In 2021, the American College of Gastroenterology and Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America released guidelines for Clostridioides difficile infection (CDI) management, with conflicting recommendations. We surveyed US gastroenterologists (GIs), infectious disease (ID) specialists, and primary care physicians (PCPs) on their use of clinical guidelines and attitudes toward gut microbial therapies for CDI. We conducted an online survey of 302 physicians (n = 101 GIs, 101 IDs, 100 PCPs; February 24 to March 13, 2023). Included GIs and IDs saw a minimum of 3 to 4 patients and PCPs 1 to 2 patients with CDI per month. Physicians working in hospital/academic settings were more familiar with CDI guidelines than those working in independent/group practices. Half of GIs used American College of Gastroenterology guidelines; 98% of IDs followed Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines. More PCPs reported that their institutions did not have set guidelines (40%). More GIs (51%) and IDs (74%) used the recommended multistep algorithm for CDI testing; PCPs were more likely to use a single diagnostic test (49%). GIs and IDs more often prescribed vancomycin taper (93% and 98%, respectively) and fidaxomicin (87% and 97%, respectively); PCPs were more likely to prescribe metronidazole (84%). Less than 10% of physicians felt very knowledgeable about donor-derived microbiome therapies. While 60% of GIs, 53% of IDs, and 50% of PCPs agreed donor-derived microbiome therapies are essential for CDI management, more than 50% cited the need for real-world evidence of safety and efficacy. Education around CDI guidelines and standardized diagnostic and treatment algorithms are needed to ensure consistent CDI management.
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Congenital choledochal cysts are well-recognized risk factors for subsequent hepatobiliary malignancy, particularly cholangiocarcinoma, even after surgical excision. However, the development of extrahepatic cholangiocarcinoma (eCCA) in early adulthood following neonatal resection of a congenital biliary cyst is exceptionally rare. We report a case of early-onset eCCA in a young woman who was previously treated surgically in the neonatal period. A 25-year-old woman with a history of neonatal resection of a congenital biliary cyst, cholecystectomy, and biliary-enteric jejunal anastomosis presented with progressive epigastric and left upper quadrant pain, postprandial vomiting, and marked weight loss. She had no jaundice, pruritus, or fever. At the age of 23, she had undergone further intervention for biliary stones, including endoscopic retrograde cholangiopancreatography, surgical stone extraction, and revision of the biliary-enteric anastomosis. Laboratory evaluation showed pancytopenia, microcytic anemia, preserved liver biochemistry, and elevated CA19-9. Magnetic resonance cholangiopancreatography demonstrated marked intrahepatic biliary dilatation with filling defects. Contrast-enhanced computed tomography revealed a large infiltrative upper abdominal mass invading the gastric wall and extending into the left hepatic lobe, with encasement of major vessels, portal hypertension, splenomegaly, ascites, and residual hilar biliary dilatation. Upper gastrointestinal (GI) endoscopy and endoscopic ultrasound showed extensive varices and an ulcerated gastric wall lesion caused by an external infiltrative mass. Endoscopic ultrasound-guided fine-needle aspiration demonstrated poorly differentiated invasive adenocarcinoma. Immunohistochemistry showed CK7 positivity and CK20 negativity, supporting a pancreatobiliary or upper GI origin. In the context of the patient's surgical history and clinicoradiologic findings, the tumor was considered most consistent with unresectable eCCA. The patient was started on systemic chemotherapy with oxaliplatin and 5-fluorouracil. This case illustrates several unusual and clinically important features. First, cholangiocarcinoma occurred at an exceptionally young age despite neonatal surgical treatment of the congenital biliary cyst. Second, the tumor presented without jaundice or biochemical cholestasis despite advanced local disease. Third, the lesion radiologically and endoscopically mimicked a primary gastric malignancy, adding diagnostic complexity. The case supports the concept that malignant transformation may occur decades after apparently corrective surgery, possibly due to persistent epithelial injury, residual biliary abnormalities, and chronic inflammatory changes related to prior biliary-enteric reconstruction. Early-onset eCCA after childhood resection of a congenital biliary cyst is exceptionally rare but possible. This case highlights the persistent, lifelong malignant potential associated with choledochal cysts and emphasizes that advanced disease may develop in the absence of jaundice or abnormal liver biochemistry. Long-term and possibly lifelong surveillance should be considered, particularly in patients with residual biliary abnormalities or prior biliary-enteric reconstruction.
Lophomoniasis is a new emerging parasitic disease caused by Lophomonas spp., a protozoan that predominantly resides in a commensal relationship within the hindgut of cockroaches. This pathogen is known to affect the lower respiratory tract in humans, resulting in clinical manifestations such as cough, sputum production, and shortness of breath. We present two case studies involving a 54-year-old- and a 38-year-old male, both with a history of cigarette smoking but no known underlying medical conditions. These individuals presented at the emergency room with respiratory symptoms and were subsequently evaluated. No significant abnormalities were shown on the lung computed tomography scan in Case 1, whereas empyema was observed in the right lung in Case 2. Analysis of bronchoalveolar lavage fluid from each patient revealed Lophomonas spp., an emerging protozoan pathogen, by microscopic examination. Based on these findings, metronidazole was administered to both patients, resulting in successful treatment of the infection. These cases highlight that Lophomonas spp. is a significant respiratory pathogen capable of causing a spectrum of disease in immunocompetent individuals, from mild bronchitis to severe pneumonia with complications. They emphasize the critical importance of including lophomoniasis in the differential diagnosis for persistent or atypical respiratory infections. Timely treatment with metronidazole was effective, resulting in clinical resolution.
Primary small-bowel tumors are uncommon and frequently present with non-specific symptoms. Timely and accurate diagnosis relies on a range of radiologic and endoscopy-based modalities, yet their comparative diagnostic performance remains uncertain. We performed a systematic review and diagnostic test accuracy meta-analysis. PubMed, Embase, CNKI, and Wanfang databases were searched from inception to August 31, 2025, and the reference lists of included studies and relevant reviews were hand-searched. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the QUADAS-2 tool. To avoid unit-of-analysis errors, the primary analysis used a de-duplicated dataset with one representative arm per study cohort according to a prespecified hierarchy: the primary or original/consensus reading reported by the source article, then the arm with the largest analyzable 2×2 denominator, and finally the estimate closest to the within-study median diagnostic odds ratio if ties remained. Pooled sensitivity and specificity were estimated using hierarchical bivariate random-effects models, while alternative arms were retained for sensitivity analyses. Twenty-one studies met the eligibility criteria and were included in the quantitative synthesis. The overall pooled sensitivity was 0.91 (95% CI: 0.87-0.93) and specificity was 0.88 (95% CI: 0.78-0.94), with an area under the summary receiver operating characteristic curve of 0.95 (95% CI: 0.93-0.97). Between-study heterogeneity was substantial. In modality-stratified analyses, dedicated enterography techniques (magnetic resonance enterography and computed tomography enterography) demonstrated the highest comprehensive diagnostic accuracy, outperforming conventional contrast-enhanced CT and functional imaging. Contemporary imaging modalities exhibit high overall diagnostic performance for primary small-bowel tumors. Enterography-based cross-sectional imaging yielded the most favorable point estimates, although confidence intervals overlapped with those of conventional CT. These findings support CTE and MRE as strong diagnostic options within a multimodality pathway rather than proving clear statistical superiority. https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251144585.
Abdominal bloating, distension, excessive gas, abdominal pain, diarrhea and constipation are common symptoms that may arise from carbohydrate malabsorption, carbohydrate intolerance, small intestinal bacterial overgrowth (SIBO), intestinal methanogen overgrowth (IMO), or disorders of gut-brain interaction. Hydrogen- and methane-based breath tests are safe, noninvasive, inexpensive and widely used, but differences in indications, patient preparation, test performance and interpretation can lead to inconsistent diagnoses and management. At the recommendation of the Israeli Gastroenterology Association, a multidisciplinary panel of adult and pediatric gastroenterologists, neurogastroenterologists, dietitians, clinical nutrition specialists and heads of gastrointestinal laboratories reviewed the literature and reached consensus during 8 meetings. This guideline provides practical standards for breath testing in adults and children. The panel recommends simultaneous measurement of hydrogen and methane, structured symptom recording during testing, standardized pretest preparation, and cautious interpretation in settings that alter anatomy or orocecal transit time. Lactulose is recommended as the preferred substrate for SIBO/IMO testing, with glucose as an acceptable alternative. Carbohydrate malabsorption should be distinguished from intolerance by the presence or absence of typical symptoms during the test. The guideline also defines suspected hypersensitivity and highlights methane production as a cause of false-negative hydrogen-based carbohydrate tests. These recommendations are intended to harmonize breath test practice and reporting, and to support rational, test-directed treatment in adult and pediatric patients.
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Streptomyces avermitilis NRRL 8165 is an industrial model strain for the production of abamectin. Phage contamination during the fermentation process can lead to significant economic losses. At present, the known phages of S. avermitilis NRRL 8165 are scarce, making it difficult to meet the demands of research on pollution control mechanisms. Here, we isolated a novel phage, termed CW39, from soil samples. This phage exhibits a unique biological characteristic of solid-dependent infection. Transmission electron microscopy (TEM) revealed that the head measures approximately 65 nm in diameter, while the tail has a length of roughly 266 nm. Whole-genome sequencing revealed phage CW39 was 122,122 bp in genome size, exhibiting a GC content of 49.34%. Average nucleotide identity (ANI) analysis showed that phage CW39 shares only 64.4% nucleotide identity with its closest relative in the genus Samistivirus, which is significantly below the 70% genus-level classification threshold set forth by the International Committee on Taxonomy of Viruses (ICTV). Phylogenetic tree analysis further revealed that phage CW39 forms an independent monophyletic branch at the root. These findings indicate that phage CW39 likely represents a novel putative genus within the class Caudoviricetes. CRISPR-Cas9 plasmids targeting three key proteins of CW39 (the major capsid protein, head maturation protease, and portal protein) were separately transformed into S. avermitilis NRRL 8165, and all conferred enhanced phage resistance. This study not only enriches the Streptomyces phage resource library, but also provides a feasible strategy for using the CRISPR-Cas9 system to prevent and control phage contamination in industrial fermentation.
Neoadjuvant chemotherapy in non-metastatic pancreatic ductal adenocarcinoma (PDAC) is increasingly being studied and used in clinical practice. However, this strategy is associated with significant toxicity, biopsy-related and biliary complications and possible treatment delay. We aimed to assess the feasible number of cycles of neoadjuvant (modified) FOLFIRINOX and the real-world toxicity, to inform an optimal interventional trial design. In this descriptive monocentric study, we identified patients with borderline resectable or locally advanced PDAC, treated with upfront (m)FOLFIRINOX from 2020 to 2023. We analyzed patient and disease characteristics, dosing of therapy, occurrence of serious adverse events (SAEs) and reasons for discontinuation, and compared this data with available evidence in the literature. Eighty-one patients were included. Median age was 65, most patients had an ECOG performance status of 0. 62.5% of tumors were borderline resectable, the others were locally advanced. 49 patients (60.5%) received mFOLFIRINOX, 32 (39.5%) received FOLFIRINOX and the median number of cycles administered was six. Most common reasons for discontinuation were surgery (n=45, 55.6%) and persistently inoperable or progressive disease (n=25, 30.9%), with toxicity accounting for a much smaller proportion (n=5, 6.2%). Global dose intensities gradually decreased over time. Dose reduction was necessary in 43 patients (53%), and 37 patients (45.7%) needed inpatient care. However, supportive care measures allowed most patients to overcome toxicity and finish the planned treatment cycles. With adequate supportive care and dose modifications, the majority of patients were able to complete the assigned chemotherapy cycles. Eight cycles of mFOLFIRINOX appear feasible for most patients and may serve as an optimal regimen for evaluation in future interventional trials.
Early gastric cancer, which is negative for Helicobacter pylori (H. pylori), is characterized by difficulties in endoscopic detection, pathological diagnosis, and differentiation. With the deepening understanding of gastric tumors, clinically, there has been a gradual discovery of some early gastric cancers that do not fit conventional categories. This article reports two cases of atypical early differentiated gastric-type adenocarcinoma with mixed features of foveolar epithelial type, mucous neck cell type, chief cell type, and parietal cell type, ultimately diagnosed as a special type of early gastric cancer. We detail the endoscopic features, histopathological findings, and immunohistochemical profiles of these cases, highlighting the diagnostic challenges and the importance of recognizing such rare variants. The identification of these mixed-cell-type adenocarcinomas has significant implications, including expanding the current pathological classification of early gastric cancer, modifying existing endoscopic surveillance strategies, and influencing treatment decisions, such as the extent of endoscopic resection or lymph node dissection. Moreover, these findings underscore the need for heightened awareness among pathologists and endoscopists when encountering H. pylori-negative early gastric cancers with ambiguous morphology. By shedding light on this underrecognized entity, our report contributes to more accurate diagnosis and personalized management of early gastric cancer patients.
Intravascular large B-cell lymphoma is a rare aggressive lymphoma confined to small-vessel lumina that may elude endoscopic detection. Diagnosis from a gastroesophageal junction biopsy is rarely reported. A 75-year-old woman underwent upper endoscopy for dysphagia, revealing only an irregular Z-line. Histopathology demonstrated CD20-positive atypical lymphoid cells within submucosal vessel lumina, suspicious for intravascular large B-cell lymphoma. She was referred for hematologic staging and rituximab-based chemotherapy. This case illustrates that an irregular Z-line, attributed to reflux, can be the only mucosal evidence of an occult systemic lymphoma; systematic biopsy of even subtle findings is decisive in this rapidly fatal but curable disease.
The Systemic Immune-Inflammation Index (SII), a composite biomarker integrating neutrophil, platelet, and lymphocyte counts, has been increasingly investigated in thyroid cancer. However, its diagnostic accuracy and association with lymph node metastasis (LNM) remain uncertain. This study aimed to systematically evaluate the diagnostic performance of SII for thyroid cancer and its association with LNM. A systematic literature search was conducted across PubMed, Scopus, and Web of Science. A diagnostic meta-analysis using the bivariate Reitsma model was performed to pool sensitivity, specificity, likelihood ratios, and the area under the summary receiver operating characteristic curve (AUC). The association between SII and LNM was assessed by pooling mean differences (MD) using an inverse-variance random-effects model. Heterogeneity was evaluated using I² statistics and Cochran's Q test. This systematic review was registered in PROSPERO (PROSPERO 2025 CRD420251233710). Ten studies were included. The diagnostic meta-analysis (6 studies; 2,209 participants) yielded a pooled sensitivity of 76.8% (95% CI: 63.8-86.1%), specificity of 71.2% (95% CI: 54.9-83.4%), and AUC of 0.805. The positive and negative likelihood ratios were 2.78 and 0.34, respectively. The LNM meta-analysis (5 studies; 2,073 participants) demonstrated significantly higher SII in patients with LNM (MD = 102.87; 95% CI: 58.86-146.89; p < 0.00001; I² = 56%). Leave-one-out sensitivity analyses confirmed the robustness of both findings. Sensitivity analysis excluding one outlier study yielded consistent results with reduced heterogeneity (MD = 105.72; I² = 32%). SII demonstrates moderate diagnostic accuracy for thyroid cancer and is significantly elevated in patients with lymph node metastasis, supporting its potential as an adjunctive biomarker for diagnostic triage and preoperative risk stratification. Given substantial between-study heterogeneity, threshold variability, and partial verification bias affecting specificity, the pooled diagnostic estimates should be interpreted as preliminary and require confirmation in prospective studies with standardized cut-offs and uniform histopathological reference standards. Further large-scale prospective studies are warranted. https://www.crd.york.ac.uk/prospero/, identifier CRD420251233710.
Severe malnutrition in adults is frequently multifactorial and may result from overlapping nutritional, infectious, inflammatory, and systemic conditions. Identifying the dominant contributors can be challenging, particularly when patients present without classic gastrointestinal symptoms. We report the case of a 24-year-old woman with a more than 10-year history of failure to gain weight despite adequate nutritional intake, associated with progressive bilateral lower limb weakness, anasarca, delayed pubertal development with primary amenorrhea, and severe functional decline. Despite multiple hospitalizations and nutritional interventions, her condition continued to deteriorate. Comprehensive evaluation revealed Helicobacter pylori (H. pylori)-associated gastritis with micronutrient deficiencies, while further investigation identified a right psoas abscess associated with a marked systemic inflammatory response. Management included H. pylori eradication therapy, surgical drainage of the abscess, antibiotic therapy, and structured nutritional rehabilitation. The patient subsequently experienced substantial weight gain, resolution of edema, restoration of mobility, attainment of menarche, and sustained clinical recovery. This case highlights the multifactorial nature of severe malnutrition and the potential contribution of both chronic gastrointestinal infection and occult deep-seated infection to nutritional decline. In patients with unexplained severe malnutrition accompanied by disproportionate inflammatory markers, clinicians should maintain a high index of suspicion for occult infectious foci and consider early imaging to avoid diagnostic delay and facilitate timely intervention.
Hashimoto's thyroiditis (HT) is a common autoimmune thyroid disease characterized by thyroid autoantibody positivity, chronic lymphocytic inflammation, and varying degrees of thyroid dysfunction. Whether HT is associated with quantifiable biological age acceleration and metabolic age-related remodeling remains insufficiently examined. This cross-sectional study included two clinical discovery cohorts, an NHANES 2007-2012 validation cohort, and a metabolomics cohort. Klemera-Doubal method biological age (KDM biological age), Phenotypic Age (PhenoAge), and corresponding age acceleration metrics were calculated from clinical biomarkers, and the proportions of participants with age acceleration were compared. In the metabolomics cohort, a random forest metabolic age model was trained in healthy controls and internally evaluated by five-fold cross-validation. Metabolic age acceleration (MAA) was defined as predicted metabolic age minus chronological age. Metabolites associated with age, FT3, FT4, and TSH, together with differential metabolites in euthyroid HT (EHT) and thyroid dysfunction HT (DHT) relative to controls, were integrated to screen candidate metabolites and construct exploratory prediction models. In the two discovery cohorts, the HT group showed higher KDM biological age and/or PhenoAge indices and higher proportions of age acceleration than healthy controls. In the NHANES validation cohort, after adjustment for age, sex, socioeconomic factors, and lifestyle factors, overall HT was associated with higher KDM biological age (beta = 3.16 years, 95% CI 1.77-4.56) and PhenoAge (beta = 1.54 years, 95% CI 1.05-2.03). Stage-specific analyses suggested relatively stable associations for euthyroid HT and subclinical hypothyroid HT, whereas results for overt hypothyroid HT should be interpreted cautiously because of the small sample size and wide confidence intervals. In the random forest metabolic age model, the mean test-set performance across five-fold cross-validation was RMSE 8.75 years, MAE 7.11 years, R 0.634, and R2 0.427. MAA differed among CON, EHT, and DHT groups (Kruskal-Wallis P = 6.6 x 10^-5), and both EHT and DHT had higher MAA than CON after adjustment for age and sex. Integrated analysis identified 18 candidate metabolites; the HT classification model based on these metabolites had an AUC of 0.980, and predicted values from the FT3, FT4, and TSH models were significantly correlated with the measured values. Considering clinical relevance, between-group expression trends, and model-intersection evidence, citric acid, LPC 20:0 sn-1, and SM 34:2 were prioritized as core candidate metabolites. In the cross-sectional cohorts included in this study, HT was associated with higher biological age and metabolic age acceleration. Metabolomics results suggest that citric acid-related energy metabolism and lipid molecules such as LPC and SM may reflect HT- and thyroid-function-related metabolic features.
Colorectal cancer (CRC) remains one of the most common gastrointestinal malignancies worldwide, characterized by high incidence and mortality rates. Ferroptosis, an iron-dependent form of regulated cell death, has emerged as a critical mechanism in tumor biology. However, the regulatory role of CFHR5 (Complement Factor H-Related Protein 5) in ferroptosis and CRC progression remains unclear. We applied Mendelian randomization (MR) to evaluate the causal role of CFHR5 in CRC. Mediation MR was further employed to assess ferroptosis-related genes as potential mediators. Differential expression and correlation analyses were conducted using multiple CRC transcriptomic cohorts. Functional enrichment and Gene Set Variation Analysis (GSVA) were performed to investigate ferroptosis-related pathways. In addition, drug sensitivity prediction and molecular docking were carried out to identify potential therapeutic targets. MR analysis demonstrated a significant positive association between CFHR5 expression and CRC risk (FinnGen: OR = 1.233, P = 0.004; UK Biobank: OR = 1.072, P < 0.001). Mediation MR identified COX4I2 as a key ferroptosis-related mediator, accounting for 16.4% and 21.8% of the total effect in Finnish and UK cohorts, respectively. Transcriptomic validation confirmed elevated CFHR5 and COX4I2 expression in CRC tissues, with a strong positive correlation between them. Enrichment analyses indicated that CFHR5-related genes were significantly involved in cholesterol metabolism, iron binding, and oxidative stress pathways. GSVA showed that CFHR5 expression was negatively correlated with ferroptosis-related pathways. Drug sensitivity analysis suggested that CFHR5 downregulation increased CRC cell sensitivity to ABT-737, while molecular docking revealed a strong binding affinity between CFHR5 and ABT-737 (binding energy: -9.4 kcal/mol). Our study demonstrates that CFHR5 promotes CRC progression by upregulating COX4I2 and inhibiting ferroptosis. These findings highlight CFHR5 as a promising biomarker and therapeutic target for CRC, warranting further validation in experimental and preclinical models.
Colouterine fistula is an exceptionally rare pelvic fistula, typically arising from diverticulitis, malignancy, or trauma.‌ The thick uterine myometrium serves as a natural barrier, rendering direct intestinal invasion of the uterine wall unlikely and thus complicating preoperative diagnosis. ‌Dynamic real-time imaging plays a pivotal role in evaluating such lesions. This case report describes a 74-year-old woman patient who presented with a 1-month history of vaginal flatus and fecaloid discharge. The symptoms were caused by a colouterine fistula secondary to a sigmoid colon malignancy. Gynecological examination confirmed the presence of vaginal flatus and fecal-like discharge. Transvaginal ultrasound revealed a 3 mm wide discontinuity in the left myometrial wall of the uterus, communicating with the sigmoid colon. Dynamic observation demonstrated intestinal gas entering the uterine cavity through the fistula, accompanied by a mobile air-fluid interface and color Doppler twinkling artifact. CT and MRI further confirmed sigmoid colon tumor invasion of the uterine wall with fistula formation. ‌Intraoperatively, the diagnosis was confirmed as sigmoid colon cancer secondary to colouterine fistula.‌ Owing to extensive tumor invasion, only a double-barrel transverse colostomy was performed. The patient experienced an uncomplicated postoperative recovery. ‌This case underscores the value of transvaginal ultrasound in early diagnosis, as it enables noninvasive, dynamic visualization of fistula morphology and gas-liquid flow, serving as a critical adjunct to CT/MRI.
This review explores how gut microbiota reshapes colorectal cancer (CRC) molecular landscape, driving initiation/progression via key mechanisms. Microbes/metabolites cause driver mutations (DNA damage, signaling interference) and alter epigenetics (DNA methylation, histone modifications, ncRNAs) to boost tumor cell proliferation/survival. Dysbiosis disrupts tumor immune microenvironment (TIME) by impairing immune cells and increasing immunosuppressive factors, fostering immune evasion.Integrating molecular biology, microbiology, and immunology, we show microbial changes are causal in oncogenesis, with species acting distinctly across tumor stages. These insights clarify CRC pathogenesis and support microbiota-based prevention, diagnosis, treatment. Targeting microbes/metabolites or signaling pathways could cut CRC risk, improve early detection, and boost therapy. The review highlights microbiota-targeted therapy's promise and guides future research/clinical translation.
The resection of colorectal polyps has diversified in recent years. Nowadays, a variety of techniques exist, including forceps and snare resection without or with prior submucosal injection (endoscopic mucosal resection [EMR]), as well as without or with diathermy current ("cold" or "hot"). Other options include underwater EMR (U-EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection. When discussing resection techniques, the endpoints of safety (e.g., perforation or delayed bleeding) and effectiveness (e.g., residual/recurrent adenoma) should be considered. The current evidence-based roles of various resection techniques are provided. Additional measures, such as margin coagulation and clip closure of the resection site, are also discussed. Cold snare resection should be performed for small polyps (≤9 mm) and sessile-serrated lesions without dysplasia of any size due to its beneficial safety profile and satisfactory effectiveness. Polyps ≥20 mm should be treated with the hot snare, as it is more effective, particularly in case of piecemeal resection with additional margin coagulation. U-EMR is an option to optimize effectiveness for the removal of polyps measuring 20-40 mm. Potentially malignant polyps are best removed en bloc by ESD. The future role of cold snare resection with margin coagulation for large low-grade adenomas is subject of ongoing studies.
Metal (MS) or plastic stents (PS) are placed for preoperative biliary drainage (PBD) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing neoadjuvant chemotherapy (NAC) or chemoradiotherapy (NACRT). This multicentre retrospective study compared the safety and efficacy of PBD using MS and PS, including surgery-related adverse events (AEs) and other clinical outcomes. This study enrolled patients with resectable or borderline resectable PDAC requiring NAC or NACRT who underwent PBD with MS or PS at 17 tertiary care hospitals in Japan between January 2016 and December 2021. Clinical outcomes were retrospectively analysed. Of the 249 patients who underwent pancreatectomy, 121 underwent PBD with MS and 128 with PS. Because there were significant differences in baseline characteristics between these groups, propensity score matching was performed, resulting in 66 matched pairs. The RBO rate was significantly lower (15.2% vs. 56.1%, p < 0.001); the time to surgery (p = 0.027) and postoperative hospital stay (p = 0.036) were significantly shorter in the MS group. The incidence of postoperative AEs was significantly lower in the MS group (18.2% vs. 34.9%, p = 0.030) than in the PS group. Univariate and multivariate analyses identified the placement of an MS for PBD as an independent protective factor for postoperative AEs (odds rates: 0.35, p = 0.017). In patients with PDAC undergoing NAC or NACRT, MS placement for PBD was associated with lower rates of postoperative AEs and RBO than PS placement. MS is a more suitable option than PS for PBD.