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BACKGROUND/AIMS: Low serum testosterone is common in cirrhotic men, but the impact of disease aetiology remains uncertain. This study compares serum total testosterone (TT) levels by disease aetiology and assesses its prognostic value. METHODS: Single-centre retrospective study of cirrhotic men who had TT levels measured between 2002 and 2020. A cut-off of 12 nmol/L was used to define low TT and 230 pmol/L for calculated free testosterone (cFT). Linear and logistic regression used to adjust for variables known to affect testosterone levels and assess for an association between levels and outcomes. RESULTS: Of 766 cirrhotic men, 33.3% had alcohol-related liver disease (ALD) and 11.9% had non-alcoholic fatty liver disease (NAFLD). The median age was 56 years (interquartile range (IQR) 50-61), and the model for end-stage liver disease (MELD) score 14 (IQR 9-20). TT levels were low in 53.3% of patients, (median 11.0 nmol/L; IQR 3.7-19.8) and cFT low in 79.6% (median 122 pmol/L; IQR 48.6-212). Median TT was lower in men with ALD (7.6 nmol/L; IQR 2.1-16.2) and NAFLD (9.8 nmol/L; IQR 2.75-15.6) compared to other aetiologies (11.0 nmol/L; IQR 3.73-19.8) (p < 0.001 for all), which remained true after adjustment for age and MELD score. TT was inversely associated with 12-month mortality or transplant (381 events, p = 0.02) and liver decompensation (345 events, p = 0.004). CONCLUSIONS: Low serum testosterone is common in cirrhotic men and is associated with adverse clinical outcomes. TT levels are significantly lower in ALD and NAFLD compared to other disease aetiologies. Further large-scale studies are required to assess the potential benefits of testosterone therapy.

BACKGROUND AND AIMS: Little is known regarding the epidemiology and outcomes of patients with primary sclerosing cholangitis (PSC) in Australia. We, therefore, evaluated the epidemiology and clinical outcomes of PSC in a large cohort of Australian patients and compared these to the general population. METHODS: We conducted a multicentre, retrospective cohort study of PSC patients at nine tertiary liver centers across three Australian states, including two liver transplant centers. RESULTS: A total of 413 PSC patients with 3,285 person-years of follow-up were included. Three hundred and seventy-one (90%) patients had large duct PSC and 294 (71%) had associated inflammatory bowel disease. A total of 168 (41%) patients developed cirrhosis (including 34 at the time of PSC diagnosis) after a median of 15.8 (95% CI 12.4, NA) years. The composite endpoint of death or liver transplantation occurred in 49 (12%) and 78 (19%) patients, respectively, with a median transplant-free survival of 13.4 (95% CI 12.2-15) years. Compared to the general population, PSC accounted for a 240-fold increased risk of development of cholangiocarcinoma (CCA) and CCA-related death. CCA risk was increased with older age of PSC diagnosis, presence of dominant stricture and colectomy. Compared to same-aged counterparts in the general population, PSC patients who were diagnosed at an older age or with longer disease duration had reduced relative survival. CONCLUSION: In this large retrospective cohort study of PSC patients in Australia, increased age and time from diagnosis was associated with increased mortality and morbidity particularly from CCA and development of cirrhosis, necessitating need for liver transplant.

BACKGROUND: Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. METHODS: We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study.

Background and Aim: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease with limited effective medical therapies and a paucity of epidemiological and outcome-based data in Australia. We aimed to retrospectively evaluate the demographics and outcomes of an Australian cohort of patients with PSC. Method(s): We performed a retrospective cohort study of patients with PSC at six tertiary health services, including two liver transplant units. Patients were identified by a computerized search of radiological reports. Predictors of transplant-free survival (need for liver transplantation or death from any cause) were analyzed. Result(s): We identified 405 patients with PSC, of whom 261 patients (64.4%) were known to a liver transplant unit. The median age at diagnosis was 36.2 years (IQR, 23.4-50.9), and 261 patients (64.4%) were male. The median alkaline phosphatase (ALP) level at diagnosis was 251 U/L (IQR, 156-436). During a median follow-up of 7.0 years (IQR, 3.3-12.0), the median ALP level improved to 143 U/L (IQR, 92-278) (P < 0.01). Most patients (247, 61%) were prescribed ursodeoxycholic acid (UDCA) at a median dose of 1000 mg (IQR, 750-1000). Of those treated with UDCA, 91 (36.8%) achieved a > 50% reduction in baseline ALP level during follow-up. An overlap syndrome was identified in 47 patients (15.2%), and a dominant stricture (DS) developed in 122 (30.1%). A total of 191 patients (47.3%) developed cirrhosis, of whom 87 (45.6%) had a decompensation episode. There were 282 patients (71.6%) with concomitant inflammatory bowel disease (IBD): ulcerative colitis (54%), Crohn's disease (16%), or IBD unspecified (2%). One hundred patients (24.7%) underwent liver transplantation, and 51 (12.6%) died (82.3% liver-related death). Gastrointestinal malignancies included cholangiocarcinoma (CCA) (26, 6.4%), hepatocellular carcinoma (HCC) (12, 3.0%), and colorectal cancer (15, 3.8%). The proportion of transplant-free survival was 88.5% at 5 years, 73.8%

Background and Aim: Acute-on-chronic liver failure (ACLF) is associated with a rising global health care burden, including a 30-day readmission rate of 30%-42%1 and 30-day mortality ranging from 27% with single organ failure to 77% in four-organ failures.2 Compared with other chronic conditions, such as heart failure, patients with ACLF have reduced access to integrated ambulatory care services,3 and care is fragmented through under-resourced outpatient clinics. LivR Well, a coordinated, multidisciplinary, 28-day program comanaged through a decompensated liver clinic and the Monash Health Hospital in the Home (HITH) unit, has been developed and piloted. LivR Well's key objectives are to improve patient outcomes and disease-related quality of life and alleviate resource burden. The aim of this study was to determine program feasibility before undertaking a randomized controlled trial. Method(s): A feasibility study was performed, enrolling patients with ACLF into a coordinated, multidisciplinary, ambulatory care program managed through Monash Health HITH. Adult patients were eligible for enrolment if they were recently discharged from an acute hospital admission with ACLF and required evaluation and management by >=3 allied health clinicians (nurse, dietitian, physiotherapist, social worker, and/or pharmacist). ACLF was defined as an acute hepatic insult with jaundice and coagulopathy (serum bilirubin level >= 50 mmol/L and international normalized ratio >= 1.5) complicated within 4 weeks by ascites and/or encephalopathy. Patients were excluded if they were receiving terminal care or heart failure management, were unable to provide informed consent, or were residents of aged care facilities. Data including blood tests and patient-reported outcome measures were collected on Day 1 and Day 28 and at 6 weeks from enrolment. The outcomes to be assessed included patient characteristics, change in Model for End-Stage Liver Disease (MELD) score and Child- Pugh class, patient

Aspartate aminotransferase-to-platelet ratio index (APRI) and Fibrosis-4 Index (Fib4) have been validated against liver biopsy for detecting advanced hepatic fibrosis in HFE hemochromatosis. We determined the diagnostic utility for advanced hepatic fibrosis of Hepascore and transient elastography compared with APRI and Fib4 in 134 newly diagnosed HFE hemochromatosis subjects with serum ferritin levels > 300 µg/L using area under the receiver operator characteristic curve (AUROC) analysis and APRI- (> 0.44) or Fib4- (> 1.1) cut-offs for AHF, or a combination of both. Compared with APRI, Hepascore demonstrated an AUROC for advanced fibrosis of 0.69 (95% CI 0.56-0.83; sensitivity = 69%, specificity = 65%; P = 0.01) at a cut-off of 0.22. Using a combination of APRI and Fib4, the AUROC for Hepascore for advanced fibrosis was 0.70 (95% CI 0.54-0.86, P = 0.02). Hepascore was not diagnostic for detection of advanced fibrosis using the Fib4 cut-off. Elastography was not diagnostic using either APRI or Fib4 cut-offs. Hepascore and elastography detected significantly fewer true positive or true negative cases of advanced fibrosis compared with APRI and Fib4, except in subjects with serum ferritin levels > 1000 µg/L. In comparison with APRI or Fib4, Hepascore or elastography may underdiagnose advanced fibrosis in HFE Hemochromatosis, except in individuals with serum ferritin levels > 1000 µg/L.

BACKGROUND Hepatic encephalopathy (HE) is a reversible neuropsychiatric complication of liver cirrhosis and occurs in up to 50% of cirrhotic patients. Studies examining the prognostic significance of HE are limited despite the high prevalence in cirrhosis. AIM To define the clinical outcomes of patients after an episode of HE treated with current standards-of-care. METHODS All patients hospitalised with HE requiring Rifaximin to 3 tertiary centres over 46-mo (2012-2016) were identified via pharmacy dispensing records. Patients with hepatocellular carcinoma and those prescribed Rifaximin prior to admission were excluded. Medical records were reviewed to determine baseline characteristics and survival. The Kaplan-Meier method was used to calculate survival probability. Univariate survival analysis was performed with variables reaching statistical significance included in a multivariate analysis. The primary outcome was 12-mo mortality following commencement of Rifaximin. RESULTS 188 patients were included. Median age was 57 years (IQR 50-65), 71% were male and median model for end stage liver disease and Child Pugh scores were 25 (IQR 18-31) and 11 (IQR 9-12) respectively. The most common causes of cirrhosis were alcohol (62%), hepatitis C (31%) and non-alcoholic fatty liver disease (20%). A precipitating cause for HE was found in 92% patients with infection (43%), GI bleeding (16%), medication non-compliance (15%) and electrolyte imbalance (14%) the most common. During a mean follow up period of 12 +/- 13 mo 107 (57%) patients died and 32 (17%) received orthotopic liver transplantation. The most common causes of death were decompensated chronic liver disease (57%) and sepsis (19%). The probability of survival was 44% and 35% at 12- A nd 24-mo respectively. At multivariate analysis a model for end stage liver disease > 15 and international normalised ratio reached statistical significance in predicting mortality. CONCLUSION Despite advances made in the management of H

BACKGROUND: Hepatic encephalopathy (HE) is a reversible neuropsychiatric complication of liver cirrhosis and occurs in up to 50% of cirrhotic patients. Studies examining the prognostic significance of HE are limited despite the high prevalence in cirrhosis. AIM: To define the clinical outcomes of patients after an episode of HE treated with current standards-of-care. METHODS: All patients hospitalised with HE requiring Rifaximin to 3 tertiary centres over 46-mo (2012-2016) were identified via pharmacy dispensing records. Patients with hepatocellular carcinoma and those prescribed Rifaximin prior to admission were excluded. Medical records were reviewed to determine baseline characteristics and survival. The Kaplan-Meier method was used to calculate survival probability. Univariate survival analysis was performed with variables reaching statistical significance included in a multivariate analysis. The primary outcome was 12-mo mortality following commencement of Rifaximin. RESULTS: 188 patients were included. Median age was 57 years (IQR 50-65), 71% were male and median model for end stage liver disease and Child Pugh scores were 25 (IQR 18-31) and 11 (IQR 9-12) respectively. The most common causes of cirrhosis were alcohol (62%), hepatitis C (31%) and non-alcoholic fatty liver disease (20%). A precipitating cause for HE was found in 92% patients with infection (43%), GI bleeding (16%), medication non-compliance (15%) and electrolyte imbalance (14%) the most common. During a mean follow up period of 12 ± 13 mo 107 (57%) patients died and 32 (17%) received orthotopic liver transplantation. The most common causes of death were decompensated chronic liver disease (57%) and sepsis (19%). The probability of survival was 44% and 35% at 12- and 24-mo respectively. At multivariate analysis a model for end stage liver disease > 15 and international normalised ratio reached statistical significance in predicting mortality. CONCLUSION: Despite advances made in the management of

BACKGROUND: Infliximab therapy may be associated with drug-induced liver injury (DILI), often resembling a drug-induced autoimmune hepatitis. However, the prevalence of DILI in patients receiving infliximab is unclear. Abnormal liver biochemistry is common in patients with inflammatory bowel disease (IBD) and definitive diagnosis may be difficult. The aim of this study was to describe the patterns of abnormal liver biochemistry in an IBD cohort. METHODS: In a retrospective cohort study of adult patients with IBD treated with infliximab through a single institution we used the Roussel Uclaf Causality Assessment Method (RUCAM) to evaluate liver biochemistry and possible DILI. All cases of abnormal liver biochemistry were ascribed a presumptive diagnosis from the electronic medical record. RESULTS: Fifty-seven of the 175 patients (149 Crohn's disease, 26 ulcerative colitis) had abnormal liver biochemistry. Of the 57 cases, one had highly probable, and 10 possible DILI due to infliximab. There were no significant differences regarding demographics, concomitant therapy/disease, indication for infliximab or outcomes between patients with normal and abnormal liver biochemistry, except for higher baseline alanine transaminase and alkaline phosphatase in the abnormal biochemistry group (P<0.001). Multivariate logistic regression showed male sex (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.22-5.09; P=0.01) and background liver disease (OR 15.09, 95%CI 4.09-55.69; P<0.001) to be associated with the abnormal liver biochemistry group. CONCLUSIONS: Abnormal liver biochemistry is common in IBD patients on infliximab. Patients who are male, or have abnormal pre-therapy liver biochemistry or background liver disease, are more likely to develop worsening liver biochemistry during infliximab therapy. RUCAM scoring may help identify true cases of DILI.

Background and Aim: Biliary calculi remain the most common cause of acute pancreatitis, accounting for about 40% of presentations. Australian guidelines recommend that all patients with biliary pancreatitis should have a laparoscopic cholecystectomy during their index admission; however, demand for hospital beds and patient factors result in many patients being deferred to have outpatient elective cholecystectomies. Previous studies have found that same-admission cholecystectomy significantly reduces the rate of recurrent gallstone-related complications compared with elective cholecystectomy; however, no studies have been completed in an Australian population. We aimed to determine the morbidity and mortality associated with elective cholecystectomy versus inpatient cholecystectomy in first presentations of acute biliary pancreatitis in an Australian cohort. Method(s): All patients presenting with acute pancreatitis and admitted under the gastroenterology unit at two metropolitan tertiary hospitals were prospectively recruited from September 2016 to August 2018. Patients with a first presentation of acute biliary pancreatitis were included and analyzed according to timing of cholecystectomy. The Bedside Index of Severity in Acute Pancreatitis (BISAP) score, total length of stay (LOS), operative morbidity, and inhospital mortality were compared between inpatient and elective cholecystectomy groups. Result(s): A total of 231 patients were included (median age, 57 years; IQR, 42-73; 44% male). The median BISAP score was 1 (IQR, 0-2) and 70% of patients were risk stratified to have mild pancreatitis with a BISAP score of 0 or 1. Median age and sex distributions were equivalent between the inpatient and elective groups. A total of 143 patients (61%) received an inpatient cholecystectomy during the index admission, while 57 patients (24%) were deferred for elective cholecystectomy. Indications for elective cholecystectomy were medical optimization before surgery (n = 21)

Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005-2008) and 9 years after its introduction (2009-2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50% male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56% reduction in the number of patients referred for surgery (32 surgical procedures, 47% male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60% male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7% vs 54.7%, P <0.0001), and shorter average LoS (1 vs 9 days, P <0.0001). A cost saving of AUD$19543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.Copyright © 2019 Georg Thieme Verlag. All rights reserved.

Abstract Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 – 2008) and 9 years after its introduction (2009 – 2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P < 0.0001), and shorter average LoS (1 vs 9 days, P < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.

Introduction: Immunotherapy is an increasingly important component of care in the management of several advanced malignancies, including metastatic melanoma and non-small cell lung cancer. Immune-mediated adverse events to therapy involving the gastrointestinal tract have been described, namely, autoimmune colitis and hepatitis. We aimed to evaluate the incidence, risk factors, and management of the gastrointestinal-related autoimmune side effects of checkpoint inhibitor therapy. Method(s): We conducted a retrospective audit of the files of all patients who received checkpoint inhibitor therapy at a major tertiary referral center from January 1, 2015, to June 1, 2017. We focused on the cytotoxic T-lym-phocyte-associated antigen 4 (CTLA-4) inhibitor ipilimumab and the programmed cell death 1 (PD-1) inhibitors nivolumab and pembrolizumab. We analyzed the data in two groups: patients who developed any autoimmune complications while being treated with checkpoint inhibitor therapy and patients who did not. We assessed for differences in pre-existing autoimmune comorbidities and liver function test results over a 16-week period from commencement of their therapy. We then performed an in-depth review of the management of the patients who developed autoimmune colitis and hepatitis. Result(s): We identified 56 patients receiving checkpoint inhibitor ther-apy, of whom 45 patients (80.4%) received nivolumab, seven (12.5%) received ipilimumab, and one (1.8%) received pembrolizumab. Three patients received both nivolumab and ipilimumab (5.4%). A total of 14/56 patients (33%) developed an autoimmune-related side effect. Of these 14 patients, four (28.6%) developed autoimmune colitis and one (7.1%) developed autoimmune hepatitis. The other common autoim-mune complications were hyperthyroidism (2, 14.3%), pneumonitis (2, 14.3%), and hypophysitis (2, 14.3%). There was no statistically significant difference between the two groups at baseline with respect to age, sex, or ethnicity. B

Introduction: Intragastric feeding via percutaneous gastrostomy (PEG) is unsuitable for many patients, and jejunal feeding is required. A PEG tube with a jejunostomy extension tube (PEG+J) is commonly used but is frequently complicated by retrograde migration of the jejunostomy extension tube into the stomach, requiring endoscopic replacement. The PEG-pedi-PEG procedure is a new method aimed at reducing this complication. In this procedure, a pediatric PEG tube acts as a jejunostomy extension and is inserted through an adult PEG tube. The pediatric bumper provides an anchor in the small bowel and remains in position by peristalsis. Method(s): We performed a single-center retrospective study looking at patients undergoing PEG-pedi-PEG insertion after a previous PEG+J insertion. The PEG+J insertion was taken as the initial time point for all calculations. The main outcome recorded was number of endoscopic replacements, as well as time between these replacements, before and after PEG-pedi-PEG insertions. If the PEG-pedi-PEG was not replaced after initial insertion, then the time until last follow-up was recorded. Additionally, we observed early and late complication rates after PEG-pedi-PEG insertions. Result(s): Six patients were identified who had undergone both procedures. Indications for jejunal feeding included gastroparesis (three patients), duodenal stricture (one), narcotic bowel syndrome (one), and Parkinson's disease (one). Mean time from PEG+J to PEG-pedi-PEG insertion was 19 months (range, 2-41 months). Mean time of follow-up after PEG-pedi-PEG insertion was 10 months (range, 7-13 months). The number of endoscopic replacements per patient after PEG+J insertion, before PEG-pedi-PEG insertion, ranged from zero to 11. The most common indication was migration of the jejunostomy extension tube into the stomach, followed by an occluded jejunostomy extension. The number of endo-scopic replacements per patient after PEG-pedi-PEG insertion ranged from zero to one. T

Introduction: Upper gastrointestinal bleeding (UGIB) is the most common gastrointestinal emergency and is associated with substantial morbidity and mortality. Studies have shown a prevalence of up to 150 patients per 100 000 population, with a mortality of 3-10% despite current standards of care. Presentation of UGIB varies from frank hematemesis to coffee ground vomitus (CGV), and melena. CGV, defined as the passage of black material which is assumed to be blood, has traditionally been considered to represent lower-risk bleeding when compared with frank hematemesis or melena. Aim(s): We aimed to compare outcomes and their severity for patients presenting with non-variceal UGIB based on their presenting symptoms (hematemesis, CGV, and/or melena) in an Australian patient cohort. Method(s): Patients presenting with UGIB to three Australian centers (two tertiary hospitals and one regional hospital) were prospectively included over a 22-month period from 2016 to 2017. Data were collected by specialist registrars using a purpose-built smartphone app. Background demographics and presenting symptom of UGIB were recorded. Patients with UGIB secondary to variceal bleeding were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were: a composite end-point of inpatient mortality, rebleeding, and endoscopic, radiological, or surgical intervention; blood transfusion requirement; intensive care unit (ICU) admission; rebleeding; and hospital length of stay (LOS). Result(s): A total of 703 patients were included in the study. Median age was 67 years (IQR, 51-79) and 63% were male. Overall in-hospital mortality was 3.7%, and 60 patients (8.5%) experienced rebleeding. Median LOS was 4 days (IQR, 3-7 days), and 417 patients (59%) required blood transfusion, with a median transfusion requirement of 2 units (IQR, 2-4 units). Sixty-seven patients (10%) required repeat endoscopy, eight (1.1%) proceeded to surgery, and 23 (3.3%) required radiological embolization. The

Introduction: Endoscopic mucosal resection (EMR) remains an under-used technique for the removal of benign colonic lesions. Patients with large or complex colonic lesions continue to be referred for surgical resection (SR). Our aim was to assess reductions in SR rates and associated benefits after the introduction of a dedicated EMR service in a large re-gional center. Method(s): This was a prospective cohort study of patients with colonic polyps referred for EMR from the time of service inception in 2009 through to 2017. Data for all patients who were not referred for EMR and subsequently underwent SR during the same period were collected retrospectively, as were data for SR undertaken over a 4-year period before the introduction of the EMR service (from 2005 to 2008). Exclusion criteria were any polyp unresectable by EMR due to location, size, or proven colorectal cancer. Baseline characteristics recorded for each patient included sex, age at diagnosis, polyp location, Paris classification, and size of the polyp treated with EMR or type of surgery performed, complications, length of stay (LOS), and total cost of EMR or surgery. Result(s): During the 4 years before introduction of the EMR service (2005-2008), 34 surgeries (50% male; median age, 67 years; median LOS, 10 days [IQR, 8.5 days]) were performed for the primary indication of removal of non-cancerous polyps. In the subsequent 9 years, from 2009 to 2017, there were 32 surgeries undertaken, representing a 63% reduction in the number of surgeries for treatment of benign polyps. Of these patients, 47% were male, the median age was 70 years, and median LOS was 8.5 days (IQR, 8 days). EMR was attempted in 139 patients and successfully performed in 132 patients with 164 polyps (58% male; median age, 70 years; median LOS, 1 day [IQR, 1 day]). Mean size of polyps resected by EMR was 26 mm (range, 10-80 mm). En bloc resection was performed in 89 cases (42%). During the study period, the cohort of patients undergoing

Introduction: About 350 million people worldwide are infected with hepatitis B virus (HBV), of whom about 600 000 die annually from HBVrelated liver disease. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver biochemistry test results in the world, both in high- and low-endemic countries for viral hepatitis. The prevalence of NAFLD is about 30% in developed countries such as Australia and the USA; thus, there is a significant burden of coexistent HBV and NAFLD.1 The correlation between HBV infection and fatty liver disease is not fully elucidated. The prevalence of steatohepatitis in patients with chronic HBV has been described by several studies as occurring at a similar rate to the general population;2-9 some studies have found a significant negative association between HBV infection and NAFLD.10-12 It remains unclear whether HBV viral activity influences the degree of hepatic steatosis in patients with HBV-related chronic liver disease. Previous studies have concentrated on steatohepatitis in patients with HBV compared with a noninfected cohort. The aim of this study was to assess the influence of HBV activity (measured by HBV viral load [VL] and the degree of viral hepatitis activity on liver biopsy) on the histological severity of hepatic steatosis in patients with HBV-related chronic liver disease. Method(s): A prospectively collected database identified patients with chronic HBV from a single liver transplant center. Data attained from medical records included the following: basic demographics, presence of hepatoma, transplant status, body mass index, alcohol intake, and HBV VL at first presentation, before transplant, and after transplant. Liver biopsies were re-examined for steatosis grade by an experienced pathologist who was blinded to the patients' HBV VL. Result(s): A total of 171 patients were included (134 male; mean age, 58 +/- 11.4 years). Of these, 115 patients (67%) had a recorded alcohol history, with 11 patients