors, length of hospital stay, and hospitalization costs, etc. were also compared and analyzed. ResultsIt demonstrated that early MS catharsis treatment was highly effective in preventing patients with p-SAP of various aetiologies from deteriorating to d-SAP and reducing their mortality significantly. In addition, it significantly reduced the incidence of OFs, pancreatic necrosis, ICU admissions, CRRT utilisation, and the cost and length of stay of hospitalisation for these patients. ConclusionsIt showed that early MS catharsis had a significant therapeutic effect on p-SAP patients, which would profoundly contribute to the clinical management of AP.

Histological analysis is crucial for understanding gastrointestinal (GI) tract homeostasis and disease pathophysiology. Various histological stains are commonly used in research settings for assessing development, disease pathogenesis, and therapeutic impacts. Specifically in the ordered architecture of the GI epithelium, current semi-quantitative analysis of histological staining relies heavily on manual scoring rubrics and often lacks robust spatial assessment. To address this gap, we developed an open-source ImageJ plugin, building on a closed-source predecessor, aimed at analyzing the spatial localization pattern of user-defined points-of-interest, such as positively stained cells, along the GI epithelial units. The plugin, developed using ImageJ 1.53.0 and Java programming language in Eclipse, interfaces with ImageJ and leverages Java libraries for data processing. The workflow involves uploading a microscopy image of the GI tissue of interest, determining base and top orientation landmarks of the GI epithelial units through manual identification, and annotating point-of-interest coordinates using ImageJ. The output includes centroid coordinates for each point-of-interest, the absolute distances of the points from the base and top landmarks, and the normalized distances of the points relative to the total height of the GI unit. The plugin generates histograms for displaying average point-of-interest distances along the GI unit axis. This information facilitates quantification of total points-of interest counts, analysis of height localization within the GI unit, and determination of average GI unit heights. The plugin serves as a crucial tool for robustly assessing various biological mechanisms within the GI tract, including EdU localization, migration distances, changes in cell type localization, and identification of new expression patterns along the GI unit axis. Overall, this open-source ImageJ plugin provides a semi-automated, user-friendly solution for leveraging important insights into spatial localization of tissue histology expression patterns within the GI structured architecture, with streamlined post-processing pipelines for robust large-scale analysis.

Malnutrition is common in Crohns disease (CD), and its assessment requires multiple tools. Comprehensive evaluation of nutritional status in a population with CD, predominantly characterized by metabolic phenotype, was inadequately reported. This study evaluated the nutritional status of CD patients using anthropometric, clinical, and biochemical measures and compared patients with active disease with those in remission. This cross-sectional study included 127 adults with CD: 63 with active disease and 64 in remission. Disease activity was classified using the Crohns Disease Activity Index, the Simple Endoscopic Score for Crohns Disease, and magnetic resonance enterography. Nutritional assessment included body mass index (BMI), mid-upper arm circumference, calf circumference, triceps skinfold thickness, mid-arm muscle circumference, Mini Nutritional Assessment-Short Form (MNA-SF), and biochemical markers including hemoglobin, serum iron, folate, vitamin B12, albumin, and zinc. Malnutrition was defined using the Global Leadership Initiative on Malnutrition criteria. Overall, 47.2% of participants were malnourished. Malnutrition was significantly more frequent in active disease than in remission (81.0% vs. 14.1%, P<0.001). Patients with active CD had lower anthropometric indices, MNA-SF score, hemoglobin, serum iron, albumin, and zinc (all P<0.001), whereas folate and vitamin B12 did not differ significantly. BMI showed positive correlations with other anthropometric measures and MNA-SF score (r=0.854-0.914, all P<0.001), whereas correlations with biochemical parameters were weaker and disappeared after subgroup stratification. Overall, the findings indicate that malnutrition is highly prevalent in CD, particularly during active disease. Anthropometric measures and MNA-SF were strongly concordant, whereas biochemical markers were less consistent, supporting a multidimensional nutritional assessment approach in CD.

Background and Aims: Endoscopic artificial intelligence is commonly validated on selected single images, whereas gastric cancer interpretation requires integrating whole examinations. We developed GutCore and evaluated whether whole-case endoscopic images could be used for patient-level assessment of gastric cancer depth, biomarkers, and prognosis. Methods: GutCore was pretrained on 5.6 million de-identified endoscopic images from more than ten hospitals. We compared it with five general, medical, and endoscopy-specific foundation models using open image-level datasets and an internal tertiary-center cohort of 11,035 de-identified endoscopic examinations (2019-2023): 8,049 with early or advanced gastric cancer and 2,986 with benign gastritis or intestinal metaplasia. All examination images were aggregated for patient-level assessment of cancer status, invasion depth, molecular biomarkers, and overall survival. Results: Aggregating all stored images from each examination enabled patient-level gastric cancer assessment without selecting representative frames. GutCore achieved AUCs of 0.995 for cancer detection, 0.960 for muscularis propria invasion, and 0.804 for SM2-or-deeper invasion. Prediction of tissue-defined biomarker status was strongest for Epstein-Barr virus status and MLH1 loss (AUC, 0.831 and 0.854), with lower HER2 performance (AUC, 0.673). In the held-out advanced gastric cancer test set, GutCore-derived risk groups showed marked survival separation (log-rank P < .0001; high-risk vs low-risk hazard ratio, 13.18; 95% CI, 6.06-28.66), with stratification persisting within pathological stage II and III disease. External frame-level benchmarks showed strong performance for anatomical landmark recognition, disease grading, and segmentation. Conclusions: GutCore supported whole-case patient-level gastric cancer assessment using routinely stored endoscopic images. Further validation in independent clinical cohorts is needed to establish generalizability and clinical utility.

BackgroundPostoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatoduodenectomy, particularly in patients with high-risk pancreatic remnants. Preventive strategies based solely on surgical technique have yielded inconsistent results, and thus there has been growing interest in strategies aiming to modify the biological behavior of the pancreatic remnant. This preclinical study evaluated the biological and histopathological effects of preoperative endoluminal radiofrequency ablation (ERFA) of the main pancreatic duct (MPD) performed 4 weeks before pancreatic transection in a porcine model. MethodsAnimals underwent laparoscopic MPD occlusion followed by pancreatic transection at 4 weeks and necropsy 15 days thereafter. Feasibility, safety, histological atrophy, and macroscopic findings associated with POPF risk were assessed. As a secondary objective, outcomes were compared with a that underwent MPD occlusion using cyanoacrylate glue. ResultsPreoperative ERFA was technically feasible and safe. At 4 weeks, ERFA induced marked and homogeneous acinar atrophy that was significantly greater than that observed after glue occlusion (p = 0.018), indicating effective biological conditioning of the pancreatic remnant. At necropsy, pseudocyst formation and intra-abdominal adhesions, known surrogate markers of pancreatic fistula in pigs, were significantly more frequent in the glue group and absent in ERFA-treated animals. Serum amylase levels, postoperative weight gain, complication rates, and preservation of endocrine architecture were comparable between groups. ConclusionsDuctal ablation of the MPD via ERFA induced stable, progressive exocrine pancreatic atrophy, effectively preconditioning the gland prior to pancreatic transection. Experimental evidence suggests that its biological effects stabilize approximately 4 weeks after treatment. Compared to cyanoacrylate occlusion, ERFA achieved more homogeneous early biological effects and fewer fistula-related macroscopic complications. These findings support the further investigation of preoperative pancreatic conditioning as a potential adjunct strategy for POPF risk reduction, although clinical studies are needed to clarify its role alongside established reconstructive approaches.

Background and Study Aims Fully covered, self expandable metal stents (FCSEMS) are used to treat biliary strictures. FCSEMS with transmural side holes may facilitate cystic duct drainage to mitigate risk of cholecystitis and impact other stent-related adverse events such as migration and occlusion. This study compared rates of premature stent occlusion and acute cholecystitis among patients with biliary strictures who underwent first time placement of a FCSEMS with or without transmural side holes. Patients and Methods This was a retrospective cohort study of adults who underwent endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS between April 2022 to April 2025 for malignant or benign extrahepatic bile duct strictures. Patients were followed for a minimum of 9 months or through planned stent removal. The primary outcome was premature bile duct occlusion. The secondary outcome was acute cholecystitis among patients with an intact gallbladder. Results Among 219 patients meeting enrollment criteria, 57 (26%) had side holes. The rate of premature stent occlusion was similar with transmural side holes (12%) vs. without (11%, HR 1.02, 95% CI 0.42 2.43, p = 0.96). Among patients with an intact gallbladder (n=129), acute cholecystitis rates were similar with side holes (6%) or without (4.8%, HR 1.01, 95% CI 0.22 4.5, p = 0.99). Conclusions FCSEMS stents with side holes do not reduce rates of premature bile duct stent occlusion or acute cholecystitis compared to FCSEMS without side holes.

Background and AimsActive capsule endoscopy could advance gastrointestinal diagnostics by enabling controlled navigation beyond passive peristalsis. However, current systems are often limited by inefficient propulsion, high power demands, or reliance on external actuation. Herein, we designed, developed and evaluated a novel electromagnetic impact-actuated capsule endoscope incorporating a ferromagnetic rail-enhanced locomotion mechanism. MethodsThe capsule employed an internal electromagnetic actuator comprising a movable coil-armature assembly guided along a ferromagnetic rail and surrounded by permanent magnets. Controlled current pulses generated reciprocating motion and propulsion through momentum transfer. Bench-top testing using a deformable intestinal model assessed locomotion and power consumption. Ex-vivo experiments were subsequently performed in porcine intestine under dry and physiologically simulated wet conditions. Transit speed, power consumption, and system stability were recorded. ResultsBench-top testing demonstrated stable propulsion at speeds up to 8.5 mm/s with a mean power consumption of 84 mW. During ex-vivo evaluation, mean capsule velocities were 1.95 mm/s and 7.2 mm/s under dry and wet conditions, respectively. Average power consumption was 96 mW and 193 mW. The actuator maintained reliable locomotion while preserving a compact system volume of [~]6.19 cm3. Lubricated conditions, representative of the intestinal environment, resulted in enhanced propulsion efficiency despite a concomitant increase in instantaneous power consumption. ConclusionThe electromagnetic impact-actuated capsule demonstrated reliable locomotion in biologically relevant ex-vivo environments while maintaining compact dimensions and moderate power requirements. Ferromagnetic rail-enhanced flux concentration offers a promising propulsion strategy for future actively navigated and therapeutic capsule endoscopy platforms.

Background and ObjectivesThe etiology of biliary obstruction has undergone notable shifts over recent decades, yet long-term epidemiological studies addressing these changes remain scarce. With the widespread clinical adoption of endoscopic ultrasound (EUS), its role in altering diagnostic patterns warrants investigation. This study aimed to characterize the evolving disease patterns of biliary obstruction and specifically evaluate the impact of EUS adoption on driving these perceived etiological shifts over a 15-year period. MethodsThis retrospective, single-center study analyzed data from patients with biliary obstruction over a 15-year period. Time-series analysis was employed to characterize evolving disease patterns. To investigate the drivers underlying the observed trends, we applied a difference-in-differences (DID) analytical framework, uniquely treating the widespread clinical adoption of EUS as a natural experiment. Furthermore, multivariable logistic regression was utilized to identify independent predictors for malignant biliary obstruction of pancreatic origin. ResultsAmong 5,672 patients with pathological diagnoses, the disease spectrum shifted significantly toward malignant etiologies, particularly pancreatic and ampullary cancers, over the study period. The DID analysis confirmed that the broad adoption of EUS was associated with a significant relative increase in the precise diagnosis of malignancies detectable by this modality. Multivariable analysis further identified the EUS promotion era and calendar year as independent predictors for the pancreatic origin of malignancy. ConclusionsThe observed increase in pancreatic and ampullary cancers among patients with biliary obstruction is significantly associated with the enhanced diagnostic capabilities brought by EUS. This suggests that the diagnostic evolution driven by the widespread adoption of EUS, alongside potential epidemiological changes, is a major contributing factor to the perceived etiological shifts in biliary obstruction.

Gastric cancer patients frequently experience skeletal muscle loss during the perioperative and adjuvant treatment period, which has been associated with poorer treatment tolerance and adverse clinical outcomes. Early identification of patients at high risk of skeletal muscle loss may allow timely supportive intervention, but repeated computed tomography assessment is not always practical in routine care. This study aimed to develop an interpretable machine learning model based on routinely available clinical data for early prediction of significant skeletal muscle loss in patients with gastric cancer. This single-center retrospective study screened 362 patients who underwent radical gastrectomy followed by adjuvant chemotherapy, of whom 292 were finally included. Significant skeletal muscle loss was defined as a decrease of at least 5% in skeletal muscle index between the baseline scan performed before surgery and the follow-up scan obtained 3 months after initiation of adjuvant chemotherapy. Candidate predictors included demographic, clinicopathological, laboratory, tumor marker, and inflammatory or nutritional variables, together with their early postoperative dynamic changes. Six machine learning models were developed and compared. Among the evaluated models, the multilayer perception showed the best overall performance in the validation set, with an area under the receiver operating characteristic curve of 0.757 and an area under the precision-recall curve of 0.745. At the selected decision threshold of 0.45, this model achieved an accuracy of 0.693, a recall of 0.833, and a specificity of 0.525. Compared with the model using baseline variables alone, the model incorporating longitudinal dynamic features showed better overall performance. Model interpretation suggested that prediction of skeletal muscle loss was mainly related to nutritional reserve, operation-related burden, and inflammatory or metabolic status. These findings indicate that routinely available preoperative and early postoperative clinical data can support early prediction of subsequent skeletal muscle loss in gastric cancer. This approach may help identify high-risk patients earlier and facilitate individualized nutritional support and supportive care during treatment.

Background: Heterogeneity in symptom presentation and treatment response in irritable bowel syndrome (IBS) remains poorly understood. The gut microbiota may contribute to this variability, but its role in shaping symptom trajectories and responses to self-management interventions is unclear. Objective: To identify symptom trajectory phenotypes and determine whether gut microbiota composition and function distinguish these phenotypes and predict multidimensional responses to pain self-management interventions in young adults with IBS. Design: Ancillary data analysis from a randomized control trial (NCT03332537). Methods: Participants with longitudinal data (n = 62) were analyzed using longitudinal k-means clustering (KML) based on trajectories of measures in IBS quality of life (QOL), Brief Pain Inventory (BPI), and psychoneurological outcomes (anxiety, applied cognition, depression, fatigue, global health, positive affect, and sleep disturbance) over 12 weeks. Baseline differences between clusters were assessed with Wilcoxon rank-sum tests, and longitudinal changes were evaluated with linear mixed models. Gut microbiota composition and predicted functional pathways were compared between phenotypes. Bayesian Additive Regression Trees (BART) models were used to identify baseline microbial taxa and pathways predictive of longitudinal changes in QOL, BPI pain interference, and severity. Results: Two distinct trajectory-defined response phenotypes were identified: a Constrained Response Phenotype (Phenotype A, n = 35) and an Adaptive Multidomain Response Phenotype (Phenotype B, n = 27). At baseline, Phenotype B showed lower pain severity and interference, but higher levels of anxiety, depression, and fatigue compared to Phenotype A. Over 12 weeks, both phenotypes showed improvements in pain outcomes (all p < 0.05), but only Phenotype B demonstrated broad improvements across psychoneurological domains and QOL (all p < 0.05). Phenotype A exhibited more limited improvements and worsening in several psychoneurological domains. Gut microbiota functional pathways differed between phenotypes, including pathways related to xenobiotic degradation, amino acid metabolism, bile secretion, and immune-related processes (all raw p < 0.05), although these did not remain significant after multiple testing correction. Machine learning models identified distinct, phenotype-specific microbial predictors of intervention response. In Phenotype A, genera such as Alistipes and Sutterella were consistently identified across models, whereas in Phenotype B, predictors included Phascolarctobacterium, Collinsella, and Parabacteroides. Functional pathways also differed between phenotypes, suggesting distinct microbiome-linked mechanisms underlying symptom trajectories and responses to pain interventions. Conclusions: Young adults with IBS exhibit distinct multidimensional response phenotypes that are associated with differential clinical and microbiome profiles. Baseline gut microbiota composition and functional capacity demonstrate phenotype-specific predictive signatures of treatment response, supporting a microbiome-informed framework for stratifying patients and advancing personalized self-management strategies in IBS.