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Gallstone disease is a recognized complication of bariatric surgery. Subsequent management of choledocholithiasis may be challenging due to altered anatomy which may include Roux-en-Y gastric bypass (RYGB). We conducted a retrospective service evaluation study to assess the safety and efficacy of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with RYGB anatomy.All the patients who underwent EDGE for endoscopic retrograde cholangiopancreatography after RYGB at two tertiary care centers in the United Kingdom between January 2020 and October 2021 were included in the study. Clinical and demographic details were recorded for all patients. The primary outcome measures were technical and clinical success. Adverse events were recorded. Hot Axios lumen apposing metal stents measuring 20 mm in diameter and 10 mm in length were used in all the patients for creation of a gastro-gastric or gastro-jejunal fistula.A total of 14 patients underwent EDGE during the study period. The majority of the patients were female (85.7%) and the mean age of patients was 65.8 ± 9.8 years. Technical success was achieved in all but one patient at the first attempt (92.8%) and clinical success was achieved in 100% of the patients. Complications arose in 3 patients with 1 patient experiencing persistent fistula and weight gain.In patients with RYGB anatomy, EDGE facilitated biliary access has a high rate of clinical success with an acceptable safety profile. Adverse events are uncommon and can be managed endoscopically.

Background/Aims: Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience.Methods: One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: “Trainees,” “Consultants group 1” (performed >75 ERCPs per year), and “Consultants group 2” (performed >100 ERCPs per year).Results: Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77–0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74–0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69–0.95).Conclusions: This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

ObjectiveWe report on the increasing incidence and outcomes from intentional foreign body ingestion (iFoBI) presenting to our hospital over a 5-year period. The aim was to assess the impact on services and to identify ways to safely mitigate against this clinical challenge.Design/methodWe performed a retrospective observational study of all patients presenting to a university hospital between January 2015 and April 2020 with iFoBI with a focus on objects swallowed, timing of endoscopy and clinical outcomes.Results239 episodes of iFoBI in 51 individuals were recorded with a significant increase in incidence throughout the study period (Welch (5, 17.3)=15.1, pConclusionIn all except those patients with oesophageal impaction of the object on radiograph, there is no need to perform endoscopic extraction out of hours. A subset of cases can avoid endoscopy with an X-ray immediately prior to the procedure as a significant proportion have passed already. We discuss more holistic approaches to deal with recurrent attendances.

BackgroundFluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) exposes staff and patients to potentially harmful ionizing radiation. We performed a UK survey to explore trainee and trainer attitudes to radiation protection and cholangiogram interpretation in ERCP.MethodsAn electronic 10-point survey was prospectively distributed to endoscopy unit leads, training programme directors between October and November 2019. Only UK-based ERCP trainees and trainers with hands-on procedural exposure were eligible for the survey.ResultsThe survey was completed by 107 respondents (58 trainees and 49 trainers), with an estimated overall response rate of 46%. Overall, 49% of respondents were up to date with their radiation protection course, 38% were aware of European Basic safety standards directive (BSSD), 38% wore radiation protection goggles, and 40% were aware of the average radiation screening dose per ERCP procedure. Compared with trainers, trainees were less likely to routinely wear thyroid protection shields (76% vs 92%; p=0.028), have awareness of the BSSD (20% vs 49%; p=0.037) or know their average procedural radiation dosages (21% vs 63%; pConclusionThis survey highlights a relative complacency in safety attitudes to radiation protection during ERCP. These data provide impetus to improve training and quality assurance in radiation protection, which should be regarded as a mandatory safety aspect prior to commencing hands-on ERCP training.

We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis. A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel–Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots. Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22–1.62, P = 0.31) between LR and NS. I2 indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission. This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.

Backgrounds/aims Post-operative pancreatic fistulas (POPF) and fluid collections (POPFC) remain significant sources of morbidity and mortality after pancreatic resections. There remains a paucity of literature describing endoscopic ultrasound (EUS) guided drainage of POPFC using a Hot AXIOS™ lumen apposing metal stent (LAMS). Methods We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS™ LAMS at our institution between January 2017 and December 2019. Primary outcome measures were technical and clinical success. Secondary outcome measures were adverse events and recurrence rates. Results Five patients underwent EUS guided drainage using Hot AXIOS™ LAMS during the study period. Mean age of patients was 67.8 ± 2.16 years. The majority (60.0%) of patients were males. Median duration of symptom onset after surgery was 9 days. All patients presented with abdominal pain. Median size of the collection measured on computed tomography was 91 mm. Median interval time between symptom onset and EUS drainage was 30 days. Two patients required percutaneous drainage prior to EUS guided drainage. Technical and clinical success were achieved for all patients. No adverse events were observed. Median duration of follow-up was 90 days. No recurrence of collection occurred during the follow-up period. Conclusions EUS guided drainage of POPFC using Hot AXIOS™ LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience.

We were interested to read the recent article by van Baar and colleagues that described an open-label phase II trial of endoscopic duodenal mucosal resurfacing (DMR) in the management of patients with type 2 diabetes mellitus (T2DM).1 van Baar and colleagues demonstrated improvements in a number of parameters, most impressive of which was the reduction in haemoglobin A1c (HbA1c) at 12 months. It is intriguing to consider what the underlying mechanisms might be for this observed improvement in glycaemic control in patients with T2DM, what confounders might be at play and how these might inform the design of future sham-controlled studies. For example, the investigators comment that the initial weight loss ~2.3 kg observed in …

To evaluate the effects of probiotics on individuals’ perception of health and bowel frequency. The VSL#3 Probiotic (V3P; Visbiome in USA; Vivomixx in EU) contains eight strains of live, freeze-dried lactic acid bacteria. It has some therapeutic potential in ulcerative colitis and pouchitis.

Objective Recent data have suggested that non-selective β-blockers (NSBB) are associated with increased mortality in patients with cirrhosis and refractory ascites. However, other evidence implies that NSBB may be beneficial in this setting by reducing bacterial translocation. Our aim was to determine whether NSBB use was a risk factor for mortality in patients with end-stage chronic liver disease and ascites awaiting liver transplantation. Design This was a single-centre retrospective study of 322 patients with ascites listed January 2007 to July 2011. Results NSBB patients (n=159) and non-NSBB patients (n=163) were comparable with regards to listing model for end-stage liver disease score (p=0.168), frequency of hepatocellular carcinoma (p=0.193) and refractory ascites (35.2% vs. 37.4%, p=0.681). 82 patients died, 221 patients were transplanted and 19 patients were removed from the list during a median follow-up duration of 72 days; the median time to death was 150 and 54 days in the NSBB and non-NSBB groups, respectively. In a multivariate competing risk Cox model, patients on NSBB had reduced mortality compared with propensity risk score-matched non-NSBB patients (HR 0.55; 95% CI 0.32 to 0.95, p=0.032). Similarly, in the subgroup of patients with refractory ascites (n=117), NSBB remained independently associated with less waitlist death (adjusted HR 0.35; 95% CI 0.14 to 0.86, p=0.022). Conclusions NSBB in patients with ascites and refractory ascites listed for liver transplantation are not detrimental, and instead are associated with reduced waitlist death. Our findings argue that NSBB are safe and may confer benefit in patients with ascites complicating end-stage liver disease.

We read with interest the article on extrahepatic manifestations of hepatitis C virus by Samuel and Rees.1 We report a dermatological manifestation of hepatitis C, which the authors have not mentioned. A 38-year-old man with hepatitis C was admitted with upper gastrointestinal bleed. He was found to have oesophageal varices that were banded. He developed a tender purpuric rash with ulceration on his lower limbs. There were no other associated symptoms. A clinical diagnosis of cryoglobulinaemia was considered. Vasculitic screen was negative. Samples were tested for the presence of cryoglobulins using standard laboratory procedures comparing plasma and serum samples kept at 37°C, with those then cooled and incubated at 4°C to demonstrate cryoprecipitation. Initial examination showed no visible …

Angiotensin converting enzyme inhibitors (ACEI) are widely used to treat benign hypertension. These drugs are generally well tolerated. Serious side effects such as angio-oedema are very rare. The authors report a 64-year-old Caucasian woman with a history of liver transplant on Mammalian Target Of Rapamycin (mTOR) inhibitor, who attended Emergency department with angio-oedema only on the left side of her tongue. Her airway was patent and she was haemodynamically stable. Trauma was denied. Her physician had 2 days earlier commenced her on Lisinopril for newly diagnosed benign hypertension. Intravenous steroids and anti-histamine were immediately administered. A good response of oedema subsidence was noted. In general, angio-oedema can present in a spectrum of severity. Precipitating factors are often difficult to pre-determine and avoid. Early recognition of risk factors for and diagnosis of angio-oedema can often be life-saving.

Introduction Hepatocellular carcinoma (HCC) is the most common primary liver tumour, and represents the third leading cause of cancer death worldwide. 1,2 The most important risk factor is liver cirrhosis, mainly due to chronic infections such as hepatitis B or C .2 Increasing HCC cases are seen in nonalcoholic fatty liver disease (NAFLD). Methods The aim of the study was to compare demographics, treatments and survival among hepatitis C virus (HCV/HCC) and NAFLD (NAFLD/HCC) cohort of patients. Data were collected from medical electronic case notes, imaging reports and HCC multidisciplinary meetings. Results Among 292 patients, 212 patients (73%) had underlying HCV/HCC and 80 patients (27%) had NAFLD/HCC. The median age at diagnosis was significantly higher in NAFLD/HCC (p The median alpha fetoprotein level in HCV/HCC patients were 32.0 compared to 12.0 in NAFLD/HCC (p = 0.085). Patients with HCV/HCC were significantly more likely to be transplanted during the study period than NAFLD/HCC (30% vs. 15%, p = 0.010). Both transarterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) were significantly more likely to be used as a single treatment in NAFLD patients, compared to HCV patients (p = 0.042, p = 0.021). Sorafenib was used as the only treatment in 6% of HCV/HCC and 3% of NAFLD/HCC cohorts (p = 0.364). Post transplant survival appeared to be worse in HCV-HCC patients compared to NAFLD/HCC, although it did not reach statistical significance (p = 0.081). Overall five year survival rates were similar between the two groups regardless of any treatment therapies (p = 0.424). Conclusion Despite the NAFLD/HCC being older and with higher metabolic risk factors, a significant proportion could undergo active therapy. Furthermore, patients with NAFLD/HCC selected for transplantation seemed to have better long term outcomes, possibly due to stricter selection for transplantation as well as variations in tumour biology between the two groups. References 1 Mittal S, El-Serag HB. Epidemiology of hepatocellular carcinoma: consider the population. J Clin Gastroenterol 2013;47 Suppl:S2–6 2 Lu T , et al . P revention of hepatocellular carcinoma in chronic viral hepatitis B and C infection . World J Gastroenterol 2013;19(47):8887–8894 Disclosure of Interest None Declared.