DDW 2026, Chicago, USA. Day 4

Brief Introduction
Acute pancreatitis remains one of the most common gastrointestinal emergencies worldwide and continues to impose major clinical and healthcare burden. At DDW 2026, emphasis was placed on evidence-based evolution in management strategies, including moderate fluid resuscitation, early enteral nutrition, delayed intervention, and minimally invasive step-up approaches for necrotizing pancreatitis.

Background / Clinical Context
The global incidence of acute pancreatitis is steadily increasing, driven primarily by biliary and alcohol-related disease. Although mortality has improved over time, severe acute pancreatitis remains associated with substantial morbidity, organ failure, prolonged hospitalization, and high healthcare utilization. Management increasingly focuses on phase-specific treatment strategies and avoidance of unnecessary invasive intervention.

Key Points from DDW 2026
The presentation highlighted a phase-oriented management model. Early disease management centers on fluid resuscitation and severity assessment, followed by enteral nutritional support during the intermediate phase, with delayed intervention reserved for organized pancreatic collections and necrosis.

Recent evidence strongly supports moderate goal-directed fluid resuscitation over aggressive hydration. The WATERFALL trial demonstrated that aggressive fluid administration increases fluid overload without improving outcomes. Lactated Ringer’s solution was favored over normal saline because of associations with reduced rates of moderately severe/severe pancreatitis, lower ICU utilization, fewer local complications, and shorter hospital stay.

Early nutrition was another major focus. Immediate oral feeding and early advancement to full solid diet in mild-to-moderate pancreatitis were associated with shorter hospitalization and lower healthcare costs without worsening pain or mortality. These findings support avoidance of prolonged fasting and overly cautious dietary progression.

The Revised Atlanta Classification was reviewed as the framework for categorizing pancreatic fluid collections and necrosis according to morphology and timing. Management of necrotizing pancreatitis has progressively shifted toward minimally invasive step-up strategies rather than upfront surgical necrosectomy. Conservative management followed by delayed drainage after encapsulation significantly reduces complications, mortality, and need for surgery, while nearly 40% of patients may avoid necrosectomy entirely.

Encapsulation of walled-off necrosis was emphasized as a critical determinant of procedural success. Delayed intervention after maturation of collections was associated with higher clinical success and fewer adverse events compared with early drainage. Direct endoscopic necrosectomy is generally reserved for patients who fail to improve after drainage alone.

Lumen-apposing metal stents (LAMS) were highlighted as an important advance facilitating efficient drainage and direct endoscopic access to necrotic cavities. However, real-world Japanese registry data demonstrated higher bleeding rates, mortality, and costs with LAMS, emphasizing the importance of patient selection. In contrast, plastic stents remained non-inferior for pancreatic pseudocyst drainage in randomized trial data, supporting continued individualized device selection.

Clinical Interpretation
These findings reinforce the transition toward less aggressive and more physiologically balanced management of acute pancreatitis. Delayed minimally invasive intervention combined with moderate resuscitation and early nutrition appears to improve outcomes while reducing unnecessary morbidity.

What Is New or Practice-Changing?
Practice-informing: DDW 2026 reinforced moderate Lactated Ringer’s–based fluid resuscitation, early oral feeding, delayed intervention for necrotic collections, and individualized selection between LAMS and plastic stents in pancreatic fluid collection management.

Limitations / Caution
Outcomes with LAMS may differ substantially between expert centers and real-world practice. Timing of intervention and patient selection remain highly individualized, particularly in necrotizing disease. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 highlighted a major shift toward evidence-based, minimally invasive management of acute pancreatitis and pancreatic necrosis. Moderate goal-directed fluid resuscitation with Lactated Ringer’s solution, early enteral nutrition, and delayed step-up intervention strategies are increasingly central to care. While LAMS offers important technical advantages in necrotic collections, careful patient selection remains essential, and plastic stents continue to play an important role in selected scenarios such as pancreatic pseudocysts.

Brief Introduction
Crohn’s disease–associated strictures remain a major cause of obstructive symptoms, recurrent hospitalization, and repeated intestinal surgery. At DDW 2026, emphasis was placed on the evolving transition from surgery-first strategies toward advanced endoscopic, bowel-preserving interventions that aim to provide durable symptom relief while minimizing intestinal loss.

Background / Clinical Context
Strictures in Crohn’s disease arise through varying combinations of inflammation and fibrosis. While inflammatory strictures may respond to medical therapy, predominantly fibrotic disease frequently requires mechanical intervention. Repeated surgery can lead to progressive bowel shortening and long-term complications, increasing interest in minimally invasive endoscopic alternatives.

Key Points from DDW 2026
The presentation introduced a conceptual framework for endoscopic stricture management centered around three principal modalities: dilation, incision, and stenting. These strategies are increasingly used individually or in combination depending on stricture anatomy, fibrosis burden, and prior treatment response.

Endoscopic balloon dilation (EBD) remains the most widely used first-line therapy, particularly for short fibrotic strictures. Controlled radial expansion provides rapid symptom relief with consistently high technical success rates. However, recurrence remains common, often requiring repeat procedures. Better outcomes were associated with shorter strictures and absence of active ulceration. Emerging drug-coated balloon technologies designed to reduce fibrosis and recurrence demonstrated encouraging early safety and efficacy signals.

Endoscopic stricturotomy was highlighted as an important evolution for fibrotic or refractory disease. Using electrocautery incision techniques—either radial or circumferential—stricturotomy enables more controlled and durable luminal expansion, particularly in anastomotic strictures or lesions inadequately responsive to balloon dilation alone. Clinical data demonstrated high technical success and sustained long-term patency with acceptable complication rates in experienced hands.

Hybrid approaches combining balloon dilation with stricturotomy are increasingly used for long, recurrent, or complex fibrotic strictures. These individualized strategies reflect a broader shift toward precision endoscopic therapy tailored to structural characteristics of the lesion.

The session also reviewed the re-emerging role of enteral stenting. Fully covered self-expanding metal stents (SEMS) may provide prolonged luminal support and reduce recurrence in selected refractory strictures. However, high migration rates, procedural costs, and absence of dedicated IBD-specific stent designs remain major limitations.

Future directions discussed included drug-eluting devices, biodegradable stents, and anti-fibrotic therapies aimed at combining mechanical intervention with biologic modulation of fibrosis.

Clinical Interpretation
These findings support the growing role of advanced endoscopic therapy as a bowel-preserving alternative in Crohn’s strictures. Tailoring intervention based on fibrosis burden, anatomy, and prior response may improve durability while reducing surgical dependence.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted expansion of stricturotomy, hybrid dilation-incision strategies, and emerging drug-coated or biologically enhanced devices as part of a precision endoscopic approach to Crohn’s strictures.

Limitations / Caution
Most advanced endoscopic stricture therapies require significant procedural expertise and careful patient selection. Long-term comparative data versus surgery remain limited, particularly for newer devices and hybrid approaches. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 emphasized that endoscopic management is becoming central to modern treatment of Crohn’s disease strictures. Balloon dilation remains foundational therapy, while stricturotomy and hybrid techniques offer more durable outcomes in fibrotic and refractory disease. Emerging technologies including drug-coated balloons, biodegradable stents, and anti-fibrotic strategies may further expand bowel-preserving options and reduce long-term surgical burden in Crohn’s disease.

Brief Introduction
Interventional endoscopic ultrasound (EUS) is increasingly transforming the management of lower gastrointestinal disorders from a predominantly diagnostic modality into an advanced therapeutic platform. At DDW 2026, focus was placed on EUS-guided drainage of pelvic collections and emerging procedures such as EUS-guided enterocolostomy, highlighting the growing role of minimally invasive endoscopic intervention in complex lower GI disease.

Background / Clinical Context
Management of pelvic abscesses and malignant bowel obstruction has traditionally relied on surgical or percutaneous approaches, which may be associated with significant morbidity, prolonged recovery, external drainage dependence, and patient discomfort. These challenges are particularly relevant in high-risk, post-surgical, or oncologic patients where less invasive therapeutic alternatives are highly desirable.

Key Points from DDW 2026
The session emphasized that conventional drainage techniques such as transgluteal catheter drainage are frequently limited by pain, fistula formation, drain dislodgement, and prolonged external drainage requirements. EUS-guided internal drainage offers an alternative approach that may improve patient comfort while reducing procedural morbidity.

EUS-guided pelvic abscess drainage using lumen-apposing metal stents (LAMS) was highlighted as a highly effective therapeutic strategy. In representative cases involving malignancy-associated pelvic abscesses, EUS-guided drainage enabled rapid decompression, symptom relief, and avoidance of external drainage systems. The procedure involves EUS-guided access to the collection followed by stent placement to establish internal drainage under endoscopic and fluoroscopic guidance.

Follow-up imaging and endoscopic evaluation demonstrated progressive cavity collapse, reduction in inflammatory burden, and sustained clinical improvement in most patients. Clinical studies reviewed during the session showed high technical and clinical success rates with low need for surgical rescue procedures. Long-term outcomes were generally favorable, with only a minority of patients experiencing recurrence or requiring repeat intervention.

The discussion also addressed more complex scenarios involving malignancy, fistulous communication, altered anatomy, or persistent infection where outcomes may be less predictable. In such patients, repeat drainage, prolonged stenting, or multidisciplinary management involving surgery and infectious disease specialists may be required. Technical considerations such as dependent drainage, stent sizing, and transition from metal to plastic stents were emphasized as important factors influencing long-term success.

An emerging application discussed was EUS-guided enterocolostomy for palliation of malignant small bowel obstruction. Using lumen-apposing metal stents to create an internal bypass, this approach offers a minimally invasive alternative to surgery in carefully selected patients with advanced malignancy.

Clinical Interpretation
These findings support the expanding role of therapeutic EUS in lower GI disease, particularly for patients in whom surgical or percutaneous approaches are high risk or poorly tolerated. Internal drainage strategies may improve patient comfort while achieving durable clinical outcomes.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted the increasing effectiveness of EUS-guided pelvic abscess drainage and introduced EUS-guided enterocolostomy as an emerging minimally invasive option for malignant bowel obstruction.

Limitations / Caution
Most available evidence derives from specialized tertiary-center experience and observational studies. Technical expertise, careful patient selection, and multidisciplinary support remain critical for safe implementation. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 demonstrated how interventional EUS is rapidly expanding therapeutic possibilities in the lower GI tract. EUS-guided pelvic abscess drainage offers a minimally invasive alternative to surgery and percutaneous drainage with high technical success and durable outcomes. Emerging procedures such as EUS-guided enterocolostomy further illustrate the growing role of advanced therapeutic endoscopy in managing complex gastrointestinal and oncologic conditions.

Brief Introduction
Gastroduodenal disorders are increasingly recognized as complex disorders of gut–brain interaction involving overlapping immune, motility, microbial, and behavioral mechanisms. At DDW 2026, emphasis was placed on functional dyspepsia (FD), rumination syndrome, inability-to-belch syndrome, and ARFID, highlighting the growing need for integrated physiologic and multidisciplinary assessment.

Background / Clinical Context
Patients with FD frequently present with chronic epigastric pain, early satiety, nausea, postprandial fullness, regurgitation, and weight loss despite absence of structural disease. Significant symptom overlap exists between FD, rumination syndrome, ARFID, and functional esophageal disorders, contributing to diagnostic uncertainty and delayed recognition.

Key Points from DDW 2026
The session reviewed Rome V classification of FD into epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS), with PDS remaining the predominant subtype. Population studies demonstrated that FD affects a substantial proportion of patients, with overlapping symptom patterns commonly observed between subtypes.

A major focus was the evolving pathophysiology of FD. Evidence increasingly supports a multifactorial disease model involving duodenal eosinophilia, mast cell activation, impaired epithelial barrier function, microbiome alterations, delayed gastric emptying, impaired accommodation, visceral hypersensitivity, and altered gut–brain signaling. These findings reinforce the concept that FD is not purely functional in the traditional sense but may involve measurable biological abnormalities.

The presentation additionally emphasized the importance of excluding alternative causes of epigastric pain including celiac disease, eosinophilic gastrointestinal disorders, medication-related injury, infiltrative disease, vascular disorders, and metabolic abnormalities before assigning a diagnosis of FD.

Rome V criteria for retrograde cricopharyngeus dysfunction (R-CPD) or inability-to-belch syndrome were also reviewed. Diagnosis requires chronic inability to belch without structural esophageal disease, often associated with bloating, chest discomfort, flatulence, and gurgling sounds. Impedance manometry may demonstrate abnormal gas handling and impaired upper esophageal sphincter relaxation.

Rumination syndrome was highlighted as another important overlapping gut–brain disorder characterized by effortless regurgitation of recently ingested food without preceding nausea or retching. Combined impedance-manometry allows objective diagnosis and differentiation from reflux disease. The session also reviewed the increasing recognition of ARFID in patients with gut–brain disorders, where restrictive eating behaviors may contribute to severe nutritional compromise, psychological burden, and healthcare utilization.

Clinical Interpretation
These findings reinforce that FD and related gastroduodenal disorders are highly heterogeneous conditions involving complex interactions between immune activation, microbiome changes, visceral sensitivity, motility dysfunction, and psychosocial factors. Recognition of overlapping behavioral and esophageal syndromes is increasingly important for accurate diagnosis and individualized treatment planning.

What Is New or Practice-Changing?
Practice-informing: DDW 2026 further strengthened the biologic and immune-based framework for FD while emphasizing recognition of overlapping disorders such as rumination syndrome, R-CPD, and ARFID within gut–brain interaction disorders.

Limitations / Caution
Many mechanistic associations remain incompletely understood, and causal relationships between immune activation, microbiome alterations, and symptom generation continue to evolve. Significant diagnostic overlap persists among functional GI disorders. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 highlighted that functional dyspepsia and related gastroduodenal disorders represent multifactorial gut–brain conditions involving immune activation, altered motility, microbiome disruption, and visceral hypersensitivity. Increasing recognition of rumination syndrome, inability-to-belch syndrome, and ARFID is reshaping diagnostic frameworks for chronic upper GI symptoms. Comprehensive evaluation and multidisciplinary management are becoming increasingly important for effective individualized care.

Brief Introduction
Endoscopic ultrasound (EUS) is rapidly evolving from a purely anatomical imaging modality into a comprehensive platform integrating structural, vascular, functional, and AI-assisted assessment. At DDW 2026, major advances in contrast-enhanced imaging, elastography, microvascular visualization, three-dimensional reconstruction, and artificial intelligence were highlighted as transformative developments in pancreatic and gastrointestinal diagnostics.

Background / Clinical Context
Conventional EUS provides high-resolution real-time imaging but remains limited by artifacts, operator dependency, and difficulty detecting early microscopic disease. Challenges are particularly important in pancreatic cancer, where subtle precursor lesions frequently evade standard imaging until advanced stages. Improving lesion characterization and early detection therefore remains a major unmet need in therapeutic endoscopy and pancreatic oncology.

Key Points from DDW 2026
The session emphasized that conventional ultrasound interpretation is frequently affected by mirror artifacts, acoustic shadowing, and motion-related distortion, which may reduce diagnostic accuracy. Advanced imaging techniques are increasingly being developed to overcome these limitations and provide more detailed tissue characterization.

Contrast-enhanced EUS was highlighted for its ability to characterize tissue vascularity and perfusion patterns, particularly in pancreatic lesions. However, newer non-contrast technologies such as tissue harmonic imaging and superb microvascular imaging are increasingly capable of visualizing subtle vascular flow patterns without intravenous contrast administration. These methods improve visualization of slow-flow microvasculature and enhance lesion characterization.

Elastography was presented as another major advancement enabling qualitative and quantitative assessment of tissue stiffness. Shear wave and strain elastography techniques may help distinguish benign from malignant lesions while improving evaluation of tissue heterogeneity through spatial mapping rather than isolated point measurements.

Three-dimensional EUS imaging was emphasized as an important step forward in spatial understanding of lesion morphology and ductal anatomy. Compared with traditional 2D imaging, 3D reconstruction improves visualization of mural nodules, pancreatic ductal pathways, and structural relationships, potentially enhancing diagnostic confidence and procedural planning.

Artificial intelligence integration emerged as a central theme throughout the presentation. AI-assisted systems can differentiate imaging patterns associated with conditions such as chronic pancreatitis and main-duct IPMN while simultaneously providing real-time anatomical segmentation and procedural guidance. These systems may reduce operator variability, improve completeness of examination, and support more standardized interpretation.

The session strongly emphasized the importance of early pancreatic cancer detection. Because precursor lesions such as pancreatic intraepithelial neoplasia are frequently microscopic and difficult to visualize, advanced imaging technologies combined with AI-driven analysis may play a critical future role in identifying disease at earlier and potentially curable stages.

Clinical Interpretation
These developments suggest that EUS is evolving toward a multidimensional diagnostic platform integrating anatomy, vascularity, biomechanics, and AI-assisted interpretation. Such advances may substantially improve lesion characterization and early pancreatic cancer detection in high-risk populations.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted major advances in AI-assisted EUS imaging, elastography, microvascular imaging, and 3D reconstruction that may improve diagnostic precision and facilitate earlier pancreatic cancer detection.

Limitations / Caution
Many AI-assisted and advanced imaging technologies remain dependent on specialized expertise, hardware availability, and ongoing validation. Standardization of interpretation and demonstration of real-world outcome benefit remain important future requirements. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 showcased how advanced EUS imaging is transitioning from conventional structural visualization toward integrated functional and AI-assisted diagnostics. Innovations including elastography, microvascular flow imaging, 3D reconstruction, and real-time AI guidance are improving lesion characterization and procedural precision. These advances may become particularly important in enhancing early pancreatic cancer detection and supporting more personalized diagnostic and therapeutic decision-making.

Brief Introduction
Small bowel neuroendocrine tumours (NETs) are biologically diverse neoplasms requiring individualized multidisciplinary management. At DDW 2026, the oncology perspective highlighted advances in molecular classification, functional imaging, peptide receptor radionuclide therapy (PRRT), targeted agents, and emerging immunologic therapies that are reshaping treatment strategies in both indolent and aggressive disease.

Background / Clinical Context
Small bowel NETs range from slow-growing well-differentiated tumours to highly aggressive neuroendocrine carcinomas. Tumour behaviour is determined by differentiation status, mitotic activity, and Ki-67 proliferation index, making expert pathological assessment central to diagnosis and treatment planning. A large proportion of tumours express somatostatin receptors, enabling both targeted imaging and radionuclide-based therapy.

Key Points from DDW 2026
The session emphasized the importance of tumour biology in guiding imaging and treatment selection. MRI with liver-specific contrast was highlighted as superior to CT for evaluating hepatic metastases, while DOTATATE PET imaging remains essential for well-differentiated somatostatin receptor–positive disease. In contrast, FDG-PET is more useful in high-grade tumours demonstrating increased metabolic activity and aggressive behaviour.

Surgery remains the primary treatment for localized disease and may continue to provide benefit even in selected metastatic settings through primary tumour resection and cytoreductive strategies. However, in advanced disease, management goals shift toward prolonged survival, hormonal symptom control, and preservation of quality of life through coordinated multidisciplinary care.

Somatostatin analogs such as octreotide and lanreotide remain first-line systemic therapies for advanced well-differentiated NETs, primarily stabilizing tumour progression and controlling carcinoid syndrome manifestations. Targeted therapies including everolimus and cabozantinib provide additional progression-free survival benefit in progressive disease, although toxicity profiles require individualized patient selection.

PRRT with lutetium-DOTATATE was highlighted as a major therapeutic advance for somatostatin receptor–positive NETs, significantly improving progression-free survival and producing meaningful tumour responses. Emerging approaches under investigation include alpha-emitter PRRT, individualized dosimetry, retreatment protocols, and combination treatment strategies.

The presentation also reviewed future therapeutic directions for aggressive neuroendocrine carcinomas, including DLL3-targeted therapy, immunotherapy, and CAR-T cell approaches directed against neuroendocrine-specific antigens such as CDH17. Early data suggest potential activity in biologically aggressive disease subsets.

Clinical Interpretation
These findings reinforce the transition of NET management toward precision oncology based on tumour differentiation, receptor expression, molecular characteristics, and functional imaging. PRRT and targeted therapies are increasingly expanding treatment possibilities beyond traditional symptom control alone.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted expanding use of PRRT, advanced functional imaging, and emerging precision therapies including DLL3-targeted treatment and CAR-T strategies for advanced neuroendocrine malignancies.

Limitations / Caution
Many emerging therapies remain investigational, and long-term comparative effectiveness data are limited. Treatment sequencing in advanced NETs continues to evolve and often requires highly individualized multidisciplinary decision-making. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 emphasized that modern management of small bowel NETs increasingly relies on precision-based multidisciplinary care integrating advanced imaging, receptor-targeted therapy, surgery, and systemic treatment. Somatostatin analogs and PRRT remain foundational therapies for well-differentiated disease, while newer targeted agents, alpha-emitter radionuclide therapies, DLL3-directed treatments, and CAR-T approaches are expanding future therapeutic possibilities for advanced and aggressive neuroendocrine tumours.

Brief Introduction
Small bowel neuroendocrine tumours (NETs) are increasingly recognized gastrointestinal neoplasms characterized by indolent biology, multifocality, and frequent metastatic spread at diagnosis. At DDW 2026, the surgical perspective focused on the complexity of operative management, limitations of imaging, and the importance of balancing long-term disease control with preservation of bowel function and quality of life.

Background / Clinical Context
Most small bowel NETs arise in the distal ileum and often remain clinically silent until advanced disease develops. Despite relatively prolonged survival even in metastatic settings, these tumours frequently produce mesenteric fibrosis, bowel obstruction, ischemia, and hepatic metastases. Multifocal disease and occult tumour burden make management particularly challenging.

Key Points from DDW 2026
The presentation emphasized that imaging frequently underestimates the true extent of disease. Although liver protocol CT and DOTAT-PET CT are central to staging, occult multifocal tumours and metastatic deposits are common. Consequently, operative exploration remains essential, particularly open surgery with manual palpation of the entire small bowel to identify lesions not visualized preoperatively. Diagnostic laparoscopy may complement open exploration by improving visualization of peritoneal disease.

Surgery remains the cornerstone of management across localized, regional, and selected metastatic disease states. Complete mesenteric lymphadenectomy extending toward the mesenteric root was emphasized as critical for disease clearance and prevention of future complications. Because of the multifocal nature of these tumours and the importance of vascular preservation, open surgical approaches remain standard in most cases despite growing interest in minimally invasive techniques.

Peritoneal metastases were highlighted as both common and frequently occult. Cytoreductive surgery may offer symptom relief, reduce future complications, and improve selected survival outcomes, particularly when high-volume tumour debulking is achievable. Additional procedures such as omentectomy and prophylactic bilateral salpingo-oophorectomy in postmenopausal women may be considered because ovarian metastases occur relatively frequently.

The role of HIPEC remains controversial. Current evidence does not demonstrate clear survival benefit and suggests increased morbidity, limiting routine recommendation in small bowel NETs. Similarly, resection of primary tumours in patients with unresectable metastatic disease remains individualized. Although retrospective studies suggest possible survival benefit, selection bias remains significant. Nonetheless, prophylactic resection may be considered in selected patients because unresected primaries can later lead to obstruction, ischemia, and mesenteric fibrosis-related complications.

Clinical Interpretation
These findings reinforce that small bowel NET management requires aggressive but carefully balanced surgical planning. Imaging alone is insufficient for accurate staging, and operative exploration remains essential due to the high prevalence of multifocal and occult disease.

What Is New or Practice-Changing?
Practice-informing: DDW 2026 emphasized the limitations of imaging in small bowel NETs, reinforced the importance of complete mesenteric lymphadenectomy and operative exploration, and highlighted selective rather than routine use of cytoreductive surgery and HIPEC.

Limitations / Caution
Much of the evidence regarding cytoreduction, primary tumour resection in metastatic disease, and HIPEC is retrospective and subject to selection bias. Long-term comparative prospective data remain limited. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 highlighted that small bowel NETs are frequently multifocal and often underestimated on imaging, making meticulous surgical exploration central to management. Complete mesenteric lymphadenectomy and preservation of bowel viability remain key operative principles. Cytoreductive surgery may provide benefit in selected metastatic patients, whereas HIPEC currently lacks sufficient evidence for routine use. Management strategies should prioritize durable symptom control, prevention of local complications, and preservation of long-term quality of life.

Brief Introduction
DDW 2026 highlighted major advances across hepatology, spanning genetic cholestatic disease, liver cancer diagnostics, metabolic therapeutics, microbiome science, and transplant hepatology. A central theme was the transition toward precision medicine and preventive hepatology through integration of molecular diagnostics, biomarker-driven risk stratification, and repurposing of metabolic therapies for liver disease.

Background / Clinical Context
Many chronic liver disorders remain diagnostically and therapeutically challenging due to heterogeneous presentations, delayed detection, and limited disease-modifying therapies. Advances in genomics, liquid biopsy technologies, metabolic therapeutics, and microbiome research are increasingly reshaping both diagnostic frameworks and long-term management strategies in hepatology.

Key Points from DDW 2026
A large multi-gene cholestasis panel study demonstrated that a meaningful proportion of adults with unexplained cholestasis carry PFIC-related genetic variants, particularly ABCB4-associated abnormalities. These findings suggest that some adult cholestatic disorders may represent milder phenotypes of inherited cholestatic disease rather than entirely separate entities, supporting earlier incorporation of genetic testing into clinical evaluation.

In PSC-IBD, a prospective study evaluating gluten-free dietary intervention showed limited impact on liver-related outcomes in patients without celiac disease, although modest intestinal and quality-of-life benefits were observed. These results argue against routine gluten restriction for PSC-IBD outside confirmed celiac disease.

Cardiac risk stratification prior to TIPS was another important focus. Pre-procedural echocardiographic parameters, particularly right ventricular basal diameter greater than approximately 4.4 cm, were associated with increased risk of post-TIPS heart failure and readmission. These findings support broader incorporation of cardiologic assessment into TIPS evaluation pathways.

Several advances in liver cancer diagnostics were presented. A machine learning–based exosomal liquid biopsy using circulating microRNAs demonstrated strong predictive accuracy for occult metastasis in intrahepatic cholangiocarcinoma, potentially refining surgical and transplant selection. In hepatocellular carcinoma, a multi-target blood-based assay combining methylation markers, AFP, and patient characteristics achieved improved sensitivity compared with ultrasound-based surveillance, particularly in patients with obesity and steatotic liver disease.

The session also highlighted emerging metabolic therapies in liver disease. Propensity-matched analyses suggested that SGLT2 inhibitors in patients with cirrhosis, diabetes, and heart failure were associated with improved survival and reduced ascites. Similarly, GLP-1 receptor agonist use after liver transplantation was associated with lower mortality, reduced graft failure, and fewer biliary complications in diabetic transplant recipients.

Finally, microbiome-focused experimental work demonstrated that transplantation of youthful microbiota into aged murine models improved liver function, reduced fibrosis, and preserved telomere length, further reinforcing the role of the gut–liver axis in hepatic aging and disease progression.

Clinical Interpretation
These studies collectively reflect a broader transition toward personalized hepatology integrating genomics, biomarker-driven diagnostics, metabolic therapeutics, and microbiome modulation. Preventive and risk-stratified approaches are increasingly becoming central components of liver disease management.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted expanding roles for genetic testing in unexplained cholestasis, liquid biopsy and blood-based assays in liver cancer detection, and metabolic therapies such as SGLT2 inhibitors and GLP-1 agonists in cirrhosis and post-transplant care.

Limitations / Caution
Several findings were based on observational analyses, propensity-matched studies, or experimental models rather than randomized controlled trials. Long-term validation, cost-effectiveness, and integration into routine clinical practice remain ongoing challenges. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 showcased major hepatology advances centered on precision diagnostics, preventive strategies, and novel therapeutic applications. Genetic profiling is redefining unexplained cholestasis, while liquid biopsy and blood-based biomarkers are improving liver cancer risk stratification and early detection. Concurrently, metabolic agents such as SGLT2 inhibitors and GLP-1 agonists are demonstrating promising liver-related benefits, and microbiome research continues to expand understanding of liver aging and disease progression.

Brief Introduction
DDW 2026 highlighted several important advances across general gastroenterology, spanning inflammatory bowel disease, Barrett’s esophagus, acute pancreatitis, ulcerative colitis, and GERD management. The session emphasized how evolving therapeutics, refined risk stratification, and less invasive procedural approaches are reshaping modern gastroenterology practice toward more individualized and patient-centered care.

Background / Clinical Context
Rapid expansion of biologics, small molecules, minimally invasive procedures, and precision-based management strategies has significantly altered treatment paradigms across GI disorders. Many traditional approaches—including surgical intervention, indefinite surveillance, and invasive anti-reflux surgery—are increasingly being reconsidered in light of newer evidence and emerging technologies.

Key Points from DDW 2026
A large multicenter EHR-based study involving more than 81,000 IBD patients demonstrated a sustained decline in IBD-related surgical rates from 1990–2024. This reduction paralleled the introduction of biologics and advanced therapies, including anti-TNF agents, IL-23 inhibitors, integrin blockers, and JAK inhibitors, suggesting that modern medical therapy is altering long-term disease trajectory and reducing surgical morbidity.

In Barrett’s esophagus, a large Nordic registry study involving over 38,000 patients showed that mortality was predominantly driven by non-esophageal adenocarcinoma causes. Less than 1% died from EAC within 15 years, supporting more individualized discontinuation of surveillance based on age, sex, and comorbidity burden. Suggested cessation thresholds included approximately 80 years for men and 75 years for women, with earlier discontinuation in patients with major comorbidities.

The WATERLAND randomized trial compared lactated Ringer’s solution with normal saline in acute pancreatitis using standardized moderate fluid resuscitation. While major clinical outcomes including severe pancreatitis, organ failure, and mortality were similar, lactated Ringer’s demonstrated favorable biochemical and safety profiles with lower systemic inflammatory markers, reduced acute kidney injury, and less hyperchloremic acidosis.

A phase 2b trial evaluating an oral IL-23 receptor peptide antagonist in ulcerative colitis demonstrated improvements in clinical remission, symptomatic response, endoscopic healing, and histologic outcomes, including in patients previously exposed to advanced therapies. These findings support expansion of oral targeted therapies within treatment-experienced UC populations.

Finally, a randomized multicenter study showed that combined laparoscopic hiatal hernia repair with transoral incisionless fundoplication (cTIF) achieved non-inferior symptom control compared with laparoscopic Nissen fundoplication in GERD, with comparable acid suppression outcomes and favorable tolerability.

Clinical Interpretation
These studies collectively suggest a continued shift toward personalized, less invasive, and mechanism-targeted gastroenterology care. Improved biologic and small molecule therapies are reducing surgical burden, while procedural innovation and individualized surveillance strategies may optimize long-term patient outcomes.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted multiple evolving strategies including individualized Barrett’s surveillance cessation, oral IL-23 receptor blockade in ulcerative colitis, and cTIF as a less invasive GERD intervention with outcomes comparable to surgical fundoplication.

Limitations / Caution
Several findings remain dependent on long-term follow-up, broader validation, and real-world implementation. Some therapies and procedural approaches are still evolving and may require additional comparative effectiveness data before widespread adoption. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 showcased major advances across gastroenterology, including reduced IBD surgical burden with modern therapeutics, more individualized Barrett’s surveillance strategies, evolving fluid management insights in acute pancreatitis, promising oral IL-23 therapy in ulcerative colitis, and minimally invasive alternatives for GERD management. Collectively, these developments reflect the ongoing transition toward precision-based, patient-centered GI care integrating advanced therapeutics with tailored procedural strategies.

Brief Introduction
Gastroenterology practice is undergoing major structural and economic transformation driven by declining procedural reimbursement, healthcare consolidation, technological disruption, and evolving patient expectations. At DDW 2026, discussion focused on the need for GI practices to diversify service lines and transition beyond traditional procedure-centric care models to remain clinically and financially sustainable.

Background / Clinical Context
Historically, many gastroenterology practices relied heavily on procedural revenue, particularly colonoscopy. However, declining fee-for-service reimbursement, growth of value-based care models, increasing operational costs, and expansion of non-invasive screening technologies are placing substantial pressure on this model. Simultaneously, digital health companies and alternative care platforms are increasingly entering areas traditionally managed within GI specialty practice.

Key Points from DDW 2026
The presentation emphasized that current reimbursement structures no longer adequately support a purely procedure-driven practice model. Declining payments for endoscopic procedures, rising anesthesia costs, and reduced infusion-related revenue due to shifts toward oral and subcutaneous therapies are contributing to operational strain despite growing demand for GI care.

A major theme was the increasing importance of chronic disease management and preventive care within gastroenterology. Areas identified for service-line expansion included obesity and metabolic disease management, hepatology, functional GI disorders, and women-focused gastrointestinal care. These domains represent opportunities to address unmet patient needs while simultaneously diversifying revenue streams and improving longitudinal patient engagement.

The session also highlighted inefficiencies within current procedural models, including incomplete recall systems and inadequate follow-up of patients with positive screening tests. Optimizing these existing pathways may improve both patient outcomes and practice sustainability. Emerging technologies such as microbiome-based diagnostics, artificial intelligence, and telehealth were discussed as potential tools to support future care delivery and personalized medicine approaches.

Alternative healthcare delivery models were additionally reviewed. Membership-based or concierge-style services may offer opportunities for enhanced patient access and continuity while reducing dependence on traditional reimbursement systems. Collaboration with primary care providers, participation in integrated risk-sharing arrangements, and adoption of digital care infrastructure were emphasized as important future directions for GI practices.

Clinical Interpretation
These discussions suggest that gastroenterology practices may need to evolve from predominantly procedural organizations toward broader chronic disease management and integrated care models. Diversification of clinical services and adoption of digital infrastructure may become increasingly important for long-term sustainability.

What Is New or Practice-Changing?
Practice-informing: DDW 2026 highlighted the growing need for gastroenterology practices to diversify beyond colonoscopy-driven revenue models and expand into chronic disease management, digital care delivery, and integrated multidisciplinary services.

Limitations / Caution
Many proposed business and care-delivery strategies remain highly dependent on regional healthcare systems, reimbursement structures, practice size, and regulatory environments. Financial outcomes and scalability may vary substantially between practice settings. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 emphasized that gastroenterology practice is entering a period of major economic and structural transition. Declining procedural reimbursement, changing care delivery models, and increasing competition from digital and non-invasive alternatives are challenging traditional practice structures. Long-term sustainability will likely require diversification into chronic disease management, obesity care, hepatology, functional GI disorders, and digitally integrated care pathways alongside continued procedural excellence.

Brief Introduction
Disorders of gut–brain interaction continue to expand beyond traditional diagnostic frameworks as newer functional syndromes gain recognition. At DDW 2026, attention focused on retrograde cricopharyngeus dysfunction (R-CPD), rumination syndrome, functional dyspepsia, and cannabinoid hyperemesis syndrome (CHS), emphasizing the importance of symptom-based diagnosis supported by physiologic testing.

Background / Clinical Context
Many upper gastrointestinal disorders present with chronic symptoms despite absence of structural disease. Advances in high-resolution manometry and impedance testing are improving understanding of abnormal esophageal and gastroduodenal physiology, enabling identification of previously underrecognized syndromes that substantially affect quality of life.

Key Points from DDW 2026
R-CPD, or inability-to-belch syndrome, was highlighted as an increasingly recognized functional esophageal disorder characterized by impaired upper esophageal sphincter (UES) relaxation during gas reflux. Diagnostic criteria include persistent inability to belch with symptoms such as chest discomfort, bloating, flatulence, epigastric pain, and socially distressing gurgling noises. Structural causes such as achalasia, reflux-related obstruction, and post-fundoplication dysfunction must first be excluded. Esophageal impedance manometry may demonstrate elevated UES pressure, impaired relaxation, and abnormal gas handling patterns.

The session also reviewed functional dyspepsia (FD), emphasizing its classification into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). PDS remains the predominant subtype globally, although substantial overlap between syndromes exists, reinforcing the heterogeneous nature of FD and the need for symptom-directed management approaches.

Rumination syndrome was discussed as a distinct functional gastroduodenal disorder characterized by effortless regurgitation of recently ingested food without preceding nausea or retching. Combined impedance-manometry can demonstrate characteristic increases in intra-abdominal pressure leading to retrograde movement of gastric contents, helping differentiate rumination from reflux or vomiting disorders.

Cannabinoid hyperemesis syndrome (CHS) was additionally reviewed as an increasingly recognized condition associated with chronic high-frequency cannabis use. Recurrent nausea, vomiting, abdominal pain, and compulsive hot bathing behavior were emphasized as characteristic clinical features. Recognition of cannabis exposure patterns remains critical because CHS is frequently underdiagnosed and may lead to repeated unnecessary investigations.

Clinical Interpretation
These findings highlight the growing importance of physiologic and behavioral frameworks in upper GI diagnostics. Recognition of syndromes such as R-CPD and rumination syndrome may substantially improve diagnostic accuracy and reduce unnecessary structural investigations in selected patients.

What Is New or Practice-Changing?
Practice-informing: DDW 2026 reinforced formal diagnostic recognition of R-CPD and emphasized the increasing role of impedance-manometry in identifying functional esophageal and gastroduodenal disorders.

Limitations / Caution
Many of these disorders remain underrecognized and may overlap clinically with reflux, dyspepsia, or motility disorders. Diagnostic criteria and physiologic interpretation continue to evolve, and broader validation is still needed. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 highlighted the expanding spectrum of functional esophageal and gastroduodenal disorders, including R-CPD, rumination syndrome, and CHS. Advances in impedance-manometry are improving physiologic understanding and diagnostic precision, particularly in patients with chronic symptoms but normal structural evaluation. Early recognition of characteristic symptom patterns and targeted physiologic testing may improve patient outcomes while reducing unnecessary investigations and delayed diagnosis.

Brief Introduction
Accurate characterization of pancreatic cystic lesions remains a major clinical challenge because conventional diagnostic tools frequently fail to reliably distinguish cyst type or predict malignant potential. At DDW 2026, emphasis was placed on emerging multimodal diagnostic strategies integrating molecular analysis, confocal laser endomicroscopy (CLE), artificial intelligence, and targeted tissue acquisition to improve precision and reduce unnecessary surgery.

Background / Clinical Context
Routine cyst fluid analysis has historically formed the basis of pancreatic cyst evaluation but has important limitations. Although cyst glucose improves differentiation between mucinous and non-mucinous cysts, substantial diagnostic uncertainty persists, with reported preoperative misclassification rates approaching 24% and nearly half of resections potentially unnecessary. Accurate risk stratification is particularly important for intraductal papillary mucinous neoplasms (IPMNs), where management decisions balance cancer prevention against overtreatment.

Key Points from DDW 2026
The session highlighted major advances in molecular diagnostics using next-generation sequencing (NGS). Molecular analysis demonstrated approximately 80% sensitivity and near 100% specificity for identifying mucinous cysts, while specific genomic markers such as VHL mutation showed high specificity for serous cystadenoma. Advanced DNA/RNA genomic classifiers further improved diagnostic performance and dysplasia risk assessment.

Confocal laser endomicroscopy (CLE) was presented as a transformative “optical biopsy” technique providing real-time microscopic imaging of cyst epithelium during EUS. Multicenter studies demonstrated diagnostic accuracy exceeding 90% for common cyst types, with additional utility in identifying dysplastic progression in IPMNs through visualization of architectural abnormalities.

Integration of artificial intelligence with needle-based confocal laser endomicroscopy (NCLE-AI) further enhanced diagnostic capability. AI-assisted systems were able to identify papillary structures and support dysplasia grading with performance exceeding that of human experts in some studies. When combined with established clinical frameworks such as Fukuoka and Kyoto criteria, AI improved sensitivity while maintaining overall diagnostic accuracy.

Tissue acquisition techniques including through-the-needle biopsy and fine-needle biopsy also improved histologic confirmation with diagnostic yield around 80%, though procedural risks such as pancreatitis remain important considerations, particularly in IPMNs. The overall discussion strongly supported a multimodal EUS-based strategy combining endomicroscopy, molecular testing, fluid analysis, and selective biopsy rather than reliance on any single modality alone.

Clinical Interpretation
These findings suggest that pancreatic cyst diagnosis is moving toward integrated precision diagnostics rather than isolated fluid analysis or morphology-based assessment. Combining advanced imaging, molecular profiling, and targeted tissue acquisition may significantly improve risk stratification and reduce unnecessary surgical intervention.

What Is New or Practice-Changing?
Potentially practice-informing: DDW 2026 highlighted how multimodal EUS-based strategies incorporating NGS, CLE, and AI-assisted interpretation may substantially improve pancreatic cyst characterization and dysplasia assessment.

Limitations / Caution
Many advanced diagnostic technologies require specialized expertise, availability, and procedural experience. Sensitivity for advanced neoplasia remains imperfect even with molecular testing, and cost-effectiveness in routine practice requires further evaluation. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
DDW 2026 emphasized that pancreatic cyst evaluation increasingly depends on multimodal diagnostic integration rather than conventional cyst fluid analysis alone. Advances in NGS, confocal laser endomicroscopy, AI-assisted interpretation, and targeted tissue acquisition are improving diagnostic precision, dysplasia detection, and clinical decision-making. A structured EUS-based stepwise approach may help optimize risk stratification while minimizing unnecessary surgery in patients with pancreatic cystic lesions.