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Transactions of the Leicestershire Archaeological and Historical Society, 29, 15-29, By kind permission of Messrs. Dryad Ltd., owners of the site, cuttings were made in August 1952 across the presumed line of Leicester City Wall, in its northern sector, on a property situated between Sanvey Gate and Cumberland Street, seventy yards east of the site of the medieval East Gate, which was demolished in 1774. The excavations took place during the fortnight 7-20 August and were carried out under the auspices of the Leicester Museums and Libraries Committee and of the British Association for the Advancement of Science. The preliminary arrangements were made by Mr. David T.-D. Clarke, Keeper of Antiquities at Leicester Museum, who has also examined and reported on the coarse pottery found in the cuttings. The problem of the City Wall of Leicester was brilliantly assessed by the late Professor F. Haverfield in 1918, and the most recent infor-mation on this subject has been published by Mr. Clarke, who in 1950 cut a section across the eastern defences of the city, in Churchgate. Later disturbance had somewhat obscured the character of the Wall in Church-gate, and it was hoped that the Sanvey Gate site would prove more inform-ative and provide information as to both the character and the date of the defences. This hope has been, in the main, fulfilled; but it became clear at an early date in the excavations that the superstructure of the City Wall had been completely quarried away, a process which probably began soon after the Civil Wars-the last occasion on which Leicester's defences were put to practical test.

BACKGROUND AND AIMS: Digital single-operator cholangioscopy (d-SOC) with cholangioscopic biopsy sampling has shown promise in the evaluation of indeterminate biliary strictures. Some studies have suggested higher sensitivity for visual impression compared with biopsy sampling, although assessors were not blinded to previous investigations. We aimed to investigate the diagnostic accuracy and interobserver agreement (IOA) of d-SOC in the visual appraisal of biliary strictures when blinded to additional information. METHODS: A multicenter, international cohort study was performed. Cholangioscopic videos in patients with a known final diagnosis were systematically scored. Pseudonymized videos were reviewed by 19 experts in 2 steps: blinded for patient history and investigations and unblinded. RESULTS: Forty-four high-quality videos were reviewed of 19 benign and 25 malignant strictures. The sensitivity and specificity for the diagnosis of malignancy was 74.2% and 46.9% (blinded) and 72.7% and 62.5% (unblinded). Cholangioscopic certainty of a malignant diagnosis led to overdiagnosis (sensitivity, 90.6%; specificity, 33%), especially if no additional information was provided. The IOA for the presence of malignancy was fair for both assessments (Fleiss' κ = .245 [blinded] and κ = .321 [unblended]). For individual visual features, the IOA ranged from slight to moderate for both assessments (κ = .059-.400 vs κ = .031-.452). CONCLUSIONS: This study showed low sensitivity and specificity for blinded and unblinded d-SOC video appraisal of indeterminate biliary strictures, with considerable interobserver variation. Although reaching a consensus on the optical features of biliary strictures remains important, optimizing visually directed biopsy sampling may be the most important role of cholangioscopy in biliary stricture assessment. ispartof: GASTROINTESTINAL ENDOSCOPY vol:94 issue:6 pages:1059-1068 ispartof: location:United States status: published

Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas and is associated with acinar cell injury and both a local and systemic inflammatory response. AP may range in severity from self-limiting, characterised by mild pancreatic oedema, to severe systemic inflammation with pancreatic necrosis, organ failure and death. Several international guidelines have been developed including those from the joint International Association of Pancreatology and American Pancreatic Association, American College of Gastroenterology and British Society of Gastroenterology. Here we discuss current diagnostic and management challenges and address the common dilemmas in AP.

Cholangiocarcinoma is an uncommon and highly aggressive biliary tract malignancy with few manifestations until late disease stages. Diagnosis is currently achieved through a combination of clinical, biochemical, radiological and histological techniques. A number of reported cancer biomarkers have the potential to be incorporated into diagnostic pathways, but all lack sufficient sensitivity and specificity limiting their possible use in screening and early diagnosis. The limitations of standard serum markers such as CA19-9, CA125 and CEA have driven researchers to identify multiple novel biomarkers, yet their clinical translation has been slow with a general requirement for further validation in larger patient cohorts. We review recent advances in the diagnostic pathway for suspected CCA as well as emerging diagnostic biomarkers for early detection, with a particular focus on non-invasive approaches.

Immunoglobulin G4-related disease (IgG4-RD) is a complex multisystem fibro-inflammatory disorder, requiring diagnostic differentiation from malignancy and other immune-mediated conditions, and careful management to minimise glucocorticoid-induced toxicity and prevent progressive organ dysfunction. We describe the experience of the first inter-regional specialist IgG4-RD multidisciplinary team meeting (MDM) incorporating a broad range of generalists and specialists, held 6-weekly via web-link between Oxford University Hospitals NHS Foundation Trust and University College London Hospitals NHS Foundation Trust. Over 3 years, there were 206 discussions on 156 patients. Of these, 97 (62%) were considered to have definite or possible IgG4-RD; 67% had multi-organ involvement and 23% had a normal serum IgG4. The average number of specialist opinions sought prior to MDM was four per patient. Management was changed in the majority of patients (74%) with the treatment escalation recommended in 61 cases, including 19 for rituximab. Challenges arose from delays and misdiagnosis, cross-specialty presentation and the management of sub-clinical disease. Our cross-discipline IgG4-RD MDM enabled important diagnostic and management decisions in this complex multisystem disorder, and can be used as a model for other centres in the UK.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory condition of which IgG4-related sclerosing cholangitis (IgG4-SC) is the biliary manifestation. In this review, we provide an overview of IgG4-RD, with a focus on the biliary manifestations. In particular, we describe the important differential diagnoses of IgG4-SC, namely, primary sclerosing cholangitis and cholangiocarcinoma, outline diagnostic criteria for IgG4-SC, provide insight into possible pathophysiological mechanisms underlying the disease and discuss short and long-term management options of this recently described disease.

Introduction IgG4-related disease (IgG4-RD) is a complex multi-system fibroinflammatory disorder, often presenting to the gastroenterologist as autoimmune pancreatitis (AIP) and sclerosing cholangitis (IgG4-SC). It requires careful diagnostic differentiation from malignancy and other inflammatory disorders. The majority of patients have persistent inflammation despite best available treatments, and many who achieve clinical remission subsequently relapse, leading to organ dysfunction and failure. Diagnostic challenges arise from multi-organ cross-speciality presentation, absence of a single diagnostic test and a plethora of diagnostic guidelines, whilst management decisions are influenced by the older demographic and identification of subclinical disease. Methods We established an inter-regional IgG4-RD specialist multi-disciplinary meeting (MDM) held six weekly via web-link between Oxford and UCLH, incorporating multiple specialists across medical, surgical, immunology, histopathology and radiology disciplines. We describe our first year experience (Nov 2016–Nov 2017). Results Over one-year, 50 patients were referred to the IgG4-RD MDM. Of these 31/50 (62%) had multiple organ involvement and 32/50 (64%) had an elevated serum IgG4 (>1xULN). 36 (72%) were referred for diagnostic clarification, of whom 16 (44%) met diagnostic criteria for IgG4-RD (Boston and/or CDC) or AIP/IgG4-SC (HISORt), 9 (25%) did not meet diagnostic criteria but were considered to have ‘possible’ IgG4-RD and were managed as such, and 11 (31%) did not meet diagnostic criteria, and an alternative diagnosis was offered in 6/11. Of those diagnosed with IgG4-RD, 25 (64%) had management changes recormmended via the MDM, including treatment escalation (21; 3 of these had rituximab), de-escalation (4), conservative approach (14), further imaging and histology investigation (9), additional specialist opinion (3). Conclusions We have demonstrated the value of a specialist IgG4-RD MDM incorporating a range of divesre specialists to aid diagnostic and management decsicions in a complex multi-system fibroinflammatory disease, providing a model for other centres across the UK.

Introduction Pancreatic stents (PS) are increasingly used to aid biliary cannulation and reduce the risk of pancreatitis during endoscopic retrograde cholangiopancreatography (ERCP). Proximal PS migration is uncommon (reported in 2–5%) but poses a significant problem due to the risk of pancreatitis and pain. We describe our experience in the endoscopic management of migrated PS. Methods A retrospective review of all ERCPs at our tertiary unit from January ’13 –February ‘19 was performed to identify cases of migrated PS. Results Twelve patients were identified; 10 received PS placement at other UK hospitals, 1 abroad and 1 at our unit. PS indications were prophylaxis of post-ERCP pancreatitis (PEP) in 9 and following pancreatic endotherapy in 3 (one for sphincter dysfunction, one for ductal stricture and one for cyst drainage). The migrated PS were 5 cm (n=11) or 7 cm (n=1) long with diameter of 3Fr (n=1), 5Fr (n=10) and 7Fr (n=1). Seven were straight and 5 single pigtail. 9 PS migrated after reported correct placement (of which 6 (67%) were straight). Two were inadvertently deployed within the pancreatic duct (PD); in one case there was no information regarding placement. The site of PS migration was within the pancreatic head (n=3), body (n=3) and tail (n=6). After MDM review one patient was referred directly for surgery where a PD stricture precluded endoscopic access. Endoscopic removal was attempted in 11 patients and successful in 9 (82%). 7 patients required two procedures. The median interval from stent placement to retrieval was 5 weeks (range 2–20). All patients had a previous pancreatic sphincterotomy. Techniques used for successful retrieval were: stent grabbers (n=3), extraction balloon/stent grabbers (n=1), snare/stent grabbers (n=2) and pancreatoscopy with SpyBiteTM forceps (n=3). Endoscopic removal was unsuccessful in 2/11 patients where pigtail stents had hooked into a side branch. In all cases a 5 cm/5Fr prophylactic PS was placed post retrieval and 8 received rectal diclofenac (one contraindicated). Mild post-ERCP pancreatitis (PEP) occurred in one case. Conclusions Endoscopic retrieval of proximally migrated PS was successful in 82% of patients. Migrated PS retrieval is challenging, and should only be attempted by endoscopists experienced in pancreatic endotherapy following case review within a specialist MDM. The mechanism of migration is unclear and spontaneous proximal migration of an appropriately placed single pigtail PS is unlikely to occur. Apparent migration in these cases most likely arises from incorrect deployment, potentially due to difficulty distinguishing the stent from the pushing device, emphasising the need for caution during PS placement. The optimal retrieval technique depends upon PS type, position, and PD anatomy. In our experience use of an extraction balloon alone was never successful. Failure of endoscopic retrieval was highest with pigtail stents and those >2 cm from the papilla.

Introduction Duodenal obstruction may occur as a complication of duodenal, locally advanced or metastatic cancer. The resulting gastric outlet obstruction may reduce quality of life and life expectancy and the physiological mileu of malnutrition may interrupt palliative chemotherapy. We aim to evaluate of the technical and clinical outcomes of patients undergoing duodenal stent placement for malignant duodenal obstruction. Methods Retrospective study of all patients referred for endoscopic duodenal stent placement from Jan 2014 - Jan 2018. Data was collected from endoscopy procedure records and electronic patient records. All patients with intent for duodenal stenting were included. Technical success was defined by endoscopic or radiographic evidence of satisfactory stent position. Outcome measures included removal of enteral tube (NG/NJ), cessation of vomiting, recommencement of oral nutrition, initiation or resumption of chemotherapy, complications and overall survival. Results 50 patients were referred for duodenal stenting (F=31, median age 68 years). CT scans were available for all patients and all cases were reviewed within our specialist MDM. The level of the obstruction was D1 (26/50), D2 (17/50) and D3 (7/50). Aetiology of malignant obstruction was: pancreatic (n=15), gastric (n=7), ovarian (n=6), cholangiocarcinoma (n=5), duodenal (n=5), colorectal (n=3), breast (n=2) and hepatocellular (n=1). Stenting was attempted in 48 patients (2 were deemed unfit). Successful stent placement was achieved in 43/48 (90%) of patients, with a failure to stent the remaining 5 patients due to an inability to cross the stricture with a wire. A total of 51 uncovered, self-expanding 22 mm diameter metal stents were placed in 43 patients (1 patient required 2 stents at the index procedure, 6 patients required 1 further stent and 1 patient required 2 further stents,). The median stent length was 9 cm (range 6–12 cm). Technical success rates were 90%. Clinical success rates were as follows: Subsequent removal of enteral tube post-procedure 68%, cessation of vomiting 64%, recommencement of oral diet 58%, further chemotherapy 29%. Overall 28 day survival was 85% and 6 month survival was 33% (median survival 66 days). There were no immediate complications following stent placement. 1 patient developed biliary sepsis 5 days post-stenting (previously normal LFTs) and died within 28 days. 3 patients developed obstructive jaundice following stenting (at 4 months, 8 months and 21 months), which was successfully treated with percutaneous stenting in all cases. Conclusion Providing a guidewire can be passed across the stricture, duodenal stenting for malignancy has a high technical success rate in our centre. Early clinical benefit is seen in the majority of patients, and of the 41 patients alive at 3 months, only 3 (7%) required re-intervention during this period. At 6 months, 16 patients were alive, 7 of whom (44%) had required re-intervention. This single centre experience demonstrates high technical and clinical success rates for stenting in patients with malignant duodenal obstruction, with benefit maintained well beyond 3 months. In those patients that survived >6 months, half had further chemotherapy.

Background Endoscopic ultrasound (EUS)–guided transmural drainage is the preferred treatment for symptomatic pancreatic walled-off necrosis (WON). Lumen apposing metal stents (LAMS) are increasingly used, although their advantage over plastic stents remains unclear. Placement of a plastic pigtail stent within the LAMS may help maintain patency and help avoid the need for subsequent endoscopic necrosectomy. We aim to describe the success and complication rates for the use of LAMS in the management of WON. Methods All patients undergoing EUS-guided cystgastrostomy using LAMS for WON between July 2015-January 2019 were included. Data collected included procedural technique, rates of technical and clinical success and complications. All patients had up to date CT or MR scans and all were reviewed in the specialist MDM prior to intervention. Results 40 patients underwent LAMS placement for WON, 75% male, median age 53 years (range 23–79). The aetiology of pancreatitis was: gallstones (n=17), alcohol (n=12), idiopathic (n=9) and post-ERCP (n=2). Mean collection size on pre-procedure imaging was 12 cm (range 4–22). 21 (52.5%) procedures were performed under general anaesthesia, 14 (35%) propofol sedation and 5 (12.5%) conscious sedation. LAMS were placed from the stomach (n=38, 95%) or duodenum (n=2, 5%) and were successfully deployed in 39 (98%). LAMS diameter was 8 mm (n=7), 10 mm (n=5), 12 mm (n=1), 15 mm (n=24) and 20 mm (n=3). Pigtail stents were placed within the LAMS in 14 cases (35%) but did not significantly alter the need for subsequent endoscopic necrosectomy (28% with pigtail stent vs 27% without). Follow up CT demonstrated a reduction in collection size in all cases with a mean maximal diameter of 2.6 cm (0–5 cm). Successful drainage was achieved in 98% at 3 months (1 patient died from complications of acute pancreatitis, unrelated to stent placement) and no patient required percutaneous or surgical drainage. There were two complications; 1) late migration of the gastric flange into the collection, presenting with sepsis 6 weeks post insertion and successfully retrieved following placement of a second LAMS and 2) buried gastric flange, leading to delayed LAMS removal and successfully retrieved 7 months post insertion after transmural tract dilation using large diameter biopsy forceps. Median time to LAMS removal was 51 days (range 26–80). LAMS remained in situ for 21 months in one patient lost to follow-up but was removed without complication. Conclusion Transmural drainage of pancreatic WON using LAMS has excellent rates of technical and clinical success with few complications. Unlike in other published series, we did not observe any late bleeding complications. In our cohort, placement of a pigtail stent through the LAMS did not negate the need for subsequent endoscopic necrosectomy.

Introduction Incidental, unexplained biliary and pancreatitic duct dilatation on imaging performed for other reasons is an increasingly common reason for EUS referral. The radiological ‘double duct’ (DD) sign is associated with pancreatobiliary (PB) malignancy, particularly in those with abnormal liver function tests (LFTs). However data regarding the yield of pathology at EUS in those with DD and normal live biochemistry are sparse. Our aim was to describe findings at EUS performed for investigation of DD in patients with normal LFTs. Methods A retrospective review was performed of EUS procedures for investigation of DD across two tertiary HPB referral centres between 2013 and 2018. Those with abnormal or unknown liver biochemistry, or where expert review of cross-sectional imaging had indicated a mass lesion, stricture or other identifiable cause were excluded. Results 46 patients were included, median age 64 years, 78% female/22% male. Long-term opiate use was documented in 17 (37%). Positive findings were identified at EUS in 10 (21.7%); chronic pancreatitis (n=5), side branch intra-ductal papillary mucinous neoplasm (IPMN) (n=2), benign papillary fibrosis (n=2) and choledocholithiasis (n=1). Ductal dilatation was not seen at EUS in 3 (6.5%) and DD was present with no cause identified in 33 (71.7%), of whom 14 (30.4%) had documented opiate use. Both cases of IPMN lacked high-risk features and the patients remained well with a minimum of 18 months surveillance. One endoscopic complication occurred in a patient without cause for DD sign identified at EUS, who sustained an endoscopic perforation requiring hepatico-jejunostomy. Two cases of ampullary carcinoma were noted during case identification in patients with minimally elevated LFTs undergoing EUS for DD. Conclusions In this cohort with DD and normal liver biochemistry there were no EUS-diagnosed malignancy and the yield of benign pathology was ∼20%, similar to that previously reported4. However, this should be interpreted with caution given the 2 cases of malignancy, not included in this cohort, found with only mild LFT abnormalities and further prospective studies are needed. References Krishna N, et al. Dilation of both pancreatic duct and the common bile duct on computed tomography and magnetic resonance imaging scans in patients with or without obstructive jaundice. Pancreas 2012;41:767–72. Kofi W Oppong, et al. Endoscopic ultrasound in patients with normal liver blood tests and unexplained dilatation of common bile duct and or pancreatic duct. Scandinavian Journal of Gastroenterology 2014;49(4):473–480.

Background Cholangiocarcinomas are a heterogeneous group of malignancies arising from a number of cells of origin along the biliary tree. Although most cases in Western countries are sporadic, large population-based studies have identified a number of risk factors. This review summarises the evidence behind reported risk factors and current understanding of the molecular pathogenesis of cholangiocarcinoma, with a focus on inflammation and cholestasis as the driving forces in cholangiocarcinoma development. Risk Factors for cholangiocarcinogenesis Cholestatic liver diseases (e.g. primary sclerosing cholangitis and fibropolycystic liver diseases), liver cirrhosis, and biliary stone disease all increase the risk of cholangiocarcinoma. Certain bacterial, viral or parasitic infections such as hepatitis B and C and liver flukes also increase cholangiocarcinoma risk. Other risk factors include inflammatory disorders (such as inflammatory bowel disease and chronic pancreatitis), toxins (e.g. alcohol and tobacco), metabolic conditions (diabetes, obesity and non-alcoholic fatty liver disease) and a number of genetic disorders. Molecular pathogenesis of cholangiocarcinoma Regardless of aetiology, most risk factors cause chronic inflammation or cholestasis. Chronic inflammation leads to increased exposure of cholangiocytes to the inflammatory mediators interleukin-6, Tumour Necrosis Factor-ɑ, Cyclo-oxygenase-2 and Wnt, resulting in progressive mutations in tumour suppressor genes, proto-oncogenes and DNA mismatch-repair genes. Accumulating bile acids from cholestasis lead to reduced pH, increased apoptosis and activation of ERK1/2, Akt and NF-κB pathways that encourage cell proliferation, migration and survival. Other mediators upregulated in cholangiocarcinoma include Transforming Growth Factor-β, Vascular Endothelial Growth Factor, Hepatocyte Growth Factor and several microRNAs. Increased expression of the cell surface receptor c-Met, the glucose transporter GLUT-1 and the sodium iodide symporter lead to tumour growth, angiogenesis and cell migration. Stromal changes are also observed, resulting in alterations to the extracellular matrix composition and recruitment of fibroblasts and macrophages that create a microenvironment promoting cell survival, invasion and metastasis. Conclusion Regardless of aetiology, most risk factors for cholangiocarcinoma cause chronic inflammation and/or cholestasis, leading to the activation of common intracellular pathways that result in reactive cell proliferation, genetic/epigenetic mutations and cholangiocarcinogenesis. An understanding of the molecular pathogenesis of cholangiocarcinoma is vital when developing new diagnostic biomarkers and targeted therapies for this disease.

Introduction Percutaneous direct cholangioscopy may expand diagnostic and treatment options where endoscopic biliary access is precluded by post-surgical anatomy. We aim to report the utility of percutaneous transhepatic cholangioscopy in patients with intrahepatic stone disease, using the SpyGlass DS cholangioscopy system. Methods Five patients underwent percutaneous cholangioscopy between July ‘17 and February ‘18. All had post-surgical duodenal anatomy and intrahepatic duct (IHD) stones, three with an associated anastomotic stricture. In all cases prior percutaneous transhepatic cholangiography (PTC) and biliary access was achieved using conventional interventional radiology techniques, with the transhepatic tract dilated to 12 F, and a drain left in situ. Results The procedures are summarised in Table 1. Five procedures were performed under general anaesthetic and one with sedation, with the patient supine. All patients received antibiotic prophylaxis. Under sterile conditions the cholangioscope was introduced percutaneously into the intrahepatic biliary tree via a peel-away sheath (12Fr in 5 cases and 11Fr in 1). Optimal stone localisation was achieved using fluoroscopy and direct visualisation, allowing application of electrohydraulic lithotripsy (EHL) using a Boston Scientific EHL probe for stone fragmentation. In one case 8 mm-10 mm sequential dilatation of an anastomotic stricture was performed. In one case a surgical stitch across the anastomosis was visualised – the likely nidus for stone formation. Stone clearance was successful in all cases where IHD stones were identified. In one case the IHD stones had cleared since the index PTC. There were no recorded procedural complications. Conclusion In this small case series direct visualisation of the biliary tree using percutaneous SpyGlass cholangioscopy was safe, successful and expanded the therapeutic capabilities of PTC. This technique could also be used to enhance the investigation and treatment of post-surgical biliary anastomotic stricturing, where retrograde endoscopic access is not feasible.

Introduction Use of hospital beds as pre/post procedure accommodation places a strain upon resources and risks ‘on the day’ cancellation. Nevertheless ‘day case then home’ may be a poor option for patients undergoing complex endoscopy who live many miles away. Our centre offers Near Hospital Accommodation (NHA) in a bespoke 35-roomed hotel 100 metres from the hospital at a cost of £120/night (versus £380 per inpatient bed). We aimed to assess the safety and utility of NHA for patients within our pancreatobiliary (PB) service. Methods We undertook a retrospective audit of all PB patients who stayed in the NHA from Jan ’15 – Dec ’17. Data collected from the endoscopy database and electronic records included: procedure type, distance travelled, type of hotel room, length of stay and unplanned post-procedural hospital admissions from the NHA. Results Over a 3 year period 152 patients stayed in NHA for 169 nights, ninety-three (61%) female with median age of 62 years (range 24–81). All patients underwent therapeutic ERCP, EUS, or cholangioscopy. The decision to use NHA was based upon case complexity and travel logistics. Most patients (89%) stayed one night and 11% stayed two nights (pre and post-procedure). Median one-way distance travelled was 107 miles (range 3–299 miles) (figure 1). The total cost of NHA was £23,660, saving £40 560 over the equivalent inpatient beds. There were five unplanned admissions (3.3%), summarised in table 1. Conclusion NHA is a safe, cost-effective alternative to hospital admission for selected patients undergoing complex endoscopy. The unplanned readmission rate was low, with no serious complications. The immediate cost saving was considerable, in addition to efficiency savings from the extra bed capacity generated and reduced late cancellations. Benefits to patients include visitor-friendly, hotel-standard accommodation, reduced travelling time on the day of the procedure and saving of private hotels fees. Further studies are needed to assess if this translates into increased patient satisfaction. With increasing centralisation of specialist services and ongoing financial pressures throughout the NHS, the NHA model of care offers advantages to hospitals and patients.

Introduction Biliary anastomotic strictures (AS) occur in 5%–15% of liver transplant (LT) recipients and cause graft dysfunction and morbidity. The main alternative to surgical reconstruction is stenting at endoscopic retrograde cholangiopancreatography (ERCP), using plastic polyethylene or fully-covered self-expanding metal stents (fcSEMS). We retrospectively reviewed outcomes after ERCP for biliary AS, aiming to assess rates of success and complications. Methods Records for all patients undergoing ERCP post LT between 2013–16 were reviewed. AS were classified as early or late ( Results In total 252 ERCPs were performed (median 4/patient, range 2–10) in 62 patients, 72.6% male, age at LT 54 years (range 20–71). 48 grafts (77.4%) were donations after brain death, 13 (21.0%) after cardiac death and 1 live donor. At first endoscopy 53 (85.4%) had a native papilla. Median time from LT was 28 days (4–75) in early AS (n=29, 46.7%, 9 presenting with bile leak) vs 11.5 mths (3.4–251) in late AS (n=33, 53.2%). Biliary stents were placed in 172 ERCPs (63.4% plastic vs 36.6% fcSEMS) and AS dilated in 68 (27.0%; 60 in conjunction with stenting). Stricture resolution was achieved endoscopically in 47/55 patients with complete outcome data (85.5%). Plastic stents were placed at index ERCP in 23/26 of early AS, in whom sequential plastic ‘upstenting’ was ultimately successful in 9 (39.1%) and 12 (52.2%) proceeded to fcSEMS (stricture remodelled in all). Of late AS, 9/29 were managed with fcSEMS (88.8% successfully), 8 plastic ‘upstenting’ (75% success), 8 fcSEMS after initial plastic stent (all successful) and 2 resolved with dilatation only. The overall rate of post-ERCP pancreatitis (PEP) was 7.1% (none severe by Cotton criteria) and was higher after fcSEMS (15.9%) than plastic stenting (5.5%, p=0.024), despite similar use of NSAID prophylaxis. Compared with plastic stents, fcSEMS were more likely to migrate (36.5% vs 12.8%, p Conclusions Endoscopic management is effective in treating 85% of biliary AS. fcSEMS appear superior to sequential plastic ‘upstenting’ but are associated with higher rates of PEP and migration.

Background Accurate diagnosis in patients with indeterminate biliary strictures remains challenging. Advances in cholangioscope design might facilitate improved visual and pathological diagnosis. Objective To compare the diagnostic yield between brushings, cholangioscopy-directed Spybite biopsies (SB) and visual impression at cholangioscopy in patients presenting with indeterminate strictures referred for cholangioscopy. Methods Prospective audit data was collected from 3 tertiary centres between June 2015-August 2017. Continuous data was expressed in mean values with 95% confidence intervals (CI) and categorical data was analysed using chi-square test. Results 76 (41 M) patients, mean age 57 years (95% CI 53–62), had cholangioscopy for indeterminate strictures. Six patients were excluded from analysis as they were lost to follow-up (n=3) or were awaiting further investigations (n=3). Seven patients (10%) had strictures in association with stones. Of 69 (90%) with indeterminate strictures 40 (53%) had had previous negative brush cytology, 9 (11.8%) had had non-diagnostic FNA, and one had negative intraductal biopsies. Brushings were repeated at cholangioscopy in 31 patients, with sensitivity and specificity of 33% (95%CI 12%–62%) and 100% (95%CI 79%–100%) for malignancy, respectively. Cholangioscopy guided SBs were taken in 58 patients and SB were not taken in 12 patients due to: stones mimicking strictures n=7, normal mucosa n=3, Mirrizi n=1, scope impassable due to stricture n=1. The SB had sensitivity and specificity of 44% (95%CI 23%–66%) and 100% (95%CI 90%–100%), respectively. Overall, a mean number of 4.6 (95% CI 3.7–5.5) SB samples were taken per patient with median size 2.2 mm (range 0.9–7). There was no difference in size between reported sufficient 1.5 (0.5–2.4) mm or insufficient 1.9 mm (1.5–2.3) biopsies. Pathologist reported insufficient (PANC-1) SB biopsies in 6 patients (10%) and these correlated with more false negative (FN) findings compared to sufficient biopsies (p=0.001). Cholangioscopic views were excellent in all patients and had sensitivity and specificity of 73% (95%CI 50%–89%) and 67% (95%CI 51–80), respectively. Sensitivity and specificity for SB were significantly different between those for visual impression (p=0.0004). Conclusion The new generation cholangioscope has acceptable diagnostic yield, where visual impression exceeds the conventional SB confirmation Despite excellent visualisation of indeterminate strictures a definitive visual diagnosis remains challenging. It is hoped that further improvements in tissue acquisition technologies might advance pathological diagnosis.

Patients with biliary strictures often represent a diagnostic and therapeutic challenge, due to the site and complexity of biliary obstruction and wide differential diagnosis. Multidisciplinary decision making is required to reach an accurate and timely diagnosis and to plan optimal care. Developments in endoscopic ultrasound and peroral cholangioscopy have advanced the diagnostic yield of biliary endoscopy, and novel optical imaging techniques are emerging. Endoscopic approaches to biliary drainage are preferred in most scenarios, and recent advances in therapeutic endoscopic ultrasound allow drainage where the previous alternatives were only percutaneous or surgical. Here we review recent advances in endoscopic practice for the diagnosis and management of biliary strictures. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni and Peter Jansen.

To redefine out-of-hours medical cover in order to improve patient care while supporting medical training. The project was to be cost neutral and to reduce locum use. A project team was appointed. An initial workload study was conducted in order to ascertain the workload of individual teams. Rotas for medicine, general surgery, urology, orthopaedics, ENT and anaesthetics were redesigned. A pool of four foundation doctors (FY1 and FY2) working across all specialties was created. The ENT and …

ObjectiveCurrent surveillance strategies for duodenal adenomatosis in familial adenomatous polyposis (FAP) miss malignancies and underestimate cancer risk in ampullary disease. This study aimed to evaluate the utility of endoscopic ultrasound (EUS) in the assessment of FAP patients with duodenal and/or ampullary polyposis referred for surgical intervention.DesignA retrospective analysis of FAP patients undergoing index EUS between December 2006 and May 2015 was performed. Follow-up was completed in January 2018, including review of all EUS procedures and surgical interventions (median follow-up 6 years).ResultsFifty-five patients underwent 188 EUS procedures. Six patients (11%) developed malignancy (three duodenal, three ampullary). Ampullary cancer risk was underestimated by Spigelman stage and overestimated by Kashiwagi classification. Ultrasound findings were poor predictors of malignancy, with common bile duct dilatation being the only finding present in one EUS prior to a diagnosis of ampullary cancer. The best predictors of ampullary malignancy were an ampullary polyp size >3 cm and an increase >1 cm in ampullary polyp size. Ampullary polyp size >3 cm provided the best predictive value, correctly identifying two of the three cases of ampullary cancer and both patients with high-grade dysplasia. EUS biopsy failed to detect malignancy later confirmed by surgical histology in two patients.ConclusionEUS surveillance confers little additional benefit to standard endoscopic surveillance in FAP patients. The best predictor of ampullary malignancy is an ampullary polyp >3 cm; this could be regarded as a relative indication for surgery.

An 81-year-old woman underwent percutaneous endoscopic gastrostomy (PEG) tube insertion following a stroke. She presented with PEG tube malfunction 2 years later, when a gastroscopy showed the bumper of the PEG tube to be covered by gastric mucosa. Endoscopic removal of the tube was attempted by incising the mucosa but was unsuccessful. A second PEG tube was placed proximally within the stomach, and the patient was discharged …

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