Introduction Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones. Methods Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Results Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. Conclusions The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Aims The recent development of through-the-needle microbiopsy (TTNB) forceps via endoscopic ultrasound (EUS) has facilitated sampling of pancreatic cyst walls for histological analysis. This novel method has added to the armamentarium of the currently available radiological, biochemical and cytological modalities in the diagnostic algorithm of patients with pancreatic cystic lesions (PCL). We aimed to describe the utility of EUS-TTNB in influencing management outcomes at a tertiary hepatopancreatobiliary unit.

Aims Endoscopic ultrasound guided choledochoduodenostomy (EUS-CDD) with electrocautery enhanced lumen apposing metal stents (EC-LAMS) has recently emerged as a viable option in the management of patients with malignant distal biliary obstruction (MDBO). We conducted a multi-centre collaboration from the UK and Ireland with an aim to analyse the pooled efficacy, safety and long term outcomes of EUS-CDD for treatment of MDBO.

Introduction: Endoscopic ultrasonography (EUS) is an essential pancreatic cancer investigation which has picked up in the last decade and is commonly used in combination with more traditional cross-sectional imaging techniques. Up to 79% of all pancreatic malignancies are locally advanced (stage 3) or metastatic (stage 4) at initial presentation. Developments in technology, such as contrast enhancement, elastography and fine needle aspiration (EUS-FNA) have further increased EUS diagnostic yield. EUS-FNA is accepted as the optimal method of obtaining tissue for histological diagnosis prior to starting neoadjuvant treatment (NAT) and has a lower incidence of complications such as pancreatitis, bleeding and tumour seeding. The aim of this study was to evaluate the role of EUS in advanced pancreatic cancers. Methods: Patients with borderline and locally advanced pancreatic ductal adenocarcinoma between 2016 and 2020 were retrieved from institutional pancreatic tumour database. Patients with IPMN, MCN, periampullary cancers and metastatic pancreatic cancer were excluded. All patients with BRPC, LAPC received NAT. Data of patients undergoing EUS were retrieved and compared with cross-sectional imaging. Appropriate statistical analysis was performed where applicable. Results: 96 patients underwent EUS and FNB. Diagnosis of PDAC was confirmed in 81.25% (78) cases before starting neoadjuvant treatment. Mean tumour size on EUS was 2.7cm as compared to 3cm on CT. CT confirmed N1 disease was seen in 21.6% (26) patients however, in only 2.5% (3) cases local lymphadenopathy was detected using EUS. Vascular involvement was seen in 50.8% (61) cases on CT and only in 44.1% (53) in the EUS group. EUS induced pancreatitis was seen in 3.12% (3) patients. > 2 attempts to confirm tissue diagnosis was seen in 3.84% of patients. Dysplasia, IPMN, Pancreatitis and Suspicious lesions were detected in 1.04%, 2.08%, 1% and 15.62% is suspected PDAC on imaging. There were no EUS induced bleeding or other complications during the study period. Conclusion: EUS has a role in the evaluation of advanced pancreatic malignancies and in assessment of vascular involvement and local lymphadenopathy. It also provides cytological and histological confirmation prior to commencing NAT. EUS-guided therapeutic interventions also provide effective biliary drainage particularly in individuals where ERCP is not feasible.

Aims Percutaneous transhepatic biliary drainage (PTBD) is associated with significant morbidity and prolonged hospital stay [1,2]. Endosonography-guided biliary drainage (EUS-BD) is an alternative to PTBD when endoscopic retrograde pancreatography (ERCP) has failed. The aims of this study were to review the technical success and adverse events with EUS-BD procedures performed at a tertiary care referral centre.

Aims The obesity epidemic and resultant growth in bariatric surgery have led to a unique problem of managing pancreaticobiliary diseases in patients with altered anatomy, particularly after Roux-en-Y gastric bypass (RYGB). Various techniques including enteroscopy-assisted [1] and laparoscopy/laparotomy-assisted [2,3] endoscopic retrograde cholangiopancreatography (ERCP) have been developed to address this problem with varying success. More recently, a novel endoscopic-ultrasound (EUS)-directed transgastric ERCP (EDGE) procedure has been described4. Here we present what the authors believe are the first five EDGE procedures performed in the United Kingdom.

Introduction Diagnostic yield from EUS-FNAC (fine needle aspiration cytology) has improved in the past few years with better tissue acquisition techniques. Core biopsy needles are now available but are more expensive than FNAC needles. We assessed the diagnostic yield and accuracy of FNAC samples processed for both cytology and histology. Method EUS-FNA samples of solid lesions (from September 2014 to September 2016) were included in a prospective audit of practice. Between September 2014 and January 2016 the standard practice was to send FNAC samples for cytology only. After this date, FNAC samples were filtered through a cassette. The solid material was sent in formalin to histology and the effluent to cytology for cytospin and cell block as previously. Cellularity was graded as adequate or inadequate. Final diagnosis was obtained from MDT outcomes. Results A total of 211 patients (118 male) were included. Samples were sent to cytology (n=135; 107 pancreas, 10 biliary, 7 lymph nodes, 11 other), or cytology and histology (n=76; 56 pancreas, 12 biliary, 5 lymph nodes, 3 other). Sample adequacy was 80.7% and 98.7% (p=0.0004). Diagnostic yield (64.4%, 94.7%) and accuracy (81.3%, 96.1%) was significantly better in the combined (histology and cytology) group (p Conclusion Our study confirms significant improvement in diagnostic yield and accuracy when samples were sent for both cytology and histology using standard FNAC needles. Disclosure of Interest None Declared

Objective Endoscopic retrograde cholangiopancreatography (ERCP) in the UK has been historically performed under conscious sedation. However, given the increasing complexity of cases, the role of propofol-assisted ERCP (propERCP) is increasing. We describe our experience of propERCP and highlight the importance of this service. Design Our prospective ERCP database was interrogated between January 2013 and January 2014. Data collection included procedural information, patient demographics, American Association of Anaesthesiologists (ASA) status, Cotton grade of endoscopic difficulty and endoscopic and anaesthetic complications. Comparison was made with patients undergoing conscious sedation ERCP (sedERCP). Results 744 ERCPs were performed in 629 patients (53% male). 161 ERCPs were performed under propofol. PropERCP patients were younger compared with the sedERCP group (54 vs 66 years, p<0.0001) but ASA grade 1–2 status was similar (84% vs 78%, p=0.6). An increased number of Cotton grade 3–4 ERCPs were performed in the propERCP group (64% vs 34%, p<0.0001). Indications for propERCP included sphincter of Oddi manometry (27%), previously poorly tolerated sedERCP (26%), cholangioscopy (21%) and patient request (8%). 77% of cases were elective, 12% were urgent day-case transfers and 11% were urgent inpatients. 59% of cases were tertiary referrals. ERCP was completed successfully in 95% of cases. Anaesthetic and endoscopic complications were comparable between the two groups (5% and 7% vs 3% and 5%). Where sedERCP had been unsuccessful due to patient intolerance, the procedure was completed successfully using propofol. Conclusions PropERCP is safe and is associated with high endoscopic success. The need for propERCP is likely to increase given patient preference and the high proportion of complex procedures being undertaken. All endoscopy units should look to incorporate propofol-assisted endoscopy into aspects of their services.

Aim To examine antenatal and intra-partum management of twin pregnancies, review the available guidelines and compare the current practice in our unit with recommendations. Methods 3 year retrospective audit from 1 April 2007 to 31 March 2010. The data was collected by proforma and anonymised for patient confidentiality. Results There were 174 twin pregnancies, out of which 39 (22%) were monochorionic and 135 (78%) dichorionic (figure 1). There was one monochorionic monoamniotic pregnancy. Chorionicity was recorded in all but one case1 and usually confirmed between 11 and 14 weeks. 27% of monochorionic and 6.7% of dichorionic twins had fewer scans than recommended. There was inadequate documentation of consultation regarding mode of delivery.2 12.1% of second twins were delivered by emergency caesarean after vaginal delivery of twin 1, and the caesarean rate for vertex/vertex presentation was 44.1% and 52.3% for vertex/non-vertex. Of these 65 caesareans, 10 were done for maternal request (15.4%). 39 first twins (22.4%) and 52 second twins (29.9%) were admitted to NICU. The mortality was 1.4% for dichorionic and 15.3% for monochorionic. Conclusion/recommendations This audit highlighted the need for better counselling regarding mode of delivery, especially when twin 1 is vertex, as 15.4% of these women had elective caesarean for maternal request. 12.1% of second twins were delivered by caesarean. The audit also brought to light the need for local guidelines, patient information leaflets and a dedicated team for the management of twins. All these issues have been addressed since the audit. We aim to re-audit in a year to assess change in practice.

Introduction Bariatric gastric bypass surgery is being increasingly performed, but ERCP in these patients poses a unique challenge because of lack of per-oral access to the stomach. Small series suggest a higher technical success rate, using Laparoscopy assisted ERCP (LA-ERCP), than with an enterosocpic approach via the Roux-en-Y anastamosis. We present the experience thus far of LA-ERCP at our UK tertiary referral Pancreaticobiliary unit. Methods Retrospective case series of consecutive patients undergoing LA-ERCP in our unit between September 2011 and June 2013. Data was retrieved from electronic, clinical and endoscopy records. Results All LA-ERCP procedures were undertaken in the operating theatre with a mobile endoscopy stack and Olympus TJF duodenoscopes equipped with standard ERCP accessories. The laparoscopic procedure involved formation of a closed pneumoperitoneum to a pressure of 12 mmHg with a Veress needle. A 15 mm trocar was placed in the epigastrium and two 5mm trocars were placed in the right and left flanks for surgical access. A 15 mm gastrostomy port was secured with purse-string sutures. The duodenoscope was inserted via the port into the gastric remnant and advanced conventionally into the duodenum. Standard therapeutic ERCP technique was then performed. Closure of the gastrostomy was achieved with a double layer of 2–0 vicryl sutures. Peri-procedural prophylactic intravenous antibiotics were administered routinely in all patients. Conclusion Five LA-ERCPs (on 5 patients) were performed. All patients were Female with median age 44 years (range 36–71). Indications included symptomatic bile duct stones (3/5), benign papillary fibrosis (1/5) and retained biliary stent (1/5). Duodenal access, biliary cannulation and completion of therapeutic aim were achieved in all patients. 4/5 (80%) patients required endoscopic sphincterotomy. The 5th patient had a prior sphincterotomy. The mean duration of procedures was approximately 94 min (range 70–135). Median post-op length of stay was 2 days (range 1–9). One patient developed mild post-procedural acute pancreatitis. Otherwise no procedure related complications were seen. Reference Our early experience of LA-ERCP is that it is safe and effective. The technique may require particular consideration, as bariatric surgery is increasingly performed, in a patient group at significant risk of bile duct stones. Disclosure of Interest None Declared.

Introduction Symptomatic benign biliary strictures (BBS) in chronic pancreatitis (CP) have historically been treated with surgical biliary bypass or multiple plastic stents. We report our experience of fully covered self-expanding metal stents (fcSEMS) for this indication in a cohort of patients with CP. Methods A prospectively recorded ERCP database including all CP patients undergoing fcSEMS for BBS, between Oct 2008 and Aug 2013, was analysed. Demographics, pathology results, stent data and patient outcomes were collated. Results A total of 256 ERCPs involving biliary SEMS insertion were performed of which 115 (45%) were fcSEMS. 48/115 (42%) fcSEMS were performed in 24 patients (75% Male, median age 55 years) with BBS related to CP. Aetiological factors included alcohol (63%), autoimmune (13%) and idiopathic (8%). Surgical bypass was precluded in 23/24 (96%) patients due to extensive choledochal varices (58%), advanced cirrhosis (13%), medical comorbidities (13%), hostile surgical abdomen (13%) and autoimmune CP (13%). 17/24 (71%) patients had previous plastic biliary stent (s). 10mm diameter fcSEMS (Boston Wallflex or Cook Evolution) of 6 or 8 cm in length were used. They remained in situ for median 9.5 months (range 1–32). 13/24 (54%) patients achieved stricture remodelling, allowing trial of fcSEMS removal and follow up without stenting for median 7 months (range 0–22). These patients required median 3 fcSEMS (range 1–6) over median 24 months (range 2–51) to achieve stricture resolution. 42% (10/24) patients who had not yet achieved stricture resolution had fewer fcSEMS to date (median 1) and a shorter duration of stenting. Complications included proximal (4%) and distal stent migration (16.5%), cholecystitis (6%) and acute pancreatitis (2%). Biliary obstruction +/- cholangitis occurred in 23% at some point. 96% (46/48) fcSEMS were easily removed without needing additional procedures. One fcSEMS was in situ for 18 months (patient lost to follow up) and it was not possible to then remove it (due to tissue in-growth). Another fcSEMS in situ for 32 months (due to tissue in-growth) was removed following a “stent-in-stent” fcSEMS procedure. 2 patients died before planned removal of their first metal stent due to pre-existing comorbidity. Conclusion As suggested by smaller published series (Kaffes, GI Endoscopy 2013), FcSEMS are a safe and effective approach to managing BBS due to CP and may promote stricture remodelling. Endoscopic removal is straightforward if the fcSEMS is in situ for <12 months. Disclosure of Interest None Declared.

Introduction Nutrition centred research in pancreatitis has largely focused on acute pancreatitis. There is limited nutritional data in patients with Chronic Pancreatitis (CP), a condition that predisposes to endocrine and exocrine failure, fat-soluble vitamin deficiency and osteoporosis, which may worsen a patient’s quality of life and long-term outcome. We aim to determine the prevalence of malnutrition (using the Malnutrition Universal Screening Tool -MUST), active alcohol consumption and cigarette smoking in patients with CP. Methods Prospective study of consecutive patients with CP attending a tertiary clinic between October and December 2013. They were invited to participate in a face-to-face questionnaire study. Behavioural and socioeconomic data were collated. Results A cohort of 86 patients identified were predominantly male (67%), White British (62%), median age 58 years (range 18–90), of socio-economic class (SEC) 8 (21% never worked/long-term unemployed) with educational level (EL) 1 (29% degree or equivalent). Aetiologies included alcohol (29%), idiopathic (25%), autoimmune (22%) and gallstones (11%). The aetiology in 6% was actively under investigation. Median follow up was 27.5 months (range 0 – 151) from index appointment. Active alcohol exposure was noted in 33% (28/86) with excessive amounts (m >21 u, f >14 u/week) in 8% (7/86). The majority of patients (> 70%) with ongoing exposure to alcohol had primary aetiologies other than alcohol. Active cigarette smoking was noted in 34%. MUST scores ≥ 1 were noted in 38% (33/86) conferring “medium to high risk of malnutrition”. Multiple linear regression analysis of age, gender, ethnicity, SEC, EL, aetiology, alcohol exposure and smoking did not show any statistically significant variables that predicted MUST score. 27% (9/33) patients “at risk of malnutrition” had been referred to or had been seen by a dietitian within the previous 12 months. The remaining 73% (24/33) “at risk” patients all claimed to have received nil or suboptimal nutritional advice with regards to CP within the previous 24 months. Conclusion Patients with CP attending our tertiary clinic are at significant risk of malnutrition, which may be under-recognised. Behavioural and socioeconomic factors do not allow reliable prediction of risk of malnutrition to be made, in this cohort. This data emphasises the need for an algorithmic approach to improve recognition of malnutrition in CP and for implementation of specialist dietetic, alcohol liaison and smoking cessation services within the outpatient environment. Disclosure of Interest None Declared.

Introduction Biliary Sphincter of Oddi dysfunction (SOD) is a benign but often debilitating condition. Significant improvement in pain following endoscopic sphincterotomy or sphincteroplasty (ES) in patients with Type 1 SOD, is excellent. Symptomatic improvement in patients with type 2 or 3 SOD is less favourable (reported 50–70% and 30–50% respectively). We aim to determine the impact of ES, on pain symptoms and global quality of life (QOL) in these groups, which has not previously been well defined. Methods An ERCP database and electronic clinic lists (from September 2011 to 2013) were analysed to identify all cases of suspected SOD. Patients underwent a telephone questionnaire. The Glasgow Benefit Inventory (GBI), which assesses multiple physical, emotional and social parameters, was used to quantify global post-interventional QOL benefit. Total GBI scores can range from -100 (maximal negative benefit) to +100 (maximal positive benefit). Results 163 new patients with suspected biliary SOD were identified of whom 89 underwent ERCP. 3 patients were excluded due to an alternative diagnosis at ERCP. The remaining cohort was predominantly Female (87%) and White British (86%) with median age 37 years (range 18–69). 88% had undergone prior cholecystectomy. Patients were attributed with the following pre-test diagnoses – 20/86 (23%) SOD1, 53/86 (62%) SOD2, 13/86 (15%) SOD3. Median post-ERCP follow up was 12 months (range 2–27). In patients who underwent endotherapy and completed questionnaires: 93% (14/15) SOD1, 76% (36/48) SOD2 and 83% (10/12) SOD3 subjectively reported pain improvement post-ERCP (within median 1 month). Sustained response (median 6 months) was noted in 60, 30 and 46% of SOD 1/2/3 respectively. Median total GBI scores in the patients who had sustained improvement were +44 (SOD1), +31 (SOD2) and +29 (SOD3). There was a clear correlation between subjective response to ES and GBI scores (see table). Negative total scores were recorded across all SOD subtypes in patients who had no symptom improvement whatsoever following ES. Total GBI scores in all categories were higher in SOD1 than SOD2 than SOD3. Conclusion ES for SOD1 appears to provide sustained benefit in symptoms and QOL above that achieved in SOD2/3. QOL measured by GBI is strongly correlated to symptomatic response to ES despite pain response being only a minor contributor to the GBI rating. Therefore, GBI may be helpful to determine clinical, emotional and social factors that could help to predict those patients who will respond to ES. Disclosure of Interest None Declared.

Introduction In the absence of biochemical or radiological evidence of biliary obstruction, Sphincter of Oddi dysfunction (SOD) is a difficult condition to diagnose and to treat. The Rome III diagnostic criteria clearly state that, to meet a diagnosis of SOD, a patient should have “episodic pain at different time intervals (not daily)”. We observe heterogeneity in symptoms amongst patients referred with suspected SOD with many patients reporting constant daily pain requiring potent analgesia. We aim to determine whether subjective reporting of pain (according to the Rome criteria) correlates with Sphincter of Oddi Manometry (SOM: the gold standard for diagnosis of SOD) and/or response to endoscopic sphincterotomy/plasty (ES). Methods An ERCP database and electronic clinic lists (from September 2011 to 2013) were analysed to identify all cases of suspected SOD. Patients underwent a telephone questionnaire based on subjective recall of pre-ERCP pain according to the Rome criteria and post-ERCP response. Patients were asked to categorise pain as either intermittent with no pattern/not daily (Rome +ve) or daily/constant pain (Rome –ve). Results 163 new patients with suspected biliary SOD were identified of whom 89 underwent ERCP. They were mostly Female (87%), White British (86%) with median age 37 years (range 18–69). 48 patients with SOD2/3, who underwent SOM, agreed to answer the questionnaire. Patients with SOD1 do not routinely undergo SOM. Biliary and/or pancreatic basal pressures were abnormally elevated (>40 mmHg) in 33/37 (89%) SOD2 and 8/10 (80%) SOD3, all of whom underwent ES. There were no significant correlations between Rome +ve pain and either biliary manometry (p = 0.3) or improvement in pain following ES (p = 0.2) in patients with either SOD 2 or 3 (see tables). However, there was a high relapse rate after initial improvement across both groups (SOD2 17/26=65%, SOD3 2/7=29%) irrespective of whether patients had Rome +ve or –ve pain initially. Conclusion Despite the clear recommendations of the Rome criteria requiring intermittent/episodic pain for a diagnosis of SOD, our data suggest that correlation between description of pain and biliary manometry is poor. 30–35% of patients who meet the current gold standards for diagnosis of SOD have constant or daily (Rome –ve) pain. Additionally, description of pain does not predict response to endotherapy suggesting that the Rome criteria and/or SOM for suspected SOD are not clinically useful and may need to be redefined. We note that high rates of positive SOM and recurrence of pain post-ES was seen in our cohort. Disclosure of Interest None Declared.

Introduction Choledocholithiasis is the commonest indication for endoscopic retrograde cholangiopancreatography (ERCP). ERCP carries substantial risk of complication when compared to other endoscopic modalities. The identification of key performance indicators (KPIs) in colonoscopy practice and implementation of related standards has driven quality assurance in the UK and elsewhere. The failure to establish similar contemporary, meaningful and measurable KPIs in ERCP has hampered the development of national standards. We aimed to quantify current performance in a potential new endoscopic KPI: the complete clearance of CBD stones at first ERCP. Methods Seven centres participated – four secondary and three tertiary HPB units. All patients undergoing first ERCP for confirmed or suspected choledocholithiasis over a twelve month period were included and data were analysed on an intention to treat basis. The primary endpoint was complete clearance of bile duct stones. Failure to clear stones was defined as i) persisting stones reported ii) placement of biliary endoprosthesis, even if considered precautionary. Secondary endpoints were CBD cannulation, successful biliary decompression and complications. Outcomes were analysed by unit and by consultant clinician performing the procedure. Results 1178 patients were included in the study. 20 consultant endoscopists carried out or supervised the procedures. Overall, deep biliary cannulation was achieved in 1074/1178 (91%, range for seven units 82–96%). Complete bile duct clearance at first ERCP was achieved in 861/1178 (73%, 65–81%). Conclusion We investigated the outcome of 1178 ERCP procedures, representing real-life practice in the UK. Duct clearance was possible at first ERCP in almost three quarters of patients. There were significant differences in performance between units and individual operators. The reasons for this are not fully elucidated. The primary endpoint of this study has strengths as a potential KPI. It is clearly defined, measurable on an intention to treat basis and is strongly focused on patient outcome. In addition, it quantifies performance in the commonest indication for ERCP, stone extraction, which is undertaken in all ERCP units. Disclosure of Interest None Declared.

IntroductionERCP in the UK has historically been performed under conscious sedation (SED). However, given the increasing complexity of cases the role of enhanced sedation assisted ERCP (ENS ERCP) is increasing. A previous audit iat UCLH showed that intolerance of SED was a major factor in ERCP failure. BSG guidance was issued in 2011 regarding the use of propofol sedation for ERCP in the UK.1 We describe our experience of ENS ERCP and highlight the importance of the regular availability of this service.MethodsOur prospective ERCP database was interrogated to include cases between Jan-Nov 2013. Two dedicated ENS ERCP lists run weekly at UCLH. Data collection included procedural information, patient demographics, ASA status, Cotton grade of difficulty (1–4), and endoscopic/anaesthetic complications. ENS ERCP was defined as the use of propofol +/- fentanyl without the need for intubation. ENS was administered by consultant anaesthetists. Data presented as median with range. Comparison was made between SED and ENS ERCP patients.ResultsDuring the 10 month study period 629 ERCPs were performed in 532 patients (52% male). 423 procedures were performed under SED and 139 under ENS. ENS patients were younger compared to SED patients (54, 9–88 years vs. 66, 20–96 years, p < 0.0001) but ASA grade 1–2 status was similar between the two groups (84 vs. 78%, p=NS). An increased number of Cotton grade 3–4 ERCPs were perfomed in the ENS group (64 vs. 34%, p < 0.0001). Common indications for ENS included previously uncomfortable/failed procedure (30%), biliary/pancreatic sphincter of Oddi manometry (24%) and single operator cholangioscopy (20%). Patient choice accounted for only 4% of cases. 59% of cases were tertiary referrals, 12% of which had failed previously. 77% of referrals were elective cases, 12% urgent day-case referrals and 11% urgent in-patients. ERCP was completed successfully in 95% of cases. Anaesthetic complications occurred in 3 cases all relating to over sedation requiring intubation. ERCP-related complications occurred in 5% of cases. Where previous SED ERCP was unsuccessful due to patient intolerance, the procedure was completed in all cases using ENS.ConclusionTo date ENS ERCP has predominately been used for previously failed/poorly tolerated procedures and Cotton Grade 3–4 ERCPs. ENS ERCP improves outcomes and is safe when delivered with anaesthetic support. It is likely to be increasingly requested by patients and referrers. Regular ENS provision should be offered by all endoscopy units offering ERCP, and the anaesthetic resource and funding implications will need to be pursued.Reference1 Guidance for the use of propofol sedation for adult patients undergoing ERCP and other complex upper GI endoscopy procedures, April 2011. RCoA and BSG guidanceDisclosure of InterestNone Declared.