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

EUS-directed transgastric intervention (EDGI) is an established technique for the management of pancreaticobiliary pathology in Roux-en-Y gastric bypass (RYGB) patients. There is an inherent risk of intraprocedural stent dislodgement, leading to perforation. The procedure is therefore often performed in 2 stages, 2 to 4 weeks apart, to allow for fistula maturation to mitigate the risk of lumen-apposing metal stent (LAMS) dislodgment. However, some clinical indications such as cholangitis require more urgent intervention, rendering this approach impractical. The aim of this study was to evaluate the safety and efficacy of same-session (SS)-EDGI with fixation of a 20-mm LAMS using endoscopic suturing.This was a 2-center, retrospective study of consecutive RYGB patients who underwent SS-EDGI using a sutured 20-mm LAMS between February 2018 and May 2020. Patient demographics, procedural details, and clinical outcomes were recorded.Thirty-seven patients (mean age, 58.1 years; 86.5% women) underwent SS-EDGI with a median follow-up of 31.8 months. The procedural intervention was ERCP in 33 patients (89.2%) and ERCP with EUS in 4 patients (10.8%). Technical success was 100%. Access was achieved through the gastrogastric fistula in 26 patients (70.3%) and the jejunogastric fistula in 11 (29.7%). The LAMS was anchored with 2 endoscopic sutures in 33 patients (89.2%) and 1 suture in 4 (10.8%). Adverse events occurred in 4 patients (10.8%; 3 postprocedural bleeding, 1 cholangitis). There were no episodes of stent dislodgement or delayed stent migration. A persistent fistula was diagnosed in 7 patients (18.9%) who underwent objective testing (n = 28, 75.7%), of which 6 were successfully closed endoscopically.Single-stage EDGI using a sutured 20-mm LAMS was associated with a high rate of technical success, low rates of adverse events, and no episodes of stent migration. Persistent fistulas, although common, were amenable to endoscopic management.

Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs.This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management.Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically.EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

Video Video 1 Cholangioscopy-guided double-guidewire technique for the management of complex malignant hilar obstruction.

Objective UK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates. Design RICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing. Results Rates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease. PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5–7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028). Conclusion Despite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.

Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) is a novel, minimally invasive technique in the palliative treatment of malignant gastric outlet obstruction (GOO). Several studies have demonstrated feasibility and safety of EUS-GE, but evidence on long-term durability is limited. The aim of this study was to evaluate patency of EUS-GE in treatment of malignant GOO. Patients and Methods An international multicenter study was performed in seven centers in four European countries. Patients who underwent EUS-GE with a LAMS between March 2015 and March 2019 for palliative treatment of symptomatic malignant GOO were included retrospectively. Our main outcome was recurrent obstruction due to LAMS dysfunction; other outcomes of interest were technical success, clinical success, adverse events (AEs), and survival. Results A total of 45 patients (mean age 69.9 ± 12.3 years and 48.9 % male) were included. Median duration of follow-up was 59 days (interquartile range [IQR] 41–128). Recurrent obstruction occurred in two patients (6.1 %), after 33 and 283 days of follow-up. Technical success was achieved in 39 patients (86.7 %). Clinical success was achieved in 33 patients (73.3 %). AEs occurred in 12 patients (26.7 %), of which five were fatal. Median overall survival was 57 days (IQR 32–114). Conclusions EUS-GE showed a low rate of recurrent obstruction. The relatively high number of fatal AEs underscores the importance of careful implementation of EUS-GE in clinical practice.

Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.

Background and Aims EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance. Methods This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE. Results Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis. Conclusions We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.

Background: Pancreatic cystic lesions (PCL) are being detected with increasing frequency. Current methods of stratifying risk of malignant transformation are imperfect. This study aimed to determine the frequency of pancreatic malignancy in patients with PCL and define clinical and radiological features that predict malignant transformation in patients managed by surgery and/or surveillance. Methods: A retrospective cohort of adults who were evaluated in a tertiary hepatopancreaticobiliary centre between January 2000 - December 2013 with a confirmed PCL and followed up for at least 5 years. All cystic lesions were discussed at a weekly multidisciplinary meeting. Results: Of the 1,090 patients diagnosed with a PCL, 768 patients were included in the study: 141 patients were referred for immediate pancreatic resection, 570 entered surveillance while 57 had a malignant PCL which was unresectable at diagnosis (n=47) or were unfit for surgery (n=10). In those who were resected following presentation, malignancy was present in 38%. During follow-up 2% of those entering a surveillance programme underwent malignant transformation. Clinical and radiological features associated with a high-risk PCL included older age, symptoms, associated solid component or dilated main pancreatic duct. In intraductal papillary mucinous neoplasms, larger size was not a feature of malignant transformation (benign vs. malignant 30mm vs. 23mm; P= 0.012). Conclusion: The sensitivity of standard diagnostic tests leading to immediate surgery for high-risk PCL (malignant or mucinous) was 92% but with a specificity of just 5%. Surveillance of PCL without high-risk features within a multidisciplinary meeting was associated with a low incidence of cancer development, supporting the use of worrisome clinical and radiological features in the initial stratification of PCL.

Pancreatic ductal adenocarcinoma is most frequently detected at an advanced stage. Such late detection restricts treatment options and contributes to a dismal 5-year survival rate of 3-15%. Pancreatic ductal adenocarcinoma is relatively uncommon and screening of the asymptomatic adult population is not feasible or recommended with current modalities. However, screening of individuals in high-risk groups is recommended. Here, we review groups at high risk for pancreatic ductal adenocarcinoma, including individuals with inherited predisposition and patients with pancreatic cystic lesions. We discuss studies aimed at finding ways of identifying pancreatic ductal adenocarcinoma in high-risk groups, such as among individuals with new-onset diabetes mellitus and people attending primary and secondary care practices with symptoms that suggest this cancer. We review early detection biomarkers, explore the potential of using social media for detection, appraise prediction models developed using electronic health records and research data, and examine the application of artificial intelligence to medical imaging for the purposes of early detection.

Background Pancreatic mucinous cystic neoplasms (MCNs) are rare mucin-producing cystic tumours defined by the presence of ovarian-type stroma. MCNs have a malignant potential and thus surgery is frequently performed. The aim of this cohort study was to define better the criteria for surgical resection in patients with MCN. Methods This multicentre retrospective study included all resected MCNs between 2003 and 2015 in participating centres. Lesions without ovarian-type stroma were excluded. Patient characteristics, preoperative findings, histopathology findings and follow-up data were recorded. Results The study included 211 patients; their median age was 53 (range 18–82) years, and 202 (95·7 per cent) were women. Median preoperative tumour size was 55 (range 12–230) mm. Thirty-four of the 211 (16·1 per cent) were malignant, and high-grade dysplasia (HGD) was found in a further 13 (6·2 per cent). One-third of MCNs in men were associated with invasive cancer, compared with 15·3 per cent in women. Five cases of malignant transformation occurred in MCNs smaller than 4 cm. All cases of malignancy or HGD were associated with symptoms or features of concern on preoperative cross-sectional imaging. In multivariable analysis, raised carbohydrate antigen 19-9 (odds ratio (OR) 10·54, 95 per cent c.i. 2·85 to 218·23; P < 0·001), tumour size (OR 4·23, 3·02 to 11·03; P = 0·001), mural nodules (OR 3·55, 1·31 to 20·55; P = 0·002) and weight loss (OR 3·40, 2·34 to 12·34; P = 0·034) were independent factors predictive of malignant transformation. Conclusions Small indeterminate MCNs with no symptoms or features of concern may safely be observed as they have a low risk of malignant transformation.

// Matthew T. Huggett 1, 2 , Slavica Tudzarova 2 , Ian Proctor 2 , Marco Loddo 2, 3 , Margaret G. Keane 1 , Kai Stoeber 2 , Gareth H. Williams 2, 3 , Stephen P. Pereira 1 1 UCL Institute for Liver and Digestive Health and UCL Cancer Institute, University College London, London, UK 2 The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK 3 Oncologica Ltd, The Science Village, Chesterford Research Park, Cambridge, UK Correspondence to: Gareth Williams, e-mail: gareth.williams@oncologica.com Keywords: pancreatic cancer, cell cycle, DNA replication, Cdc7 Received: July 22, 2015 Accepted: January 23, 2016 Published: February 23, 2016 ABSTRACT Purpose: Cdc7 is a serine/threonine kinase which is responsible for the ‘firing’ of replication origins leading to initiation of DNA replication. Inhibition or depletion of Cdc7 in normal cells triggers a DNA origin activation checkpoint causing a reversible G1 arrest. Here we investigate Cdc7 as a novel therapeutic target in pancreatic cancer. Experimental design: Cdc7 target validation was performed by immunoexpression profiling in a cohort of 73 patients with pancreatic adenocarcinoma including 24 controls. Secondly Cdc7 kinase was targeted in Capan-1 and PANC-1 pancreatic cancer cell line models using either an siRNA against Cdc7 or alternatively a small molecule inhibitor (SMI) of Cdc7 (PHA-767491). Results: Cdc7 was significantly overexpressed in pancreatic adenocarcinoma compared to benign pancreatic tissue (median LI 34.3% vs. 1.3%; P

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 Endoscopic retrograde cholangio-pancreatography (ERCP) remains the standard tool for biliary stone extraction, biliary drainage and intraductal stricture assessment. Cholangioscopy allows direct intraductal visualisation without requiring fluoroscopy. Therefore, the aim of this study was to assess radiation dose during ERCP in patients with stones or strictures with or without cholangioscopy. Methods Data from patients referred for cholangioscopy between June 2015 and December 2016, for difficult biliary stones (following failed stone extraction with conventional ERCP), or to acquire tissue diagnosis for indeterminate strictures was prospectively collected. In all patients with stones, first conventional ERCP was attempted, using mechanical lithotripsy and or sphincteroplasty combined with balloon trawls before cholangioscopy was attempted. Radiation exposure was indirectly measured using total dose area product (DAP) measured in Grey per square cm (Gy/cm2). Continuous variable differences were assessed using Student t-tests. Results A total of 194 patients, mean age 62±18 years [48% male] were included based on intention to undergo cholangioscopy. Indications comprised: 128 with stone disease, 56 strictures, 7 stone and stricture and 3 ‘other’. Conventional ERCP for stone clearance sufficed for 29 (23%) patients without cholangioscopy (group I); 1 patient had conventional ERCP for a stricture. Cholangioscopy was needed in 99 (77%) patients (group II) for stones and 55 (98%) patients referred for strictures (group III). The mean DAP in group I was 85±661 compared to 1912±1817 Gy/cm2 in group II; p=0.003. Radiation dose for conventional ERCP radiation for stones was comparable to the dose (857±921 Gy/cm2) needed for stricture assessment for group III; p=0.98. The mean duration of the procedure (minutes) was 48±20 in group I, vs 72±27 in group II; p=0.0001. For strictures necessitating cholangioscopy, 49±19 min were needed for assessment which was comparable to group I; p=0.92. Radiation dosages per minute were persistently higher in group I compared to group II; 17±12 vs 29±24 Gy/cm2/min (p=0.02). As only 1 patient had stricture not necessitating cholangioscopy, no comparison was made between group III for above findings. Conclusion Cholangioscopy for stones adds considerably to procedure duration and total radiation dose compared to ERCP alone for stone disease. This likely reflects the high complexity of stone cases necessitating cholangioscopy. Of note, the radiation exposure/minute for ERCP with cholangioscopy in stone disease is no different to conventional ERCP. Our data on cholangioscopy in stricture assessment suggests that this may enhance diagnostic information (ie direct visualisation) without adding procedure time or radiation exposure.

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.