DDW 2026, Chicago, USA. Day 1

Brief Introduction Endoscopic ultrasound-guided biliary drainage (EUS-BD) is emerging as a key alternative to traditional approaches for biliary obstruction, with potential to redefine standard practice. Background / Clinical Context Endoscopic retrograde cholangiopancreatography (ERCP) remains the standard for biliary decompression, but limitations such as failed cannulation and altered anatomy necessitate alternative strategies. EUS-BD offers internal drainage without external catheters. Key Points from DDW 2026 EUS-BD enables direct access to the biliary system through the gastrointestinal lumen, allowing physiologic internal drainage. Techniques such as hepaticogastrostomy and choledochoduodenostomy are tailored based on obstruction level, supported by lumen-apposing metal stents that improve procedural stability and outcomes. In cases of failed ERCP, EUS-guided rendezvous and antegrade approaches expand therapeutic options by facilitating guidewire access and stenting. Comparative data suggest EUS-BD may offer outcomes comparable or superior to percutaneous drainage, with fewer re-interventions and improved patient comfort. Advances in imaging, device design, and operator expertise have improved safety, although risks such as bile leak and bleeding remain. The procedure remains technically demanding, requiring specialized training. Clinical Interpretation EUS-BD provides an effective, minimally invasive alternative for biliary drainage, particularly in complex or failed ERCP cases, with growing applicability as a primary strategy in selected patients. What Is New or Practice-Changing? Practice-informing: Transition of EUS-BD from rescue therapy toward first-line consideration in appropriate clinical settings. Limitations Evidence is evolving and dependent on operator expertise. The available information is limited, so the interpretation should be cautious. Final Clinical Summary EUS-guided biliary drainage is reshaping the management of biliary obstruction by enabling precise, internal drainage with favorable outcomes. With advancing technology and expertise, it is moving beyond a rescue option toward a potential first-line approach in selected patients.

Brief Introduction Endoscopic ultrasound (EUS) is transforming the management of chronic pancreatitis by enabling early diagnosis and offering minimally invasive therapeutic interventions. Background / Clinical Context Chronic pancreatitis is a progressive disease with delayed diagnosis due to limitations of conventional imaging, which often detects only advanced structural changes. Early identification remains critical to alter disease progression. Key Points from DDW 2026 EUS provides high-resolution imaging of pancreatic parenchyma and ducts, allowing detection of early features such as lobularity, ductal irregularities, and subtle calcifications that are often missed on CT or MRI. Standardized frameworks like the Rosemont classification improve diagnostic consistency. The addition of elastography enhances fibrosis assessment by evaluating tissue stiffness, bridging structural and functional evaluation. EUS also plays a key role in differentiating chronic pancreatitis from pancreatic malignancy through targeted tissue acquisition. Importantly, EUS has evolved into a therapeutic platform. Interventions include celiac plexus block for pain control, EUS-guided ductal drainage in obstructive disease, and minimally invasive management of pancreatic fluid collections using lumen-apposing stents. These approaches reduce the need for surgery and improve outcomes. Clinical Interpretation EUS enables a comprehensive approach, combining early diagnosis, risk stratification, and targeted therapy within a single platform. What Is New or Practice-Changing? Practice-informing: Expansion of EUS from a diagnostic modality to a combined diagnostic–therapeutic tool in chronic pancreatitis. Limitations Data are primarily based on evolving techniques and expert experience. The available information is limited, so the interpretation should be cautious. Final Clinical Summary EUS is central to modern chronic pancreatitis care, allowing earlier diagnosis, improved differentiation from malignancy, and minimally invasive therapy. Its integration into clinical pathways represents a significant step toward precision-based pancreatic disease management.

Brief Introduction The gut–liver axis is increasingly recognized as a central regulator of metabolic and immune homeostasis, with emerging therapies targeting intestinal pathways to influence liver disease outcomes. Background / Clinical Context Communication between the gut and liver is mediated through bile acids, microbial metabolites, and immune signaling. Disruption of this coordinated system contributes to hepatic inflammation and metabolic dysfunction. Key Points from DDW 2026 Bile acids function as key immunometabolic regulators, influencing epithelial integrity, immune balance, and microbiome composition through receptor-mediated pathways. When bile acid signaling is disrupted, intestinal immune equilibrium is lost, leading to impaired barrier function and increased inflammatory signaling. Defective epithelial renewal further weakens barrier integrity, perpetuating a cycle of inflammation. The microbiome plays a central modulatory role by transforming bile acids and shaping immune responses, with disturbances contributing to systemic metabolic imbalance. These altered intestinal signals propagate to the liver via the portal circulation, activating hepatic immune pathways and driving disease progression. This creates a feedback loop in which gut dysfunction sustains liver injury. Therapeutic strategies are now shifting toward targeting the gut, including modulation of bile acid pathways, restoration of epithelial integrity, and regulation of immune signaling. Clinical Interpretation Liver disease should be viewed through a systems-based lens, where intestinal dysfunction is a primary driver rather than a secondary consequence. What Is New or Practice-Changing? Research-oriented: Emphasis on gut-targeted therapies, including bile acid modulation and microbiome-based interventions. Limitations Primarily mechanistic and conceptual data. The available information is limited, so the interpretation should be cautious. Final Clinical Summary The gut–liver axis represents a critical therapeutic target in liver disease. Disruption of bile acid signaling, barrier integrity, and microbiome balance drives hepatic inflammation. Restoring intestinal homeostasis offers a promising strategy for disease modification and future precision therapies.

Brief Introduction The gut–liver axis plays a central role in liver disease, with growing evidence linking intestinal microbes directly to hepatic injury and disease progression. Background / Clinical Context Under normal conditions, the intestinal barrier prevents microbial translocation and maintains immune balance. Disruption of this barrier leads to pathological signaling, contributing to liver inflammation, particularly in alcohol-associated liver disease. Key Points from DDW 2026 Intestinal barrier integrity is maintained by tight junctions, mucus layers, antimicrobial peptides, and immune defenses. Alcohol disrupts this system by impairing antimicrobial peptide secretion, altering microbiota composition, and increasing permeability, allowing bacterial translocation into portal circulation. Microbial translocation is a key driver of hepatic inflammation. Specific pathogens play a targeted role, particularly Enterococcus faecalis, which produces cytolysin associated with worse outcomes, and virulent strains of Escherichia coli, which sustain inflammatory signaling. These findings shift the paradigm from generalized dysbiosis to mechanism-driven microbial injury. Persistent host–microbe interaction leads to continuous immune activation, amplifying hepatocyte damage. Therapeutic strategies are now focusing on restoring gut barrier integrity rather than solely eliminating microbes. Activation of pathways such as the muscarinic receptor (M3R) enhances antimicrobial defense and reduces translocation. Clinical Interpretation Liver disease progression is closely linked to gut barrier dysfunction and specific microbial virulence factors, emphasizing the need for targeted, mechanism-based interventions. What Is New or Practice-Changing? Practice-informing: Shift toward gut barrier restoration and microbiome modulation as therapeutic targets. Limitations Data are largely mechanistic and emerging. The available information is limited, so the interpretation should be cautious. Final Clinical Summary The gut is a key driver of liver disease through barrier dysfunction and microbial translocation. Targeting gut integrity and host–microbe interactions offers a promising, mechanism-based approach to improving outcomes in alcohol-associated liver disease.

Brief Introduction Robotic systems are increasingly integrated into surgery and endoscopy, enhancing procedural precision and expanding the scope of minimally invasive interventions. Background / Clinical Context Traditional endoscopic and surgical techniques are limited by operator dependency and technical complexity. Robotics has evolved to address these challenges by improving control, stability, and reproducibility without fundamentally altering core clinical outcomes. Key Points from DDW 2026 Robotic-assisted surgery has progressed from simple camera-holding systems to advanced platforms offering three-dimensional visualization, motion scaling, and tremor filtration. These systems standardize performance and enable complex procedures with greater consistency, particularly benefiting less experienced operators. Integration of robotics into endoscopy represents a major advancement. Early limitations in flexibility and precision have been addressed with modern systems featuring motorized tips, robotic endoscopes, and fully integrated platforms. These technologies improve maneuverability and reduce technical difficulty in advanced procedures. Clinical studies suggest that robotic endoscopy may achieve higher rates of complete lesion resection, shorter procedure times, and fewer complications, while also reducing operator fatigue. Importantly, robotic platforms shorten the learning curve, supported by simulation-based training programs. Next-generation systems provide multiple degrees of freedom, enhanced visualization, and real-time feedback, with emerging capabilities including remote operation and hybrid surgical-endoscopic applications. Clinical Interpretation Robotic systems enhance procedural precision and consistency, making complex interventions more accessible while maintaining minimally invasive approaches. What Is New or Practice-Changing? Practice-informing: Expansion of robotic platforms into endoscopy with potential to reduce technical barriers and improve procedural outcomes. Limitations Most data are early-stage with ongoing validation. The available information is limited, so the interpretation should be cautious. Final Clinical Summary Robotics is transforming endoscopy by improving precision, reducing variability, and shortening learning curves. As integrated platforms evolve, they are likely to play a central role in advancing minimally invasive, technology-driven gastrointestinal care.

Brief Introduction Endoscopy is evolving into a therapeutic discipline that bridges gastroenterology and surgery, enabling minimally invasive, anatomy-preserving interventions for complex gastrointestinal conditions. Background / Clinical Context Conventional surgical approaches often carry significant morbidity. With growing patient preference for less invasive options, endoscopy has expanded beyond diagnostics to offer therapeutic solutions through natural orifice access. Key Points from DDW 2026 Hybrid and rendezvous procedures integrate endoscopic and surgical techniques to manage complex diseases more effectively. In conditions such as esophageal perforation, combined approaches allow external debridement with internal closure, avoiding extensive surgery. Similarly, overlapping conditions like GERD and obesity can be addressed using combined endoscopic interventions that preserve anatomy while improving outcomes. The field has expanded beyond the gastrointestinal lumen through endoscopic ultrasound and lumen-apposing stents, enabling creation of internal anastomoses without open surgery. Advancements in technology are central to this evolution. Emerging robotic and multi-luminal platforms improve precision and overcome technical limitations. Novel non-thermal energy modalities such as pulsed electric fields allow tissue modification without structural damage. Additionally, integrating immune modulation into endoscopic therapy represents a conceptual shift toward biologically driven interventions. Clinical Interpretation Hybrid endoscopic approaches offer a less invasive yet effective alternative to traditional surgery, particularly in complex or high-risk patients, while preserving anatomical integrity. What Is New or Practice-Changing? Primarily research-oriented, this work highlights the transition toward “Endoscopy 3.0,” combining advanced platforms, energy systems, and biological integration. Limitations These innovations are largely early-stage with limited long-term outcome data. The available information is limited, so the interpretation should be cautious. Final Clinical Summary Hybrid endoscopy is redefining gastrointestinal intervention by integrating surgical and endoscopic techniques. This multidisciplinary, technology-driven approach enables precise, minimally invasive treatment and represents a key step toward future non-invasive therapeutic strategies.

Brief Introduction Pancreatic cyst surveillance aims to prevent malignancy but poses a major clinical challenge due to the mismatch between high cyst prevalence and low cancer risk. Background / Clinical Context Pancreatic cysts are common (~16% prevalence), yet the annual risk of malignant transformation is low (~0.25%). This creates a dilemma between avoiding missed cancers and preventing unnecessary interventions. Key Points from DDW 2026 Despite widespread surveillance, nearly 50% of surgical resections are unnecessary, with only half showing high-grade dysplasia or cancer. Surgery carries 2% mortality and ~30% morbidity, underscoring the risks of overtreatment. Current surveillance strategies (Fukuoka/Kyoto, AGA) provide only modest mortality benefit (~8–9%) but require extensive imaging, often with poor cost-effectiveness. Progression risk remains low: among 1,000 IPMN patients, only ~3 may develop cancer over 5 years. Comorbidities significantly influence outcomes—older patients often have a higher competing mortality risk than cancer risk. Clinical Interpretation A universal surveillance strategy may not be appropriate. Management should incorporate patient age, comorbidity, and cyst risk profile, rather than relying solely on guideline-driven imaging intervals. What Is New or Practice-Changing? Practice-informing: Growing emphasis on de-escalation of surveillance in low-risk patients and more selective surgical decision-making. Limitations Data are largely modeling and observational; long-term prospective validation is limited. The available information is limited, so interpretation should be cautious. Final Clinical Summary Pancreatic cyst surveillance requires a shift toward personalized, risk-based strategies. Given the low malignancy risk and high burden of surveillance and surgery, careful patient selection—integrating clinical, imaging, and emerging molecular data—is essential to optimize outcomes while avoiding overtreatment.

Brief Introduction Accurate characterization of pancreatic cysts is critical to avoid unnecessary surgery while identifying high-risk lesions. Traditional cyst fluid analysis has limitations, prompting the use of advanced multimodal diagnostics. Background / Clinical Context Pancreatic cyst evaluation involves distinguishing mucinous from non-mucinous lesions and assessing malignant potential. Despite improvements, routine fluid analysis often fails to reliably classify cysts or stratify dysplasia risk, leading to overtreatment. Key Points from DDW 2026 Routine cyst fluid analysis remains insufficient, with misclassification rates ~24% and nearly 44% unnecessary resections. Molecular analysis offers ~80% sensitivity and near 100% specificity for mucinous cysts, with high specificity for advanced neoplasia. Confocal laser endomicroscopy (CLE) enables real-time “optical biopsy” with ~93% diagnostic accuracy for mucinous cysts and visualization of dysplastic changes. AI-assisted endomicroscopy further improves detection of high-risk features and outperforms expert interpretation in some settings. Tissue acquisition (TTNB/FNB) provides histology (~80% yield) but carries procedural risks, including pancreatitis. Clinical Interpretation No single modality is sufficient. A multimodal approach integrating imaging, molecular testing, endomicroscopy, and selective biopsy improves diagnostic precision and reduces overtreatment. What Is New or Practice-Changing? Practice-informing: Integration of CLE and AI into routine evaluation pathways, alongside molecular diagnostics. Limitations Data are largely summary-level with variable access to advanced modalities. The available information is limited, so the interpretation should be cautious. Final Clinical Summary Pancreatic cyst evaluation is shifting toward a multimodal, precision-based strategy. Combining molecular analysis, endomicroscopy, AI, and selective biopsy improves risk stratification, reduces unnecessary surgery, and supports more individualized management decisions.

Brief Introduction Accurate reflux assessment is essential in patients with persistent or unclear GERD symptoms. Modern reflux testing using pH and impedance monitoring provides objective evaluation beyond symptom-based diagnosis. Background / Clinical Context Symptom overlap and normal endoscopy often make GERD diagnosis challenging. Reflux monitoring helps distinguish true GERD from functional disorders, with interpretation dependent on testing conditions and duration. Key Points from DDW 2026 Combined pH-impedance monitoring differentiates acid, weakly acidic, and non-acid reflux while assessing MNBI and PSPW, improving diagnostic precision. Off-therapy testing establishes baseline acid exposure and confirms GERD, whereas on-therapy testing evaluates refractory symptoms and detects persistent reflux or functional pathology. Significant day-to-day variability in acid exposure was observed, indicating that short-duration studies may misclassify patients. Clinical Interpretation Testing strategy should align with the clinical question—diagnosis vs refractory symptom evaluation. Extended monitoring may improve accuracy, especially in borderline cases. What Is New or Practice-Changing? Practice-informing: Emphasis on tailored testing strategy and longer monitoring duration. Limitations Data are summary-level without detailed study design. Interpretation should be cautious. Final Clinical Summary Reflux testing should be individualized. Off-therapy studies confirm GERD, while on-therapy testing refines refractory cases. Variability in acid exposure supports extended monitoring and integration of advanced impedance metrics for accurate classification.