BACKGROUND AND AIM:Direct cholangioscopy and pancreatoscopy have become widely implemented techniques in the diagnostic and therapeutic algorithms of several pancreaticobiliary disorders. This study aimed to generate general and indication-specific European consensus recommendations on cholangioscopy and pancreatoscopy. METHODS:Supported by the available literature, statements were formulated and grouped into the following categories: (1) pre-procedural considerations, (2) general technical aspects, (3) biliopancreatic stones, (4) biliary strictures, and (5) other indications. The evidence level of each statement was determined using the GRADE methodology. Cholangioscopy experts were invited to participate in a modified Delphi process. When 80% consensus was not reached, the statement was modified based on expert feedback and subjected to an additional Delphi round. Statements were rejected if they failed to reach consensus after three Delphi rounds. RESULTS:Thirty cholangioscopy experts completed the Delphi process. Forty-two (97.6%) generated statements were accepted, of which 39 (92.9%) in the first Delphi round. 12 statements on preprocedural and periprocedural settings, 8 statements on biliopancreatic stones, 13 statements on biliary strictures, and 9 statements on other indications were accepted. CONCLUSION:Using a modified Delphi process, we developed general and indication-specific consensus recommendations for cholangioscopy to guide clinical practice.

BACKGROUND:A patient with an extensively drug-resistant (XDR) New Delhi metallo-β-lactamase (NDM) and oxacillinase (OXA-48) producing Escherichia coli (E. coli) infection was awaiting orthotopic liver transplant. There is no standardized antibiotic prophylaxis regimen; however, in line with the Infectious Diseases Society of America guidance, an antibiotic prophylactic regimen of ceftazidime-avibactam 2.5 g TDS with aztreonam 2 g three times a day (TDS) IV was proposed. METHODS:The hollow fiber system (HFS) was applied to inform the individualized pharmacodynamic outcome likelihood prior to prophylaxis. RESULTS:A 4-log reduction in CFU/mL in the first 10 h of the regimen exposure was observed; however, the killing dynamics were slow and six 8-hourly infusions were required to reduce bacterial cells to below the limit of quantification. Thus, the HFS supported the use of the regimen for infection clearance; however, it highlighted the need for several infusions. Standard local practice is to administer prophylaxis antibiotics at induction of orthotopic liver transplantation (OLT); however, the HFS provided data to rationalize earlier dosing. Therefore, the patient was dosed at 24 h prior to their OLT induction and subsequently discharged 8 days after surgery. CONCLUSION:The HFS provides a dynamic culture solution for informing individualized medicine by testing antibiotic combinations and exposures against the bacterial isolates cultured from the patient's infection. .

Introduction: Because of improved life expectancy in people living with HIV (PLWH), liver disease is increasingly being recognized. We assessed nonviral chronic liver disease burden in PLWH. Methods: The HIV non-virAL liver disease study (2014–2021) prospectively recruited PLWH with elevated serum alanine aminotransferase levels and negative hepatitis serology. Clinically significant hepatic fibrosis (CSHF) was defined as liver stiffness measurement of >7.1 kPa and hazardous alcohol use as Alcohol Use Disorders Identification Test score ≥ 8. Primary outcome was prevalence/predictors of CSHF. Results: Total recruited were n = 274, 92% male, median age 52 (45–59) years, and 96% having undetectable HIV viral load. Overall, n = 97 (35%) had hazardous alcohol use, n = 72 (26%) had metabolic syndrome, and 17%–27% had exposure to hepatotoxic antiretrovirals. Prevalence of CSHF was 20% (n = 54), prevalence of cirrhosis (liver stiffness measurement > 12.5 kPa) being 7% (19/274). Risk factors for CSHF were hazardous alcohol use in 44% (n = 24), metabolic syndrome in 46% (n = 25), and hepatotoxic antiretrovirals in 56% (n = 30), most having more than one risk factor. Independent predictors of CSHF were serum high-density lipoprotein (odds ratio [OR] 0.220; 95% confidence interval [CI]: 0.061 to 0.790, P = 0.020) (inverse relationship); serum aspartate aminotransferase (OR 1.033, 95% CI: 1.001 to 1.067, P = 0.045), and didanosine use (OR 2.878, 95% CI: 1.228 to 6.774, P = 0.015). Moderate–severe hepatic steatosis was identified in 52% (n = 142). FIB-4 and aspartate aminotransferase-to-platelet ratio index performed poorly in predicting CSHF (positive predictive value 27.3% and 30.6%, respectively) and advanced fibrosis (≥F3) (positive predictive value 17.6% and 5.9%, respectively). Conclusion: In this study, 20% of PLWH had CSHF associated with high prevalence of hazardous alcohol use/metabolic syndrome/potentially hepatotoxic antiretrovirals. These potentially modifiable risk factors need addressing.

Background & aims An extensively-drug resistant (XDR) NDM and OXA-48 producing E. coli contributing to repeat episodes of biliary sepsis was isolated from the blood stream of a 45-55 year-old male with a background of IgG4 related sclerosing cholangitis. The patient was awaiting orthotopic liver transplant (OLT). There is no standardized antibiotic prophylaxis regimen however in line with the Infectious Diseases Society of America (IDSA) guidance an antibiotic prophylactic regimen of Ceftazidime-Avibactam (CZA) 2.5g TDS with Aztreonam (ATM) 2g TDS IV was proposed.Methods To inform the individualised pharmacodynamic outcome likelihood prior to prophylaxis dosing the hollow fibre infection model (HFIM) was applied to simulate the in vivo antibiotic exposures of the CZA-ATM regimen. The HFIM was inoculated with ∼10 x 10[5][1] bacterial CFU/mL of the XDR E. coli strain and CFUs/mL were measured for a total of 120 hours to determine the in vitro PK/PD killing dynamics.Results A 4-log reduction in CFU/mL in the first ten hours of the regimen exposure was observed however the killing dynamics were slow and six eight-hourly infusions were required to reduce bacterial cells to below the limit of quantification. Thus, the HFIM supported the use of the regimen for infection clearance however highlighted the need for several infusions. Standard local practise is to administer prophylaxis antibiotics at induction of OLT however the HFIM provided data to rationalise earlier dosing therefore the patient was dosed at 24 hours prior to their OLT induction. The patient was subsequently discharged 8 days after surgery.Conclusions The HFIM provides a dynamic culture solution for informing individualised medicine by testing antibiotic combinations and exposures against the bacterial isolates cultured from the patient’s infection.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis work was conducted as part of Z.S. PhD studentship that was partially funded by an educational grant from Shionogi B.V. and by University College London. FK has been recipient of a UKRI Medical Research Council Skills Development Fellowship MR/P014534/1, and a Sir Henry Dale Fellowship jointly funded by the Wellcome Trust and the Royal Society (grant number 220587/Z/20/Z).### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Health Research Authority Decision Panel advisors did not consider the work research but a deviation from standard of care that was purely for clinical needs. Review by an NHS Research Ethics Committee was therefore not required.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data produced in the present study are available upon reasonable request to the authors [1]: #ref-5

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.

Background: There continues to be debate about the lower limit of graft-to-recipient weight ratio (GRWR) for living donor liver transplant (LDLT). Objectives: To identify the lower limit of GRWR compatible with enhanced recovery after living donor liver transplant and to provide international expert panel recommendations. Data sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies assessing how GRWR affects recipient outcomes such as small for size syndrome, other complications, patient and graft survival, and length of stay were included. Protocol registration: CRD42021260794. Results: Twenty articles were included in the qualitative synthesis, and all were retrospective observational studies. There was heterogeneity in the definition of study cohorts and key outcome measures such as small-for-size syndrome. Most studies lacked risk adjustment given limited single-center sample size. GRWR of >= .8% is associated with enhanced recovery. Recipients of grafts with GRWR < .8%, however, were found to have similar outcomes as those with >= .8% when appropriate consideration is made for portal flow modulation and recipient illness severity. Conclusions: GRWR >= .8% is often compatible with enhanced recovery, but grafts < .8% can be used in selected LDLT recipients with optimal donor-recipient selection, surgical technique, and perioperative management (Quality of Evidence; Low | Grade of Recommendation; Strong).

Liver transplant is a life-saving treatment with 1-year and 5-year survival rates of 90% and 70%, respectively. However, organ demand continues to exceed supply, such that many patients will die waiting for an available organ. This article reviews for the general gastroenterologist the latest developments in the field to reduce waiting list mortality and maximise utilisation of available organs. The main areas covered include legislative changes in organ donation and the new 'opt-out' systems being rolled out in the UK, normothermic machine perfusion to optimise marginal grafts, a new national allocation system to maximise benefit from each organ and developments in patient 'prehabilitation' before listing. Current areas of research interest, such as immunosuppression withdrawal, are also summarised.

BACKGROUND:Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is, however, little consensus on the best method of PIM, its exact role in preventing SFSS and on early post-LDLT recovery. OBJECTIVES:To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations. DATA SOURCES:Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS:Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO ID:CRD42021260997. RESULTS:Five hundred and ninety four articles were identified through databases' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures. CONCLUSIONS:Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).

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.

BACKGROUND:There is some evidence in the literature to suggest that pre-operative counselling improves pain scores postoperatively. However, it is unclear whether pre-operative counselling of the donor improves immediate and short-term outcomes after living liver donation.OBJECTIVES:This systematic review aimed to investigate the available quality of evidence (QOE) of pre-operative counselling for living donors on short term outcomes, provide expert opinion, grade recommendations and identify relevant components for Enhanced Recovery after Surgery (ERAS) protocols.DATA SOURCES:Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.METHODS:Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Endpoints were defined by the WHOQOL-BREF scale: physical health, psychological, social relationships, and environment.PROSPERO ID:CRD42021260677.RESULTS:Screening of 452 records and full texts led to 12 articles matching inclusion criteria, of which one was a randomized controlled trial (RCT), and 11 were observational retrospective cohort studies. A total of 933 individuals undergoing donor hepatectomy were included, of whom only 90 received dedicated perioperative ERAS protocols. Donors that received pre-operative counselling had fewer physical symptoms post donation, lower rates of fatigue, lower rates of pain, shorter recovery times and fewer unexpected medical problems, and less anxiety post donation. Female donors had higher affective and adverse effects scores, and 50% of donors reported adverse effects to analgesia that interfered with functional activity. Receiving information about analgesic options increased perception of care among donors.CONCLUSIONS:Providing comprehensive pre-operative counselling to living liver donors is associated with improved short-term outcomes after donation (QOE; moderate to low I Grade of Recommendation; Strong).

BACKGROUND:The optimal immunosuppression protocol to prevent early acute cellular rejection (ACR) after liver transplantation (LT) avoiding prolonged hospitalization and early hospital readmission is undefined. OBJECTIVES:To identify the most suitable immunosuppression regimen for inclusion in ERAS programs in order to minimize early ACR after LT and to provide expert panel recommendations DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS:Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies from January 2000 onward focusing on early ACR were included. Rates of early renal dysfunction and infection were evaluated. CRD42021245586 RESULTS: Thirty-seven studies met inclusion criteria; 23 randomized controlled trials, 14 retrospective or prospective observational comparative or noncomparative studies. Several sources of biases which potentially confound conclusions were identified: heterogeneity in immunosuppression protocols, higher serum tacrolimus levels than currently used in clinical practice, differences in the definition of ACR. CONCLUSIONS:Tacrolimus is the standard immunosuppression after LT and can be used in combination with other drugs such as corticosteroids and MMF, and in association with anti-IL2 receptor antibody (IL2Ra) induction. (Quality of Evidence; Low | Grade of Recommendation; Strong). Low dose or delayed introduction of tacrolimus in association with corticosteroids and MMF and/or anti-IL2Ra induction can be used to reduce acute kidney injury. (Quality of Evidence; Low | Grade of Recommendation; Strong). Use of tacrolimus in association with corticosteroids and MMF and/or anti-IL2Ra induction does not lead to increased infection rates. (Quality of Evidence; Low | Grade of Recommendation; Weak).

Background: The optimal analgesic strategy for patients undergoing donor hepatectomy is not known and the potential short- and long-term physical and psychological consequences of complications are significant. Objectives: To identify whether a multimodal approach to pain of the donor intraoperatively enhances immediate and short-term outcomes after living liver donation, and to provide international expert panel recommendations. Data sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO 2021 CRD42021260699. Results: Nine studies assessing multi-modal analgesia strategies were included in a qualitative assessment. Interventions included local, regional, and neuro-axial anesthetic techniques, pharmacological intervention (NSAIDs, COX-2 inhibitors, ketamine, dexmedetomidine, and lidocaine), and acupuncture. Overall, there was a significant (40%) reduction in opioid requirement on day 1 and a significant reduction in pain scores in the intervention vs control groups. Significant reductions in either length of stay or post-operative complications were demonstrated in four of nine studies. Conclusions: Opioid use for patients undergoing donor hepatectomy is likely to impact both their short- and long-term outcomes. To reduce post-operative pain scores, shorten length of hospital stay, and promote earlier post-operative return of bowel function, we recommend that multi-modal analgesia be offered to patients undergoing living donor hepatectomy. Further research is required to confirm which multi-modal techniques are most associated with enhanced recovery in living liver donors.

Background Liver disease in the absence of viral hepatitis co-infection in people living with HIV (PLWH) is likely due to alcohol excess, metabolic syndrome (MS), and hepatotoxic antiretrovirals (ARV). We assessed the prevalence of hepatic fibrosis and associated risk factors in HIV mono-infected individuals with abnormal liver tests. Methods PLWH with persistently elevated alanine aminotransferase (ALT) for >6 months were prospectively assessed using transient elastography, AUDIT questionnaire, and screening for MS. Thresholds for clinically significant hepatic fibrosis (CSHF) and cirrhosis were >7.1kPa and >12.5kPa respectively, and hepatic steatosis (HS) by a controlled attenuation parameter (CAP) >237dB/m. Results Of 274 recruited individuals the median age was 52yrs (IQR 45–59), 93% men, median HIV duration 15yrs (IQR 10–20), and undetectable viral load in 96%. Overall, HS was seen in 169 (61.7%) and CSHF was seen in 54 (19.7%), of whom 19 (35.2%) had cirrhosis and 40 (74.1%) had HS. Alcohol, MS and ARV were implicated in 24 (44.4%), 31 (57.4%), and 15 (27.8%) of patients with CSHF, respectively. No risk factors were identified in 10 (18.5%) with CSHF. On binary and multinomial logistic regression lower HDL cholesterol (HR 0.255, 95% CI 0.103–0.629, P=0.003) and diabetes (HR 2.558, 95% CI 1.175–5.571, P=0.018) were independent predictors of CSHF. Both FIB-4 and APRI performed poorly in identifying CSHF (AUROC 0.556 and 0.603 respectively; figure 1). Conclusion In these PLWH and elevated ALT, ~20% had CSHF and ~60% had HS, in most cases associated with hazardous drinking or MS. Lower HDL and diabetes were independent predictor of CSHF. No risk factors were identified in almost 20% raising the intriguing possibility that CSHF may be caused directly by the HIV infection.

Introduction Identifying the underlying cause of liver disease is important, however in 5–30% of patients with cirrhosis no cause can be found, which is referred to as cryptogenic cirrhosis (CC). From registry data 4% of liver transplants are performed for CC. UK Transplant Registry data suggests CC recipients have a lower 1-year and 5-year survival than the national rate. Understanding of the genetics underpinning liver disease has evolved significantly. More recently whole exome sequencing (WES) has been proposed for the evaluation of cryptogenic liver disease. We sought to evaluate the diagnostic work-up of patients listed for transplant in the UK with CC, with a specific focus on the use of genomics. Method A retrospective search of the UK Transplant Registry was performed for adult elective NHS patients registered for first liver transplant at 6 transplant centres between 1/1/15 and 31/12/20. Patients with CC or genetic liver disease as an indication at registration were included. Clinical information and results of diagnostic tests were collected. Results After exclusion of 59 patients (42 genetic co-factor, 17 alternate aetiology), 228 patients were included: 120 CC, 4 diagnosed with genetic liver disease during assessment, 104 known genetic liver disease. The patients without previously known genetic liver disease (n=124) had a median age at onset of liver disease of 49 years (IQR, 37–56), 82 (66%) were male, 16 (13%) had a family history of liver disease. Median age at listing was 55 years (IQR, 42–62), UKELD 56 (52–59) and MELD 15 (12–20). Prior diagnostics included: liver biopsy 80 (65%), cross sectional imaging 123 (99%), and cholangiography 26 (21%). A genetic test was performed in 29 (23%) patients: 10 ATP7B, 20 HFE, 9 cholestasis gene panel, and 1 underwent WES. There were 4 new diagnoses of genetic liver disease made during evaluation: 2 MDR3 deficiency, 1 Wilson disease, 1 alpha-1-antitrypsin. In 2 other patients there were ABCB4 variants of uncertain significance and potential MDR3 deficiency. Discussion Genetic sequencing is performed in selected patients assessed for transplant with CC, and in some cases a new diagnosis of genetic liver disease has been made. With increasing access to genetic testing and the NHS Long Term Plan to offer whole genome sequence as routine care, more widespread use of genetic testing in patients with CC listed for transplant should be considered.

Background COVID-19 pandemic is an unprecedented global medical emergency. National and international gastrointestinal societies recommended that any endoscopic activity during the lockdown phase of the pandemic should be limited to emergency or non-deferrable procedures only. We assessed the financial implications and impact on endoscopy activity of the lockdown phase in a tertiary referral endoscopy unit. Methods The number of endoscopy procedures canceled and performed in our endoscopy unit during our “delay phase” (16-22/03/2020) and “lockdown phase” (23/03-29/05/2020) was reviewed and compared with endoscopy activity conducted during the same period in 2019. The financial impact was subsequently analyzed. Results Between 16/03/2020 and 29/05/2020, 683 procedures were canceled and 365 non-deferrable procedures were performed. In contrast, in 2019, 3437 procedures were performed over the same timeframe, resulting in a revenue contraction of approximately €2,062,857. We estimated that the number of lists required to recuperate the canceled endoscopic activity, ranges from 103-155, depending on the level of personal protective equipment required and mitigating policy relating to COVID-19. Conclusion Our results highlight that COVID-19 pandemic had a substantial negative impact on our endoscopy activity and on the revenue generated by our endoscopy unit.

A 60-year-old male liver transplant recipient presented to his local hospital with left-sided partial seizures following a few days of generalised headache. He had undergone transplantation for primary sclerosing cholangitis 4 years earlier and maintained on tacrolimus monotherapy immunosuppression. He had no other comorbidities of note and worked as an arable farmer. At last follow-up, he had been well with preserved graft function and afternoon trough tacrolimus levels of 2–4 ng/mL. Over the preceding 4 weeks, he had been investigated locally for weight loss and a productive cough, where CT of the chest showed calcified mediastinal and hilar lymphadenopathy. Bronchoscopy samples were negative for acid-fast bacilli and he had been empirically treated for assumed community acquired pneumonia. Initial seizure management was with intravenous diazepam and phenytoin. On transfer to our centre, he was noted to be dysarthric with persisting 4/5 left upper limb weakness and nystagmus to all extremes of gaze. Blood tests were significant for mild anaemia (haemoglobin 90 g/L) and elevated C reactive protein (134 mg/L). The peripheral white cell count was 6.6×10 9 /L. Biochemical liver graft function was normal and the 8am trough tacrolimus level was low at 2 ng/mL. CT head revealed bilateral ring enhancing cerebral lesions with surrounding vasogenic oedema but no mass effect. On MRI these exhibited restricted diffusion and marked perilesional oedema, suggestive of infection. Cerebrospinal fluid (CSF) analysis was as follows: white cell count <1/mm 3 , protein 0.57 g/L (normal range <45 g/L) and glucose 3 mmol/L (paired plasma glucose 4.8 mmol/L). Testing for virological causes via PCR, toxoplasma serology and blood and CSF cultures, including for tuberculosis, were all negative. Whole body positron emission tomography-CT demonstrated uptake in numerous peritoneal and intramuscular lesions as well as right-sided cervical lymphadenopathy, which was sampled with fine needle aspiration. Microscopy revealed a filamentous, beading and branching Gram-positive bacillus that was partially acid-fast, subsequently speciated as Nocardia farcinica .

Question: A middle-aged patient presented with cholangitis and cholestatic liver tests. He was originally from Albania, but had lived in the UK for 10 years. He reported recurrent episodes of fever with abdominal pain over the last 3 months. There was no significant past medical or surgical history. On admission, he had intermittent febrile episodes, but vitals were stable. Physical examination revealed tenderness in right upper quadrant without guarding. He was commenced on antibiotics and a contrast-enhanced computed tomography scan revealed a large lesion in the liver. Appropriate laboratory investigations were sent based on this finding. However, liver tests continued to worsen and a magnetic resonance cholangiopancreatography was performed. This revealed erosion and communication of the liver lesion with the right posterior intrahepatic duct with multiple filling defects within the common right duct (Figure A). An endoscopic retrograde cholangiopancreatography (ERCP) was performed and cholangiogram revealed a nondilated common bile duct, but significant dilatation in the right posterior duct with multiple filling defects (Figure B). A sphincterotomy was performed and large amount of gelatinous matter was removed with a balloon trawl (Figure C, D). A double pigtail stent was placed to prevent further episodes of obstruction. Treatment was altered appropriately based on this finding. What is the lesion in the liver? What is the etiology of the biliary obstruction? How would you manage this patient? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The large lesion is a hydatid cyst in the liver fistulizing into the biliary system causing biliary obstruction owing to cyst fluid and daughter cysts. The etiology is infection with Echinococcus granulosus, and the cysts are usually asymptomatic until their size causes pressure on surrounding structures. The communication between a cyst and the biliary tract is the most common complication of this with a reported incidence between 13% and 37%.1Kayaalp C. Bostanci B. Yol S. et al.Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications.Am J Surg. 2003; 185: 175-179Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar,2Bedirli A. Sakrak O. Sozuer E.M. et al.Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts.Surg Today. 2002; 32: 594-597Crossref PubMed Scopus (62) Google Scholar Fistulas are either a result of high intracystic pressure leading to rupture into the bile duct or owing to compression, erosion, and necrosis into the biliary wall. Minor cystobiliary fistulas develop in 80%–90% of all hepatic hydatid cysts and are usually asymptomatic and only discovered intraoperatively. Frank fistulas can lead to obstructive jaundice, pancreatitis, cholangitis and have high morbidity. A cyst diameter of >10 cm, alkaline phosphatase >133 U/L, bilirubin >1.2 mg/dL, and white blood cells >10,000/mm are predictors of fistula formation. Undetected fistulas can lead to significant postoperative morbidity and mortality due to biliary leaks and biliary abscesses. Symptomatic preoperative fistulas can be managed effectively with ERCP. Our patient went on to have an ERCP with stenting, treatment with albendazole followed by surgical cyst excision, and is currently well.