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

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.

Background Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom. Methods Consecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records. Results Twenty five patients (15 males) with a median age of 63 years old (range 29–80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p Conclusion EUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.

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

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

Background The use of EUS (endoscopic ultrasound) guided drainage with endoscopic LAMS (lumen apposing metal stent) necrosectomy is an emerging treatment option for walled-off pancreatic necrosis (WOPN) secondary to acute severe pancreatitis. It can delay or remove the need for surgical necrosectomy, which can be associated with high morbidity and mortality. However, the endoscopic approach is not always successful due to a multitude of factors and salvage transgastric necrosectomy can be performed using the tract created by the LAMS to achieve internal drainage and remove necrotic pancreas. Methods We describe our unit’s experience in managing WOPN in two patients. We suggest a treatment pathway of WOPN which includes a step-up approach including salvage transgastric necrosectomy in patients where multiple endoscopic necrosectomies and washouts have failed. Results Two patients, aged 67 and 69, were admitted as intensive care transfers for gallstone and alcohol pancreatitis respectively. They underwent a step-up approach to treat their infected WOPN, starting with the deployment of LAMS and endoscopic necrosectomy. They both showed brief clinical improvement after repeated endoscopic necrosectomy but further imaging showed ongoing large collections that could not be treated endoscopically. Both patients underwent successful transgastric open necrosectomy where necrotic pancreatic tissue was accessed surgically through the already created cyst-gastrostomy. This had the advantage of internal drainage of the collection into the stomach without the need for external surgical drains. Conclusions The emphasis in the treatment of WOPN has shifted to minimally invasive percutaneous or endoscopic drainage modalities. Endoscopically inserted LAMS may not always achieve definitive drainage of the WOPN but should be employed in the first instance as they are associated with reduced morbidity and mortality compared to surgery. Ultimately, open necrosectomy with washout remains the definitive management strategy in the step-up approach. We believe that the trans-gastric open necrosectomy approach can be used successfully in patients where the minimally invasive approach has failed.

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

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

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

Background The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection. Methods A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included. Results Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5–60.0 days). Mean operating time was 351.8 ± 80.5 minutes. Median blood loss was 850 mL (IQR, 475–1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4–7 days). Radical resection was obtained in eighteen patients (94.7%). Conclusion Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

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

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

Introduction: Hepatocellular carcinoma (HCC) is increasing in incidence in the UK and globally. Liver cirrhosis is the common cause for developing HCC. The common reasons for liver cirrhosis are viral hepatitis C (HCV), viral hepatitis B and alcohol. However, HCC caused by non-alcoholic fatty liver disease (NAFLD)-cirrhosis is now increasingly as a result of rising worldwide obesity. Aim: To compare the clinical presentation, treatment options and outcomes of HCC due to HCV and NAFLD patients. Methods: Data were collected from two liver transplant centres in the UK (Birmingham and Newcastle upon Tyne) between 2000 and 2014. We compared 275 patients with HCV-related HCC against 212 patients with NAFLD- related HCC. Results: Patients in the NAFLD group were found to be significantly older (P < 0.001) and more likely to be Caucasian (P < 0.001). They had lower rates of cirrhosis (P < 0.001) than those in HCV-HCC group. The NAFLD group presented with significantly larger tumours (P = 0.009), whilst HCV patients had a higher alpha fetoprotein (P = 0.018). NAFLD patients were more commonly treated with TACE (P = 0.005) than the HCV patients, whilst the HCV group were significantly more likely to be transplanted (P < 0.001). In patients selected for liver transplantation, 5-year survival rates in NAFLD were not significantly different from HCV-HCC (44 and 56% respectively, P = 0.102). Conclusion: In this study, NAFLD patients presented with larger tumours that were less likely to be amenable to curative therapy, as compared with HCV patients. Despite this disadvantage, patients with NAFLD had similar overall survival compared to patients with HCV.

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

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

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