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The incidental discovery of pancreatic cysts in asymptomatic patients is on the rise due to the widespread use of cross-sectional imaging. The challenge in the management of pancreatic cysts is in distinguishing those with malignant potentials, like mucinous pancreatic cysts, from non-mucinous cysts that have negligible malignant potentials. Similarly, it can be difficult to identify mucinous cysts that harbour high-grade dysplasia or early cancer. This review focuses on the recent advances in detecting pancreatic cancer and cysts with premalignant potential.

ObjectiveTo assess the risks and benefits of reverse mentoring of consultants by junior doctors.DesignA feasibility study divided into two phases: first a semistructured interview where performance of participating consultants was assessed by junior doctors and then a second phase allowing for feedback to be given on a one-to-one basis. Data collected through questionnaires with free text questions and Likert scores.SettingTertiary teaching hospital in the UK.ParticipantsSix junior doctors (66.6% male, age range 31–40 years) and five consultants (80% male, age range 35–65 years and consultants for 5–20 years).InterventionReverse mentoring session.Main outcome measureThe concerns and/or benefits of the process of reverse mentoring. Confidence was assessed in 7 domains: clinical practice, approach to juniors, approachability, use of technology, time management, strengths and areas for improvement using Likert scales giving a total out of 35.ResultsThe most common concerns cited were overcoming the hierarchical difference and a selection bias in both mentors and mentees. However, no participant experienced this hierarchical difference through the reverse mentoring process and no relationships were negatively affected. Mentors became more confident in feeding back to seniors (23 vs 29 out of 35, p=0.04) most evident in clinical practice and areas to improve (3 vs 4 out of 5, p=0.041 and 3 vs 5 out of 5, p=0.041, respectively).ConclusionWe present the first study of reverse mentoring in an NHS clinical setting. Initial concerns with regard to damaged relationships and hierarchical gradients were not experienced and all participants perceived that they benefited from the process. Reverse mentoring can play a role in engaging and training future leaders at junior stages and provide a means for consultants to receive valuable feedback from junior colleagues.

Purpose The presence of a sarcopenia adversely affects the prognosis of patients with pancreatic cancer. There is an emerging role for using computed tomography (CT) to calculate skeletal muscle index (SMI) and the presence of sarcopenia. The aim of this study was to assess if detecting ‘computed tomographic sarcopenia’ is feasible and can contribute to the management of patients with locally advanced pancreatic cancer (LAPC). Methods Patients diagnosed with LAPC referred for endoscopic ultrasound-guided biopsy (EUS-B) by our regional cancer network were identified. Age, body mass index (BMI), and Eastern Cooperative Oncology Group performance status (ECOG-PS) were noted. CT images were analysed for SMI and the presence of sarcopenia. Decision outcomes on receiving chemotherapy or not were collected from the regional oncology database. Results In total, 51/204 (25%) patients with LAPC who underwent EUS-B were not given chemotherapy and received best supportive care (BSC) only. The prevalence of sarcopenia (p = 0.0003), age ≥ 75 years old (p = 0.03), and ECOG-PS 2–3 (p = 0.01) were significantly higher in the patients receiving BSC only. Logistic regression analysis demonstrated that SMI was the only independent associated factor identifying patients with LAPC who were treated with BSC only and not chemotherapy after adjusting for age and ECOG-PS. Conclusion Our study has shown that computed tomographic skeletal muscle analysis at the time of a diagnostic CT for patients with pancreatic cancer is feasible and can detect sarcopenia and malnourished patients who are much less likely to take up chemotherapy. These patients could be triaged to oncology assessment prior to EUS-B to avoid unnecessary investigations.

Background: Pancreatic exocrine insufficiency (PEI) and subsequent malnutrition can be difficult to diagnose but lead to sarcopenia and increased mortality and morbidity even in benign disease. Digital skeletal muscle analysis has been increasingly recognised as a tool to diagnose sarcopenia. Objective: The aim of the study was to assess the prevalence of sarcopenia in patients with PEI secondary to benign disease using novel skeletal muscle recognition software. Methods: Prospective recruitment of patients referred for endoscopic ultrasound (EUS) with suspected pancreatic pathology. Patients with suspected pancreatic cancer on initial computed tomography (CT) were excluded. The diagnosis of chronic pancreatitis (CP) was based on CT and EUS findings. PEI was assessed with faecal elastase-1. Digital measurement of skeletal muscle mass identified sarcopenia, with demographic and comorbidity data also collected. Results: PEI was identified in 45.1% (46/102) of patients recruited, and 29.4% (30/102) had changes of CP. Sarcopenia was significantly more prevalent in PEI 67.4% (31/46) than no-PEI 37.5% (21/56) (37.5%), regardless of CP changes (p < 0.003). The prevalence of sarcopenia (67% vs. 35%; p = 0.02) and sarcopenic obesity (68.4% vs. 25%; p = 0.003) was significantly higher when PEI was present without a radiological diagnosis of CP. Multivariate analysis identified sarcopenia and diabetes to be independently associated with PEI (odds ratio 4.8 and 13.8, respectively, p < 0.05). Conclusion: Sarcopenia was strongly associated with PEI in patients undergoing assessment for suspected benign pancreatic pathology. Digital skeletal muscle assessment can be used as a tool to aid identification of sarcopenia in patients undergoing CT scan for pancreatic symptoms.

Background It is estimated that one in four persons in the UK will be > 65 years old by 2050. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended therapy for removals of common bile duct (CBD) stones. There is a lack of UK data on the outcome of ERCP in the very elderly. We aimed to investigate the safety and efficacy of ERCP in the management of CBD stones in the elderly >90 years old compared with those aged 65-89 years old. Methods We retrospectively analysed patients undergone ERCP between 2016-2020. Those with conditions other than suspected CBD stones were excluded. The following data was collected: general demographics, comorbidities, American Association of Anaesthesiology (ASA) grading, presence of dementia, anticoagulation therapy, endoscopic report on completed intention of treatment which is defined by either removal of stone and/or stent insertion. Also, post-procedure complications were collected including post-ERCP pancreatitis (PEP), bleeding, perforation, cholangitis, respiratory, and cardiovascular (CVS) events. Readmission within 7 days and death within 30 days were collected. Outcomes were reported as mean ± (SD) or n (%). Statistical significance was considered when P Results Total, 126 patients ≥ 90 years(group A) compared to 262 patients aged 65-89 years(group B). Higher rate of dementia, and anticoagulation therapy in Group A (17.4%) vs (0.4%),p Conclusions ERCP for removal of CBD stones in > 90 years old is effective. Risk of post-ERCP pancreatitis and overall adverse events were not higher in the > 90 years compared to 65-89 years old. We report a 30-day mortality rate of 3.2%. The most common cause of death was pneumonia including COVID-19 peumonia.

Purpose: The presence of a sarcopenia adversely affects the prognosis of patients with pancreatic cancer. There is an emerging role for using computed tomography (CT) to calculate skeletal muscle index (SMI) and the presence of sarcopenia. The aim of this study was to assess if detecting ‘digital sarcopenia’ is feasible and can contribute to the management of patients with locally advanced pancreatic cancer (LAPC).Methods: Patients diagnosed with LAPC referred for endoscopic ultrasound guided biopsy (EUS-B) by our regional cancer network were identified. Age, body mass index (BMI), and Eastern Cooperative Oncology Group performance status (ECOG-PS) was noted. CT images were analysed for SMI and the presence of sarcopenia. Decision outcomes on receiving chemotherapy or not were collected from the regional oncology database. Results: In total 51/204 (25%) patients with LAPC who underwent EUS-B were not given chemotherapy and received BSC only. The prevalence of sarcopenia (p=0.0003), age ≥ 75 years old (p=0.03) and ECOG-PS 2-3 (p=0.01) were significantly higher in the patents receiving BSC only. Logistic regression analysis demonstrated that SMI was the only independent associated factor identifying patients with LAPC who were treated with BSC only and not chemotherapy after adjusting for age and ECOG-PS. Conclusion: Our study has shown that digital skeletal muscle analysis at the time of a diagnostic CT for patients with pancreatic cancer is feasible and can detect sarcopenia and malnourished patients who are much less likely to take up chemotherapy. These patients could be triaged to oncology assessment prior to EUS-B to avoid unnecessary investigations.

Overseas doctors are playing an important role in the successful running of the NHS. They represent one-third of the total number of UK doctors and include doctors from the European Economic Area and international medical graduates. The main aim of this review is to explore the challenges that overseas doctors might face when they take up their first job in the UK. We conducted literature search using MEDLINE and EMBASE databases. The inclusion and exclusion criteria were designed to include published literature concerning overseas doctors in the UK and the NHS. Lack of information about the UK health system; language and communication challenges; clinical, educational and work-culture challenges; and discrimination challenges are some of the difficulties that overseas doctors might experience. Understanding these challenges and providing support are important steps in helping overseas doctors to make a smooth transition.

Background Recent reports showed that overseas doctors were more likely than UK graduates to be referred by their employers to the General Medical Council (GMC). We investigated the trend of medico-legal insurance awareness and uptake of medical defence organisations (MDOs) by junior doctors and to examine if there is a difference between overseas and UK graduates. Methods Online questionnaire survey sent to junior doctors within the Yorkshire and Humber Deanery. Data regarding year of graduation, country of origin of primary medical qualification, year of starting work in the National Health Service (NHS) and date of joining an MDO were collected. Participant-identifiable information was not collected. Results A total of 202 junior doctors completed the survey: 153 (76%) UK graduates and 49 (24%) overseas. Overseas doctors were less likely to know about MDO compared to UK graduates prior to working in the NHS (13 [26.5%] vs. 146 [95.4%]; p < 0.0001). At the time of starting practice, MDO uptake was still significantly lower amongst overseas graduates (4 [8.2%] vs. 144 [94.1%]; p < 0.0001). Uptake by overseas doctors increased after starting work to 33 (67.3%). However, despite improvement in MDO uptake, a significant number of overseas doctors still did not have independent cover compared with UK graduates (16 [32.7%] vs. 3 [2%]; p < 0.0001). Conclusions Overseas graduates joining the NHS are still less likely to be aware of the requirement of adequate medico-legal cover and are less likely to join an MDO compared with UK graduates. Healthcare providers and regulators should work to decrease the existing gap and increase awareness amongst newly arrived overseas doctors.

Background Pancreatic exocrine insufficiency (PEI) is an important cause of malnutrition. There is scarce information on the effect of PEI on body composition including muscle mass. Objective To assess the prevalence of sarcopenia using a novel skeletal muscle recognition software in PEI patients compared to normal exocrine function. The secondary aim was to assess the prevalence of sarcopenia in PEI with normal BMI compared to those with PEI and obesity. Methods Prospective recruitment of patients referred for endoscopic ultrasound examination for the assessment of chronic pancreatitis and/or abdominal pain. All pancreatic enzyme replacement therapy naive and none had steatorrhoea as a main symptom. Age, sex, BMI, presence of DM, smoking and alcohol history were collected. FEL-1 Results A total of 102 patients were recruited, median age 52 years, 52(51%) female. PEI was present in 46(45.1%) patients. Diagnosis of CP based on EUS and cross section images was made in 21(45.6%) patients in PEI compared to 7(12.5%) in normal FEL-1, p=0.003. Sarcopenia was prevalent in PEI group 31(67.4%) compared to normal FEL-1 18(32.1%), p=0.0006. Similar prevalence of sarcopenia was found in PEI with no-CP 66.7% and in PEI with CP 68.2%. Sarcopenic obesity was more prevalent in PEI 14/20 (70%) compared to normal FEL-1 8/28(28.6%), p=0.008. Sarcopenia and DM was strongly associated with PEI in multivariate analysis. Pack-year smoking was significantly higher in PEI, p=0.03. Conclusions Sarcopenia was strongly associated with PEI. The prevalence of sarcopenia was the same in both PEI with CP and PEI with no-CP. Risk of sarcopenia still exit in PEI patients with obesity, therefore, quantification of skeletal muscle using digital analysis software could make a rapid, and objective assessment of nutritional status.

Introduction Patients with iron deficiency anaemia are commonly referred to gastroenterology for exclusion of significant pathology. Some of these patients will have been previously investigated. We aimed to ascertain how often a cause of anaemia is found and subsequent action if no cause found. Methods Retrospective audit across 10 sites in Yorkshire, by a trainee-led research network. We included patients referred on a suspected cancer pathway with IDA in November 2018. Data on referral criteria, investigations, diagnosis and follow-up were collected. Anonymised data was pooled for comparative analysis in Excel and SPSS. Results 508 patients were included: median age 72 years (range 24–97); 55% female. 48% of these patients were asymptomatic. 42 cancers (8%) were diagnosed: 25 colorectal (5%), 6 oesophageal/gastric (1%), 2 renal, 1 bladder, 2 pancreatic, 2 hepatobiliary, 1 prostate, 2 lung and 1 unknown primary. There was no correlation between patient and age and likelihood of malignancy, but an association was seen with mean Haemoglobin (Hb) and gastrointestinal cancer diagnosis. Other pathology was found in 33% of those investigated: erosive gastritis 8%, oesophagitis 5%, erosive duodenitis 1%, peptic ulcer 3%, gastric polyp 1%, gastric antral vascular ectasia 1%, angiodysplasia 1%, coeliac disease 2%, colonic polyp >10 mm 2%, colonic polyp Where no significant pathology was found, 43% patients were discharged without clinic review, 30% patients were discharged following discussion of results, 9% were seen again in clinic with no further investigations requested and 16% required ongoing follow-up or further investigations. Advice regarding Hb monitoring (with timeframe) was given in 11%, vague advice was given in 19% and no advice was given to general practitioners (GPs) in 48%. Conclusions An expected rate of significant pathology was found. 1 in 5 patients had undergone gastrointestinal investigations previously. 1 in 3 patients were seen in clinic following normal investigations. Better advice to GPs regarding Hb monitoring and subsequent management is needed and may reduce unnecessary re-referrals. Further exploratory work to identify additional predictors of significant pathology is planned.

Background The BSG offers a mentorship programme aimed at those in transitional phases of their career and less at experienced consultants. Reverse mentoring, the act of junior persons mentoring seniors, has gained traction in non-healthcare settings as a means of closing the gap between Boomers and Millennials. There is no data on applying this to a medical workforce. We present the first data of real clinical experience. Methods A mixed-methods feasibility study on the practicalities of reverse mentoring complete in two phases. Phase 1: all clinical fellows in a teaching hospital were invited to provide feedback in a group semi structured interview on their supervisors in 7 domains: use of technology, clinical practice, approach to juniors, time management, approachability, strengths and areas for improvement. Phase 2: information was fed back to consultants on a 1-2-1 basis with the opportunity to discuss the points raised. Pre and post mentoring questionnaires were collected. Likert scales were used to assess several aspects on a scale from 0 to 35 and thematic analysis to record participants thoughts. Results A total of 6 clinical fellows participated in the phase 1 feedback session (66.6% male, age range 31–40 years) and agreed to be mentors. All supervising consultants invited agreed to being mentees (80% male, age range 35–65 years) and have been consultants for 5–20 years. Mentoring sessions lasted 45 minutes (range 28–180 minutes) and all felt the time devoted was about right. Both mentors and mentees reported a good or excellent experience. Juniors became more confident in feeding back to seniors after the session (21vs 31, p=0.008) and had a greater understanding of their role as reverse mentors (2.5/5 vs 4/5, p=0.024). Seniors became more aware of how they were viewed after mentoring (25vs 32, p=0.04). All seniors felt this was a useful experience that will change their clinical practice and 80% reported less concern about reverse mentoring afterwards. All participants believed that feedback was important both prior to and after the study (31 vs 33, p=0.196) Common themes highlighted included the benefit of a different perspective to the norm and new ideas which can be implemented. There were concerns raised of the power gradient preventing effective mentoring and risks to relationships, however these were expressed as potential concerns and not experienced. Conclusion The experience of all participants in this feasibility study were positive supporting the benefits of reverse mentoring in a healthcare setting. Junior doctors became better equipped to be future mentors. Consultants were given a new perspective which inspired them to improve their clinical practice and work environment.

Introduction Iron deficiency anaemia (IDA) is a common reason for gastroenterology referral. We aimed to see whether straight-to-test (STT) endoscopy referrals enable more rapid diagnosis in patients with cancer or improve chances of treatment success. Methods Retrospective audit across 10 sites in Yorkshire, by a newly formed trainee research network. We included patients referred on a suspected cancer pathway with IDA in November 2018. Data on referral criteria, initial review, investigations, time to diagnosis and outcome were collected. Anonymised data was pooled for comparative analysis. Results 508 patients included: median age 72 years (range 24–97); 55% female. 93 (18%) patients underwent STT investigations, varying significantly across 8 sites (1.4–78.2% referrals). Patients were more often seen in surgical (42%) or gastroenterology (23%) clinic. Cancer was diagnosed in 41 (8%) patients: 5% colorectal, 1% upper gastrointestinal (GI) and 2% other cancers. The STT group were younger and had a significantly reduced time to first investigation/cancer diagnosis, than those not referred STT (non-STT). However, patients were no more likely to receive curative treatment (table 1). All patients in the STT group were investigated (82% both upper and lower GI investigations). In the non-STT group, 71 (17%) underwent plain CT only (7%) or no investigations (10%): as the patient declined 7%; patient unfit 4%; not indicated (clinical decision) 2%; did not attend 2% or investigations previously performed 1%. There was no difference in laboratory values between groups. STT patients were less likely to be discharged without clinic review (18% vs. 48%) following normal investigations. Conclusions STT investigations removed the need for initial (but not follow-up) review in 1 of 5 patients with IDA and reduced time to diagnosis, but did not increase likelihood of treatment success. Patient choice was the main reason for incomplete investigation. We plan to re-audit after introduction of formal STT pathways in the region, to see if better patient selection can improve outcomes.

Clinical trials have demonstrated efficacy of vedolizumab in ulcerative colitis (UC) and Crohn's disease (CD). Further real-world data is needed to inform clinical practice. The primary outcome was to assess corticosteroid-free and clinical remission after vedolizumab initiation. Secondary outcomes included effect on disease activity scores, biochemical markers, concomitant drug use, endoscopic remission, surgical intervention, hospital admissions and adverse events.A multi-centre retrospective observational study was conducted with patients initiated on vedolizumab across seven UK hospitals 1/11/14-30/11/16. Clinical disease activity was assessed using the partial Mayo Scores (pMS) and Harvey Bradshaw Index (HBI). Clinical remission was defined as HBI ≤4 or pMS2 with a combined stool frequency and rectal bleeding sub score of ≤1. Clinical response was defined as ≥2-point decrease from baseline in pMS and ≥3-point decrease from baseline in HBI.One hundred ninety-two patients were included in the final analysis. 45% of UC and 10% of CD patients were anti-TNF naive. Over the observation period corticosteroid-free remission rates for UC and CD were 46% and 45%, while clinical remission rates were 52% and 44%, respectively. Time to corticosteroid free remission for UC and CD was 17.6 [IQR: 8.7-29.6] and 14.1 [QR: 6.0-21.7] weeks, respectively. Time to clinical response for UC was 9.4 [IQR: 5.7-15.4] and CD was 9.5 [IQR: 6.1-18.2] weeks. There was a substantial decrease in the concomitant use of immunomodulators and a similar decrease in concomitant corticosteroid use over the study period.Results in this predominately anti-TNF experienced population mirror other published real-world data, demonstrating good clinical effectiveness and a comparable safety profile.

The incidence of pancreatic neuroendocrine tumours (PNET) is rising mainly due to the increased use of cross-sectional imaging. Although many PNETs are asymptomatic and non-functioning, the overall 5-year survival is still less than 50%. In this article, we review the advances in diagnosis, classification and staging of PNET that have evolved with the development of new cross-sectional imaging methods and biopsy techniques. With accurate classification, evidence-based, individualised prognostic outcomes and treatments are able to be given which are also discussed.

Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.

Introduction Patients with pancreatic exocrine insufficiency (PEI) are at an increased risk of nutritional deficiency which can lead to cardiovascular disease and associated mortality. Faecal elastase-1 (FEL-1) has a good sensitivity and specificity in severe PEI but the diagnostic accuracy decreases in mild to moderate PEI. Some serum nutritional markers and vitamin serum levels have been shown to be associated with malnutrition. The aim of this study was to investigate if serum nutritional markers could be used to diagnose PEI. Methods Patient at high risk of PEI (abdominal pain suggestive of chronic pancreatitis, high alcohol intake and diabetes mellitus) were prospectively recruited. Patients with known PEI or taking enzyme replacement therapy were excluded. All patients had demographic information collected, BMI calculated and FEL-1 performed. Blood samples were taken for levels of sodium, potassium, calcium, magnesium, phosphate, prealbumin, vitamin D, copper, zinc and selenium. A FEL-1 result of Results A total of 144 patients were included in the study (mean age 52.1 ± 18 years, 76 males). A FEL-1 A significant number of PEI patients had selenium deficiency 8/31 (25.8% below normal level) compared to non-PEI group 7/98 (7.4%), p=0.028. None of the patients with normal pancreatic function and morphology on images had low selenium (0/30) compared to patients with PEI and confirmed chronic pancreatic changes 5/17 (29.4%), p=0.004. Analyses of other markers did not show significant differences in proportions of biochemical marker deficiencies between PEI and non-PEI groups. Using selenium ( Conclusion Although a selenium deficiency was significantly associated with PEI, its poor sensitivity as a test for PEI would only make it supportive of a diagnosis and other tests would be required. Apart from selenium levels it would appear that checking serum nutritional markers for suspected cases of PEI at diagnosis results in a low diagnostic yield. PEI patients are overweight suggesting that using a low BMI to target patients is insufficient to prompt testing for PEI or malnutrition in this patient group.

Introduction The BSG and AUGIS quality standards in upper gastrointestinal endoscopy recommend taking biopsies for histological examination to diagnose inflammatory, pre- or malignant lesions which may or may not be visible to the naked eye [Beg, Gut 2018]. This may increase the duration and cost of the procedure and potentially reduce the focus on mucosal inspection. This study aimed to investigate the diagnostic value (changes in diagnosis and contribution to management) added by histology and its cost. Methods Patients undergoing consecutive diagnostic OGDs performed by four fellows were recruited. Incomplete, surveillance or therapeutic procedures, procedures for dysphagia and those arranged in order to obtain histology (eg. positive coeliac serology) were excluded. Biopsies were performed according to BSG quality standards [Beg, Gut 2018]. The utility of biopsies (changes in diagnosis and contribution to management) were examined from endoscopic and histological findings. Results Of 509 patients examined, 314 were included. OGD was performed for dyspepsia (66%), anaemia (26%), weight loss (16%), diarrhoea (2%) and vomiting (1%). Biopsies occurred in 86% of patients with an mean of 1.5 samples per patient biopsied. Biopsy sampling provided additional pathological information not evident at endoscopy in 28% of cases. However, if benign pathologies are excluded (mostly chemical or Helicobacter gastritis or duodenitis), this falls to 6.7% (n=18: dysplasia n=3, adenocarcinoma n=1, gastric intestinal metaplasia (GIM) n=7, villous atrophy (VA) n=2, Barretts n=5). In total, management change occurred in 19% consequent on histological findings, but this falls to 12% (n=34: adenocarcinoma n=2, dysplasia n=3, GIM, n=10, Barretts n=15, VA n=3, peptic stricture n=1) where Helicobacter pylori (which can be detected by other non-invasive methods) eradication is excluded. Fifty seven focal lesions were biopsied where dysplasia or cancer was diagnosed in 7% (1/14 oesophageal, 2/35 gastric and 1/8 duodenal). Barretts, GIM and VA were found more commonly in abnormal compared to normal mucosa (See table 1). The overall cost of tissue sampling approximates to £17,100 (£82 per person). Routine biopsies of patients with only normal mucosa costed over £3,500. Conclusions Although 86% undergoing OGD have biopsies taken, contributing to aetiopathological understanding in 28%, only a small minority (6.7%) have pre-malignant or malignant pathologies and result in a change in management in only 12%. Non-targeted biopsies are of limited value and costly when sampled from normal mucosa.

Introduction An endoscopic ultrasound guided biopsy (EUS-B) is required prior to treatment with palliative chemotherapy for patients with suspected pancreatic ductal adenocarcinoma (PDAC). Given the urgency of treatment, EUS-B is often done prior to oncological assessment after which a significant proportion of patients do not take up chemotherapy. Low skeletal muscle index (SMI), termed sarcopenia, is common in PDAC and has been associated with poor outcomes. We aimed to assess if novel digital software can calculate SMI using a computerised tomography (CT) image to predict palliative chemotherapy uptake in patients with suspected PDAC, and streamline EUS-B. Methods Patients who underwent an EUS-B showing PDAC between Jan 2016 and Dec 2017 with a CT scan performed within a month prior to biopsy were included in the study. SMI was calculated by a single slice CT image taken at the level of the third lumbar vertebra. Software was used to identify skeletal muscle (sliceOmatic, Tomovision). Sarcopenia was defined as SMI Results EUS-B confirmed PDAC in 85 eligible patients during the study (median age 70;41–84 years). A total of 61/85(71%) of patients received at least one dose of chemotherapy. Sarcopenia was present in 57/85 (57.6%). Despite a raised BMI of >25 in 41/85 (48.1%) of the patients, sarcopenia was present in 25 (61.0%) of them. Patients who did not take up chemotherapy had a lower SMI (40.5 vs 45.2 cm2/m2, p=0.04) and a poorer mean performance status (1.25 vs 0.7: t-test p=0.002). There was no difference in BMI (26.8 vs 24.6 p=0.10) in patients that did and did not take up chemotherapy. No patients with a performance status of 3 (n=3) or age >80 (n=5) proceeded to chemotherapy. In those having chemotherapy, survival was higher in non-sarcopenic patients compared to sarcopenic patients (11.8 vs 7.7 months, p=0.04). Survival was similar in sarcopenic patients having chemotherapy and non-sarcopenic patients who did not have chemotherapy (7.7 vs 7.4 months p=0.5). Patients with performance status ≥2 and sarcopenia were much less likely to receive chemotherapy compared to those with performance status 0–1 without sarcopenia (83.9% vs 37.5%, p=0.02). Conclusion Patients with PDAC and a performance status of ≥2 and low SMI were significant less likely to take up chemotherapy and had poorer survival. SMI measurement could act as part of a decision tool to assess suitability of patients to triage patients for rapid EUS-B, or clinical assessment prior to considering chemotherapy.

Introduction Pancreatic adenocarcinoma (PDAC) has a very poor prognosis with most patients presenting with advanced incurable disease. Palliative chemotherapy can have a significant improvement in survival, but given the potential severe complications patient assessment and histological confirmation with endoscopic ultrasound fine needle aspiration (EUS-FNA) is required. The rapid progression of PDAC can result in patients urgently travelling to tertiary centres and undergoing EUS-FNA (which is an invasive, sedated procedure with associated morbidity) prior to formal assessment in patients where the chemotherapy is subsequently not given. We aimed to see if there are pre-test prediction factors for non-uptake of palliative chemotherapy in PDAC in our cancer network. Methods We retrospectively reviewed consecutive patients referred for EUS-FNA over a 2 year period for evaluation of inoperable locally advanced pancreatic masses on imaging. Details recorded were: age, body mass index (BMI), co-morbidity including cardiovascular, diabetes mellitus, chronic airway disease and anticoagulation. Also recorded were the World Health Organisation (WHO) performance status, position of the tumour and the requirement of a biliary stent. Patients who received chemotherapy were identified from the chemotherapy registry data. The diagnosis of PDAC was based on histological diagnosis or with clinical progression compatible with the diagnosis or death from malignancy. Results In total 104 underwent EUS-FNA [55 men, mean age 68.5 years SD ±9.1]. All patients had a performance status of Conclusion In this study, no patients over 80 years old having undergone EUS-FNA went on to receive palliative chemotherapy for PDAC. We would advise an initial oncology consultation first in these patients to avoid unnecessary EUS procedures. In patients under 80 years old clinical assessment should be considered when referring patients for suspected inoperable PDAC for EUS-guided FNA as only half go on to receive treatment, however no factors apart form age seemed to predict the uptake of palliative chemotherapy. Further validation of these outcomes could form a decision tool to decide who should be triaged to oncology clinics before EUS-FNA performed.

Introduction Oesophagogastroduodenoscopy (OGD) is the accepted gold standard investigation for upper GI symptoms although quality has rarely been assessed. In this study, quality of OGD and the effects of sedation, procedural tolerance and duration of examination were investigated. Methods Consecutive out-patients undergoing OGD were recruited. Patients scored (none-severe: 0–10) procedural distress, abdominal discomfort (AD) and pain (AP). Video recordings of the OGDs were reviewed, scoring the views (score 1–5: 75% and 100% of mucosa seen) of eight upper GI stations and time spent in retroflexion and in the duodenum. Scores and times are reported as mean (±SEM). Results OGD was performed on forty patients (58±3 years old, 62.5% male, 25% sedated) by one of three endoscopists. There was a significant difference between visualisation scores (oesophagus, 4.5 (±0.1); gastro-oesophageal junction, 4.5 (±0.1); cardia, 4.0 (±0.2); fundus, 3.7 (±0.2); upper body, 3.8 (±0.1); distal body, 4.1 (±0.1); incisura, 4.0 (±0.2) and antrum, 4.9 (±0.1); Kruskal-Wallis H Test: H(7)=60.2; p Conclusion Visualisation at OGD is variable, with excellent antral but comparatively poorer proximal gastric and incisura views. OGD is the cause of significant distress to patients, rather than discomfort or pain, although duodenal examination may be painful in some. There was little correlation of quality of views with sedation, tolerance or duration of examination.