BACKGROUND:While endoscopic step-up approach with delayed drainage (more than 28 days from diagnosis) was shown to produce the best outcomes in the treatment of pancreatic walled-off necrosis (WON), we assessed our single centre experience of early versus delayed endoscopic drainage of pancreatic necrotic collections. METHODS:Patients who underwent endoscopic drainage of pancreatic necrotic collections between 2011 and 2022 under Monash Health were identified. They were excluded if below 18 years old or their follow up data were missing. The included patients' medical records, pathology results, and imaging findings were retrospectively reviewed. RESULTS:A total of 60 patients were included. 31.58% required percutaneous drainage and 15% received either endoscopic or surgical necrosectomy. The disease related mortality was 8.47% and the average length of stay (LOS) was 70.92 days. No significant difference was shown in disease-related mortality (10.5% vs. 7.5%, P = 0.697) or LOS (75.35 vs. 68.7, P = 0.644) between early and delayed drainage cohorts, but patients who received early drainage have higher qSOFA score on the day of drainage (2 vs. 0, P = 0.004). DISCUSSION:Repetitive endoscopic drainage with selective percutaneous drainage is effective in the management of pancreatic necrotic collections. Early drainage should be considered in patients who developed severe sepsis.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed with patients in the prone position (PP). However, this poses a potentially increased risk of anesthetic complications. An alternative is the left lateral (LL) decubitus position, which is commonly used for endoscopic procedures. Our aim was to compare cannulation rate, time, and outcomes in ERCP performed in LL versus PP. Patients and methods We conducted a non-inferiority, prospective, randomized control trial with 1:1 randomization to either LL or PP position. Patients > 18 years of age with native papillae requiring a therapeutic ERCP were recruited between March 2017 and November 2018 in a single tertiary center. Results A total of 253 patients were randomized; 132 to LL (52.2%) and 121 to PP (47.8%). Cannulation rates were 97.0% in LL vs 99.2% in PP (difference -2.2% (one-sided 95% CI: -5% to 0.6%). Median time to biliary cannulation was 03:50 minutes in LL vs 02:57 minutes in PP (P=0.62). Pancreatitis rates were 2.3% in LL vs 5.8% in PP (P=0.20). There were significantly lower radiation doses used in PP (0.23 mGy/m(2) in LL vs 0.16 mGy/m(2) in PP, P=0.008) without a difference in fluoroscopy times. Conclusions Our analysis comparing LL to PP during ERCP shows comparable procedural and anesthetic outcomes, with significantly lower radiation exposure when performed in PP. We conclude that ERCP undertaken in the LL position is not inferior to PP, except for higher radiation exposure, and should be considered as a safe alternate position for patients undergoing ERCP.

BACKGROUND:Recent prospective studies suggest combination therapy with immunomodulators improves efficacy, but long-term data is limited.AIM:To assess whether anti-tumour necrosis factor alpha (anti-TNF) monotherapy was associated with earlier loss of response (LOR) than combination therapy in a real-world cohort with long-term follow up.METHODS:A retrospective audit was conducted of inflammatory bowel disease patients receiving anti-TNF therapy in a tertiary centre and specialist private practices. All patients with accurate data for anti-TNF commencement and adequate correspondence to determine end-points were included. Outcomes measured included time to first LOR, causes and biochemical parameters.RESULTS:Two hundred and twenty-four patients were identified; 139 (62.1%) on combination therapy and 85 (37.9%) on monotherapy. Forty-five percent of patients had LOR during follow up until a maximum of 8.5 years; 59.4% on combination therapy and 40.6% on monotherapy (P = 0.533). The median time to LOR was not different between groups; 1069 days for combination therapy and 1489 days for monotherapy (P = 0.533). There was no difference in time to LOR between patients treated with different combination regimens or different anti-TNF agents.CONCLUSION:In this large cohort of patients in a real-world setting, patients treated with anti-TNF monotherapy had similar rates of LOR as patients on anti-TNF combination therapy, at both short- and long-term follow up.

Pseudocyst of the pancreas extending into the thorax represents a rare but potentially catastrophic diagnosis. It can be difficult to both diagnose and manage, with only limited management suggestions within the literature. While pleural effusion is a common complication of pancreatitis, transthoracic extension of a pseudocyst is a rare phenomenon. Herein we discuss a patient with a difficult to recognize extension of pancreatic pseudocyst into the left hemithorax, with unique imaging findings. He had good response to trans-gastric and percutaneous drainage and ultimately proceeded to thoracotomy and decortication. Around this case, the options for investigation and management are discussed.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used in the treatment of pancreato-biliary disease. Despite advances in technique and equipment, ERCP complications occur and can be significant. ERCP is traditionally performed with patients in prone position (PP). However, this poses a potentially increased risk of anaesthetic complications. An alternative position is the left lateral decubitus (LL) position, which is the most common position for endoscopic procedures. As there is currently no data comparing LL with PP and their success and complication rates, we conducted a study to show that LL position is non-inferior to PP for ERCP.

ANZ Journal of SurgeryVolume 89, Issue 5 p. E202-E203 IMAGES FOR SURGEONS Anastomotic stricture: a complication of endoscopic choledochoduodenostomy Tegan Ormston MBBS, Tegan Ormston MBBS orcid.org/0000-0003-4213-1239 Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDavid Devonshire FRACP, David Devonshire FRACP Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDaniel Croagh FRACS, Daniel Croagh FRACS Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this author Tegan Ormston MBBS, Tegan Ormston MBBS orcid.org/0000-0003-4213-1239 Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDavid Devonshire FRACP, David Devonshire FRACP Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDaniel Croagh FRACS, Daniel Croagh FRACS Monash Medical Centre, Monash Health, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 05 October 2017 https://doi.org/10.1111/ans.14211Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume89, Issue5May 2019Pages E202-E203 RelatedInformation

A 29 year old female who previously underwent a pylorus preserving pancreaticoduodenectomy for an insulinoma 9 months previously presented with a biliary stricture causing obstructive jaundice. Attempts to traverse the stricture radiologically were unsuccessful. The stricture could not be reached with a paediatric colonoscope and she was considered for surgical revision of the hepaticojejunostomy. Prior to this, one final attempt at endoscopic revision of the hepaticojejunostomy was made.

The interventional management of necrotizing pancreatitis has evolved from early open surgery to delayed endoscopic or percutaneous intervention. However, few studies have directly compared the three treatment modalities. We aim to compare the outcomes of patients who had endoscopic, percutaneous or surgical interventions for necrotizing pancreatitis at our institution.

INTRODUCTION:Laparoscopic bile duct exploration at the time of laparoscopic cholecystectomy has been promoted as being equally successful as endoscopic bile duct clearance. Further, if successful it offers the possibility of reducing the number of interventions required and therefore reducing overall costs. However, there is little in the literature that describe current treatment patterns in the Australian environment.METHODS:Medicare data were obtained for the number of patients undergoing laparoscopic cholecystectomy, intraoperative cholangiography, laparoscopic transcystic bile duct exploration, laparoscopic choledochotomy and bile duct exploration, endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and endoscopic biliary stent insertion.RESULTS:Although there was significant state-to-state variation in the prevalence of laparoscopic bile duct exploration (0.6-3.7%), ERCP remained the predominant method of bile duct clearance in the setting of laparoscopic cholecystectomy (5.4%). Transcystic bile duct exploration is far more common than laparoscopic choledochotomy, which is a rare procedure. This suggests that patients with a dilated common bile duct and large or multiple stones are typically undergoing ERCP rather than laparoscopic bile duct clearance.CONCLUSION:Despite the apparent attractiveness of laparoscopic bile duct exploration at the time of cholecystectomy, ERCP remains the most common method of dealing with choledocholithiasis in the setting of an intact gallbladder in Australia.

Background . Self-expandable metal stents (SEMs) are increasingly being utilised instead of invasive surgery for the palliation of patients with malignant gastroduodenal outlet obstruction. Aim . To review two tertiary centres’ experience with placement of SEMs and clinical outcomes. Methods . Retrospective analysis of prospectively collected data over 12 years. Results . Ninety-four patients (mean age, 68; range 28–93 years) underwent enteral stenting during this period. The primary tumour was gastric adenocarcinoma in 27 (29%) patients, pancreatic adenocarcinoma in 45 (48%), primary duodenal adenocarcinoma in 8 (9%), and cholangiocarcinoma and other metastatic cancers in 14 (16%). A stent was successfully deployed in 95% of cases. There was an improvement in gastric outlet obstruction score (GOOS) in 84 (90%) of patients with the ability to tolerate an enteral diet. Median survival was 4.25 months (range 0–49) without any significant differences between types of primary malignancy. Mean hospital stay was 3 days (range 1–20). Reintervention rate for stent related complications was 5%. Conclusion . The successful deployment of enteral stents achieves excellent palliation often resulting in the prompt reintroduction of enteral diet and early hospital discharge with minimal complications and reintervention.

Perforations and post anastomotic leaks of the gastrointestinal tract are a significant source of morbidity in clinical practice. Surgery has been the standard of care but advances in endoscopic treatment may change this. The OTSC system is a clip fixed over a cap fitted on the tip of the endoscope and used to close defects that would have previously not been amenable to endoscopic treatment. We present our experiences with this novel endoscopic procedure.

Large colonic polyps follow a well-defined pathway of progression to carcinoma. Endoscopic mucosal resection (EMR) has been widely adopted and is minimally invasive and cost effective compared to surgery. However, recurrence following EMR of large colorectal lesions occurs in between 10-50% of cases at follow up within 12 months; this is likely due to remnant or residual tissue. Argon plasma coagulation (APC) is an ablative technique that may reduce recurrence rates following EMR, to 10-14%, ( 1 Brooker J.C. Saunders B.P. Syed G.S. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endo. 2002; 55: 371-375 Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar ).

Background: Chronic radiation proctitis (CRP) manifests as rectal bleeding 12 to 24 months after pelvic radiotherapy. No criterion standard of treatment has been established, although argon plasma coagulation (APC) has increasingly become the treatment of choice. Previous studies have applied APC over multiple sessions, necessitating increased numbers of treatments.Objective: To assess the safety and efficacy of large-volume APC application in the treatment of CRP with the intention of a single-session treatment protocol.Design: Prospective study.Setting: Tertiary referral hospital.Patients: Over an 8-year period, consecutive patients with CRP with rectal bleeding were prospectively enrolled.Intervention: Large-volume APC application to affected rectal mucosa.Main Outcome Measurements: Number of treatments, bleeding scores, complications.Results: Fifty patients (mean age 72.1 years; range 51-87 years) were treated; 45 were men (prostate cancer). The mean period between radiotherapy and initial APC treatment was 23 months (range 4-140 months). Seventeen (34%) patients had grade A endoscopic severity, 23 (46%) grade B, and 10 (20%) grade C. Other therapies failed in 16(32%) patients. The mean number of treatments was 1.36 (range 1-3) with a mean follow-up of 20.6 months (range 6-48 months). Sixty-eight percent of patients were successfully treated after 1 session and 96% after 2 sessions. Bleeding scores improved in all patients (P < .001). Seventeen (34%) patients experienced short-term, self-limiting complications; 1 (2%) patient experienced a long-term complication.Limitations: Nonrandomized study.Conclusions: Large-volume APC treatment was successful in the treatment of CRP, including those in whom other therapies had previously failed, and resulted in a decreased number of treatments compared with other published studies. The benefits were offset by an increased incidence of short-term complications but no increase in long-term complications. (Gastrointest Enclose 201.0;72:150-4.)

OBJECTIVE: To assess the ability of MRCP to alter the differential diagnosis and to prevent diagnostic and/or therapeutic ERCP. The diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) for biliary and pancreatic disease is well documented. Some believe MRCP may prevent diagnostic ERCP or add useful information, however there are no reports of its impact on clinical management. METHODS: Consecutive patients referred for ERCP underwent clinic evaluation, then MRCP, and then ERCP. In Phase 1, the number of differential diagnoses and the perceived need for diagnostic ERCP were evaluated after each step by the endoscopist who performed the ERCP. In Phase 2, the process was repeated after presenting clinical information and MRCP results to different individual physicians: another endoscopist, a hepatologist, a radiologist, and a surgeon (all were blinded to ERCP results). RESULTS: Forty patients were enrolled. Clinical contexts were jaundice (19.7%), abnormal liver enzymes (42.6%), abdominal pain (11.5%), recurrent acute pancreatitis (11.5%), and suspected complications of chronic pancreatitis (14.7%). In Phase 1, adding MRCP information to diagnostic ERCP information did not change the mean number of differential diagnoses significantly and prevented no therapeutic ERCP. In Phase 2, adding MRCP to clinical information only (without ERCP) reduced the differential diagnosis significantly for the radiologist and the surgeon only and would have prevented ≤3% of diagnostic and therapeutic ERCP for all physicians. CONCLUSION: The value of MRCP information may be limited if patient selection is inappropriate and may differ in physicians depending on their speciality.