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Background Data are limited regarding pancreatic cancer diagnosed following a pancreaticobiliary endoscopic ultrasound (EUS) that does not diagnose pancreatic cancer. We have studied the frequency of, and factors associated with, post-EUS pancreatic cancer (PEPC) and 1-year mortality. Methods Between 2010 and 2017, patients with pancreatic cancer and a preceding pancreaticobiliary EUS were identified in a national cohort using Hospital Episode Statistics. Patients with a pancreaticobiliary EUS 6–18 months before a later pancreatic cancer diagnosis were the PEPC cases; controls were those with pancreatic cancer diagnosed within 6 months of pancreaticobiliary EUS. Multivariable logistic regression models examined the factors associated with PEPC and a Cox regression model examined factors associated with 1-year cumulative mortality. Results 9363 pancreatic cancer patients were studied; 93.5 % identified as controls (men 53.2 %; median age 68 [interquartile range (IQR) 61–75]); 6.5 % as PEPC cases (men 58.2 %; median age 69 [IQR 61–77]). PEPC was associated with older age (≥ 75 years compared with 5, OR 1.90, 95 %CI 1.49–2.43), chronic pancreatitis (OR 3.13, 95 %CI 2.50–3.92), and diabetes mellitus (OR 1.58, 95 %CI 1.31–1.90). Metal biliary stents (OR 0.57, 95 %CI 0.38–0.86) and EUS-FNA (OR 0.49, 95 %CI 0.41–0.58) were inversely associated with PEPC. PEPC was associated with a higher cumulative mortality at 1 year (hazard ratio 1.12, 95 %CI 1.02–1.24), with only 14 % of PEPC patients (95 %CI 12 %–17 %) having a surgical resection, compared with 21 % (95 %CI 20 %–22 %) of controls. Conclusions PEPC occurred in 6.5 % of patients and was associated with chronic pancreatitis, older age, more co-morbidities, and specifically diabetes mellitus. PEPC was associated with a worse prognosis and lower surgical resection rates.

Background A novel fork-tip fine-needle biopsy (FNB) needle has recently been introduced for endoscopic ultrasound (EUS)-guided sampling. The aim of this study was to compare the performance of fork-tip FNB histology and standard fine-needle aspiration (FNA) cytology in the diagnosis of solid pancreatic masses. Methods A randomized crossover study was performed in patients referred for EUS-guided sampling. Three passes were taken with each needle in a randomized order. Only samples reported as diagnostic of malignancy were considered positive. The primary end point was the sensitivity of diagnosis of malignancy. Secondary end points included the amount of sample obtained, ease of diagnosis, duration of tissue sampling, pathologist viewing time, and cost. Results 108 patients were recruited. Median age was 69 years (range 30 – 87) and 57 were male; 85.2 % had a final diagnosis of malignancy. There were statistically significant differences in sensitivity (82 % [95 % confidence interval (CI) 72 % to 89 %] vs. 71 % [95 %CI 60 % to 80 %]), accuracy (84 % [95 %CI 76 % to 91 %] vs. 75 % [95 %CI 66 % to 83 %]), proportion graded as a straightforward diagnosis (69 % [95 %CI 60 % to 78 %] vs. 51 % [95 %CI 41 % to 61 %]), and median pathology viewing time (188 vs. 332 seconds) (P Conclusion The diagnostic performance of the fork-tip FNB needle was significantly better than that of FNA; it was associated with ease of diagnosis, shorter pathological viewing times, and was cost neutral.

Main Recommendations1 ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence.2 ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence.3 ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence.4 ESGE recommends en bloc resection of ampullary adenomas up to 20–30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence.5 ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence.6 ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence.7 ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence.8 ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.

Introduction Population level data on complications and outcomes of pancreaticobiliary (PB) endoscopic ultrasound (EUS) are limited. A perforation rate of 0.03% and attributable morbidity and mortality from pancreatic EUS fine needle aspiration (FNA) of 2.4% and 0.02% respectively are reported. We have examined PB EUS & FNA use in England, how it relates to pancreatic cancer (PC) therapy and associated mortality and adverse events. Methods Adults undergoing PB EUS from 2007–17 were identified in Hospital Episode Statistics. A PC diagnosis within 6 months of EUS was required for PC cohort inclusion. EUS and FNA numbers per year, associated 7-day adverse events and 30-day mortality were examined. A logistic regression model examined the impact of variables on mortality and surgical resection. Results 79,490 PB EUS in 69,120 subjects were identified. The number per year increased from 2,915 (29% FNA) to 12,764 (35% FNA) over the study period. 8,859 subjects were diagnosed with PC. Bleeding was coded in 0.4% of PB EUS. Perforation was coded in 0.03% and in 0.05% of the PC cohort. 1.6% of PB EUS subjects and 2.8% in the PC cohort died within 30 days of their final EUS. The following factors were associated with increased mortality: increasing age (odds ratio 1.04(95%CI 1.03–1.04),p 782 EUS] 8–111 (3.99 (2.95–5.38), p 32.9% of PC subjects had a surgical resection, 43.1% received chemotherapy alone and 33.1% had no active therapy. Increasing age (0.97(95%CI 0.96–0.97), p Conclusions The number of PB-EUS undertaken in England has increased six-fold over the last decade, with an increased proportion of FNA. Deprivation and low provider volume were associated with 30 day mortality. A third of subjects undergoing PB EUS for PC did not receive surgery or chemotherapy. The results of this study support a reappraisal of the provision of and indications for PB EUS.

Background Stents are frequently placed in patients with biliary obstruction due to a mass in the head of the pancreas. The impact of plastic or self-expandable metal stents (SEMSs) on endoscopic ultrasound (EUS)-guided tissue sampling is unclear. This study aimed to assess, using strict pathological criteria, whether stents impair fine-needle aspiration (FNA) or fine-needle biopsy (FNB). Methods All patients with a solid mass in the head of the pancreas who underwent EUS-guided tissue sampling between 2010 and 2016 at our unit were included. Factors with possible impact on diagnostic performance were analyzed using logistic regression. Analysis was performed using both strict (malignant only) and less strict (suspicious for malignancy) cutoffs. Results Of 631 individuals undergoing 698 procedures, 535 (84.8 %) had a final diagnosis of malignancy, 141 had SEMS, 149 had plastic stents, and 341 had no stent. Using strict criteria, SEMS were associated with an increased occurrence of incorrect diagnosis of EUS tissue sampling, with an odds ratio (OR) of 1.96 (95 % confidence interval [CI] 1.24 – 3.10). Increasing tumor size (OR 0.72, 95 %CI 0.59 – 0.87), increasing number of passes (OR 0.84, 95 %CI 0.72 – 0.99), and fork-tip biopsy needle (OR 0.52, 95 %CI 0.31 – 0.86) were independently associated with a decrease in incorrect diagnosis. Repeat tissue sampling was more common with SEMSs (10.2 %) than with plastic stents (2.9 %) or no stents (4.5 %) (P Conclusion SEMS use had a negative impact on tissue diagnosis in pancreatic head masses, whereas use of a fork-tip biopsy needle and increasing number of passes were independently associated with improved accuracy.

Introduction Biliary complications after liver transplantation (LT) are common and some risk factors have been identified. Optimum endoscopic management including use of fully covered self-expanding metal stents (fcSEMS) in patients following LT requires evaluation. We aimed to identify risk factors for biliary complications following LT and present our experience of endoscopic management. Methods Retrospective analysis of adult LT’s performed at our centre. Patient demographics, donor characteristics, transplantation data (including graft type; donation after brain death (DBD) or cardiac death (DCD)), biliary complications and subsequent management were recorded and the DRI calculated. The cohort consisted of all LT performed between 2007 and 2016. Univariate and multivariable analysis was used to identify risk factors for biliary complications and ascertain factors associated with biliary stricture resolution. Results A total of 353 (n=322 DBD and n=31 DCD) patients were included of which 80 (22.7%) patients developed biliary complications. DCD patients had a higher prevalence of biliary complications compared to DBD patients (16/31 vs 64/322, OR 4.3, 95% CI 2.0–9.2, p=0.0002). Biliary leak rate was not significantly different (DCD 9.7% vs DBD 8.1%) but biliary strictures were more common in DCD patients compared to DBD (12/31 vs 36/322, OR 5.0, 95% CI 2.3–11.2, p=0.0001). Biliary strictures were also associated with higher DRI (1.97 vs 1.76, p=0.015). Hepatic artery thrombosis rate was the same in both groups (9.3% vs 7.2%, p=0.74). Multivariable analysis showed that only DCD was independently associated with biliary strictures (adjusted OR 4.6, 1.9–11.2, p=0.0007). 21/80 with biliary complications underwent surgical (n=8), radiological (n=8) or conservative (n=5) management. The remainder underwent ERCP; 42 patients had 116 procedures for strictures, 19 patients had 35 procedures for biliary leak and 12 had 20 procedures for stone disease (some multiple indications). There were no differences in stricture resolution between DCD and DBD (6/10 vs 21/32, p=ns). Per stent analysis showed higher stricture resolution rates following fcSEMS insertion compared to plastic stents (18/20 (90%) vs 17/69 (24.6%) respectively, p Conclusion Biliary complications are associated with DCD livers. Endoscopic management of biliary complications leads to high resolution rates but patients undergo a high volume of procedures for strictures. fcSEMS had a higher stricture resolution rate compared to plastic stents.

Introduction Radiofrequency ablation (RFA) has been used in the treatment of blocked biliary metal stents in patients with pancreaticobiliary (PB) tumours with varying results. Complications have been reported with the commonly used probe. This could be related to lack of temperature control and the inability to establish contact with malignant tissue. We report the preliminary results of a novel temperature controlled probe with better tissue apposition for the treatment of blocked biliary stents in PB tumours. Method Patients with a confirmed diagnosis of inoperable cancer and a blocked biliary stent were included in this study. Informed consent was obtained for the procedure. ELRATM RFA electrode (Taewoong Medical) was used for the treatment of these patients (Figure 1). The probe is a bipolar electrode with a temperature sensor which helps with controlled ablation and prevents tissue charring. The catheter is 7Fr in diameter (length=175 cms) with an exposure length of 18 mm. Standard protocol was 10 W at 75 degrees administered for 2 min. The procedure was repeated if stricture resolution was suboptimal. Biliary stent was reinserted if necessary to maintain drainage. Immediate and late adverse events and outcomes at 30 days were recorded. Results 8 procedures were done on 7 patients (5 males) from April 2016 to January 2017. Aetiology were pancreatic cancer (2); hilar cholangiocarcinoma (2), gall bladder cancer (1), colorectal metastasis (1) and distal cholangiocarcinoma (1). All patients had one prior ERCP procedure. The median length of the stricture was 17 mm (15–25 mm). In 2 patients the procedure was repeated to ensure definitive treatment. One patient had 2 procedures due to a very tight stricture. 5/7 patients required additional stents to ensure optimal drainage. There were no complications and none of the patients have required repeat procedures. Mean follow up period=82.6 days (32 – 225) and 3/7 (43%) patients died due to end stage disease. Conclusion This is the first reported data on the use of a novel temperature controlled RFA catheter for the treatment of blocked biliary stents in patients with inoperable PB tumours. The device appears safe and effective; however further randomised trials with long term follow up and larger numbers are required. Disclosure of Interest None Declared

Background and study aims: This report describes the use of a novel, fully covered, self-expanding metal stent (FCSEMS) for endoscopic ultrasound (EUS)-guided drainage of walled-off pancreatic necrosis (WON). Patients and methods: Patients with WON, as defined by the revised Atlanta Criteria, were included in this open-lable, two-center, observational study. The WON was punctured using a cystotome, and the FCSEMS was inserted under fluoroscopic guidance. Necrosectomy procedures were performed as necessary. Results: A total of 19 patients were included. The median maximum collection size was 15 cm with a median of 50 % necrosis. A total of 14/19 patients underwent necrosectomy, requiring a median of 4 procedures. Resolution or reduction in the size of collection by at least 80 % was achieved in all patients. Percutaneous or surgical drainage was required in three patients. Five stents migrated or dislodged. One patient had abdominal pain post-procedure. Five patients died during follow-up (three from multi-organ failure, and two unrelated to pancreatitis). Conclusions: Use of this stent is feasible and safe for drainage of WON. However, stent displacement rates were high, and improvements to the stent design are required before it can be advocated for routine use in WON.

Introduction In cases of obstruction of the gallbladder (GB) or cystic duct where surgery is high risk, EUS guided GB drainage (EUS-GBD) is reported to have comparable efficacy to percutaneous drainage. 1 However, the technique has not been widely adopted due to lack of specific devices and concerns about leakage and stent migration. Lumen apposing metal stents (LAMS) have been developed to minimise the risk and simplify the procedure. A novel (Hot AXIOS™) device has recently become available and this consists of a stent and electrocautery-enhanced delivery system, enabling a single device to be used when previously multiple devices and steps were required. There is a single case report of its use for EUS-GBD in the literature. 2 A 68 year-old female, presented with obstructive jaundice, due to inoperable hilar cholangiocarcinoma. A Percutaneous transhepatic cholangiography (PTC) procedure was performed and an internal external drain placed. Shortly afterwards she developed clinical features of cholecystitis. A CT scan showed gross distension of the GB and a GB stone. There was extensive pericholecystic fluid with fat stranding. Following HPB MDT discussion, a decision was made to perform EUS-GBD using a Hot AXIOS™. Methods The procedure was undertaken under conscious sedation, using a therapeutic echoendoscope. The optimal site for access was identified as being in the antrum. The GB was punctured with the Hot-AXIOS device (15 mm x 10 mm (W x L) 24 mm flange diameter stent) and a cutting current was applied. X-ray screening was used; however, deployment was entirely under EUS control. The stent was dilated with a 10 mm balloon. Results The procedure was well tolerated and completed within 15 minutes. The stent was in a good position on EUS and fluoroscopy. A large amount of pus drained immediately. There was a rapid improvement in clinical condition and inflammatory markers over the next few days. Biliary drainage was internalised with placement of 2 metal stents. CT scans 8 days and 7 weeks post placement showed the stent in a good position with resolution of the cholecystitis. Conclusion Technical and clinical success was achieved in this case which to the best of our knowledge is the first EUS-GBD procedure in the UK utilising this device. Further experience of EUS-GBD with the Hot AXIOS™ and randomised controlled trials against percutaneous drainage are required to delineate its role in high risk surgical cases. References 1 Jang JW, et al. Gastroenterol . 2012 Apr; 142 (4):805–11. 2 Teoh AYB, et al. GIE 2014; 80 (6):1171. Disclosure of Interest None Declared