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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 %.

Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts.To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values.A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis.CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p 0.05.The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.

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. Method 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 DBD LT’s performed between 2013 and 2016 and all DCD LT’s performed between 2007 and 2016. Univariate and multivariable analysis was used to identify risk factors for biliary complications and ascertain factors associated with stricture resolution and ascertain factors associated with biliary stricture resolution. Results A total of 153 (n=122 DBD and n=31 DCD) patients were included of which 43 (28%) patients developed biliary complications. There was no difference in the rate of biliary leaks but biliary strictures were associated with DCD (16/31, 51.6%) compared to DBD (27/122, 22.1%) OR 3.1 (1.6–8.6, p=0.0017), higher donor risk index (2.08 vs. 1.85, p=0.017) and warm ischaemia time >40 min (p=0.033). Late biliary strictures (>1 year) occurred more frequently in DCD compared to DBD livers (4/11 vs. 1/15 respectively). 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 6.4, 2.4–17.0, p=0.0002). 11/43 with biliary complications underwent surgical or radiological management. The remainder underwent ERCP; 24 patients had 60 procedures for strictures, 6 patients had 17 procedures for biliary leak and 2 had 4 procedures for stone disease (all DCD). There were no differences in stricture resolution between DCD and DBD (7/11 vs. 11/13, p=ns) or the number of procedures required (32 in DBD vs. 28 in DCD). However, stricture resolution rates were higher following fcSEMS insertion compared to plastic stents (8/10 vs. 10/39 respectively, p=0.006). Conclusion Biliary complications are associated with DCD livers, higher DRI and longer warm ischaemia time. Endoscopic management of biliary complications leads to high resolution rates but patients undergo a high volume of such procedures. fcSEMS appear to have improved efficacy for stricture resolution compared to plastic stents. Disclosure of Interest None Declared

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

To determine the yield of endoscopic ultrasound (EUS) in the investigation of patients with normal liver function tests (LFTs) and unexplained dilatation of common bile duct (CBD) and/or pancreatic duct (PD), following CT and/or magnetic resonance cholangiopancreatography.Consecutive patients undergoing linear EUS between January 2007 and August 2011 for the indication of dilated CBD and/or PD, normal LFT, and nondiagnostic cross-sectional imaging formed the study group. The study was performed as a retrospective analysis of prospectively collected data.During the study period, 83 patients (CBD and PD dilatation n = 38, PD dilatation n = 5, CBD dilatation n = 40) met the inclusion criteria and underwent EUS. Five (13.1%) of the CBD and PD groups had a new finding, which in one (2.6%) case was causal. In this group, men were significantly more likely to have a new finding (p = 0.012). Eight (20%) of the CBD group had a new finding, which in seven (17.5%) cases was causal. In the CBD group, cholecystectomy was significantly (p = 0.005) more common in those without a finding. Three (60%) of the PD group had a finding on EUS, all of which were causal, including a case of pancreatic malignancy.There is a significant yield from EUS in individuals with isolated PD dilatation and isolated CBD dilatation. Previous cholecystectomy is significantly associated with a negative EUS in the group with isolated CBD dilatation. The yield in those with CBD and PD dilatation was low and a finding was more likely in males.

We read with interest the paper by Bang et al 1 concerning their interim analysis of an ongoing randomised study comparing a novel fully covered self-expanding metal stent (fcSEMS) to plastic stents in patients undergoing endoscopic drainage of walled-off pancreatic necrosis (WOPN). This was following concerns over higher than expected adverse events in the fcSEMS (50%) compared with the plastic stent group (0%). Specifically, these adverse events were three cases of bleeding, two cases of buried stent and one case of biliary stricture. The three cases of bleeding were found to have pseudoaneurysms, which were treated by radiologically guided coiling. One of the buried stent cases developed severe bleeding on removal and requiring radiological intervention. The biliary stricture was managed endoscopically with fcSEMS removal and biliary …

Background Secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) facilitates better visualization of the pancreaticobiliary ductal system but its role in patients with acalculous biliary pain (ABP) is yet to be established. The aim of this study was to assess the diagnostic yield and the role of S-MRCP in the investigation of ABP patients. Methods This is a retrospective analysis of patients who had S-MRCP to investigate ABP over a 5-year period from June 2008 to May 2013. The findings and diagnosis as reported in the S-MRCP were compared with the findings on MRCP. The primary endpoint was the diagnostic yield of S-MRCP in ABP patients. Results A total of 117 patients with ABP [28 (24%) male] had S-MRCP during the study period. The most common abnormality identified was obstruction at the level of ampulla or in the proximal pancreatic duct. S-MRCP was able to identify significant pathological findings in 8 of 34 (22%) patients in whom MRCP did not detect any abnormality. Endoscopic ultrasound (EUS) was performed in 67% of patients. S-MRCP identified abnormalities in 21 of 41 (54%) patients who had a normal EUS. Conclusions We conclude that the diagnostic yield of S-MRCP for recognizing anatomical variants of the pancreatic ductal system, in particular ampullary or proximal pancreatic duct stricture, is better than MRCP and EUS. These findings reflect the dynamic nature of S-MRCP and its complementary role alongside MRCP, EUS and endoscopic retrograde cholangiopancreatography in ABP patients. Keywords MRCP, secretin, abdominal pain, visceral pain, endosonography Ann Gastroenterol 2016; 29 (3): 367-372

Acute upper gastrointestinal bleeding (AUGIB) is a major medical emergency. In 2007, a UK-wide GI bleed audit showed an overall mortality of 10% in patients admitted with AUGIB. Following results of this audit, both SIGN (Scottish Intercollegiate Network Guidelines) and NICE (National Institute for Health and Clinical Excellence) have published guidance on the management of this common and challenging gastroenterological condition to improve the standard of care for people with AUGIB. In this article, Vikramjit Mitra, Benjamin Marrow and Manu Nayar describe an evidence-based approach to the management of this common and life-threatening condition and review the literature around this topic.

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are complex endoscopic procedures requiring highly skilled nursing assistants. For these procedures to be performed safely and efficiently, regular training and teaching for all staff involved is essential. Currently there are no mandatory training courses in the region for these procedures despite the recognized need. The aim of the first Newcastle ERCP and EUS course was to address the basic principles of these complex endoscopic procedures and highlight recent developments in the field. In this article, Manu Nayar, Gillian Nicholson, Heather Gray and Linda Hodgson outline the experiences of fifty nurses who attended the course.

Pancreaticobiliary disorders are common in clinical practice and often require complex investigations before a final diagnosis and management plan is formulated. Many patients will undergo an endoscopic investigation or therapy, both of which can be challenging. Endoscopic ultrasound is increasingly used as one of the modalities for investigating and treating such patients and the indications for interventional endoscopic ultrasound appear to be increasing. In this review article, the role of endoscopic ultrasound in the investigation pathway of patients with benign and malignant pancreaticobiliary diseases will be considered. The limitations of endoscopic ultrasound and some areas of future expansion will also be discussed.

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

Background & Aims: Our study aimed to assess the sensitivity of EUS and EUS-FNA for pancreatic neuro-endocrine tumors (pNETs) and compare performance over two consecutive 4 year 2 month periods, to investigate the comparative performance between solid and cystic pNETs and determine the incremental yield of EUS±FNA in individuals with a mass not diagnosed as a pNET after cross-sectional imaging.Methods: A retrospective review of a prospectively maintained database was carried out to identify all pNET patients who underwent EUS-FNA between April 2003 and September 2011.Results: A final diagnosis of solid and cystic pNETs was made in 43 and 10 patients, respectively. Overall, the yield of combined EUS imaging and cytology was significantly higher than that of CT and/or MRI (p< 0.05) across all groups [solid (83.7% vs. 41.8%), cystic (70% vs. 10%) and combined solid-cystic (81.1% vs. 35.8%)]. The yield of combined EUS imaging and cytology was significantly better than EUS imaging alone (p

Ulcerative colitis and Crohn’s disease result from an interaction between genetic and environmental factors. Only one gene, NOD2/CARD15, has been clearly identified; a minority of people with alteration of this gene develop Crohn’s disease. The NOD2/CARD15 protein is thought to be involved in defence against intracellular bacteria. This supports the idea that Crohn’s disease and ulcerative colitis result from altered immunological responses to the normal intestinal flora. Life expectancy is normal in ulcerative colitis and nearly so in Crohn’s disease, but both conditions cause considerable morbidity. Approximately 80% of patients with Crohn’s disease eventually require surgery, and about 25% of patients with ulcerative colitis require colectomy. Treatment of ulcerative colitis is generally by corticosteroids for acute disease and mesalazine for maintenance, but the range of therapies for Crohn’s disease is expanding. Alternative therapies include immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab), corticosteroids, and surgery. High dosages of corticosteroids may provide symptomatic relief in Crohn’s disease but do not affect the long term natural history of the disease, and management strategies should avoid using steroids whenever possible.

Background & Aims: Autoimmune pancreatitis (AIP) is a fibroinflammatory condition affecting the pancreas and could present as a multisystem disorder. Diagnosis and management can pose a diagnostic challenge in certain groups of patients. We report our experience of managing this condition in a tertiary pancreaticobiliary centre in the North East of England.Methods: Patients were identified from a prospectively maintained database of patients diagnosed with AIP between 2005 and 2013. Diagnosis of definite/probable AIP was based on the revised HISORt criteria. When indicated, patients were treated with steroids and relapses were treated with azathioprine. All patients have been followed up to date.Results: Twenty-two patients were diagnosed with AIP during this period. All patients had pancreatic protocol CT performed while some patients had either MR or EUS as part of the work up. Fourteen out of 22 (64%) had an elevated IgG4 level (mean: 10.9 g/L; range 3.4 - 31 g/L). Four (18%) patients underwent surgery. Extrapancreatic involvement was seen in 15 (68%) patients, with biliary involvement being the commonest. Nineteen (86%) were treated with steroids and five (23%) required further immunosuppression for treatment of relapses. The mean follow up period was 36.94 months (range 7 - 94).Conclusion: Autoimmune pancreatitis is being increasingly recognized in the British population. Extrapancreatic involvement, particularly extrahepatic biliary involvement seems to be a frequent feature.Diagnosis should be based on accepted criteria as this significantly reduces the chances of overlooking malignancy. Awareness of this relatively rare condition and a multi-disciplinary team approach will help us to diagnose and treat this condition more efiectively thereby reducing unnecessary interventions.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is used as the first-line modality for biliary drainage in patients with obstructive jaundice. However, anatomical or technical factors may preclude conventional trans-papillary biliary access in less than 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an alternative method to percutaneous transhepatic biliary drainage (PTBD) or surgical biliary bypass after unsuccessful ERCP in patients with inoperable pancreatobiliary malignancies. We present initial experience of EUS-BD in our unit. Methods A prospectively collected database, of consecutive patients undergoing EUS-BD in our unit, was analysed. Data was retrieved from electronic, clinical and endoscopy records. All EUS-BD procedures were undertaken in the endoscopy department, under conscious sedation, using Pentax echoendoscopes and Hitachi ultrasound workstations. In all cases, conventional diagnostic EUS procedure was performed followed by trans-luminal EUS-guided placement of metal stents. One of three endoscopists (KO/MN/MD) performed the procedures. The primary outcome measurements were technical success, clinical success and adverse events. Results 4 EUS-BD procedures were performed in 4 patients – ¾ were female (75%) with median age 70 years (range 51–79). The primary indication in all patients was malignant biliary obstruction, which was not amenable to either PTBD or surgery. One patient had symptomatic cystic duct obstruction with gallbladder empyema. 1 patient received a Hot AXIOS™ covered lumen apposing metal stent (cLAMS), 1 had a Wallflex™ biliary fully covered self-expanding metal stent (fcSEMS) and the others had NAGI™ covered self-expanding metal stents (cSEMS) inserted. Technical and clinical success was 100% across all procedures with symptomatic improvement noted in all patients. Serum bilirubin measurements decremented post EUS-BD by median 89% (range 85–98%). No procedure related complications were seen. During follow up, 3/4 patients have died (median 7 months (range 3–8) from date of EUS-BD) of end-stage disease (unrelated to the EUS-BD procedure). The 4th patient remains clinically stable on follow-up (2 months after EUS-BD) with no evidence of further biliary symptoms. Conclusion Our early experience of EUS-BD confirms that it is a safe and effective palliative procedure in patients with malignant biliary tract obstruction, in whom surgery and/or PTBD are less favourable. We recommend that EUS-BD is performed after multidisciplinary team discussion and by experienced therapeutic endosonographers. Disclosure of Interest None Declared

Introduction Pancreatic fluid collections (PFC) are a common local complication of pancreatitis with incidences of 5–16% and 20–40% in acute and chronic pancreatitis, respectively. 1 Classification of PFC includes acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis (WON). A new lumen-apposing, covered self-expanding metal stent on a catheter-based delivery system (Hot AXIOS, Boston Scientific) may have higher technical success rates, easier deployment and lower migration than plastic stents. We present the first multicentre prospective case series from the UK and Ireland to assess success and complication rates associated with Hot AXIOS stent for the drainage of PFC. Methods All adult patients who had Hot AXIOS stent placement for PFC from July 2015-February 2016 were included. Eight centres participated (London, Glasgow, Edinburgh, Newcastle, Cambridge, Manchester, Dublin and Leeds). All patients had CT of the PFC prior to placement. Data including technical success, resolution of collection, complications and stent migration were collected. Results Forty patients were treated with a single Hot AXIOS stent in each case. The median age was 57 years (range 31–78). 25 were male and 15 female. Indications were WON (24), pseudocyst (15) and abscess. 1 The median size of the PFC was 11 cm (4–20 cm). Thirty-eight patients (95%) had trans-gastric stents, 1 had trans-duodenal and 1 had a trans-oesophageal stent. Procedures were technically successful in all patients. Of 22 patients with available follow-up data to date, the collection resolved in 19 (86%) and reduced in size in 3 (14%). The median time to resolution was 36 (7–208) days. Twelve patients (30%) had 33 necrosectomies and/or endoscopic lavage following stent insertion. Stents migrated out in 2 patients and was displaced during necrosectomy in 1. Serious adverse events occurred in 1/40 (2.5%): a small bowel obstruction resulting from stent migration, managed surgically. There was no procedure related or 30 day mortality (data available in 27 patients). Conclusion This multicentre case series demonstrates that the Hot AXIOS system is safe and effective in draining PFC with a technical success rate of 100% and low serious adverse event rate. Reference 1 Banks PA, Bollen TL, Dervenis C, et al . Classification of acute pancreatitis—2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013. Disclosure of Interest None Declared

Introduction A new core biopsy needle (SharkCore) with a novel design has recently been introduced for endoscopic ultrasound guided biopsy. There is as yet no data on how its diagnostic performance compares to the existing core biopsy needle (Procore) in the diagnosis of pancreatic masses. The aim of this study was to compare the diagnostic performance and yield of the two core biopsy needles i.e. the ProCore and the Sharkcore needles in the biopsy of solid pancreatic lesions. This is the first study in literature to compare 2 core biopsy needles. Methods A retrospective comparison of a prospectively maintained database. Consecutive patients who had EUS guided fine needle biopsy with Procore (100) and Sharkcore (101) were included in the study. Demographic details, site of lesion, number of passes and histological diagnosis. Final diagnosis was based on positive histology or at least 6 months follow up in cases with a benign pathology. Primary outcome was to compare the diagnostic accuracy of the two needles using only samples graded as definitely malignant as diagnostic for malignancy. The secondary outcome was to compare the diagnostic yield for both needles. Results The sensitivity, specificity, negative predictive value and accuracy between the groups were - Procore =71%, 100%, 28% and 74% vs. Sharkcore =91%, 100%, 53% and 94%. There was a significant difference in sensitivity (p = 0.0003) and accuracy (p = 0.006). The proportion of samples classified as adequate for histological analysis was 87% for Procore and 99% for Sharkcore - this was significantly different (p = 0.0009). There were no complications in either group. Conclusion In this study the SharkCore biopsy needle demonstrated significantly better diagnostic accuracy and tissue yield. Prospective randomised studies are required. Disclosure of Interest None Declared

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

Background Recent data suggest that quantitative EUS elastography, a novel technique that allows real-time quantification of tissue stiffness, can accurately differentiate malignant from benign solid pancreatic masses. Objective To externally validate the diagnostic utility of this technique in an independent cohort. Design and Setting Prospective, single-center study. Patients, Interventions, and Methods A total of 104 patients with evidence of a solid pancreatic mass on cross-sectional imaging and/or endosonography underwent 111 quantitative EUS elastography procedures. Multiple elastographic measurements of the mass lesion and soft-tissue reference areas were undertaken, and the corresponding strain ratios (SRs) were calculated. The final diagnosis was based on pancreatic cytology or histology. Main Outcome Measurements The area under the receiver-operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of quantitative EUS elastography for discriminating malignant from benign pancreatic masses. Results The final diagnoses were primary pancreatic carcinoma (71.2%), neuroendocrine tumor (10.6%), metastatic cancer (1.9%), and pancreatitis (16.3%). Malignant masses had a higher SR ( P = .01) and lower mass elasticity ( P = .003) than inflammatory ones. The areas under the receiver-operating characteristic curve for the detection of pancreatic malignancy of both SR and mass elasticity (0.69 and 0.72, respectively) were less favorable than reported recently. At the cut points providing the highest accuracy in this cohort (4.65 for SR and 0.27% for mass elasticity), quantitative EUS elastography had a sensitivity of 100.0% and 95.7%, specificity of 16.7% and 22.2%, positive predictive value of 86.1% and 86.4%, negative predictive value of 100.0% and 50.0%, and overall accuracy of 86.5% and 83.8%, respectively. Limitations Relatively small number of patients with benign disease. Conclusion In the largest single-center study to date, the diagnostic utility of quantitative EUS elastography for discriminating pancreatic masses was modest, suggesting that it may only supplement rather than supplant the role of pancreatic tissue sampling in the future.

The diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been suggested as a benchmark of quality performance in EUS. However, there is paucity of data on the training requirement for competency in EUS-FNA of the pancreas. KO commenced the service without prior formal training in EUS-FNA. A formally trained colleague (MN) who underwent a fellowship in the same unit was appointed to a substantive post in 2007. The aims of the study were to assess if a dedicated training program in pancreaticobiliary (PB) EUS-FNA of solid lesions: (1) produced better results at the outset of independent practice than produced at the initiation of service without formal training and (2) produced results comparable with those of an experienced endosonographer.This is a retrospective review comparing the first 80 consecutive cases at the onset of practice of operator KO1 (2003/2004) and MN (2007/2008) as well as consecutive cases of operator KO2 (2007/2008) in the same time frame as the initial cases of operator MN.There was a significant difference in EUS-FNA sensitivity for pancreatic malignancy between operator KO1 (56%) and operator MN (77%) p0.05. There was no significant difference in test performance between operator KO2 (82%) and MN (77%) (p0.05).Our data show that formal training in PB EUS produces test performance at the outset of independent practice that is comparable with an experienced endosonographer, in line with the published standards for EUS-FNA of the pancreas and significantly better than that achieved without training.

This article reviews the development of the hepatopancreatobiliary (HPB) endoscopic ultrasound (EUS) service at Freeman Hospital and seeks to identify from our experience learning points for good practice and pitfalls to avoid. The Freeman HPB EUS service has expanded rapidly over the past 10 years in response to the consolidation of cancer care and aligned to the needs of the cancer network. Effective multidisciplinary teamwork and increased subspecialisation by the endosonographers has allowed the efficient use of capacity and development of skills. Mechanisms for monitoring diagnostic performance put in place at the outset of the EUS-fine needle aspiration programme have helped to identify interventions that have led to improved test performance. An excellent working relationship between all stakeholders is critical to the success of such a service as is a preparedness to seek and respond to the views of patients and referrers.

Individuals with suspected malignant biliary obstruction commonly undergo ERCP for drainage and tissue sampling via biliary brushings. EUS with EUS-FNA facilitates staging and potentially more accurate tissue sampling.The aim is to compare the diagnostic performance of EUS-FNA and ERCP with biliary brushings (ERCP-BB) in the diagnosis of pancreatobiliary carcinoma and the utility of combining the two procedures under conscious sedation.Retrospective analysis of a prospectively maintained database.Thirty-seven patients with suspected malignant obstructive jaundice underwent 39 paired procedures, either combined (n=22) or within a few days (n=17).Using strict cytological criteria the sensitivity of EUS-FNA in the diagnosis of malignancy was 52.9% (95% CI: 35.1-70.2%) versus 29.4% (95% CI: 15.1-47.5%) for ERCP-BB. Combining the two tests improved sensitivity to 64.7% (95% CI: 46.5-80.3%) which was significantly better than ERCP-BB alone (P=0.001) but not EUS-FNA alone (P=0.125). When both procedures were performed under the same conscious sedation, there was a significant difference (P=0.031) between the sensitivity of EUS-FNA (52.6%; 95% CI: 28.9-75.6%) and that of ERCP-BB (21.1%; 95% CI: 6.1-45.6%). When both procedures were performed together the mean±SD in-room time was 79±14 min (range: 45-105 min). Two of the patients (9.1%) had a complication.In patients undergoing EUS-FNA and ERCP-BB under the same sedation, EUS-FNA was significantly more sensitive in diagnosing malignancy. Combining the results of both tests improved diagnostic accuracy. Combining therapeutic ERCP and EUS-FNA under the same conscious sedation is feasible, with a complication rate similar to that of ERCP alone.

Autoimmune pancreatitis is increasingly being diagnosed as a multiorgan disorder and a small group of patient present a diagnostic and management dilemma.We report a complicated case of autoimmune pancreatitis with multiorgan involvement. This is the first reported case of pericardial involvement and agrees with other authors that autoimmune pancreatitis is a multisystem disorder predominantly affecting the pancreas.In such cases more intensive immunosuppressive therapy may be necessary to get better control of the disease as is apparent from this case.

Introduction EUS-guided FNA is the standard of care for tissue sampling of pancreatic lesions. The new Echo Tip ProCore biopsy needle (Cook Medical) was developed to obtain core tissue specimens for histological analysis improving the diagnostic yield and potentially obviating the need for onsite cytopathologist. Our aim was to compare the standard Echo tip ultra FNAC needle with the new Echo Tip Ultra ProCore FNAB needle in the sampling of solid pancreatic lesions. Method Randomised multicenter trial (REC Ref 12/EM/0189). All patients referred for EUS-guided tissue sampling of a solid pancreatic mass were invited to participate. Linear EUS (Aloka-Olympus/Hitachi-Pentax) was performed and patients were randomised to either FNAC or FNAB. Due to the nature of the study the endoscopist could not be blinded. A 22G needle was used when sampling from the stomach and a 25G from the duodenum. A maximum of 5 passes were allowed. Sampling time from first insertion of the needle into the lesion to the time the last tissue sample is transferred into the histology pot, number of passes and adequacy for diagnosis were recorded and included for analysis. Immediate and delayed complications were also recorded. Results 266 patients were recruited (median age 67 years, 52% men); 142 randomised to the FNAC group and 124 to the FNAB group. Two patients were excluded after randomization; no mass lesion was seen in 1 patient randomised to FNAC and the needle failed in 1 patient in the FNAB group and FNAC was performed. 264 patients were analysed, 141 in the FNAC group (22G=83 and 25G=58. Median max diameter of the lesion 34 mm, range 10–87 mm) and 123 in the FNAB group (22G=53 and 25G=71. Median max diameter 33 mm, range 8–85 mm). There was no statistical significant difference between groups in number of passes (median 4, range 1–5 in the FNAC group vs. median 3, range 1–5 in the FNAB group, p = 0.12), sampling time (median 13 min, range 1–32 min vs. median 13 min, range 2–42 min, p = 0.63) and adequacy of the specimen for diagnosis (90.8% vs. 87%, p = 0.33). Three technical failures were observed in the FNAB group and none in the FNAC cohort (1.6% vs. 0%, p = 0.99). No complications reported in either group. Conclusion FNAC and FNAB needles were comparable in terms of sampling time, number of passes, sample adequacy for diagnosis and safety. Technical failure was higher in the FNAB arm but not statistically significant. Disclosure of interest None Declared.