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Treatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated.To critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP.A literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details.Eleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-3660%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health.This review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.

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.

We recently published in GUT the outcomes of acute pancreatitis (AP) and coexisting SARS-CoV-2 infection.1 A number of patients who were SARS-CoV-2 positive had AP of unknown aetiology (25%) speculating SARS-CoV-2 as a cause for AP similar to other viruses.2 However, most patients did not complete investigations to exclude other causes of AP. In addition, SARS-CoV-2 infection may cause aberrant glycometabolic control,3 however it is unknown if this increases the risk of long-term diabetes mellitus (DM). The follow-up data were collected 12 months from the date of recruitment for 1476 patients (118 patients who were SARS-CoV-2 positive and 1358 patients who were negative) to establish an aetiology for AP and development of DM. Among the 118 patients who were SARS-CoV-2 positive, 35 patients had idiopathic or unknown aetiology AP. Sixteen patients underwent either MRCP (n=13) or EUS (n=4) and the remaining patients underwent biochemical investigations to exclude other causes of AP. The final aetiology of AP was available for 83 (70.3%) patients and included gallstones (56, 47.4%), alcohol (19, 16.1%), post ERCP (2, 1.7%) and other (6, 5.1%). Overall, 23 patients had a change of aetiology, and in 35 (29.7%) patients AP was considered idiopathic. Patients who were SARS-CoV-2 positive were more likely to have idiopathic AP (34.7% vs 13.9%, p

Background and study aims Population-level data on the outcomes of pancreaticobiliary endoscopic ultrasound (PB-EUS) are limited. We examined national PB-EUS and fine-needle aspiration (FNA) activity, its relation to pancreatic cancer therapy, associated mortality and adverse events. Patients and methods Adults undergoing PB-EUS in England from 2007–2016 were identified in Hospital Episode Statistics. A pancreatic cancer cohort diagnosed within 6 months of PB-EUS were studied separately. Multivariable logistic regression models examined associations with 30-day mortality and therapies for pancreatic cancer. Results 79,269 PB-EUS in 68,908 subjects were identified. Annual numbers increased from 2,874 (28 % FNA) to 12,752 (35 % FNA) from 2007 to 2016. 8,840 subjects (13 %) were diagnosed with pancreatic cancer. Sedation related adverse events were coded in 0.5 % and emergency admission with acute pancreatitis in 0.2 % within 48 hours of PB-EUS. 1.5 % of subjects died within 30 days of PB-EUS. Factors associated with 30-day mortality included increasing age (odds ratio 1.03 [95 % CI 1.03–1.04]); male sex (1.38 [1.24–1.56]); increasing comorbidity (1.49 [1.27–1.74]); EUS-FNA (2.26 [1.98–2.57]); pancreatic cancer (1.39 [1.19–1.62]); increasing deprivation (least deprived quintile 0.76 [0.62–0.93]) and lower provider PB-EUS volume (2.83 [2.15–3.73]). Factors associated with surgical resection in the pancreatic cancer cohort included lower provider PB-EUS volume (0.44 [0.26–0.74]) and the least deprived subjects (1.33 [1.12–1.57]). 33 % of pancreatic cancer subjects who underwent EUS, did not subsequently receive active cancer treatment. Conclusions Lower provider PB-EUS volume was associated with higher 30-day mortality and reduced rates of both pancreatic cancer surgery and chemotherapy. These results suggest potential issues with case selection in lower-volume EUS providers.

Objectives: We analyzed randomized controlled trials (RCTs) to assess the impact of PERT on weight change, quality of life, and overall survival (OS) in patients with advanced pancreatic cancer (AP...

Objective: There are limited data on the impact of the pandemic upon endoscopy service provision and quality indicators. Methods: Analysis of number and type of procedure, in-room time (minutes), key performance indicators, and list utilization was performed over three periods; pre-lockdown, lockdown, and early recovery and compared with the previous year. Results: Endoscopy activity reduced to 13.3% of the same period in 2019 with the largest drops in colonoscopy and flexible sigmoidoscopy numbers. In-room time increased significantly for gastroscopy (35 vs. 24, p < 0.0001), flexible sigmoidoscopy (20 vs. 15, p < 0.0001), endoscopic ultrasound (40 vs. 32, p = 0.0009), and ERCP (59 vs. 45, p = 0.0041). There was no increase for colonoscopy (35 vs 35, p = 0.129). There was a significant reduction in in-room time for gastroscopy alone (44.5 vs. 30.0, p = 0.0002) over the study period. There was no significant difference in cecal intubation rate, polyp detection rate, or biliary cannulation rate compared to the previous year. Conclusions: The pandemic has profoundly reduced the number of endoscopies performed with some recovery. In-room time has significantly increased but with the preservation of key performance indicators. List utilization remains a significant problem and resources need to be adequately aligned to improve this.

Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) performs poorly in the histological diagnosis of type 1 autoimmune pancreatitis (AIP). The aim of this study was to assess the performance of fine-needle biopsy (FNB) comparing reverse bevel (RB) and fork-tip (FT) needles. Patients and methods A retrospective study of prospectively maintained databases was performed. Patients with a final diagnosis of type 1 AIP who underwent EUS-FNB during diagnostic workup were included. Pathology reports were reviewed and classified as per international consensus diagnostic criteria (ICDC). The Primary outcome was EUS-FNB sensitivity in diagnosing type 1 AIP. Results Between March 2011 and December 2018, 24 patients with a final diagnosis of type 1 AIP underwent FNB. Six patients underwent biopsy with the RB needle and 18 with the FT needle. Mean age (± SD) 62.2 (± 11.4), 17 (70.8 %) male. No RB samples were diagnostic compared to 14 (78 %) FT; P = 0.001; of which 13 (72 %) were level 1. In eight (44 %) of FT cases a diagnosis was not possible without histology. Initial biopsy was diagnostic in five (62.5 %) of these cases. Including repeat biopsy, seven (87 %) had a diagnosis made by FT needle. Obliterative phlebitis (44 %) was the least frequently identified pathological feature and immunoglobulin (IgG)4 + plasma cells > 10 per high power field (78 %) the most common. Conclusion The FT needle demonstrated good performance for diagnosing type 1 AIP. The results support the preferential use of this core biopsy needle for EUS pancreatic tissue sampling.

The surgical operation associated with improved pain and quality of life (QoL) in patients with chronic pancreatitis (CP) is unknown. The Scopus, EMBASE, Medline and Cochrane databases were systematically searched until May 2019, and all randomised trials (RCTs) comparing surgical operations for CP pain were included in a network meta-analysis (NMA). Four surgical operations for treating CP were directly compared in eight RCTs including 597 patients. Patients were mainly male (79%, 474/597) with alcoholic CP (85%, 382/452). Surgical operations included were pancreatoduodenectomy (224, 38%), Berne procedure (168, 28%), Beger procedure (133, 22%) and Frey procedure (72, 12%). The NMA revealed that the Beger procedure ranked best for pain relief, whilst the Frey procedure ranked best for postoperative QoL, postoperative pancreatic fistula rate and postoperative exocrine insufficiency rate during a median follow-up of 26 months (reported range 6–58 months). Overall the Frey procedure ranked best for the combination of primary outcome measures based on surface under cumulative ranking curve scores. Overall the Frey procedure may perform the best for both pain relief and postoperative QoL in patients with CP. Further trials are warranted in defining the role of surgery in relation to endotherapy.

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.

There is a paucity of data on the incidence, risk factors, and treatment of splanchnic vein thrombosis (SVT) in acute pancreatitis (AP).All AP admissions between 2018 and 2021 across North East of England were included. Anticoagulation was considered in the presence of superior mesenteric vein/portal vein (SMV/PV) thrombus or progressive splenic vein thrombus (SpVT). The impact of such a selective anticoagulation policy, on vein recanalisation rates and bleeding complications were explored.401 patients (median age 58) were admitted with AP. 109 patients (27.2%) developed SVT. The splenic vein in isolation was the most common site (n = 46) followed by SMV/PV (n = 36) and combined SMV/PV and SpVT (n = 27). On multivariate logistic regression alcohol aetiology (OR 2.64, 95% CI [1.43-5.01]) and50% necrosis of the pancreas (OR 14.6, 95% CI [1.43-383.9]) increased the risk of developing SVT. The rate of recanalization with anticoagulation was higher for PVT (66.7%; 42/63) than in SpVT (2/11; p = 0.003). 5/74 of anticoagulated patients developed bleeding complications while 0/35 patients not anticoagulated had bleeding complications (p = 0.4).The risk of SVT increases with AP severity and with extent of pancreatic necrosis. A selective anticoagulation policy for PVT and progressive SpVT in AP is associated with favourable outcomes with no increased risk of bleeding complications.

Background The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. The present systematic review and meta-analysis aims to compare the efficacy of several analgesic modalities trialled in AP. Methods A systematic search of PubMed, MEDLINE and EMBASE was conducted up until June 2021, according to PRISMA Guidelines to identify all randomised control trials (RCTs) comparing analgesic modalities in AP. The primary outcome measure was improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), placebo, local anaesthetic, epidural, paracetamol and metamizole. A weighted single-arm effects estimate showed global improvement in VAS across all modalities from baseline to day 2. On visual inspection, epidural analgesia appears to provide the greatest improvement in pain scores within the first 24hrs, however at 48hrs it was comparable to opiates. Within the first 24hrs, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant heterogeneity in pain-relief reporting with relatively small datasets per study. Conclusions Given the incidence of AP there is remarkable paucity of level 1 evidence to guide pain management. Epidural administration is most effective analgesic modality within the first 24hrs of AP. NSAIDs are an effective opiate sparing alternative during the first 24hrs.

Background There is paucity of data on the incidence, risk factors and role of anticoagulation for splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). Methods A retrospective review of AP admissions between 2018-2021 across North East England was undertaken. Data on demographics, etiology, severity of AP and SVT was collected. In addition, a selective anticoagulation policy for portal vein thrombosis (PVT) and progressive splenic vein thrombosis was explored. Results 401 patients were included with a mean age of 57.0 and M:F ratio of 1.6:1. 152 patients developed intestinal oedematous pancreatitis and 249 developed necrotising pancreatitis based on Revised Atlanta criteria (RAC). 109 patients (27.2%) developed SVT of which 27 developed a PVT and splenic vein thrombus, 36 PVT only and 46 splenic vein thrombus only. On univariate analysis, alcoholic aetiology, severe pancreatitis, necrotising pancreatitis with >50% necrosis and elevated CRP at 2 weeks were risk factors for developing SVT. On multivariable analysis, alcohol aetiology (OR 2.6, p = 0.002), and >50% pancreatic necrosis (OR 14.6,p = 0.048) increased the risk of developing SVT . 58 patients received anticoagulation for SVT, with a median duration of 90 days of anticoagulation. Recanalization rates were higher for PVT when compared to splenic vein thrombosis. 6 patients developing bleeding complications whilst on anticoagulation therapy. Conclusions A third of patients with AP develop SVT, particularly those with severe AP secondary to alcohol and with extensive pancreatic necrosis. A selective anticoagulation policy was associated with improved recanalization rates and fewer bleeding complications.

The basal-like molecular subtype of pancreatic ductal adenocarcinoma (PDAC) is associated with poor prognosis and upregulation in TP63ΔN (p40) network. Adenosquamous histology can be observed. This study assessed immunohistochemical p40 expression in fine needle biopsy (FNB) samples with PDAC and association with cytomorphological features of squamous differentiation and clinical data. 106 EUS FNBs with PDAC were assessed for eight cytomorphological features of squamous differentiation. P40 H-score (intensity 0–3 × percentage positive nuclei) was analysed for association with morphological features, patient age, gender, operability, chemotherapy and survival. P40 H-score in 14 paired FNBs and resections was compared. P40 h-score was 1–3 in 31%, 4–30 in 16% and > 30 in 13% of FNBs. It was significantly associated with intercellular bridges, elongated cell shape, sharp cell borders, angular nuclei with homogenous chromatin (p 30 (n = 9, 1.8 months) than for h-score ≤ 30 (n = 66, 6.7 months) not quite reaching statistical significance (p = 0.08). P40 was significantly associated with squamous morphology in FNBs with PDAC. P40 H-score > 30 showed a trend towards shorter survival in inoperable patients. Squamous differentiation may be a treatment target in PDAC.

Pancreatic cystic lesions (PCLs) can present complex diagnostic and management challenges with uncertainty as to the most appropriate investigations, interventions and surveillance. Guidelines have been developed to aid decision making, including the European Study Group, American College of Gastroenterology and International Study Group guidelines. This paper presents issues relating to risk stratification and the appropriate management of patients with PCLs, reviewing these recently published guidelines. While there are similarities across these expert guidelines, there are notable differences in terms of features associated with increased risk of malignant transformation, the most appropriate imaging modality and timing of interval imaging. Where variations exist, this reflects differing interpretations of a limited evidence base, and decision making will likely evolve further as experience with these guidelines develops.

Background and Aims Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDD) with an electrocautery enhanced lumen-apposing metal stent (EC-LAMS) has emerged as a viable method of establishing biliary drainage in patients with MDBO. Our aim was to assess the efficacy, safety, and outcomes in patients with malignant distal biliary obstruction (MDBO), who underwent EUS-CDD with EC-LAMS. Methods A retrospective review of consecutive patients with MDBO who underwent EUS-CDD with EC-LAMS at 8 tertiary institutions across the United Kingdom and Ireland between September 2016 to November 2020 was undertaken. Results One hundred twenty patients (55% male) with a median age of 73 years (IQR 17, range 43 – 94) were included. The median follow-up period in 117 patients was 70 days (IQR 169, range 3 – 869) and 23 patients (19.2%) were alive at the end of the follow-up. Three patients were lost to follow-up. Technical success was achieved in 109 patients (90.8%). Clinical success (reduction of serum bilirubin to ≤50% of original value within 14 days) was achieved in 94.8% (92/97 patients). The adverse event (AE) rate was 17.5% (n=21). Biliary reintervention after initial technical success was required in 9 patients (8.3%). Conclusion EUS-CDD with EC-LAMS at tertiary institutions within a regional HPB network for treatment of MDBO is effective in those where ERCP was not possible or unsuccessful. When technical failures or adverse events occur, the majority can be managed with conservative or endoscopic therapy

Introduction Autoimmune pancreatitis is a rare paediatric condition with management driven by adult guidelines. However, case reports suggest that the paediatric disease presents differently with few children presenting with elevated IgG4 levels. Management is also unclear with limited evidence to suggest any management strategy superior to another or the long-term outcomes of paediatric patients. Aim To present a case of possible autoimmune pancreatitis, presenting with obstructive jaundice, managed without steroids. Subject: A 12-year-old Caucasian male presented with a week of pruritus and bruising with a 48-hour history of diarrhoea and jaundice. There was no history of abdominal pain, weight loss or fatigue. He was previously fit and well with no significant family history. Examination revealed petechiae and ecchymosis but no positive abdominal findings. Results At presentation bloods showed bilirubin 277 umol/L (201 umol/L conjugated), alanine transaminase 88 unit/L, alkaline phosphatase 802 unit/L, gamma glutamyltransferase 79 unit/L and international normalised ratio 0.9. Amylase and lipase were normal throughout. Abdominal ultrasound at the presenting hospital revealed a 2.5 cm mass at the head of the pancreas with a dilated gallbladder. The child underwent a MRCP which showed a 3 cm mass at the pancreatic head with marked intra and extrahepatic biliary dilatation. The pancreatic duct was not visible in the pancreatic head. Endoscopic ultrasonography confirmed a diffusely abnormal pancreas with no pancreatic duct dilatation. There was no discrete mass visible. An ERCP revealed a smooth single stenosis of 20 mm in the distal and mid common bile duct with pre-stenotic dilatation. A stent was inserted. Autoantibodies were normal, as were immunoglobulins, including IgG4. Hepatitis serology and alpha-fetoprotein were also normal. A pancreatic biopsy was taken which showed mild chronic inflammation, minor acinar atrophy with intralobular oedema and some fibrosis. Immunohistochemistry for IgG4 disease was negative. Maximal bilirubin was 334, alkaline phosphatase 869 and alanine transaminase 81 prior to stent insertion. These were falling prior to stent insertion however fell rapidly post insertion and were within normal limits 4 weeks post stent insertion. The patient received no further medical management and is due for repeat imaging prior to proposed stent removal in the next few weeks. Summary We present a 12-year-old boy who presented with typical radiological findings of presumed autoimmune pancreatitis. He was managed endoscopically with stent insertion and achieved a rapid resolution in symptoms and biochemical markers. Autoimmune screening was negative and there were no positive diagnostic findings with regard to IgG4. The child did not receive steroid therapy and is awaiting repeat imaging prior to proposed stent removal. Conclusion Autoimmune pancreatitis is a rare condition in children and management is often extrapolated from adult guidelines. Collaborative working is required for the creation of paediatric guidelines to guide further management of this rare condition.

Main recommendations 1 ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2 ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3 ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4 ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5 ESGE suggests cold snare polypectomy for small (Weak recommendation, low quality evidence. 6 ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7 ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8 ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9 ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.

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 Endoscopic ultrasound and ERCP are complimentary modalities and some units offer same session procedures. This offers the opportunity to provide a ‘one-stop-shop’ which may speed up the patient pathway by providing rapid diagnostics and therapy in the same session. It is unknown whether there is any effect on diagnostic tissue acquisition rates, biliary cannulation rates, procedure success rates or adverse event rates particularly in those having conscious sedation. The aim of this study was to evaluate these outcomes in a large tertiary referral HPB centre. Patients and Methods Retrospective analysis of all EUS and ERCP procedures over the period 2018 - 2019 was performed. Patients having same session EUS and ERCP were identified and demographics, indication, total amount sedation given, order of procedure, results of brushings or needle sampling (definite malignancy or benignity), desired duct cannulation rate, successful intervention rate (duct cleared or stent inserted for drainage) and 7 day adverse event rate was calculated. Patients undergoing both EUS and ERCP more than 7 days apart had the same details recorded as a control group. Results 393 patients were included in the study (median age 69 years, 188 males, 206 for a malignant indication). 243 patients underwent same session EUS/ERCP and 150 were included in the control group. There were no significant differences in median age, sex distribution or procedure order between the two groups. Patients having same session EUS/ERCP were significantly more likely to be for a malignant indication (155/243 vs. 51/150 OR 3.4 95% CI 2.2 - 5.2, p Conclusions Same session EUS/ERCP is feasible and more common in patients referred for suspected malignancy. There is no difference in diagnostic sampling rate, cannulation rates, success rates or adverse event rates when combining the two procedures. More information is needed to determine whether there is economy in list dynamics, cost effectiveness and patient preference.

Introduction Two groups of high-risk individuals (HRI) for pancreatic ductal adenocarcinoma (PDAC) have been defined. 1) Individuals from familial pancreatic cancer (FPC) kindreds and 2) individuals with identified genetic syndromes (GS) due to a germline mutation. Screening of HRI has been proposed to identify premalignant lesions and early stage malignancy with the aim of improving outcomes. Screening criteria have been formulated by a number of organisations including the international Cancer of the Pancreas-Screening consortium (CAPS) and the Italian Society for the Study of the Pancreas (IASP). Recent CAPS and IASP publications have reported a significant yield. A prior meta-analysis concluded that 135 patients with HRI were needed to be screened to identify one high risk lesion. The aim of this study is to review compliance with guidelines and the yield of HRI screening in our screening programme. Methods The study is a retrospective review of a prospectively maintained database of HRI. EUS, was the preferred annual screening method. MRI and CT were used in some patients due to intolerance of endoscopy or preference. Data was cross-checked with the endoscopy database and electronic patient record. Results A total of 110 individuals (71F) median age 46 (IQR, 41–57.75) were enrolled and underwent at least one screening procedure between January 2006 and January 2019. 108 (98.2%) met either or both CAPS/IASP criteria: 58 were classified as FPC and 50 GS. The 2 who didn’t meet criteria were a patient with idiopathic juvenile onset chronic pancreatitis (CP) and a patient with idiopathic CP and one first degree relative with PDAC. 487 screening procedures were performed. 407 (83.6%) EUS, 49 (10.1%) CT and 23 (4.75%) MRI with a median of 4 [IQR, 2–6] procedures per individual and median follow up 4.3 years [IQR, 2–7.75]. 9 (8.2%) had solid or cystic abnormalities identified on EUS and underwent tissue sampling. Two patients subsequently underwent distal pancreatectomy. The first (60 yr old female with hereditary pancreatitis) had a 20 mm cystic lesion in the tail of pancreas on her 2nd EUS. Resection histology was mucinous cystic neoplasm (follow up 11 years). The 2nd (48 yr old male, FPC) had a 14 mm nodule in body of pancreas. Histology was low grade pancreatic intraepithelial neoplasia (follow up 11.5 years). There were no adverse events consequent on screening. Conclusions In a large cohort of HRI undergoing screening, compliance with international criteria was good with no screening related adverse event. However, the yield to date has been low with only one high grade precursor lesion resected from 487 screening procedures.

Introduction IgG4 related disease (IgG4-RD) is a rare immune mediated fibroinflammatory condition that can affect nearly any organ. Pancreaticobiliary (PB) manifestations include autoimmune pancreatitis (AIP) and cholangiopathy. [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is the only technique that allows imaging of metabolic activity by detecting FDG accumulation in cells and correlation with anatomical structures. Increased tracer uptake is typically seen in inflammatory or neoplastic tissue thereby potentially aiding diagnosis, and assessment of disease extent and activity. There is limited data currently available on its utility in IgG4-RD and whether this varies according to presentation. The aim of this study is to determine the utility of FDG PET/CT in diagnosis, monitoring disease activity and identifying multi system involvement. Methods We performed a retrospective study of a prospectively maintained multi-disciplinary IgG4-RD database to identify patients who underwent FDG PET/CT over a 3-year period. Additional organ involvement and change in management consequent on FDG PET/CT was recorded. Fisher’s exact test was used for the comparison of proportions. Results 25 patients with a diagnosis or suspicion of IgG4-RD underwent FDG PET/CT between November 2016 and October 2019. The median age [IQR] at presentation was 59 [48.5–65.5], 18 (72%) were male. 15 (72.5%) suspected or proven PB disease, 6 (24%) head and neck (HN), 1 (4%) each of retroperitoneal, both PB and HN, pulmonary and renal. In 22 (88%) cases (15/15 PB, 7/10 non PB) FDG PET/CT findings had a direct impact on management. The difference in utility between PB (100%) and non-PB (70%) was not quite statistically significant (p=0.059). In 1 patient it enabled exclusion of PB IgG4-RD. In 15 (60%) it led to a decision to escalate therapy this included 3 AIP cases (21.4% of definite PB cases) in which new organ involvement was identified. In 6 cases (5 PB and 1 renal IgG4-RD) with concern of active disease because of persistently elevated or rising IgG4 levels it excluded FDG avid inflammation. Conclusion In this retrospective study FDG PET/CT had a clinically important impact on management of IgG4-RD. Identifying other organ involvement as well as influencing therapeutic decision making particularly in PB disease. Further studies are required to fully delineate its role in IgG4-RD.

Background Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. Methods The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. Results Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0–95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7–77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6–90.5) and 87.4% (95%-CI 81.2–91.8), respectively (P = 0.389). Conclusions Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Background IgG4-related disease (IgG4-RD) is a multisystem immune mediated fibro-inflammatory condition characterised by the three histopathologic features of IgG4-RD lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. The condition can be indolent with few symptoms or present with organ or life-threatening disease. First-line treatment with high dose corticosteroids is often effective, however when tapering steroids, the disease can relapse, and second line agents such as methotrexate (MTX), azathioprine (AZA) or mycophenolate (MMF) are not always effective or tolerated. In 2016, following evidence from observational studies, NHS England approved the use of rituximab (RTX) in refractory IgG4-RD according to strict criteria. In our unit we have used rituximab, with or without cyclophosphamide induction, in eight patients with IgG4-RD. Our aim was to assess effectiveness of rituximab treatment and adherence to NHS England guidelines. Methods Using our connective tissue disease database, patients with IgG4-RD were identified and their electronic notes were reviewed. Outcome after rituximab treatment was assessed by the evaluation of clinical and radiological responses. Results Between August 2017 and September 2019, 15 patients with IgG4-RD were seen in the rheumatology service. 8 patients went on to receive rituximab therapy, 4 with IV cyclophosphamide (CYP). 5/8 patients had head and neck disease and 3/8 had abdominal disease (pancreas, retroperitoneal, renal). By comparison, those patients that did not receive rituximab had a preponderance of abdominal disease (4/7 had abdominal disease, 2/7 head and neck, 1/7 breast). 8/8 patients receiving rituximab were discussed in a designated MDT and met NHS diagnostic guidelines. MDT treatment decisions were made based on ‘refractory’ or ‘organ critical’ disease criteria. In all patients, with available post treatment imaging, radiological response was demonstrated. In one case, imaging showed improvement in some areas and progression in other areas and response was described as ‘partial’. Conclusion In the patients treated to date in our unit, rituximab has been shown to be an effective treatment for IgG4-RD. Cyclophosphamide induction has been used in a subset of patients. Patients with head and neck disease were more likely to require escalation to rituximab therapy, compared with those with abdominal disease. Disclosures F. Rayner None. B. Griffiths None. M. Nayar None. K. Oppong None. J. Vila None.

Background and study aims Radiofrequency ablation (RFA) is used to treat blocked biliary stents in patients with pancreaticobiliary (PB) tumors with varying results. We report our experience with a novel temperature-controlled probe for treatment of blocked metal stents. Patients and methods Patients with histologically proven PB cancers and a blocked biliary stents were treated using ELRATM electrode (Taewoong Medical) under fluoroscopic guidance. Demographics, clinical outcome, stricture diameter improvements, complications and mortality at 30 days were prospectively recorded. Results Nine procedures were performed on seven patients (4 male, 3 female); mean age 65.33 (range 56 – 82 years). Mean stricture diameter prior to RFA was 1.13 mm (SD ± 0.54) and 4.42 mm (SD ± 1.54) following RFA (P Conclusion These are the first reported data on use of a temperature-controlled RFA catheter in humans to treat blocked metal biliary stents. The device is safe but further randomized trials are required to establish the efficacy and survival benefits of this probe.

Background and study aims Bi-flanged metal stents (BFMS) have shown promise in the drainage of walled-off pancreatic necrosis (WON), but their placement requires multiple steps and the use of other devices. More recently, a novel device consisting of a combined lumen-apposing metal stent (LAMS) and electrocautery-enhanced delivery system has been introduced. The aim of this study was to compare the placement and outcomes of the two devices. Patients and methods This was a retrospective review of consecutive patients undergoing endoscopic ultrasound-guided placement of BFMS or LAMS for drainage of symptomatic WON. Data from procedures between October 2012 and December 2016 were taken from a prospectively maintained database. We compared technical and clinical success, procedure time, costs, and composite end point of significant events (adverse events, stent migration, additional percutaneous drainage) between BFMS and LAMS. Results 72 consecutive patients underwent placement of BFMS (40 patients, 44 stents) or LAMS (32 patients, 33 stents). Technical success was 91 % for BFMS and 97 % for LAMS. Clinical success was 65 % vs. 78 %, respectively. Median in-room procedure time was significantly shorter in the LAMS group (45 minutes [range 30 – 80]) than in the BFMS group (62.5 minutes [range 35 – 135]; P Conclusion LAMS was superior to BFMS in terms of procedure time, with comparable adverse events, success, and costs.

Background and Aims A new core biopsy needle with a novel tip, opposing bevel, and sheath design has recently been introduced for EUS-guided fine-needle biopsy (FNB). The diagnostic utility of this needle for differentiating solid pancreatic masses is currently unknown. The aim of this study was to compare the diagnostic performance and yield for tissue acquisition from solid pancreatic lesions of the opposing bevel needle with those of a reverse bevel EUS-FNB needle. Methods Consecutive patients with solid pancreatic masses undergoing EUS-FNB using the opposing bevel (n = 101) and the reverse bevel (n = 100) core biopsy needles were included in the study. Final diagnosis was based on positive histology or at least 12 months of follow-up in cases with a negative biopsy. The primary outcome was the diagnostic performance of the 2 needles for malignant pancreatic masses. A secondary outcome was the diagnostic yield. Results Compared with the reverse bevel needle, using strict criteria the opposing bevel needle provided significantly higher sensitivity (71.1% vs 90.1%; P = .0006) and overall accuracy (74% vs 92%; I = 0.0006) for discriminating malignant from benign solid pancreatic masses. The proportion of samples classified as adequate for histologic analysis was 87% for the reverse bevel needle versus 99% for the opposing bevel needle ( p = 0.002) Multivariate analysis controlling the needle gauge and site did not show any significant difference in accuracy and sensitivity between the 2 groups. There were no adverse events in either group. Conclusions In this first, large, single-center preliminary cohort study, an EUS core biopsy needle with a novel tip, opposing bevel, and sheath design afforded substantially superior tissue yield and diagnostic performance compared with a reverse-bevel needle. If replicated by randomized controlled trials, our findings suggest that similarly designed needles could become the standard of care for EUS-guided tissue acquisition from solid pancreatic masses.

Endoscopic ultrasound (EUS) is now firmly established as one of the essential tools for diagnosis in most gastrointestinal MDTs across the UK. However, the ability to provide therapy with EUS has resulted in a significant impact on the management of the patients. These include drainage of peripancreatic collections, EUS-guided endoscopic retrograde cholangiopancreatogram, EUS-guided coeliac plexus blocks, etc. The rapid development of this area in endoscopy is a combination of newer tools and increasing expertise by endosonographers to push the boundaries of intervention with EUS. However, the indications are limited and we are at the start of the learning curve for these high-risk procedures. These therapies should, therefore, be confined to centres with a robust multidisciplinary team, including interventional endoscopists, radiologists and surgeons.

Introduction Brush cytology is routinely performed during ERCP to assess biliary strictures but is limited by modest sensitivity (45%). Recently a biliary brush with a new design (Infinity® brush - U.S.Endoscopy) has been introduced and preliminary reports suggest improved sensitivity.1 The brush is more abrasive and larger than conventional brushes. The aim of our study was to compare the efficacy of the new biliary brush compared with the conventional brush (RX Cytology Brush – Boston Scientific) that is routinely used in our unit. Methods This is a matched case control study. Biliary brushings were performed with the novel brush in 50 consecutive patients from July 2017 to September 2018 for distal biliary obstruction. The cases were matched to 100 consecutive controls of the traditional brush from January 2016 to December 2016. The technique and preparation of the sample was similar for both groups. Cytology grading: C1 – inadequate, C2 = benign, C3 = atypia, C4 – suspicious for malignancy & C5 = diagnostic for malignancy. Demographic data, sensitivity, specificity & negative predictive values (NPV) were analysed for C5 alone and C4 & C5 combined. Final diagnosis was based on a minimum follow up of 6 months. Student t test & Chi square test was used for analysis. Results The mean age for cases was 65.4 yrs.(SD = 31.4;range = 35–91). The mean age for controls was 66.8 years (SD = 23.5; range = 35–88). M:F ratio = Cases = 26:24 & controls = 48:52. There was no statistically significant difference between the age(p=0.86 & 0.91) & sex distribution (p=0.79 & 0.94) across the two groups. Cases = 75% had final diagnosis of malignancy. The sensitivity, specificity and NPV for the diagnosis of malignancy using strict criteria i.e. C5 was 49%, 100% & 40% respectively. However if C4 & C5 were combined the values were 75%, 93% 60% respectively. Controls = 75% had final diagnosis of malignancy. The sensitivity, specificity and NPV for the diagnosis of malignancy using strict criteria i.e. C5 was 52%, 100% & 41% respectively. However if C4 & C5 were combined the values were 71%, 100% & 56% respectively. The mean follow up for the cases was 9.2 months and 31.7 months for the control group. There was no statistically significant difference in sensitivity (p=0.92), specificity(p=0.79) & NPV(p=0.09)between the two brushes . Conclusions Our data suggest that the novel brush design does not confer improved diagnostic performance in malignant biliary strictures. This highlights the difficulties of intra ductal brush sampling possibly reflecting the paucity of malignant cells within the stricture reflecting the desmoplastic nature of biliary and pancreatic malignancy. Reference Shieh F, et al. World J Gastrointest Endosc 2014 Jul 16;6(7):312–7.

Introduction Endoscopic ultrasound (EUS) fine needle aspiration (FNA) has poor performance in diagnosing autoimmune pancreatitis (AIP) due to small sample size and lack of preserved tissue architecture. In mass forming disease non-diagnostic EUS-FNA may result in a presumptive diagnosis of malignancy and unnecessary surgery. A core biopsy needle with a novel fork-tip design (SharkCore™) has been introduced with the aim of improving yield and maintaining tissue architecture. Literature on its performance in the diagnosis of AIP is limited to a few case reports. Aim To assess the diagnostic performance of EUS tissue sampling with a fork-tip needle in the diagnosis of type 1 AIP. Methods Retrospective review of a prospectively maintained AIP database in a tertiary center to identify patients with a final diagnosis of type 1 AIP who underwent EUS-TS during diagnostic workup. Pathology reports were reviewed and classified as per International Consensus Diagnostic Criteria (ICDC); Level 1 (highly suggestive) requires the presence of 3 or all 4 histological features and level 2 (probable) requires 2 features. Results Between March 2006 and November 2018, 35 procedures were performed on 28 individuals (29 lesions) with a final diagnosis of Type 1 AIP. Mean age ( ± SD) 63 (±11.4), 21 male. 29 procedures were for a mass lesion and or biliary obstruction. 2 patients underwent surgical resection and 2 laparoscopic biopsy. There were 8 procedures with an FNA needle, 7 reverse bevel and 20 fork-tip. There were 6 inadequate samples (3 FNA, 2 reverse bevel and 1 fork-tip). Of the 29 adequate samples, 15 (51.7%) met ICDC criteria for diagnosis of AIP all at level 1. 0/13 FNA or reverse bevel samples were diagnostic compared to 15/19 (79%) fork-tip samples (p=0.0001). Obliterative phlebitis was identified in 10/19 (52.6%), storiform fibrosis in 14/19 (70%), dense lymphoplasmocytic infiltrate in 14/19 (70%) and IgG4 positive plasma cell count > 10 per high power field in 14/19 (70%) of adequate fork-tip samples. Of the 17 individuals who underwent 20 procedures (2 repeat and 1 sampling of 2 separate lesions) with a fork-tip needle, 14 (83.2%) had a final ICDC level 1 diagnostic fork-tip biopsy. Conclusion In this the largest study to date of the fork-tip core biopsy needle in the diagnosis of AIP, the needle demonstrated very good overall diagnostic performance. This study supports the preferential use of this needle in suspected type 1 AIP.