Objectives The Archimedes biodegradable stents (ABSs) are licensed for use in endoscopic retrograde cholangiopancreatography (ERCP). The objectives of this study were to evaluate the clinical use in both biliary and pancreatic indications in paediatric and adult populations. Methods This was a retrospective study of an unselected population of 132 patients who received an ABS during an ERCP over a 53-month period. Data collected included baseline characteristics, indications for ERCP and success of ABS placement. Postprocedural adverse events were also collected. Results 138 ABSs were inserted into 132 patients of which 20 patients were paediatrics (60% male, median age 11.8 years). 96 pancreatic ABSs were placed (n=89 fast degradation). Fast degradation stents were used prophylactically to mitigate against pancreatitis or for a strictured pancreatic duct (PD). 42 biliary Archimedes stents were placed (n=40 slow degradation stents). Slow degradation stents were placed following stone fragmentation and for those awaiting surgical intervention. Overall, 63.6% of patients (n=84) required a pancreatic ABS to mitigate against pancreatitis as the PD was initially cannulated or contrast was injected—only 3.0% developed post-ERCP pancreatitis. 97% of ABSs were placed successfully. There were no reported adverse events relating to the use of ABS. Conclusion The ABS is safe and highly efficacious in the use of both pancreatic and biliary indications at ERCP in adult and paediatric populations. Further indications for the use of the ABS appear to be evolving in clinical practice.

Aims The Archimedes biodegradable stents (ABS) are licensed for use in ERCP. Its unique design allows for drainage through and around the stent. The aim of this study was to evaluate the clinical use in both biliary and pancreatic indications in paediatric and adult patients.

Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort.

Conclusions The Apollo OverStitch system can be used in the management of esophageal leaks and has proven efficacy and safety. Although this technique does require expertise, it provides a successful minimally invasive method that can help in the management of these often critically ill patients. This is the first reported case series of successful utilisation of the Apollo OverStitch System in combination with a stent in the management of esophageal leaks

Objective Faecal calprotectin (fCAL) is an established marker of intestinal inflammation in inflammatory bowel disease (IBD). Disproportionally high fCAL levels, for the severity of intestinal inflammation, have been previously observed in primary sclerosing cholangitis associated IBD (PSC-IBD). The aim of this study was to test the hypothesis that fCAL is a marker of biliary injury in PSC-IBD. Methods We used two cohorts: (1) post hoc analysis of a colonoscopic surveillance study allowing correlation of fCAL to endoscopic severity as measured by the ulcerative colitis endoscopic index of severity (UCEIS) in PSC-IBD (n=20) and ulcerative colitis (UC, n=20) and (2) prospective recruitment of patients attending for endoscopic retrograde cholangiopancreatography allowed the correlation of fCAL to biliary calprotectin (n=8). Results A strong correlation was seen between fCAL and UCEIS in UC (r=0.821, 95% CI (0.585 to 0.929), p<0.0001). In PSC-IBD, the correlation was weaker (r=0.596, 95% CI (0.195 to 0.8260), p=0.006). PSC-IBD patients with endoscopically quiescent colitis (UCEIS: 0–1) had higher fCAL than patients with UC (279 µg/g, IQR (68–601) vs 30 µg/g, IQR (14–107), p=0.015) . This was associated with higher risk of biliary complications like need for antibiotics or instrumentation (HR 16.39, 95% CI (2.98 to 90.25)) rather than colitis flares (follow-up: 12 months). Calprotectin measured in faeces correlated positively with biliary calprotectin (r=0.898, p=0.0024). Conclusion fCAL is a surrogate marker for biliary inflammation in PSC-IBD. Trial registration number NCT02543021.

Background and Aims: EUS-guided choledochoduodenostomy (EUS-CDD) with an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has emerged as a viable method of establishing biliary drainage in patients with malignant distal biliary obstruction (MDBO). Our aim was to assess the efficacy, safety, and outcomes in patients with MDBO who underwent EUS-CDD with an EC-LAMS. Methods: A retrospective review of consecutive patients with MDBO who underwent EUS-CDD with EC-LAMSs at 8 tertiary institutions across the United Kingdom and Ireland between September 2016 and November 2020 was undertaken. Results: One hundred twenty patients (55% men) with a median age of 73 years (interquartile range, 17; range, 43-94) were included. The median follow-up period in 117 patients was 70 days (interquartile range, 169; range, 3869), and 23 patients (19.2%) were alive at the end of the follow-up. Three patients were lost to follow-up. Technical success was achieved in 109 patients (90.8%). Clinical success (reduction of serum bilirubin to <= 50% of original value within 14 days) was achieved in 94.8% of patients (92/97). The adverse event rate was 17.5% (n = 21). Biliary reintervention after initial technical success was required in 9 patients (8.3%). Conclusions: EUS-CDD with EC-LAMSs at tertiary institutions within a regional hepatopancreatobiliary network for treatment of MDBO was effective in those where ERCP was not possible or was unsuccessful. When technical failures or adverse events occur, most patients can be managed with conservative or endoscopic therapy.

Introduction Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant anastomotic strictures (AS). They are increasingly used in a non-transplant (NT) setting. We conducted a multi-centre study across nine tertiary centres in the UK to analyse their use and efficacy Methods Consecutive patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) with insertion of IDSEMS were retrospectively analysed. Results 178 episodes (109 males, 61%) were identified. 162 (91%) underwent IDSEMS stent insertion for AS and 16 (9%) for a NT indication. Age at transplant was 54 years (range 12-74) and stent duration was 15 weeks (range three days-78 weeks). 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases. The most frequent indication for stenting in the NT setting was bile leak post partial hepatectomy (n=8, 50%). In the NT cohort, stent duration was 15 weeks (range 2- 41 weeks). 10 (83%) patients had complete resolution of biliary pathology on stent removal. At removal, there were 26 (14%) adverse events, five (3%) episodes of cholangitis and two (1%) of pancreatitis. In 13 (7%) cases the removal wires unravelled, 3 (2%) stents migrated, and three (2%) stents were embedded. All were removed endoscopically. Conclusions IDSEMS appear to be safe and highly efficacious in the management of post-liver transplant AS, with low rates of AS recurrence. IDSEMS can be effectively used in the non-transplant setting.

Taimur Shafi: NO financial relationship with a commercial interest | Margaret Keane: NO financial relationship with a commercial interest | Tassos Grammatikopoulos: YES financial relationship with a commercial interest;Albireo:Consulting | David Reffitt: NO financial relationship with a commercial interest | Mark Davenport: NO financial relationship with a commercial interest | John Devlin: NO financial relationship with a commercial interest | Phillip Harrison: NO financial relationship with a commercial interest | Deepak Joshi: NO financial relationship with a commercial interest

Background: Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis. Objectives: We conducted a multicentre study to analyse their use and efficacy in the management of AS. Design: This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom. Methods: Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data. Results: In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma ( n = 35, 22%), followed by alcohol-related liver disease ( n = 29, 18%), non-alcoholic steatohepatitis ( n = 20, 12%), primary biliary cholangitis ( n = 15, 9%), acute liver failure ( n = 13, 8%), viral hepatitis ( n = 13, 8%) and autoimmune hepatitis ( n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12–74), and stent duration was 15 weeks (range, 3 days–78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4–88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically. Conclusion: IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.

Introduction Endoscopic ultrasound (EUS) guided tissue acquisition is an indispensable tool in the diagnostic pathway of upper GI and hepatobiliary cancer. We sought to assess its utility in guiding patient management in patients presenting with lymphadenopathy of unknown cause. Methods Consecutive patients with lymphadenopathy undergoing EUS guided lymph node sampling were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics, histological findings and patient management. Results 90 episodes (males n=51, 57%) were identified over a ten-year period. Median age at EUS was 62 years old (range 13-88 years old). Median size of lymph node sampled was 20mm (range 6-71mm), with a median of 2 passes (range 1-4). A 22 G needle was used in 62 (68.89%) of cases. The majority of lymph nodes sampled were from the peri-pancreatic area (n= 50, 56%), followed by peri-hepatic (n=15, 17%), celiac (n= 14, 16%), para-esophageal (n=4, 4.%), peri-gastric (n=3, 3%), mediastinum (n=2, 2%) and para-duodenal (n=2, 2%). The final diagnosis were benign lymphadenopathy (n= 31, 34%) followed by adenocarcinoma (n=23, 26%), lymphoma (n=6, 7%), tuberculosis (TB) (n=5, 6%), sarcoidosis (n=5, 6%), and neuroendocrine tumour (n=5, 6%). There was insufficient tissue for histological diagnosis in 15 (17%) cases. Sensitivity for malignancy was 78% with a specificity of 100%. Sensitivity for inflammatory disorders was 88%. All the cases with TB had a positive diagnosis. There were no complications associated with EUS guided sampling. Conclusions EUS is a highly safe and effective method of tissue acquisition in patient presenting with unexplained lymphadenopathy.

Taimur Shafi: NO financial relationship with a commercial interest | Margaret Keane: NO financial relationship with a commercial interest | Tassos Grammatikopoulos: YES financial relationship with a commercial interest;Albireo:Consulting | David Reffitt: NO financial relationship with a commercial interest | Mark Davenport: NO financial relationship with a commercial interest | John Devlin: NO financial relationship with a commercial interest | Phillip Harrison: NO financial relationship with a commercial interest | Deepak Joshi: NO financial relationship with a commercial interest

Introduction Nasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms. Methods Consecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy. Results Twenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2–67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%), NBD remained in situ for a median of 8 days (range 1–45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases. Conclusion NBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.

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.

Aims To describe the clinical outcomes in patients undergoing EUS guided pancreatic necrosectomy in non-walled off organised collections.

With great interest, we read the report of Lu et al on the influence of proton pomp inhibitor (PPI) therapy on the outcome of infliximab therapy in inflammatory bowel disease (IBD). The authors analysed patientlevel data from five randomised controlled trials (RCTs) of patients with IBD treated with infliximab. A total of 1036 patients were enrolled, of whom 147 on PPI therapy. They found that patients on PPI were less likely to achieve remission compared with patients not taking PPIs (OR 0.45, p<0.001) and conclude that PPIs negatively affects outcome in patients with IBD treated with infliximab and PPIs should be prescribed with caution. We like to congratulate the authors to study the effect of frequently prescribed drugs on the outcome of antitumor necrosis factor therapy, since the knowledge on drug–drug interactions is scarce and based on observational research, which is highly prone to bias. 3 There are, however, some remarks to consider. First, the objectives of the included RCTs did not comprise the use of PPIs. To account for this lack of randomisation, propensity score matching was used, with the nearest neighbour method without replacement, in a 3:1 fashion. Simply put, for each subject on PPI therapy, three subjects were sought with similar characteristics in terms of age, sex, race, smoking status, immunomodulator use, history of intestinal resection and infliximab dose. These were matched to the subject on PPI therapy and excluded from matching to any following subjects. This resulted in 147 subjects taking PPI and 441 not, thereby excluding 448 for analysis. Furthermore, since almost half of the subjects were excluded, hypothesis testing and p values might be confounded by sample size reduction. 5 Second, the matched variables were well chosen, as the baseline characteristics of patients on PPI therapy showed a significantly older age, more Caucasians and more intestinal resections compared with patients not on PPI therapy. Interestingly, there were significantly more patients on 10 mg/kg of infliximab (suggesting more serious disease) and less patients taking an immunomodulator (possibly resulting in a lower efficacy) in the infliximab with PPI therapy group. Moreover, other possibly important variables including disease duration, prior IBD therapy, comorbidities and use of other medications were not accounted for. Finally, the proposed mechanistic explanation that PPIs reduce antimicrobial activity by affecting acidity and increase gastroenteritis was not supported by the data. The other proposed mechanisms of altered immune function and gut dysbiosis promotion, seem inconclusive as well. The antiinflammatory effect of PPIs in eosinophilic esophagitis has long been established and evidence of dysbiosis induced by PPIs in patients with IBD is ambiguous, with no causal relationship proven so far. 3 6 7 Large populationlevel studies provided conflicting results concerning the importance of PPIs as modulators of intestinal microbiota. Unfortunately, the timing of PPI and the relationship with hospitalisation is not specified by Lu et al, while starting or changing corticosteroid treatment during the trials was permitted. Thus, the negative effect of PPIs might relate to flares or complications with subsequent need for hospitalisation or corticosteroids with consecutive PPI prescription. Lamentably, the reason for prescription of PPIs is ‘not available’ in more than halve of patients. Considering the Flemish gut flora project that showed that other drugs, frequently consumed by patients with IBD, seemed to have a larger effect on the microbiota composition, we feel the need to put the results of Lu et al into perspective. At least the lack of adjustment for other medications is a missed opportunity. To summarise, we feel the conclusion to prescribe PPIs with caution in patients with IBD starting infliximab therapy, is not supported by hard evidence and to deny patients a prescription, when firm indications are met, would be wrong.

Introduction Endoscopic ultrasound guided choledochoduodenostomy (EUS-CDD) with electrocautery enhanced lumen apposing metal stents (EC-LAMS) has 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. Methods Consecutive patients with MDBO who underwent EUS-CDD with EC-LAMS at 8 tertiary hepatopancreatobiliary institutions between September 2016 and September 2020 were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and follow-up data. Results 112 patients (59 male) were identified. The mean age was 72 years old (range 46 - 94 years old). Pancreatic adenocarcinoma was the commonest underlying malignancy in 63.4% (n=71). The indications for EUS-CDD were: an inaccessible papilla (n=49), tumour infiltration of papilla (n=29) and unsuccessful biliary cannulation/stricture impassable with guidewire (n=34). Technical success was achieved in 91.1% (n=102) of patients. Additional stenting with plastic pigtails through the EC-LAMS was performed in 26 patients at the discretion of the endoscopist to augment biliary drainage. Data for clinical success (reduction of serum bilirubin to ≤50% of original value at day 7) was available for 90 patients and was achieved in 94.4% of these (n=84). The adverse event rate was 16.9% (n=19) and further details are summarised in the table. The biliary re-intervention rate was 8.1% (n=8) in 99 patients with successful EUS-CDD (3 lost to follow-up), over a median follow-up of 70 days (range 3 - 761 days). Eight patients underwent attempted surgical resection of their primary tumour and in those who did, resection and formation of hepaticojejunostomy was successful. Conclusion We present the first collaborative data from the UK and Ireland demonstrating EUS-CDD in MDBO to be efficacious with a reasonable safety profile.

Introduction Chronic pancreatitis (CP) is a fibroinflammatory condition of the pancreas leading to pancreatic fibrosis, duct distortion and calcification with progressive pain, exocrine and endocrine dysfunction. We sought to assess the effects of endoscopic intervention via Endoscopic Retrograde Cholangiopancreatography (ERCP) on pancreatic duct (PD) remodelling and pain. Methods Consecutive patients with CP who underwent ERCP with pancreatic intervention at a tertiary centre over a ten-year period were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and follow-up data. Fishers test was used to calculate statistical significance. Results 51 patients (36 male) with PD strictures and intraductal calcification were identified. The median age was 50 (range 20 – 82 years old). 131 ERCPs were undertaken (one procedure in 23, two- three in 19, four- five in 3, six and above in 6). Alcohol was the commonest aetiology in 39.22% (n=20), followed by idiopathic 25.5% (n=13) and obstructive stone disease 21.57% (n=11). 43.14% (n=22) were smokers and 41.18% (n=21) were consuming alcohol. Technical success was achieved in 84.31% (n=43). 72.09% (n= 31) had a main PD stricture. 62.79% (n= 27) had main PD stones of which 33.33% (n=9) were larger than 5mm. 88.37% (n=38) underwent pancreatic endotherapy. Dilatation of pancreatic strictures was carried out in 44.74% (n=17), with 94.74% (n=36) undergoing pancreatic stenting. Sequential pancreatic stenting was utilised in 66.16% (n=24). In total there were 81 stents inserted over the study period. Plastic stents were the most commonly used at 62.96% (n=51), followed by Niti-S™ BUMPY™ Pancreatic Stent 30.86% (n=25) and Fully Covered Self Expanding Metal stents (FC-SEMS) 4.94% (n=4) and one ARCHIMEDES Biodegradable pancreatic stent. The median duration of sequential stenting was 17 months (range 1- 65 months). 42.11% (n=16) had resolution of their strictures with intervention and 57.89% (n=22) had improvement in pain. Patients with intraductal stones <5mm were more likely to have improvement in pain with endoscopic therapy than those >5mm (15 vs 2, P= 0.0001). Patients having sequential stenting were more likely to have improvement in their strictures (14 vs 2, p= 0.0157). The same effect on pain was not apparent with sequential stenting (17 vs 7, p= 0.2979). There were 2 episodes of pancreatitis and 6 episodes of stent migration. Conclusions Pancreatic endotherapy is more effective in patients with intraductal stones less than 5mm. Sequential stenting seems to have a beneficial effect on pancreatic strictures which may impact disease progression.

Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.