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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.

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.

Introduction Severe acute pancreatitis is a condition with high mortality with 40% of patients requiring intervention. NCEPOD recommends that this is best managed in a multidisciplinary team with access to specialist regional services as and when required. We report our experience of the management of pancreatic fluid collections (PFC) within the region’s first remote care pancreatitis network. Methods Data on patients with severe pancreatitis who were transferred to the service between June 2015 - July 2017 were analysed. The network was formally established in 2015 and serves a population of 3.5 million & 17 referring hospitals in the Northern region. All patients were discussed in the multidisciplinary meeting and only patients requiring specialist input were transferred. Baseline characteristics, aetiology, nutritional support, antibiotic treatment, intensive care unit (ITU) stay, interventions, complications, mortality and follow up of atleast one year were reported. Results 285 patients were referred during this period. 83/285 (29%; 46 male) were transferred with a mean age 56 years [range 18–85]. The commonest aetiology was gall stones(45%) & alcohol(31%). The main reason for transfer(91%) was drainage of peripancreatic collections. Patients were referred after a mean of 13.7 [1–188] days from admission locally; 26% were admitted directly to ITU. Patients were transferred 4.5 [0–16] days post-MDT discussion. Fifty-five (66%) received antibiotics; however only 17 (20%) had appropriate antibiotics based on positive blood cultures. Appropriate feeding was 98%; 70 (84%) patients were enterically fed and 12 received parenteral nutrition (PN). One patient had inappropriate PN. 21% patients had intervention prior to transfer. On transfer, 15/83(18%) did not require intervention as there was spontaneous resolution of the collections. In the remaining patients the interventions included: endoscopic drainage only = 48%, percutaneous only = 29%, endoscopic + percutaneous = 12% & others = 5%. 35%(29/83) had multiorgan failure. 31/83 (37%) had complications following intervention. These were: sepsis = 35%, bleeding = 39%, thromboembolic events = 16% & others = 10%. Twelve (14%) patients died, 10 had MOF and 2 had pulmonary embolism, 11/12 were in ITU. Mean follow up was 18.2 months (range = 14 – 35). Conclusions Majority of patients (82%) required intervention for treatment of PFCs. Endoscopic drainage was the commonest route of drainage. Inappropriate antibiotic use remains a concern however nutritional support was adequate in majority of the patients. This is the first reported data from the U.K. regarding a remote care network & the results highlight the role of regional multidisciplinary network in the management of patients with acute severe pancreatitis.

Introduction In an attempt to overcome the limitations of Endoscopic ultrasound (EUS) fine needle aspiration (FNA) a fine needle biopsy (FNB) needle (SharkCore™) with a novel fork-tip, has been introduced. This needle is designed to increase tissue yield and preserve tissue architecture. The aim of this study was to determine if FNB histology samples had better diagnostic performance for solid pancreatic masses than FNA cytology samples. Methods Consecutive patients referred for EUS-guided sampling of solid pancreatic lesions were recruited. Each patient had 3 passes with a standard (Beacon™) FNA needle and 3 passes with a core (SharkCore™) FNB needle performed in a randomised order. 25g needles were used for transduodenal sampling and 22g for transgastric. A single slide was made from each pass with the FNA needle and the remaining aspirate placed in CytoRich™ fluid and sent for liquid based cytological analysis. All samples from the SharkCore™ needle were placed in a single container of formaldehyde and sent for histological analysis.. Samples were reported by expert cytopathologists and histopathologists respectively who were blinded to the results of the other needle. Only samples reported as diagnostic of malignancy were considered positive. Inadequate samples were not excluded from the analysis. Sample quality and ease of diagnosis were assessed on a 3 point scale. The primary endpoint was the accuracy of the diagnosis of malignancy. Secondary endpoints were the quality of sample obtained, ease of diagnosis and the duration of tissue sampling and pathological reporting. Results 108 participants were recruited, 57 male; mean age 66.9 ± 10.9. 85.2% had a final diagnosis of malignancy. Median lesion size (IQR) was 25 mm (19–34.5). 62 (57.4%) of lesions were in the head of pancreas. Tissue results from the FNB needle were significantly more accurate than FNA (84.2% vs 75%, p=0.041) in discriminating malignant from benign masses. A greater proportion of FNB samples had abundant diagnostic material (59.2% vs 44.4%, p=0.017) and a straight forward diagnosis (68.9% vs 51.9%, p=0.03). Biopsy sampling time median (IQR) 685s (565–832) vs 752s (651–835), p=0.0006) and pathology reporting times (191s (134–258) vs 332s (260–358), p Conclusion The diagnostic performance of the SharkCore™ FNB needle was significantly better than that of a standard FNA needle in the diagnosis of solid pancreatic masses and was associated with better sample quality, ease of reporting and shorter sampling and pathological reporting times.

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.

Introduction Pancreatic cystic lesions are being identified more frequently as cross sectional imaging has improved. Referral for endoscopic ultrasound (EUS) for further assessment and possible sampling is well recognised however there is little data on whether the characteristics of such lesions have changed over time. There is also a paucity of data concerning changes in pathological findings and surgical resection rates with respect to cystic lesions. The aim of this study was to assess trends in referral for EUS with respect to patient and cyst characteristics, pathological adequacy and surgical resection rates over a 10 year period to our centre. Patients and methods Retrospective analysis of the EUS database was performed over the period 2003 to 2012. EUS procedures for assessment of cystic lesions were identified and information concerning number per year, patient age and sex at referral, cyst size, cyst site, ability to give a cytological diagnosis, surgical resection and malignant surgical resection pathology were recorded. Kendall’s tau test (continuous data) or the Chi squared (categorical data) for trend test was used to determine significant changes over time. Results 417 patients (mean age 64.3 years, 163 males) underwent EUS in our unit for the assessment of cystic lesions over the study period. There was no significant difference in patient age or sex at referral over the study period. There was a significant increase in the number of procedures per year from 2003 (n=11) to 2012 (n=74)(tau 0.556, p=0.032) but a significant decrease in cyst size from 4.75cm in 2003 to 2.2cm in 2012 (tau -0.112, p=0.001). There was a significant change in the cyst site over time mainly due to an increase in the proportion of cysts found in the body of pancreas (p for trend Conclusions Cyst referrals for EUS have increased significantly but cysts are smaller, less likely to undergo resection, have a lower rate of malignancy and more likely to be in the body. Inability to give a cytological diagnosis rates also reduced significantly which may be due to improved laboratory techniques or a learning curve effect.

Endoscopic Ultrasound (EUS) with tissue sampling has an established role in the diagnosis of pancreaticobiliary (PB) disease. Malignancy occurring following colonoscopy or gastroscopy that does not diagnose cancer is a recognised phenomenon and has been extensively investigated. There is little data on pancreatic cancer (PC) occurring following an EUS without evidence of cancer. We have studied the frequency, time course and potential risk factors for post EUS PC. Methods PB EUS in England between Jan 2007 – Dec 2016 were identified in Hospital Episodes Statistics. Subjects with a diagnosis of PC made between 6 and 18 months after index PB-EUS were cases of post EUS PC. A logistic regression model examined risk factors for post EUS PC. Results 79,490 PB EUS procedures were performed in 69,120 subjects, with 8,859 diagnosed with PC within 6 months of index EUS. 563 (0.9%) subjects had post EUS PC (71% 6 to 12 months and 29% 12 to 18 months post EUS): median age was 70 (IQR 61–71) years and 57% were male. The following factors were associated with post EUS PC: chronic pancreatitis (odds ratio 3.11(95%CI 2.24–4.31), p 5 (1.44 (1.04–1.98), p=0.028); and increasing age (1.01(1.00–1.02), p=0.005) Ethnicity, gender and EUS volume were not associated with post EUS PC (table 1). Post EUS PC rates varied in individual providers from: 1.0% in providers undertaking 8 to 111 PB EUS over the study period to 1.1% in providers undertaking 112 to 782 PB EUS and 0.7% in providers undertaking >782 PB EUS. Conclusions 0.9% of subjects undergoing a PB EUS that did not diagnose PC were diagnosed with PC between 6 and 18 months later. Post EUS PC was associated with chronic pancreatitis, co-morbidity and increasing age.

We present the British Society of Gastroenterology (BSG) position statement on patient experience of GI endoscopy, recently published on the BSG website—www.bsg.org.uk/resource/patient-experience-of-gi-endoscopy-2019.html. The three dimensions of healthcare quality are patient safety, clinical effectiveness and patient experience, with much of healthcare practice focusing on the first two dimensions. Greater emphasis is now being given to the patient experience dimension in light of reports from Francis1 and Darzi2 highlighting the interaction between patient experience and quality of care. Clinical standards and safety in endoscopy are well reported and reviewed via the Joint Advisory Group on GI Endoscopy (JAG) accreditation programme. The Global Rating Scale3 used in JAG assessments includes a patient experience domain, but gives limited guidance available on how that should be measured or what standards should be …

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.

Background: Neoadjuvant therapy (NAT) represents a paradigm shift in the management of patients with pancreatic ductal adenocarcinoma (PDAC) with perceived benefits including a higher R0 rate. However, it is unclear whether NAT affects the sites and patterns of recurrence after surgery. This review seeks to compare sites and patterns of recurrence after resection between patients undergoing upfront surgery (US) or after NAT. Methods: The EMBASE, SCOPUS, PubMed, and Cochrane library databases were systematically searched to identify eligible studies that compare recurrence patterns between patients who had NAT (followed by resection) with those that had US. The primary outcome included site-specific recurrence. Results: 26 articles were identified including 4986 patients who underwent resection. Borderline resectable pancreatic cancer (BRPC, 47% 1074/2264) was the most common, followed by resectable pancreatic cancer (RPC 42%, 949/2264). The weighted overall recurrence rates were lower among the NAT group, 63.4% vs. 74% (US) (OR 0.67 (CI 0.52&ndash, 0.87), p = 0.006). The overall weighted locoregional recurrence rate was lower amongst patients who received NAT when compared to US (12% vs 27% OR 0.39 (CI 0.22&ndash, 0.70), p = 0.004). In BRPC, locoregional recurrence rates improved with NAT (NAT 25.8% US 37.7% OR 0.62 (CI 0.44&ndash, 0.87), p = 0.007). NAT was associated with a lower weighted liver recurrence rate (NAT 19.4% US 30.1% OR 0.55 (CI 0.34&ndash, 0.89), p = 0.023). Lung and peritoneal recurrence rates did not differ between NAT and US cohorts (p = 0.705 and p = 0.549 respectively). NAT was associated with a significantly longer weighted mean time to first recurrence 18.8 months compared to US (15.7 months) (OR 0.18 (CI 0.05&ndash, 0.32), p = 0.015). Conclusion: NAT was associated with lower overall recurrence rate and improved locoregional disease control particularly for those with BRPC. Although the burden of liver metastases was less, there was no overall effect upon distant metastatic disease.

Background/Objectives: Serum IgG4 level is used as a diagnostic criterion for immunoglobulin G4-related disease (IgG4-RD) but whether it predicts disease progression is unclear. Aim of the study was to investigate if serum IgG4 level at the time of diagnosis correlates with disease outcome. Methods Patients with a definitive diagnosis of IgG4-RD were included in this study. They were divided into two groups – Group 1 : Elevated serum IgG4 at diagnosis and Group 2: Normal serum IgG4 at diagnosis. Outcome parameters including multiple organ involvement, exocrine and endocrine dysfunction, relapse and mortality were compared. Data was subanalysed for outcomes on 2 levels of serum IgG4 cut-off – A: The upper limit of normal (ULN) and B: Twice the ULN. Results Of 47 patients, 31 (66%) patients had elevated serum IgG4 at diagnosis. There was no statistically significant difference between the two groups in any of the outcome parameters. Data analysed with the serum IgG4 levels > ULN showed no difference between the 2 groups for any of the outcome parameters. However, when the serum IgG4 cut-off was set to twice the ULN, there was a significantly higher rate of disease relapse (42.9% vs 11.5%, p = 0.02) and pancreatic exocrine insufficiency (PEI) (76.2% vs 42.3%, p = 0.041). Conclusion Raised serum IgG4 greater than two times the ULN was significantly associated with disease relapse and PEI in patients with IgG4-RD. Larger multicentre studies with longer follow-up are required to corroborate these findings and define the role and cut-off value of serum IgG4 in outcomes of IgG4-RD.

Introduction Chronic pancreatitis is associated with metabolic bone disease which increases the risk of fragility fractures. The National Institute of Clinical Excellence (NICE) guidance recommends that all patients aged 50 or over should be considered for DEXA scanning if at risk. Previous data has shown underutilisation of DEXA scanning in this population despite increased risk of osteoporosis. The aim of this study was to assess compliance with metabolic bone assessment in patients with chronic pancreatitis, assess the prevalence of abnormal DEXA scans and the impact of this assessment on appropriate management. Patients and methods Retrospective analysis of outpatient coding for “chronic pancreatitis” was performed over a 2 year period. Patient demographics, aetiology of chronic pancreatitis, prescription of pancreatic enzyme replacement therapy (PERT), vitamin D levels, DEXA scan result, history of fractures and bone protection medications were noted. Univariate and multivariable analysis were performed to explore why DEXA scanning was not performed as well as factors associated with abnormal scans. The impact of DEXA scanning on prescription of bone protection was also assessed. Results 134 chronic pancreatitis patients (mean age 57.6 years, 88 males) were included with aetiology recorded as alcohol (n=68), idiopathic (n=52), hypertriglyceridaemia (n=5), autoimmune (n=4), hereditary (n=3), anatomical (n=1) and biliary (n=1). 102/134 (76.1%) had vitamin D levels tested of which 82/104 (78.8%) were low. 62/134 (46.3%) had been sent for DEXA scanning of which 8 results were unavailable, 19 (30.6%) were normal, 24 (38.7%) showed osteopenia and 11 (17.7%) osteoporosis. 46/62 (74.2%) who had a DEXA scan were on bone protection compared to 30/72 (41/7%) who did not have a DEXA scan (p=0.002). Lack of DEXA scanning was associated with female sex (adjusted OR 0.22, 95% CI 0.09–0.57, p=0.0017) and not requiring PERT (adjusted OR 0.44, 0.20–0.95, p=0.035). Not requiring PERT was also independently associated (protective) with abnormal DEXA scan results (adjusted OR 0.17, 95% CI 0.03–0.98, p=0.047). 76 patients were prescribed bone protection with a higher proportion in those that had undergone a DEXA scan (46/62 with DEXA vs 30/72 without DEXA, p=0.002). 21/134 (15.7%) had a previous fracture of which 10 had DEXA scanning. 8/10 were on bone protection compared to 2/11 who had not had a DEXA scan (p=0.03). Conclusions Despite a high prevalence of metabolic bone disease, less than half of chronic pancreatitis patients were assessed. Not requiring PERT and females were less likely to have a DEXA. Interestingly, DEXA scanning was associated with appropriate prescription of bone protection. Whether a standardised proforma would improve rates of metabolic bone assessments needs to be studied.

Introduction The most effective investigation for suspected gallstones between MRCP and EUS is unclear. A 2015 Cochrane systematic review of their performance in common bile duct (CBD) stones concluded that the tests were of comparable accuracy. Conversely, a 2017 meta-analysis found EUS to be more sensitive. Any superiority of EUS may be due to better accuracy in detecting small stones. MRCP is routinely favoured as the 2nd line test following a non-diagnostic abdominal ultrasound and EUS subsequently performed as the 3rd line test when suspicion remains after a non-diagnostic MRCP. The yield and clinical utility of EUS in this setting is unclear. The aim was to identify the yield of EUS in patients with prior non-diagnostic MRCP undergoing EUS in our tertiary service. Methods All EUS reports from 2017 were reviewed along with the electronic patient records to identify cases with prior MRCP. Indication for the procedure, symptoms, liver blood tests and interval between MRCP and EUS were recorded. Findings of sludge, microlithiasis (stones Results A total of 1058 diagnostic EUS were screened of whom 253 (24%) had prior MRCP and formed the study group. Median age was 58 (16–88) years, 179 (71%) were female and 91 (36%) had a cholecystectomy. Median interval between EUS and MRCP was 5.2 (0.1–37) months. Indications for EUS were: n=76 (30%) dilated CBD, n=65 (26%) query CBD stones, n=54 (21%) unexplained acute pancreatitis (AP), n=23 (9%) right upper quadrant pain, n=17 (6.7%) abnormal LFTs, n=16 (6.3%) double duct sign and n=2 (1%) dilated PD. There was a yield from EUS in 30 (12%) patients with no significant difference between those with (n=11) or without cholecystectomy (n=19). Stones were identified in 24 cases with median size of 4 mm (range 2–8) in: CBD (n=16), cystic duct (n=1) and GB (n=7). Three had abnormal CBD without stones (calcification CBD wall, thick walled CBD, polyp), 1 patient with possible stone on MRCP had no stone seen on EUS, 1 had a pancreatic mass, and 1 had chronic pancreatitis. All patients in whom EUS findings indicated an intervention (26/30) have been referred: ERCP in 13, cholecystectomy in 9, ERCP and cholecystectomy in 3 and chemotherapy in 1. Conclusion EUS following non-diagnostic MRCP is a sizeable workload accounting for 24% of diagnostic activity in our unit with a clinically significant yield in 12% of predominantly small stones. Further prospective studies are required to ascertain the most cost-effective way to incorporate EUS into the investigation of suspected gallstone disease.

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 IgG4-related disease (IRD) is a multisystem disease where raised serum IgG4 may predict relapse and multiorgan involvement.1 The aim of this study was to compare demographics, multi-organ involvement, response to treatment, relapse rate and end organ damage in patients with versus those without a raised serum IgG4 level at the point of diagnosis. Methods Patients diagnosed with IgG4 disease between January 2005 and September 2016 according to the ICD Criteria formed the study population. Patients were divided into two groups – Group 1: patients with elevated serum IgG4 and Group 2: normal serum IgG4. Patients’ demographics, other organs involvement, response to steroid treatment, relapse rate and long-term complications (organ dysfunction, exocrine and endocrine insufficiency) were compared between the 2 groups. For this study, we analysed the data based on 2 levels of IgG4 A:>than upper limit of normal and B: Twice the upper limit of normal as reported in literature.1 The patients were followed up for at least 12 months from the time of diagnosis. Results Of the 47 patients identified, 31 (66%) patients had elevated serum IgG4 at diagnosis. There was no statistically significant difference between the 2 groups in age (median age 66 vs 63, p=0.116) and sex (male 85.7% vs 58.8%, p=0.072); other organs involvements (85.7% vs 94.1%, p=0.635), response to steroids (92.6% vs 87.5%, p=0.062), relapse rate (32.1% vs 11.8%, p=0.165) and organ dysfunction (10.7% vs 5.9%, p=1.0).When the serum IgG4 cut-off was twice the upper limit of normal (ULN), more patients had exocrine insufficiency (78.9% vs 46.2%, p=0.035). However other organs involvement (89.4% vs 88.5%, p=1.0), response to steroids (94.4% vs 88.0%, p=0.628), relapse rate (36.8% vs 15.4%, p=0.160), organ dysfunction (10.5% vs 7.5%, p=1.0) and endocrine insufficiency (42.1% vs 46.2%, p=0.973) showed no statistically significant difference. Median follow-up was 40 months (range 12–140 months). Conclusions This single centre observational study shows that a raised serum IgG4 at the point of diagnosis greater than ULN did not affect prognosis in patients with IRD. However a raised serum IgG4 greater than two times the ULN was significantly associated with pancreatic exocrine insufficiency and relapse in patients with IgG4-RD. Larger multicentre studies with longer follow-up are required to corroborate these findings and define the role and cut-off value of serum IgG4 in outcomes of IgG4-RD. Reference . Culver EL, et al. Elevated serum IgG4 levels in diagnosis, treatment response, organ involvement, and relapse in a prospective IgG4-related disease UK cohort. Am J Gastroenterol. 2016;111(5):733–743.

Introduction Pancreatic neuroendocrine tumours (PanNET) are a distinct tumour type with outcomes dependent, in part, upon grading by Ki67. Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) shows variable accuracy to determine Ki67 or grading. Our aim was to assess whether Ki67 and grade can be more accurately determined using fine needle biopsy (FNB) compared to FNA using surgical excision histology as the gold standard. Methods Retrospective analysis of all pancreatic pathology for neuroendocrine tumours was performed for the period Jan 2009 – Jun 2017. Patients were included if they had undergone EUS guided sampling of the lesion prior to surgical resection. Patient demographics, lesion size and location were noted. FNA and FNB results were examined and Ki67 and grade recorded. Surgical histology reports were examined and time from EUS to surgery, operation performed, Ki67 and grade recorded and compared using correlation coefficient and Cohen’s Kappa. Results 162 patients were diagnosed with PanNET in our centre over the study period of which 57 underwent surgical resection (mean age 55.6, 30 males). 22 lesions (mean size 24.5 mm) were located in the head, 10 in the body and 25 in the tail of the pancreas. 35 lesions underwent FNA and 26 FNB (4 lesions underwent both) all of which confirmed PanNET on cytology or histology respectively. On surgical histology 33 lesions were grade 1, 22 were grade 2, 1 was grade 3 and 1 was mixed neuroendocrine-acinar. 23/35 FNA samples could report Ki67/grading compared to 26/26 FNB samples (p=0.0006). Ki67 on FNA showed a weak correlation with surgical pathology (R=-0.08, p=0.74) whereas Ki67 on FNB showed a moderate correlation (R=0.65, p=0.0004). With respect to tumour grading, FNA samples showed a poor correlation (kappa=0.026) and FNB samples showed a moderate correlation (kappa=0.474). Excluding cystic lesions gave similar results. 12 samples had been obtained using the Procore needle and 13 samples obtained using the Sharkcore needle. Procore correlation of Ki67 to surgical resection histology was moderate (r=0.521, 95% confidence interval −0.07–0.84, p=0.08). Sharkcore correlation of Ki67 to surgical resection histology was good (r=0.788, 95% confidence interval 0.42–0.93, p=0.0013). With respect to tumour grading, both Procore and Sharkcore showed moderate correlation (kappa=0.47 and 0.435 respectively). Conclusion Both FNA and FNB can be used to confirm a diagnosis of PanNET. However, FNB samples were significantly more likely to provide adequate material for Ki67/grading and showed a closer match to Ki67/grading of the final surgical histology.

Background and study aims Pancreatic fluid collection (PFC) is a common complication of pancreatitis for which endoscopic ultrasound-guided drainage is first-line treatment. A new single-device, lumen-apposing, covered self-expanding metal stent (LAMS) has been licensed for PFC drainage. We therefore present our multicenter experience with the LAMS for PFC drainage in a multicenter prospective case series to assess success and complication rates. Patients and methods All adult patients from 11 tertiary centers who had LAMS placement for PFC from July 2015 to July 2016 were included. Data including indications, technical success, clinical success, collection resolution, stent removal, early and late adverse events (AEs), mortality and recurrence at 6 months were collected. Results 116 patients, median age 52.5 years (range 16 – 80) and 67 % male, were treated with a single LAMS in each case. The indication was walled off necrosis (WON) in 70 and pseudocyst in 46. Median size of the PFC was 11 cm (5 – 21 cm) and the estimated median necrotic volume in WON was 30 % (5 % – 90 %). Stent insertion was technically successful in 115 (99.1 %) and clinically successful in 109 (94 %). Early serious AEs (SAEs): n = 7 sepsis, n = 1 stent blockage with food, n = 1 stent migration requiring laparotomy, n = 1 stent dislodgement and n = 1 bleeding requiring emboliZation. Late AEs: n = 1 buried stent and n = 1 esophageal fistula. Non-procedure-related deaths: n = 3 (2.5 %). Conclusion This multicenter case series demonstrates that use of the new LAMS is feasible, effective and relatively safe in draining PFC with a technical success rate of 99 % and cumulative SAE rate of 11.2 %.