PURPOSE OF REVIEW:Pancreatic exocrine insufficiency (PEI) has long been associated with intrinsic pancreatic disease, yet emerging evidence shows it is under-recognized in patients with nonspecific gastrointestinal symptoms. This review summarizes prevalence data, evaluates the performance and utility of faecal elastase-1 (FE-1), highlights the co-existence of PEI with other luminal conditions, and explores the presence of early pancreatic dysfunction among a subset of patients with irritable bowel syndrome (IBS)-type symptoms. Updates from the 2025 European guidelines are discussed. RECENT FINDINGS:Population studies estimate PEI prevalence at 11-21% in unselected gastroenterology cohorts. PEI is reported across coeliac disease, inflammatory bowel disease and functional gastrointestinal disorders, where overlapping symptoms can delay diagnosis. A 2025 meta-analysis of FE-1 performance demonstrated high sensitivity for moderate-severe PEI. Cohort data indicates repeat sampling can clarify borderline results. PEI may be an early marker of pancreatic dysfunction in a subset of patients with IBS-type symptoms. Identifying this group may offer opportunities for lifestyle modification with potential long-term benefit. SUMMARY:Collectively, these findings expand the relevance of PEI beyond classical pancreatic disease. Broader, proactive FE-1 testing may allow earlier recognition, which might allow intervention at a potentially modifiable stage of pancreatic dysfunction, accepting the limitations of the test.

Background/Objectives: Most adult patients require endoscopy and duodenal biopsies to diagnose coeliac disease. However, individuals who are unwilling or unable to undergo conventional endoscopy are left without diagnostic options or a formal diagnosis. We aimed to determine whether the small-sized biopsy forceps used during the more tolerable transnasal endoscopy (TNE) can provide adequate duodenal biopsy specimens for diagnosing coeliac disease. Methods: We prospectively recruited adult patients (≥18 years) with suspected coeliac disease between May and July 2024. All patients underwent peroral endoscopy, with four biopsies taken from the second part of the duodenum (D2) and one from the duodenal bulb (D1) using standard 2.8 mm biopsy forceps. The biopsy protocol was then repeated using smaller 2 mm biopsy forceps. Expert pathologists evaluated all samples for size, quality, and Marsh classification. Results: Ten patients (median age 45 years, 50% female) were included in this study, of whom seven (70%) were diagnosed with coeliac disease. In total, 100 duodenal biopsy specimens were collected and analysed (50 using standard biopsy forceps and 50 using smaller biopsy forceps). The size of D2 biopsies was significantly larger when using standard biopsy forceps compared with smaller forceps (4.5 mm vs. 3 mm, p = 0.001). Similarly, biopsies from D1 were also larger with standard forceps (3 mm vs. 2 mm, p = 0.002). Smaller forceps provided sufficient material for accurate classification in all cases, and the agreement between biopsies obtained using both forceps in D2 and D1 was 100% (k = 1.0). Conclusions: This pilot study demonstrates that small-sized biopsy forceps, used during TNE, can provide adequate tissue for histopathological diagnosis in patients with suspected coeliac disease. These findings pave the way for considering TNE as a more tolerable alternative to conventional endoscopy in diagnosing coeliac disease.

Objective The career intentions of the endoscopy workforce within the UK are unclear. We performed the first UK-wide, multi-society, pan-workforce endoscopy survey with the primary aim of estimating attrition rates of the workforce over time to forecast training and recruitment needs. Design An electronic questionnaire was developed by the British Society of Gastroenterology and National Health Service (NHS) England with representation from major UK endoscopy societies and distributed to members between November and December 2023. The survey covered: demographics, service provision, career intentions and reasons for leaving. Attrition rates were plotted on Kaplan-Meier curves and comparisons made using the log-rank test. Results 3564 respondents from 149 UK NHS Trusts were included (consultants 924, endoscopy nurses 837, clinical endoscopists 373, trainees 183). The response rate was 35% for gastroenterology consultants and 57% for clinical endoscopists. Consultants (gastroenterologist 64.0%, colorectal surgeon 19.3%, hepatologist 10.1%, upper gastrointestinal (GI) surgeon 6.1%) delivered a median of 11.5 weekly programmed activities (PAs) with 2.0 hands-on endoscopy PAs. 26.4% of consultants had PAs for Bowel Cancer Screening (BCS), 19.0% endoscopic retrograde cholangiopancreatography (ERCP) and 7.9% endoscopic ultrasound. Clinical endoscopists delivered more weekly endoscopy sessions than consultants (mean 4.04 vs 2.27, p<0.001). The reported 5-year intention to leave endoscopy rate was 23.7% for consultants, 26.5% nurses, 31.5% clinical endoscopists and 10% specialist trainees. For those aged 55+, this outcome was reported by 62.0% of consultants, 70.7% BCS endoscopists, 76.6% ERCP practitioners and 84.0% clinical endoscopists. The most common reason for workforce attrition was retirement in non-trainees and emigration in trainee respondents. Conclusion As many as 23.7% of consultants and 31.5% of clinical endoscopists are thinking of leaving endoscopy within 5 years. Immediate action should be taken to develop a future endoscopy workforce strategy.

Background The updated Shape of Training curriculum has shortened the duration of specialty training. We present the potential role of out of programme clinical fellowships.Method An electronic online survey was sent to all current fellows to understand their experiences, training opportunities and motivations.Data were collected on fellows’ endoscopic experiences and publications using PubMed for all previous doctors who have completed the Sheffield Fellowship Programme.Results Since 2004, 39 doctors have completed the Sheffield Fellowship.Endoscopic experience: current fellows completed a median average of 350 (IQR 150–500) gastroscopies and 150 (IQR 106–251) colonoscopies per year. Fellows with special interests completed either 428 hepato-pancreato-biliary procedures or 70 endoscopic mucosal resections per year.Medline publications: Median average 9 publications(IQR 4–17). They have also received multiple national or international awards and 91% achieved a doctoral degree.The seven current fellows in the new Shape of Training era (57% male, 29% Caucasian, aged 31–40 years) report high levels of enjoyment due to their research projects, supervisory teams and social aspects. The most cited reasons for undertaking the fellowship were to develop a subspecialty interest, take time off the on-call rota and develop endoscopic skills. The most reported drawback was a reduced income.All current fellows feel that the fellowship has enhanced their clinical confidence and prepared them to become consultants.Conclusion Out of programme clinical fellowships offer the opportunity to develop the required training competencies, subspecialty expertise and research skills in a supportive environment.

BACKGROUND AND AIMS:International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS:Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS:39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS:An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.

Background: When commencing enteral feeding, patients and families will want to know the likelihood of returning to an oral diet. There is a paucity of data on the prognosis of patients with gastrostomies. We describe a large dataset of patients, which identifies factors influencing gastrostomy removal and assesses the likelihood of the patient having at home enteral nutrition. Methods: Retrospective data was collected on patients from Sheffield Teaching Hospitals who had received a gastrostomy and had outpatient enteral feeding between January 2016 and December 2019. Demographic data, indication and outcomes were analysed. Results: A total of 451 patients were assessed, median age: 67.7. 183/451(40.6%) gastrostomies were for head and neck cancer, 88/451 (19.5%) for stroke, 28/451 (6.2%) for Motor Neuron Disease, 32/451 (7.1%) for other neurodegenerative causes, 120/451 (26.6%) other. Of the 31.2% who had their gastrostomy removed within 3 years, head and neck cancer was the most common indication (58.3%) followed by stroke (10.2%), Motor Neuron Disease (7.1%) and other neurodegenerative diseases (3.1%). Gastrostomy removal was significantly influenced by age, place of residence, and having head and neck cancer (p < 0.05). There was the greatest likelihood of removal within the first year (24%). 70.5% had enteral feeding at home. Conclusion: This large cohort study demonstrates 31.2% of patients had their gastrostomy removed within 3 years. Head and neck cancer patients, younger age and residing at home can help positively predict removal. Most patients manage their feeding at home rather than a nursing home. This study provides new information on gastrostomy outcomes when counselling patients to provide realistic expectations.

Introduction UK endoscopy training faces challenges from increasing service pressure and changes to specialty training curricula.1 Endoscopy training academies are a potential solution and in the North East and North Cumbria, a multicentre immersion training model was established in September 2022. Novice gastroscopy trainees will attend a 4-week block of 20 dedicated training lists at one of four immersion centres, in addition to regular training at base hospital site. Methods The JETS eportfolio KPI and DOPS data of novice gastroscopy trainees were compared between 3 historical trainees receiving weekly dedicated training lists (DTLs) plus other ad hoc training, and 4 trainees undergoing an immersion block in the first 20 weeks of gastroscopy training plus typical weekly DTLs and other ad hoc. For each trainee, five 4-weekly PDF summaries were taken from their eportfolios from the start of their endoscopy training to give a summary of their KPIs over 20 weeks. The 4-week period was chosen to allow for immersion block effect. Results Higher procedure volumes were seen in the immersion group (table 1) and this was associated with shorter time to achieve minimum D2 intubation and unassisted procedure rates. DOPS competence for independent practice was similar at each interval for both groups. Conclusion Early immersion training can lead to earlier acquisition of minimum KPI requirements for certification, compared to historical controls. Similar rates of DOPS assessed competence aligns with previous studies indicating that procedure competence should incorporate ENTS and pathology recognition.2 This was a small sample but indicates the potential of this model accelerate skill acquisition and reduce time to certification. Further work is required to expand this intervention to surgical and clinical endoscopists and incorporate ENTS and pathology recognition into the programme. References FitzPatrick M, et al. How can gastroenterology training thrive in a post-COVID world? Frontline Gastroenterology 2020;0:1–4. doi:10.1136/flgastro-2020-101601 Ward ST, Hancox A, Mohammed MA, et al. The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database. Gut 2017;66:1022–1030.

BACKGROUND:Narrow-band imaging (NBI) is a readily accessible imaging technique that enhances mucosal visualisation, allowing for a more accurate assessment of duodenal villi. However, its role in the diagnosis of coeliac disease (CD) in clinical practice remains limited. METHODS:We systematically searched several databases in June 2023 for studies evaluating the diagnostic accuracy of NBI for detecting duodenal villous atrophy (VA) in patients with suspected CD. We calculated the summary sensitivity, specificity, and likelihood ratios using a bivariate random-effects model. The study followed PRISMA guidelines and was registered at PROSPERO (CRD42023428266). RESULTS:A total of 6 studies with 540 participants were included in the meta-analysis. The summary sensitivity of NBI to detect VA was 93% (95% CI, 81% - 98%), and the summary specificity was 95% (95% CI, 92% - 98%). The area under the summary receiver operating characteristic curve was 0.98 (95% CI, 96 - 99). The positive and negative predictive values of NBI were 94% (95% CI, 92% - 97%) and 92% (95% CI, 90% - 94%), respectively. CONCLUSION:NBI is an accurate non-invasive tool for identifying and excluding duodenal VA in patients with suspected CD. Further studies using a validated classification are needed to determine the optimal role of NBI in the diagnostic algorithm for CD.

IntroductionThere are limited studies comparing the safety and effectiveness of Radiologically Assisted Gastrostomies (RAGs) against Percutaneous Endoscopic Gastrostomies (PEGs). The Sheffield Gastrostomy Score (SGS) can be used to help predict 30-day mortality, more information is needed on its validity in RAGs. Our aim is to compare mortality between RAGs (Radiologically Inserted Gastrostomies (RIGs) and Per-oral Image Guided Gastrostomies (PIGs)) with PEGs and validate the SGS.MethodData on gastrostomies newly inserted in three hospitals from 2016-2019 were retrospectively collected. Demographics, indication, insertion date, date of death, inpatient status and blood tests (albumin, CRP and eGFR) were recorded.Results1977 gastrostomies were performed: Gastrostomy mortality at 7 days was 1.3% and at 30 days was 6%. There was a 5% 30-day mortality for PEGs, 5.5% RIGs, 7.2% PIGs (p = 0.215). Factors increasing 30 day mortality were age & GE;60 years (p = 0.039), albumin <35 g/L (p = 0.005), albumin <25 g/L (p < 0.001) and CRP & GE;10 mg/L (p < 0.001). For patients who died within 30 days; 0.6% had an SGS of 0, 3.7% = 1, 10.2% = 2 and 25.5% = 3, with similar trends for RAGs and PEGs. ROC curves showed the area under the curve for all gastrostomies, RAGs and PEGs as 0.743, 0.738, 0.787 respectively.DiscussionThere was no significant difference between 30-day mortality for PEGs, RIGs and PIGs. Factors predicting risk include age & GE;60 years, albumin <35 g/L, albumin <25 g/L and CRP & GE;10 mg/L. The SGS has been validated in this study for PEGs and for the first time in RAGs as well..

Background Significant morbidity and mortality can be associated with gastrostomy insertion, likely influenced by patient selection, indication and aftercare. We aimed to establish what current variation in practice exists and how this has improved by comparison to our previously published British Society of Gastroenterology survey of 2010. Methods We approached all National Health Service (NHS) hospitals in England (n=198). Email and web-based questionnaires were circulated. These data were correlated with the National Endoscopy Database (NED). Results The response rate was 69% (n=136/198). Estimated Percutaneous Endoscopic Gastrostomy (PEG) placements in the UK are currently 6500 vs 17000 in 2010 (p<0.01). There is a dedicated PEG consultant involved in 59% of the centres versus 30% in 2010 (p<0.001). Multidisciplinary team meeting (MDT) discussion occurs in 66% versus 40% in 2010 (p<0.05). Formal aftercare provision occurs in 83% versus 64% in 2010 (p<0.001). 74/107 respondents (69%) reported feeling pressurised to authorise a gastrostomy. Conclusion This national survey, validated by the results from NED, demonstrates a reduction of over 60% for PEG insertion rates compared with previous estimates. There has also been an increase in consultant involvement, MDT discussion and aftercare provision. However, two-third of responders described 'pressure' to insert a gastrostomy. Perhaps further efforts are needed to include and educate other specialty teams, patients and next of kin.

Introduction Within the NHS, the delivery of flexible roles, including less than full time (LTFT) working, is important for recruiting and retaining staff for the provision of clinical services.1 The BSG has issued a position statement recommending flexible and LTFT working where practicable.2 We aimed to determine the proportion of UK endoscopy trainers who worked flexibly or LTFT and explore their provision of training. Methods An online survey was sent to endoscopy trainers registered on JETS eportfolio via email. Trainers were asked to record their professional role and if they worked flexibly/LTFT. They were asked if they provided regular Dedicated Training Lists (DTL) or Adhoc (ATL) endoscopy training lists, had completed endoscopy trainer courses (Train the Trainer or TTT). They were asked if they had access to trainer development opportunities and if they completed DOTS using a 5-point Likert scale (Always, Often, Sometimes, Rarely, Never) Results In total, 1024 responses were received from a total of 3292 trainers registered on JETS. 159 trainers (15%) reported they worked flexibly/LTFT. of these 159 trainers 32% were clinical endoscopists, 40% were gastro consultants and 14% were surgeons. A full breakdown of training list provision and training course participation is provided in table 1. In terms of appraisal, 40% of LTFT/flexible trainers had their DOTS and LETS reviewed, compared to 37% of full timers. and 25% of LTFT/flexible trainers and 23% of full timers were 'Always' encouraged to access trainer development opportunities. Conclusion Flexible/LTFT trainers report strikingly similar frequency of registered endoscopy training provision in their job plan as well as delivering similar regular DTL and ATL per week compared to their full time colleagues. TTT completion, acting as faculty and appraisals were equivalent to full timers. This suggests that despite working potentially fewer clinical sessions, there is no self-reported reduction in training provision and, in fact, higher participation in regional training courses. References https://www.england.nhs.uk/wp-content/uploads/2022/02/B0395-flexible-working-raising-the-standards-for-the-NHS.pdf. Accessed 17 January 2023 https://www.bsg.org.uk/workforce-reports/british-society-of-gastroenterology-position-statement-on-flexible-working/. Accessed 17 January 2023

Introduction There are a limited number of studies comparing the safety and effectiveness of Radiologically Assisted Gastrostomies (RAGs) against Percutaneous Endoscopic Gastrostomies (PEGs). The Sheffield Gastrostomy Score (SGS) can be used to help predict 30-day mortality and guide clinicians when consenting patients, this was however developed using data from patients undergoing PEGs and more information is needed on its validity in RAGs. We collected information on both PEGs and RAGs performed for all indications across 3 teaching hospitals: Sheffield, Leeds and Hull. The aim is to compare mortality between RAGs and PEGs, as well as further validate the SGS. Method Data on all gastrostomies newly inserted in 3 teaching hospitals over a 4-year period (2016–2019) were retrospectively collected. Demographics, indication, date of insertion, date of death, inpatient status and blood tests including albumin, C-reactive protein (CRP) and eGFR within the last 30 days were recorded. Data was analysed with chi-squared test, multivariant analysis and Receiver Operating Characteristic (ROC) curves. Results 1988 new gastrostomies were performed, 76.2% RAGs, 23.8% PEGs. Median age 65. 51.6% were requested as an inpatient, 44.8% for RAGs, 73.4% for PEGs. Overall gastrostomy mortality at 7 days was 1.3%, 30 days 6.1%, 6 months 24% and 1 year 34.9%. There was a 6.5% 30-day mortality for RAGs and 5.1% for PEGs (P = 0.264). Factors that increased gastrostomy 30-day mortality on analysis of variance were age ≥60 (p = 0.038), albumin <35 (p = 0.006), albumin <25 (p <0.001) and CRP >10 (p < 0.001). 0.6% of patients that died within 30 days of a gastrostomy had a SGS of 0, 4.1% had a score of 1, 10.2% had a score of 2 and 25.5% had a score of 3, there were similar trends for both RAGs and PEGs. ROC curves for the SGS showed the area under the curve is similar for all gastrostomies, RAGs and PEGs: 0.736, 0.731, 0.787 respectively. Discussion This large multicentre study showed no significant difference between 30-day mortality for RAGs vs PEGs. Factors that help predict those at risk of death within 30-days include age ≥60, albumin < 35, albumin < 25 and CRP > 10. We have been able to validate the SGS in this study and for the first time in RAGs as well. The SGS may over predict 30-day mortality and adding in CRP to the formula could potentially improve the validity of the current scoring system.

AbstractBackgroundParameters to adapt individual treatment strategies for patients with pancreatic ductal adenocarcinoma (PDAC) are urgently needed. The present study aimed to evaluate body composition parameters as predictors of overall survival (OS) in PDAC patients.MethodsMeasurements of body composition parameters were performed on computed tomography scans at diagnosis. Height‐standardized and Body Mass Index‐ and sex‐adjusted regression formulas deriving cut‐offs from a healthy population were used. The Kaplan‐Meier method with the log‐rank test was performed for survival analysis. Independent prognostic factors were identified with uni‐ and multivariable Cox regression analyses.ResultsIn total, 354 patients were analyzed. In a multivariable Cox model, besides tumor stage and resection status, only myosteatosis (HR 1.53; 95% CI 1.10–2.14, p = 0.01) was an independent prognostic factor of OS among body composition parameters. Subgroup analyses revealed that the prognostic impact of myosteatosis was higher in patients ≤68 years of age, with advanced tumor stages and patients without curative intended resection.ConclusionsThe analysis of one of the largest Caucasian cohorts to date, demonstrated myosteatosis to be an independent prognostic factor of OS in PDAC. To improve outcomes, prospective trials aiming to investigate the utility of an early assessment of myosteatosis with subsequent intervention by dieticians, sports medicine physicians, and physiotherapists are warranted.

There is cumulative evidence that pancreatic exocrine insufficiency (PEI) is under-recognised and can occur in patients with 'at-risk' conditions. Thus, we aimed to assess the current practice and yield of requesting faecal elastase (FEL-1), an indicator of PEI, in patients with 'at-risk' conditions. We prospectively recruited patients attending secondary care clinics with diabetes mellitus (DM), people living with HIV (PLHIV) and inpatients admitted to hospital with high alcohol intake (HAI). All patients underwent testing with FEL-1. Those patients with PEI (FEL-1 <200 μg/g) were contacted and offered a follow-up review in gastroenterology clinic. In total, 188 patients were recruited (HAI, n=78; DM, n=64; and PLHIV, n=46). Previous FEL-1 testing had not been performed in any of the patients. The return rate of samples was 67.9% for patients with HAI, 76.6% for those with DM and 56.5% for those with PLHIV. The presence of PEI was shown in 20.4% of patients with DM, 15.4% of patients with PLHIV and 22.6% in those with HAI. Diarrhoea and bloating were the most reported symptoms in followed-up patients with low FEL-1 (31.8% and 22.7% of patients, respectively). Follow-up computed tomography (CT) scans in those patients with PEI identified chronic pancreatitis changes in 13.6% and pancreatic atrophy in 31.8% of patients. These results suggest that there is a lack of testing for PEI in 'at-risk' groups. Our findings also suggest that using FEL-1 to test for PEI in patients with DM, PLHIV and HAI has a significant impact, although further studies are required to validate these findings.

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

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.

Familial adenomatous polyposis (FAP) is a hereditary disease that, without intervention, will cause nearly all patients to develop colorectal cancer by the age of 45. However, even after prophylactic colorectal surgery the eventual development of duodenal adenomas leads to an additional risk of duodenal and ampullary cancers. Endoscopy is an essential part of the multidisciplinary management of FAP to aid the early identification or prevention of advanced gastrointestinal malignancy. This review article details the current evidence and consensus guidance available regarding the role of endoscopic surveillance and treatment strategies for FAP.

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) can be difficult to diagnose and causes maldigestion symptoms and malabsorption. There has been a number of studies that have identified PEI associated micronutrient deficiencies (PEI-MD), however there is variation in both the frequency and type of PEI-MD reported, with the majority of studies including patients with PEI due to chronic pancreatitis (CP) or CP without PEI. There is a paucity of information regarding the prevalence of PEIMD in patients with PEI without CP and the yield of testing for PEI-MD in a clinical setting in patients with suspected benign pancreatic diseases. AIM To prospectively assess the yield and type of PEI-MD in patients with and without PEI secondary to benign pancreatic disease. METHODS Patients investigated for maldigestion symptoms with Faecal Elastase-1 (FEL-1) and suspected or proven benign pancreatic disease were prospectively identified. At the time of FEL-1 testing, serum samples were taken for micronutrients identified by previous studies as PEI-MD: prealbumin, retinol binding protein, copper, zinc, selenium, magnesium and later in the study lipid adjusted vitamin E. FEL-1 was recorded, with a result < 200 mu g/g considered diagnostic of PEI. Patients underwent computed tomography (CT) imaging when there was a clinical suspicion of CP, a new diagnosis of PEI recurrent, pancreatic type pain (epigastric abdominal pain radiating to back with or without previous acute pancreatitis attacks) or weight loss. RESULTS After exclusions, 112 patients were recruited that underwent testing for FEL-1 and PEI-MD. PEI was identified in 41/112 (36.6%) patients and a pancreatic CT was performed in 82 patients. Overall a PEI-MD was identified in 21/112 (18.8%) patients. The yield of PEI-MD was 17/41 (41.5%) if PEI was present which was significantly higher than those without 4/71 (5.6%) (P = 0.0001). The yield of PEI-MD was significantly higher when PEI and CP were seen together 13/22 (59.1%) compared to CP without PEI and PEI without CP (P < 0.03). Individual micronutrient assessment showed a more frequent occurrence of prealbumin 8/41 (19.5%), selenium 6/41 (14.6%) and magnesium 5/41 (12.2%) deficiency when PEI was present (< 0.02). The accuracy of using the significant micronutrients identified in our cohort as a predictor of PEI showed a positive predictive value of 80%-85.7% [95% confidence interval (CI): 38%-100%] and a low sensitivity of 9.8%19.5% [95% CI: 3.3%-34.9%]. CONCLUSION Testing for PEI-MD in patients with suspected pancreatic disease has a high yield, specifically when PEI and CP are found together. PEI-MD testing should include selenium, magnesium and prealbumin.