Annals of Gastroenterology

Single incision laparoscopic surgery for ileal J-pouch–anal anastomosis: a 15-year review of the literature

Evangellia Balla — 2026-01-19

Single-incision laparoscopic surgery (SILS) has emerged as a refinement of minimally invasive techniques, offering potential cosmetic and postoperative recovery benefits. This review aimed to evaluate the current evidence regarding the safety, feasibility, and outcomes of SILS for ileal J-pouch–anal anastomosis (IPAA). A structured literature search was performed in PubMed for studies published between January 2010 and January 2025, focusing on adult and pediatric patients undergoing restorative proctocolectomy with IPAA performed through a single incision. Twentytwo studies were identified, encompassing 182 procedures. The mean operative time ranged from 144-284 min. Reported conversion to multiport laparoscopy or open surgery occurred in 3.9% of cases, while the mean estimated blood loss varied from 27-136 mL. The median length of hospital stay was 4 days in most studies. Major postoperative complications (Clavien-Dindo grade ≥III) occurred in approximately 9% of patients, most commonly small-bowel obstruction or anastomotic leak. Cosmetic satisfaction and postoperative pain scores were generally favorable, although longterm functional outcomes were rarely reported. SILS-IPAA appears feasible and safe in selected patients, particularly when performed by experienced surgeons familiar with conventional laparoscopic restorative proctocolectomy. The current literature is heterogeneous and limited by
small sample sizes and overlapping institutional data. Further comparative studies, especially in the context of robotic platforms, are needed to define the role of SILS in modern pouch surgery.

Keywords Single incision laparoscopic surgery, ileal J-pouch–anal anastomosis, ulcerative colitis, minimally invasive surgery, colorectal surgery

Ann Gastroenterol 2026; 39 (1): 1-10

The impact of depression, anxiety and stress on self-care in inflammatory bowel disease: a systematic review

Simone Amato — 2026-01-19

Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, compromises both physical and psychological health. High levels of stress, anxiety, and depression are common yet often overlooked, negatively impacting treatment adherence and self-care. This review examines how psychological factors influence self-care behaviors in IBD and explores strategies to improve disease management. Following PRISMA guidelines and registered on PROSPERO (CRD42024575631), this systematic review applied the PICO model to identify studies involving IBD patients, self-care interventions, and outcomes related to depression, anxiety and stress. A comprehensive search was conducted in PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, APA PsycInfo and Google Scholar (October–December 2024). JBI tools were used to assess risk of bias, and evidence was graded using the framework established by the Oxford Centre for Evidence-Based Medicine. Data extraction and synthesis were performed using structured tables and graphs. IBD patients frequently experience psychological distress that impairs self-care and quality of life. Depression is associated with low self-efficacy and maladaptive coping, while anxiety reduces treatment adherence, particularly in younger patients. Stress contributes to disease management difficulties, reinforcing the need for integrated psychological support. Psychological distress in IBD patients significantly affects self-care behaviors. Incorporating mental health support into standard care may enhance adherence, disease control, and overall well-being.

Keywords Inflammatory bowel disease, self-care, depression, anxiety, stress

Ann Gastroenterol 2026; 39 (1): 11-22

Capillary microvascular function in patients with liver cirrhosis: a nailfold video-capillaroscopy study

Ioanna Papagiouvanni — 2026-01-19

Background Liver cirrhosis is characterized by major circulatory dysregulation, related to an imbalance between several vasoactive agents. Although alterations in intrahepatic and systemic vasculature have been rather well described, the peripheral microcirculation and endothelial function are less well studied. Our aim was to evaluate peripheral microcirculatory function in patients with cirrhosis via nailfold video-capillaroscopy.

Methods We enrolled 60 patients with cirrhosis and 20 controls. All participants underwent nailfold video-capillaroscopy. Capillary density was measured at rest (baseline), after 4-min arterial occlusion (post-occlusive reactive hyperemia) and after 2-min venous congestion.

Results Cirrhotic patients presented lower capillary density than controls at baseline (35.8±3.6 vs. 38±1.1 capillaries/mm2, P=0.01), during post-occlusive reactive hyperemia (40.0±4.4 vs. 45.3±1.5 capillaries/mm2, P<0.001), and after venous congestion (43.3±4.2 vs. 47.2±1.5 capillaries/mm2, P<0.001). Capillary density decreased significantly with deterioration of Child-Pugh class at baseline (Child-Pugh A: 38.0±3.9 vs. Child-Pugh B: 35.6±2.7 vs. Child-Pugh C: 33.9±3.2 capillaries/mm2, P<0.001), during post-occlusive reactive hyperemia (43.5±3.4 vs. 39.8±3.0 vs. 36.8±3.9 capillaries/mm2, respectively, P<0.001), and after venous congestion (46.7±3.1 vs. 43.0±2.7 vs. 40.1±3.8 capillaries/mm2, respectively, P<0.001).

Conclusions Capillary density in all phases was significantly lower in cirrhotic patients compared to controls. Moreover, a lower capillary density was associated with deteriorating Child-Pugh stages, suggesting that increasing severity of cirrhosis is associated with more impaired peripheral microcirculatory function.

Keywords Cirrhosis, peripheral microcirculation, nailfold video-capillaroscopy

Ann Gastroenterol 2026; 39 (1): 23-31

Predictors of a need for cholangioscopy-guided electrohydraulic lithotripsy in the management of difficult common bile duct stones

Dionysios Kogias — 2026-01-19

Background While standard endoscopic methods effectively clear most common bile duct stones, complex cases require specialized management. This study compared the effectiveness of cholangioscopy-guided electrohydraulic lithotripsy (EHL) against conventional techniques for treating difficult common bile duct stones (DBS).

Methods This retrospective study included 436 patients who underwent endoscopic retrograde cholangiopancreatography between April 2020 and April 2024. Demographic, laboratory and procedural data were recorded. Categorical regression identified predictors for EHL, and classification tree analysis was used to develop a prioritization algorithm.

Results Among patients with DBS (305/436, 70%), conventional methods succeeded in 28.9% (88/305). Endoscopic papillary large balloon dilation followed failed first-line techniques in 115 cases, with a 21.7% success rate. EHL was used in 192 patients, achieving a 98.4% success rate. Multivariate analysis showed that DBS (P<0.001), absence of wedged stones in the ampulla of Vater (P<0.001), and small papillae (P=0.002) were strong independent predictors for EHL use, with DBS being the most significant.

Conclusions DBS, absence of wedged stones in Vater and small papillae are key predictors of the need for cholangioscopy-guided EHL. Given its high success rate and comparable safety profile, EHL should be considered an early-line treatment in selected cases.

Keywords Electrohydraulic, lithotripsy, endoscopic retrograde cholangiopancreatography, choledocholithiasis, common bile duct stone

Ann Gastroenterol 2026; 39 (1): 32-39

Serum anti-integrin αvβ6 autoantibodies for diagnosis of primary sclerosing cholangitis: a systematic review and meta-analysis

Stavros P. Papadakos — 2026-01-19

Background Currently, there is no noninvasive serological marker for primary sclerosing cholangitis (PSC). Serum anti-integrin αvβ6 autoantibodies were recently suggested as potential diagnostic PSC biomarkers. We conducted a systematic review and meta-analysis to evaluate their diagnostic performance, the influence of concomitant inflammatory bowel disease (IBD), and differentiation from other cholestatic liver diseases.

Methods PubMed, Embase, Cochrane Library and Web of Science databases were systematically searched for studies assessing the diagnostic value of serum anti-αvβ6 autoantibodies in PSC. Pooled sensitivity, specificity, diagnostic odds ratio and area under the summary receiver operating characteristic curve (AUC) were calculated using a bivariate random-effects model. Subgroup analyses were performed based on IBD status and differentiation from other cholestatic liver diseases.

Results Four studies including 1294 subjects (398 PSC patients and 896 controls) were analyzed. The pooled sensitivity and specificity of anti-αvβ6 autoantibodies for PSC diagnosis were 62.3% and 87.3%, respectively (AUC: 0.76). The specificity increased to 96% (AUC: 0.86) in PSC without IBD, while it decreased to 71% (AUC: 0.67) in PSC with IBD. For the differentiation of PSC from other cholestatic liver diseases, anti-αvβ6 autoantibodies had pooled sensitivity 81% and specificity 95% (AUC: 0.90).

Conclusions Serum anti-αvβ6 autoantibodies exhibit moderate sensitivity and high specificity for PSC diagnosis, especially in differentiation from other cholestatic diseases. Their clinical utility as a noninvasive diagnostic biomarker is promising and warrants validation in larger, multicenter prospective studies to establish their role in routine clinical practice.

Keywords Primary sclerosing cholangitis, anti-integrin αvβ6 autoantibodies, diagnostic biomarker, inflammatory bowel disease

Ann Gastroenterol 2026; 39 (1): 40-47

MUC1 as a biomarker in primary sclerosing cholangitis and cholangiocarcinoma

Jana G. Hashash — 2026-01-19

Background MUC1 is a glycoprotein expressed at low levels in fully glycosylated form on healthy epithelial cells. In inflammation and malignancy, MUC1 becomes overexpressed and hypoglycosylated. We aimed to describe patterns of MUC1 expression in bile-duct tissue of patients with primary sclerosing cholangitis (PSC), PSC/cholangiocarcinoma, cholangiocarcinoma, and healthy controls.

Methods In this proof-of-concept pilot study, archived human liver tissue samples were identified and stained using anti-MUC1 antibodies. Staining for all MUC1, and specifically hypoglycosylated MUC1, was performed.

Results Tissue from controls minimally expressed the hypoglycosylated/abnormal MUC1. Tissue from patients with PSC demonstrated moderate expression. Very high levels were expressed in sporadic cholangiocarcinoma.

Conclusion MUC1 may serve as a biomarker in the identification of bile-duct disease and cancer.

Keywords MUC1, primary sclerosing cholangitis, cholangiocarcinoma, bile ducts, biomarker

Ann Gastroenterol 2026; 39 (1): 48-53

Dietary supplement based on dihydromyricetin in metabolic dysfunction-associated steatotic liver disease: a double-blind, placebo-controlled, randomized clinical trial

Elisavet Michailidou — 2026-01-19

Background Despite its increasing prevalence, effective treatment options for metabolic dysfunction-associated steatotic liver disease (MASLD) are limited. We assessed the efficacy of a dietary supplement containing dihydromyricetin (DHM) in MASLD.

Methods Adult MASLD patients were randomized to receive a dietary supplement containing DHM (300 mg/day), vitamins C/E and choline (group A), or identical placebo (group B) for 12 months. Patients were assessed every ≤6 months for clinical and laboratory parameters and liver stiffness measurements (LSM).

Results Fifty-five patients were randomized to group Α (n=28) or Β (n=27), but 9 patients (group Α/Β=2/7) were withdrawn early for personal reasons. Median liver enzymes decreased at 6 or 12 months only in group A. Group A compared to B patients achieved higher 12-month rates of combined alanine aminotransferase (ALT)/γ-glutamyl transpeptidase (GGT) normalization (35% vs. 5%, P=0.028). Only in group A, glucose, glycated hemoglobin and total/low density lipoprotein mean levels had declined significantly at 6 and/or 12 months, whereas median liver stiffness measurements (LSM) were lower than baseline at both 6 and 12 months. In multivariate analysis, group A was the only factor associated with ALT/GGT normalization (P=0.038). Generalized estimating equation analysis revealed a significant treatment by time interaction for 12-month combined ALT/GGT normalization only in group A (P=0.021).

Conclusions The 6/12-month use of DHM supplement seems to result in improvements in liver enzymes and LSM, as well as in diabetes and lipid parameters in MASLD patients. Therefore, the use of such a supplement in MASLD needs further evaluation.

Keywords Metabolic dysfunction-associated steatotic liver disease, flavonoids, insulin resistance, elastography

Ann Gastroenterol 2026; 39 (1): 54-62

Risk factors for sedation-related adverse events during endoscopic ultrasound

Patricia Abellán-Alfocea — 2026-01-19

Background Complex endoscopic procedures such as endoscopic ultrasound (EUS) require higher doses of sedation, and thus carry a higher risk of adverse events compared to conventional endoscopy. This prospective cohort study assessed the safety of propofol sedation administered by nonanesthesiologists, and identified factors associated with sedation-related adverse events during EUS.

Methods A total of 2986 examinations were performed between January 2011 and May 2019. We collected data on patient characteristics (including age, body mass index and American Society of Anesthesiologists [ASA] class), procedural details, and sedation-related outcomes. Procedure characteristics and sedation-related adverse events were compared, firstly between interventional and diagnostic EUS, and then based on body mass index, ASA class and age. Logistic regression was performed to search for independent risk factors for sedation-related adverse events.

Results Sedation-related complications occurred in 4.8% of patients, hypoxemia being the most frequent (3.8%). Obese patients exhibited the highest rates of hypoxemia, early discontinuation and bag-mask ventilation (29.6%, 22.2% and 11.1%, respectively). Multivariate analysis revealed that obesity (odds ratio [OR] 8.57, 95% confidence interval [CI] 3.62-20.28) and comorbidities (ASA III/IV) (OR 2.04, 95%CI 1.44-3.01) were independently associated with sedation-related adverse events, while age was not significant.

Conclusions Propofol sedation administered by non-anesthesiologists during EUS was safe, with low rates of adverse events, the vast majority of which were clinically insignificant. Comorbidities and obesity, but not age, were independent risk factors for sedation-related complications during EUS. Appropriate patient selection and adequate training of endoscopists are warranted to minimize the risks associated with sedation during EUS.

Keywords Endoscopic ultrasound, sedation-related complications, obesity, American Society of Anesthesiologists class, propofol

Ann Gastroenterol 2026; 39 (1): 63-70

Lumen-apposing metal stents versus double pigtail plastic stents for early (<4 weeks of illness) endoscopic transluminal drainage of pancreatic necrotic collections

Surinder S. Rana — 2026-01-19

Background Pancreatic necrotic collections (PNC) gradually liquefy over time. In the early phase of pancreatitis (<4 weeks), collections contain more solid debris. This study retrospectively compared the safety and efficacy of endoscopic transluminal drainage (ETD) using multiple plastic stents (MPS) vs. lumen-apposing metal stents (LAMS) in early-phase PNC.

Methods A retrospective, single-center, and non-randomized review was conducted of patients who underwent endoscopic ultrasound-guided drainage/debridement of PNC between January 2018 and November 2024. Patients who had early ETD with either MPS or LAMS were included. Data compared included demographics, clinical features, indications, intervention details, need for endoscopic necrosectomy (ETN), complications, need for surgery, and outcomes.

Results Forty-five patients (39 male) received LAMS, and 21 (18 male) received MPS. PNC size and necrotic content were similar between groups. Technical success was 100% in both groups, but clinical success was significantly higher with LAMS (89% vs. 48%; P<0.001). ETN was more frequent in the MPS group (86% vs. 58%; P=0.02), as was the mean number of procedures (6.1 vs. 4.1; P=0.009). MPS was associated with higher mortality (19% vs. 6%), need for surgical necrosectomy (52% vs. 11%), and post-procedure bleeding (24% vs. 11%).

Conclusion LAMS seem to be superior to MPS for ETD of early-phase symptomatic PNC, showing higher clinical success, with fewer complications, procedures and rescue surgical interventions.

Keywords Pancreatitis, lumen-apposing metal stents, necrosectomy, computed tomography, endosonography

Ann Gastroenterol 2026; 39 (1): 71-78

Immune-mediated diarrhea and colitis with normal biochemical, endoscopic and histologic findings: a retrospective study

Malek Shatila — 2026-01-19

Background Immune-mediated diarrhea and colitis (IMDC) due to checkpoint inhibition infrequently presents with normal stool biomarkers and no endoscopic or histologic evidence of inflammation. Little is known about the treatment needs and outcomes of this subset of patients. We aimed to describe this entity and clarify the role of immunosuppressive treatments in its management.

Method This was a single-center, retrospective study of patients treated with immune checkpoint inhibitors who developed clinical symptoms of IMDC, with no evidence of inflammation based on fecal calprotectin or endoscopic/histologic evaluation, between January 2010 and February 2024.

Results Of 1151 patients with IMDC, 131 (11.4%) had no evidence of inflammation. These patients more frequently had PD-1/L1 agent exposure (P=0.019) and presented with less severe diarrhea than patients with evidence of inflammation (P<0.001). This group had a lower rate of hospitalization (P=0.003). Around 40% of patients with no evidence of inflammation required immunosuppressive treatment. There was no difference in clinical symptoms or severity between patients requiring immunosuppression and those who did not.

Conclusions Our study is the first to explore IMDC with no elevations in calprotectin and normal endoscopic/histologic findings. We found that PD-1/PD-L1 inhibition may predispose patients to developing this form of IMDC, which is associated with a lower severity of diarrhea, fewer hospitalizations and lower recurrence rates. Many patients still require immunosuppressive treatment, and a small subset later develop colonic inflammation. Future studies are needed to further elucidate the treatment needs and outcomes of this patient population.

Keywords Immune-mediated diarrhea and colitis, immunotherapy, infliximab, vedolizumab

Ann Gastroenterol 2026; 39 (1): 79-87

KRAS p.G12C mutated-targeted treatments in metastatic colorectal cancer: a systematic review and meta-analysis

Maria Smaragdi Vlachou — 2026-01-19

Background Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. The presence of the KRAS G12C mutation in patients with CRC is associated with poor responses to standard therapies and worse outcomes. This study systematically reviewed and analyzed the existing evidence on the efficacy of KRAS G12C inhibitors.

Methods PubMed, Scopus, and ISI Web of Knowledge were searched, along with conference proceedings, posters, and major oncology journals. Eligibility criteria included clinical trials involving adult patients with KRAS G12C-mutant CRC. Data on treatment outcomes, study design, and patient demographics were extracted and analyzed using a random-effects model, with heterogeneity assessed via I2 statistics.

Results Seventeen trials, comprising 663 patients with KRAS G12C-mutant metastatic CRC, were included. Monotherapy with KRAS G12C inhibitors demonstrated an objective response rate of 23%, while combination therapies with agents such as cetuximab and panitumumab showed a higher response rate of 43%. Stable disease rates were also higher in monotherapy (62%) compared to combination therapy (44%). The highest disease control rates were observed with combination therapies (96%). The overall progressive disease rate was lower with combination therapies (1%) than with monotherapies (10%).

Conclusions The results indicate that KRAS G12C inhibitors, particularly in combination with other agents, show promising efficacy in treating metastatic CRC. High heterogeneity across studies suggests variability due to small sample sizes and early-phase trial designs. While preliminary data are promising, further large-scale phase III trials are essential to establish these inhibitors as a standard treatment for KRAS G12C-mutant CRC.

Keywords Colorectal cancer, KRAS G12C mutation, targeted therapy, KRAS G12C inhibitors, meta-analysis

Ann Gastroenterol 2026; 39 (1): 88-98

Efficacy and safety of bipolar energy-based therapy for hemorrhoids: a systematic review

Renuka Verma — 2026-01-19

Background Hemorrhoids arise from dilated vessels in the submucosal layer of the anorectal canal. Hemorrhoids are responsible for 4 million office and emergency visits annually in the US. Hemorrhoidal energy therapy (HET) is a novel nonsurgical, bipolar energy-based instrument for treating hemorrhoids. It has multiple benefits, such as requiring only a single session for resolution of symptoms, and minimizing heat-related collateral damage. However, there are limited data regarding the effectiveness and adverse events of HET. We performed the first systematic review to evaluate the efficacy and safety of HET in the treatment of internal hemorrhoids.

Methods A comprehensive search was performed from major databases to identify studies that investigated HET to treat hemorrhoids. The primary outcomes were technical success and clinical success. The secondary outcomes were total adverse events and individual adverse events, such as postprocedural bleeding and incontinence.

Results Eight studies with 512 patients were included in the meta-analysis. The average age was 55.6 years, and the majority of patients were female. Most patients presented with grade I and grade II hemorrhoids. The HET demonstrated technical and clinical success rates of 100% and 86.1%, respectively. All adverse events were determined to be mild, according to the ASGE lexicon, except for 1 case of perianal hematoma that required hospitalization.

Conclusion Our study demonstrates that HET is an effective and safe treatment for grade I and II internal hemorrhoids.

Keywords Bipolar energy-based therapy, hemorrhoidal energy therapy, internal hemorrhoids

Ann Gastroenterol 2026; 39 (1): 99-103

A prospective international multisite randomized controlled trial of water exchange with and without distal cap(s) in adenoma detection

Felix W. Leung — 2026-01-19

Background Interval cancers are linked to a low adenoma detection rate (ADR), prompting calls for benchmark-guided ADR performance improvement. Although water exchange and a straight cap (CAP) have been reported to independently improve ADR, the effects of Daisycuff™ and Endocuff Vision® remained unknown. We hypothesized that selected cap(s) could increase ADR and related water exchange outcomes.

Methods Subjects were randomized to No cap, or CAP, Daisycuff™ and Endocuff Vision® at 7, 5 and 2 sites. The primary outcome was ADR. Outcomes were compared for No cap vs. the above randomized caps.

Results Demographic and historic data revealed adequate randomization. Despite variations in sitespecific pretrial ADR, the aggregated data showed that the ADR of No cap (45.6%) exceeded the latest benchmark (35%). Each added cap increased the ADR, and the difference using Daisycuff™(52.8%) approached statistical significance (P=0.05). In the right colon, CAP and Daisycuff™ significantly increased ADR. In the left colon, Daisycuff™ significantly increased adenoma per colonoscopy. Factors that improved adenoma detection were consistent with published reports. Detection rates based on site, indication, sedation type, polyp size, shape and pathology in the No cap group were consistent with conventional data and were not influenced by the caps.

Conclusions The significantly higher right-colon ADRs with CAP and Daisycuff™ suggest potential clinical relevance for reducing interval cancers. Although water exchange with or without caps yields ADRs that surpass the benchmark, the positive findings for selected cap(s) need to be confirmed in order to enhance the options for further improvement of water exchange.

Keywords Water exchange colonoscopy, distal cap, adenoma detection rate

Ann Gastroenterol 2026; 39 (1): 104-1

Bezlotoxumab for prevention of Clostridioides difficile recurrence in patients with inflammatory bowel disease: a retrospective multicenter experience

Christian Karime — 2026-01-19

Background Bezlotoxumab can reduce recurrent Clostridioides difficile infection (rCDI); however, data from patients with inflammatory bowel disease (IBD) are limited. Since rCDI is common in IBD, we assessed the efficacy of bezlotoxumab for rCDI prevention in patients with and without IBD.

Methods Adults who received bezlotoxumab for CDI were identified. Clinical variables and adverse events were collected during a minimum follow-up of 1 year. The primary outcome was rCDI, classified at 4 time intervals (30, 60, 90 days, and 1 year).

Results Of the 70 patients identified, 34 patients had IBD. Most patients (88.6%) had ≥2 prior CDI episodes (interquartile range [IQR] 1-4). Bezlotoxumab was commonly combined with vancomycin (61.4%) or fidaxomicin (42.9%), which did not differ between patients with and without IBD. Following bezlotoxumab, the 1-year rCDI rate was 28.6% (median 65 days, IQR 32.8-158.3), while the 30-, 60- and 90-day rCDI rates were 5.7%, 12.9% and 22.9%, respectively. Patients with IBD had comparable rCDI rates to non-IBD patients, including at 30 (5.9% vs. 5.6%, P>0.99), 60 (17.6% vs. 8.3%, P=0.30), and 90 days (20.6% vs. 13.9%, P=0.54), and 1 year (32.4% vs. 25.0%, P=0.60). A history of colorectal surgery or vancomycin exposure was more common among patients with IBD and rCDI. Adverse events occurred in 6 patients (8.6%), most commonly heart failure exacerbation.

Conclusions The rCDI rate following bezlotoxumab was similar in patients with and without IBD. In patients with IBD, a history of colorectal surgery or prior vancomycin exposure was more common among those who experienced rCDI.

Keywords Inflammatory bowel disease, bezlotoxumab, recurrent Clostridioides difficile infection

Ann Gastroenterol 2026; 39 (1): 114-122