Background: Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients’ lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety. Methods: A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI). Results: Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31–57; 352/767; I2 = 93.7%), and the respective partial response rate was 30% (95%CI: 20–39; 206/767; I2 = 86.1%). Adverse events were recorded in 14% (95%CI: 8–20; 164/840; I2 = 87.2%) of cases, rated as mild in 10% (95%CI: 5–15; 128/840; I2 = 86.7%), and severe in 4% (95%CI: 3–5; 36/840; I2 = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64–76; I2 = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33–54; I2= 0%) for lauromacrogol, 32% (95%CI: 27–36; I2 = 88.4%) for ethanol, and 13% (95%CI: 4–22; I2 = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13–20; I2 = 91.0%). Conclusion: EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

Aims Current guidelines recommend endoscopic ultrasound guided hepaticogastrostomy (EUS-HGS) as a choice in malignant biliary obstruction [1]. We present a series of 3 patients who underwent HGS for benign disease

Aims Mirizzi’s syndrome, in which biliary obstruction occurs due to a stone in the cystic duct or neck of gallbladder, can rarely be resolved with conventional endoscopic retrograde cholangio-pancreatography (ERCP), and so surgery has been considered the primary therapy. This retrospective cohort study aims to present the emerging role of single operator cholangioscopy (SOC) and electrohydraulic lithotripsy (EHL) as first line treatment.

Aims Current guidelines (based on low quality data) recommend endoscopic ultrasound (EUS) to stage ampullary polyps for surgical or endoscopic resection [1]. This case series reviewed the outcome of endoscopic papillectomy (EP) without preprocedural EUS assessment in patients without signs of persistent ductal obstruction in laboratory tests and cross-sectional imaging.

Background: Helicobacter pylori (H. pylori) has definite or possible associations with multiple local and distant manifestations. H. pylori has been isolated from multiple sites throughout the body, including the nose. Clinical non-randomized studies with H. pylori report discrepant data regarding the association between H. pylori infection and nasal polyps. The aim of this first systematic review and meta-analysis was the assessment of the strength of the association between H. pylori infection and incidence of nasal polyps. Methods: We performed an electronic search in the three major medical databases, namely PubMed, EMBASE and Cochrane, to extract and analyze data as per PRISMA guidelines. Results: Out of 57 articles, 12 studies were graded as good quality for analysis. Male-to-female ratio was 2:1, and age ranged between 17–78 years. The cumulative pooled rate of H. pylori infection in the nasal polyp group was 32.3% (controls 17.8%). The comparison between the two groups revealed a more significant incidence of H. pylori infection among the nasal polyp group (OR 4.12), though with high heterogeneity I2 = 66%. Subgroup analysis demonstrated that in European studies, the prevalence of H. pylori infection among the nasal polyp group was significantly higher than in controls, yielding null heterogeneity. Subgroup analysis based on immunohistochemistry resulted in null heterogeneity with preserving a statistically significant difference in H. pylori infection prevalence between the groups. Conclusion: The present study revealed a positive association between H. pylori infection and nasal polyps.

Text A 78-year-old male presented with recurrent right upper abdominal pain. He recalled undergoing biliary surgery as a neonate in 1945, but the nature of the procedure was unknown. MRCP suggested possible choledochoduodenostomy for presumed biliary artresia. At ERCP there was a normal ampulla but no connection between the lower common bile duct and the intrahepatic ducts. Instead, the bile drained through the cystic duct and gallbladder into the stomach via a fistula. A cholecystogram revealed multiple stones in the gallbladder. The fistula opening was dilated and cholangioscopy-guided lithotripsy performed. Complete stone extraction was achieved after intubation of the gallbladder with a gastroscope.

Introduction Percutaneous direct cholangioscopy may expand diagnostic and treatment options where endoscopic biliary access is precluded by post-surgical anatomy. We aim to report the utility of percutaneous transhepatic cholangioscopy in patients with intrahepatic stone disease, using the SpyGlass DS cholangioscopy system. Methods Five patients underwent percutaneous cholangioscopy between July ‘17 and February ‘18. All had post-surgical duodenal anatomy and intrahepatic duct (IHD) stones, three with an associated anastomotic stricture. In all cases prior percutaneous transhepatic cholangiography (PTC) and biliary access was achieved using conventional interventional radiology techniques, with the transhepatic tract dilated to 12 F, and a drain left in situ. Results The procedures are summarised in Table 1. Five procedures were performed under general anaesthetic and one with sedation, with the patient supine. All patients received antibiotic prophylaxis. Under sterile conditions the cholangioscope was introduced percutaneously into the intrahepatic biliary tree via a peel-away sheath (12Fr in 5 cases and 11Fr in 1). Optimal stone localisation was achieved using fluoroscopy and direct visualisation, allowing application of electrohydraulic lithotripsy (EHL) using a Boston Scientific EHL probe for stone fragmentation. In one case 8 mm-10 mm sequential dilatation of an anastomotic stricture was performed. In one case a surgical stitch across the anastomosis was visualised – the likely nidus for stone formation. Stone clearance was successful in all cases where IHD stones were identified. In one case the IHD stones had cleared since the index PTC. There were no recorded procedural complications. Conclusion In this small case series direct visualisation of the biliary tree using percutaneous SpyGlass cholangioscopy was safe, successful and expanded the therapeutic capabilities of PTC. This technique could also be used to enhance the investigation and treatment of post-surgical biliary anastomotic stricturing, where retrograde endoscopic access is not feasible.

Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.

Introduction Use of hospital beds as pre/post procedure accommodation places a strain upon resources and risks ‘on the day’ cancellation. Nevertheless ‘day case then home’ may be a poor option for patients undergoing complex endoscopy who live many miles away. Our centre offers Near Hospital Accommodation (NHA) in a bespoke 35-roomed hotel 100 metres from the hospital at a cost of £120/night (versus £380 per inpatient bed). We aimed to assess the safety and utility of NHA for patients within our pancreatobiliary (PB) service. Methods We undertook a retrospective audit of all PB patients who stayed in the NHA from Jan ’15 – Dec ’17. Data collected from the endoscopy database and electronic records included: procedure type, distance travelled, type of hotel room, length of stay and unplanned post-procedural hospital admissions from the NHA. Results Over a 3 year period 152 patients stayed in NHA for 169 nights, ninety-three (61%) female with median age of 62 years (range 24–81). All patients underwent therapeutic ERCP, EUS, or cholangioscopy. The decision to use NHA was based upon case complexity and travel logistics. Most patients (89%) stayed one night and 11% stayed two nights (pre and post-procedure). Median one-way distance travelled was 107 miles (range 3–299 miles) (figure 1). The total cost of NHA was £23,660, saving £40 560 over the equivalent inpatient beds. There were five unplanned admissions (3.3%), summarised in table 1. Conclusion NHA is a safe, cost-effective alternative to hospital admission for selected patients undergoing complex endoscopy. The unplanned readmission rate was low, with no serious complications. The immediate cost saving was considerable, in addition to efficiency savings from the extra bed capacity generated and reduced late cancellations. Benefits to patients include visitor-friendly, hotel-standard accommodation, reduced travelling time on the day of the procedure and saving of private hotels fees. Further studies are needed to assess if this translates into increased patient satisfaction. With increasing centralisation of specialist services and ongoing financial pressures throughout the NHS, the NHA model of care offers advantages to hospitals and patients.

In adults ERCP and endoscopic ultrasound (EUS) are standard methods of evaluating and treating many hepatopancreaticobiliary (HPB) conditions. HPB disease is being diagnosed with increasing frequency in children but information about role of ERCP and EUS and their outcomes in this population remain limited. Therefore the aims of this study were to describe the paediatric ERCP and EUS experience from a large tertiary referral HPB centre, and to systematically compare outcomes with those of other published series.

Background and aims: Understanding of the significant genetic risk factors for Cholangiocarcinoma (CC) remains limited. Polymorphisms in the natural killer cell receptor G2D (NKG2D) gene have been shown to increase risk of CC transformation in patients with Primary Sclerosing Cholangitis (PSC). We present a validation study of NKG2D polymorphisms in CC patients without PSC. Methods: Seven common Single Nucleotide Polymorphisms (SNPs) of the NKG2D gene were genotyped in 164 non-PSC related CC subjects and 257 controls with HaploView. The two SNPs that were positively identified in the previous Scandinavian study, rs11053781 and rs2617167, were included. Results: The seven genotyped SNPs were not associated with risk of CC. Furthermore, haplotype analysis revealed that there was no evidence to suggest that any haplotype differs in frequency between cases and controls (P > 0.1). Conclusion: The common genetic variation in NKG2D does not correlate significantly with sporadic CC risk. This is in contrast to the previous positive findings in the Scandinavian study with PSC-patients. The failure to reproduce the association may reflect an important difference between the pathogenesis of sporadic CC and that of PSC-related CC. Given that genetic susceptibility is likely to be multifaceted and complex, further validation studies that include both sporadic and PSC-related CC are required.

Multidisciplinary meetings are central to the management of chronic and complex diseases and they have become widely established across the modern healthcare. Patients with pancreatobiliary diseases can often present with complex clinical dilemmas, which fall out with the scope of current guidelines. Therefore, these patients require a personalised management approach discussed in a multidisciplinary meeting.

Background: Biliary brush cytology is the standard method of evaluating biliary strictures, but is insensitive at detecting malignancy. In pancreaticobiliary cancer minichromosome maintenance replication proteins (MCM 2–7) are dysregulated in the biliary epithelium and MCM5 levels are elevated in bile samples. This study aimed to validate an immunocolorimetric ELISA assay for MCM5 as a pancreaticobiliary cancer biomarker in biliary brush samples. Methods: Biliary brush specimens were collected prospectively at ERCP from patients with a biliary stricture. Collected samples were frozen at −80 °C. The supernatant was washed and lysed cells incubated with HRP-labelled anti-MCM5 mouse monoclonal antibody. Test positivity was determined by optical density absorbance. Patients underwent biliary brush cytology or additional investigations as per clinical routine. Results: Ninety-seven patients were included in the study; 50 had malignant strictures. Median age was 65 years (range 21–94) and 51 were male. Compared with final diagnosis the MCM5 assay had a sensitivity for malignancy of 65.4% compared with 25.0% for cytology. In the 72 patients with paired MCM5 assay and biliary brush cytology, MCM5 demonstrated an improved sensitivity (55.6% vs 25.0%; P =0.0002) for the detection of malignancy. Conclusions: Minichromosome maintenance replication protein5 is a more sensitive indicator of pancreaticobiliary malignancy than standard biliary brush cytology.

Objective Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy, or endoscopic approaches. Here, we report our experience of pancreatoscopy + electrohydraulic lithotripsy (EHL) for pancreatic duct (PD) stones using SpyGlass. Methods We retrospectively audited the use of SpyGlass (Legacy and DS) + EHL. Indication, procedural details, and clinical outcomes were assessed. Results A total of 118 SpyGlass + EHL procedures for stones were performed, of which 8 (7%) for pancreatic stones, in 6 patients (3 female; mean [standard deviation] age, 45 [7] years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated PD, and main duct stone disease. Surgical options had been considered in all cases. Stone fragmentation and PD decompression were achieved in 83% (n = 5) without complications. Two patients required 2 EHL procedures to achieve clearance. In 1 patient with failed clearance, pancreatoscopy revealed a stone in the adjacent parenchyma and not in PD. All patients with successful EHL had pain relief/marked improvement at clinical review (mean [standard deviation] follow-up, 2.7 [1.1] years). Conclusions Pancreatoscopy + EHL may have a valuable role in treating obstructing PD stones, possibly avoiding the need for surgery in some patients.

The presence of tertiary lymphoid structures (TLSs) may confer survival benefit to patients with pancreatic ductal adenocarcinoma (PDAC), in an otherwise immunologically inert malignancy. Yet, the precise role in PDAC has not been elucidated. Here, we aim to investigate the structure and role of TLSs in human and murine pancreatic cancer.Multicolor immunofluorescence and immunohistochemistry were used to fully characterize TLSs in human and murine (transgenic [KPC (KrasG12D, p53R172H, Pdx-1-Cre)] and orthotopic) pancreatic cancer. An orthotopic murine model was developed to study the development of TLSs and the effect of the combined chemotherapy and immunotherapy on tumor growth.Mature, functional TLSs are not ubiquitous in human PDAC and KPC murine cancers and are absent in the orthotopic murine model. TLS formation can be induced in the orthotopic model of PDAC after intratumoral injection of lymphoid chemokines (CXCL13/CCL21). Coadministration of systemic chemotherapy (gemcitabine) and intratumoral lymphoid chemokines into orthotopic tumors altered immune cell infiltration ,facilitating TLS induction and potentiating antitumor activity of chemotherapy. This resulted in significant tumor reduction, an effect not achieved by either treatment alone. Antitumor activity seen after TLS induction is associated with B cell-mediated dendritic cell activation.This study provides supportive evidence that TLS induction may potentiate the antitumor activity of chemotherapy in a murine model of PDAC. A detailed understanding of TLS kinetics and their induction, owing to multiple host and tumor factors, may help design personalized therapies harnessing the potential of immune-oncology.

Introduction Late diagnosis is thought to be a significant cause of the observed lower cancer survival in UK compared to equivalent countries worldwide. A significant proportion of patients with intra-abdominal cancer are often diagnosed after attending Emergency Departments with late stage disease, highlighting the fact that often symptoms of early upper gastrointestinal (UGI) cancer are nebulous and ill-defined. Methods A pilot Multidisciplinary Diagnostic Centre (MDC) at UCLH was established in June 2015. The MDC is for: (a) patients with severe but non-specific worrying symptoms, warranting rapid diagnosis but not qualifying for a ‘2 Week Wait’ referral; (b) patients with severe symptoms for whom admission to hospital currently offers the only clinically appropriate route to timely care. The Centre aims to provide rapid access to specialist assessment and appropriate diagnostic tests, leading to a defined management plan within 28 days of referral, aligning to the Independent Cancer Taskforce recommendations. Initial assessment is by a clinical nurse specialist (CNS) with consultant support. Once the diagnostic tests are performed, follow up is by face to face consultant assessment. Feedback to the service was elicited by a series of phone calls to a proportion of referring doctors. Results Of the initial 91 patients, the majority of patients (47%, 43) presented with vague abdominal symptoms alone. A further 24% (22) of patients had unexplained weight loss. 93% of patients were offered an initial appointment to MDC within 5 working days. Relevant eventual clinical diagnoses were cancer of unknown primary (1), pancreatic cancer (1), adrenal adenoma (1) and intraductal papillary mucinous neoplasm of pancreas (1). Other non-cancer diagnosis include hiatus hernia (10%), irritable bowel syndrome (8%), and colonic/rectal polyp (5%). The majority of patients underwent CT scanning (54%) and UGI endoscopy (39%). Primary care feedback (n = 6) highlighted the importance even of non-cancer diagnoses. Conclusion The ability to provide a rapid access diagnostic clinic is feasible and will enable the NHS to achieve the Independent Cancer Taskforce recommendation on providing a definitive cancer diagnosis, or cancer excluded within 28 days. Cancer rates are in keeping with other cancer pathways. Input from CNS and efficient administration support are essential in ensuring the diagnostic journey is centred around the patients. We need to understand more about patient experience in this novel pathway, in particular whether rapid access to diagnostic tests and specialist opinion is being perceived as an excellent service. Disclosure of Interest None Declared