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EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure.This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon.Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P.05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%).Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.

s / Pancreatolog S4 Aims: To evaluate the long-term outcome after surgical resection of sporadic, asymptomatic NF-pNET < 2 cm, stratifying the results by resection type and histopathologic features. Patients & methods: Patients resected between June 1997 and November 2008 at our institution (minimum follow-up of 60months) were retrieved from a prospectively maintained electronic database and analyzed retrospectively. Results: Study population consisted of 49 patients (27 females and 22 males), with amedian age of 59 years (range 38-61). 31 patients underwent parenchyma-sparing resections (15 enucleations, 15 middle pancreatectomies, 1 spleen-preserving distal pancreatectomies), while 18 patients underwent formal resections (8 pancreaticoduodenectomies, 10 distal pancreactomies with splenectomy). Mean lymph node yielding was 1.35 (0-9) in atypical resections and 19 (7-32) in formal resections (p1⁄40.0001). Lymph node metastases were found in only one patient undergoing pancreaticoduodenectomy. The median tumor size was 16 mm. 48 tumors were G1, one was G2, none was G3 (2010 WHO classification). The final pathologic report showed microscopic local invasion (perineural invasion, lymph vascular invasion or fat invasion) in 8 patients. At a median followup of 80 months (60-193), 4 patients died of other causes, 4 were lost to follow-up the remaining 37 patients did not develop recurrence and are alive and disease-free. Conclusion: Long-term outcome of surgically resected asymptomatic sporadic NF-pNET < 2 cm is excellent. Atypical resections with limited lymph node dissection may be oncologically adequate. Microscopic local invasion did not impact on the natural history of the disease.

Introduction The diagnostic features, disease course, and management of autoimmune pancreatitis (AIP)/IgG4 systemic disease are still being defined. Here we report long-term data on the largest European cohort of prospectively followed patients. Methods All patients referred to our centre from 2004–2010, in whom a diagnosis of AIP was made, were followed prospectively. Results 52 patients (41 M, 11 F; median age 59 years (range 26–85)) were included, with a median follow-up from diagnosis of 32 months (range 0–76). 40 patients were jaundiced at presentation (77%) and 7 patients (14%) had undergone surgery for suspected pancreaticobiliary cancer. HISORt criteria were fulfilled in 46 (89%) patients. Serum IgG4 was raised in 35 patients (67%). Histological samples were taken in 49 patients. Tissue IgG4 was raised (>10 cells/hpf) in 29 patients (59% of those who had at least one biopsy). 17 patients had associated autoimmune disease (7 Sjogren9s, 7 thyroid disease, 4 IBD and 1 vitiligo). 41 patients (79%) had extrapancreatic disease: biliary involvement in 37 patients (71%) (of whom 2 (4%) developed cirrhosis and 1 (2%) underwent liver transplantation); retroperitoneal fibrosis in 5 patients (10%); renal infiltrates in 5 (10%); arthropathy/arthralgia in 3 (6%); IgG4-related cerebral involvement in 2 patients (4%) (encephalitis and pituitary mass); biopsy-proven peripheral lymphadenopathy (submandibular, iliac or axillary) in 3 (6%); extensive small bowel mesenteric involvement in 1; and pulmonary involvement in 1 patient. Exocrine insufficiency occurred in 23 patients (44%) and diabetes in 17 (33%). Portal and/or splenic vein thrombosis developed in 7 patients (14%). 45 patients (87%) received steroids for a median of 4.6 months (range 0.6–76). A good response to steroids was seen in 43 (96%) of these patients. Disease relapse occurred in 24 (46%), with a median time to relapse of 4.2 months (range 0–38). Extrapancreatic disease at presentation predicted relapse (P = 0.0004), but elevated serum IgG4 did not (P = 0.14). 19 patients (37%) received additional immunosuppression (azathioprine (n = 17), mycophenylate (n = 1), ciclosporin (n = 1), methotrexate (n = 1), infliximab (n = 1)). All patients who relapsed responded to subsequent treatment. 37 patients required biliary stenting with a mean of 2 stents (range 1–10 stents). Three patients (6%) died during follow-up, all from probable IgG4-related disease: autoimmune encephalitis, progressive liver disease and hilar cholangiocarcinoma. Conclusion Long-term follow-up in this large cohort shows that AIP/IgG4 systemic disease may be associated with multi-organ complications, which cause significant morbidity, and a small but significant mortality. Extrapancreatic involvement at presentation predicts a complicated course.