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Dedicated studies evaluating the impact of COVID-19 on outcomes of pancreatobiliary IgG4 related disease (IgG4-RD) patients are scarce. Whether COVID-19 infection or vaccination would trigger IgG4-RD exacerbation remains unknown.Pancreatobiliary IgG4-RD patients ≥ 18 years old with active follow-up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID-19 infection, IgG4-RD disease activity and treatment status, interruption of indicated IgG4-RD treatment. Prospective data on COVID-19 vaccination status and new COVID-19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort.Of the 124 pancreatobiliary IgG4-RD patients, 25.0% had active IgG4-RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre-vaccination period), two patients (1.6%) had COVID-19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4-RD. Despite a high vaccination rate (85.0%), COVID-19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID-19 infection rate was noted in the non-fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4-RD exacerbation following COVID-19 vaccination or infection was observed.While a low COVID-19 infection rate with no mortality was observed in pancreatobiliary IgG4-RD patients in the pre-vaccination period of COVID-19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4-RD exacerbation after COVID-19 infection or vaccination was observed.

Pancreatic cysts are a heterogenous group of lesions that can be differentiated into mucinous and non-mucinous cysts based on their malignant potential. Crosssectional imaging alone is inadequate to reliably distinguish between the two groups. Endoscopic ultrasound (EUS) and fine needle aspiration has been used for analysis of the cyst morphology and cyst fluid. Traditional markers such as fluid carcinoembryonic antigen and cytology have been useful particularly for the assessment of indeterminate cysts or those with high-risk features, but the overall diagnostic accuracy is still sub-par. As a result, new techniques have been described to improve the ability of EUS to risk stratify a pancreatic cyst. In this review, we describe some of the novel EUS‑based techniques in the evaluation of pancreatic cysts, namely needle-based confocal laser endomicroscopy, through the needle cystoscopy, and through the needle biopsy techniques.

BACKGROUND Endoscopic submucosal dissection (ESD) has shown to be effective in management of colorectal neoplasm in the Asian countries, while its implementation in Western countries where endoscopic mucosal resection (EMR) is preferred is still debatable. AIM To compare the surgical, histological, and oncological outcomes between ESD and EMR in the treatment of colorectal polyps, with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world. METHODS Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc, complete resection, margin involvement, resection time, need for additional surgery, complications, and recurrence rate of ESD with EMR. RESULTS Of 281344 colorectal polyps from 21 studies were included. When compared to EMR, the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate, and lower lateral margin involvement and recurrence. ESD led to increased procedural time, need for additional surgery, and perforation risk. No significant difference in bleeding risk was found between the two groups. Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD. Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate, bleeding risk and recurrence. In subgroup analysis, Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4% and 0.0002%, respectively, as compared to perforation risk of 8% and 1%, respectively, in reports coming from rest of the world. CONCLUSION ESD resulted in better resection outcomes and lower recurrence compared to EMR. With appropriate training, ESD is preferred over EMR as the first-line therapy for resection of colorectal polyps, without restricting to lesions greater than 20 mm and those with high suspicion of submucosal invasion.

Omeprazole is commonly co-prescribed with clopidogrel. Clopidogrel requires bio-activation by cytochrome P450 CYP2C19. Omeprazole may reduce clopidogrel’s antithrombotic efficacy by inhibiting CYP2C19. Studies in Caucasians receiving omeprazole with clopidogrel showed no significant increase in death and myocardial infarction with this drug–drug interaction. There are limited large-scale studies in Asians, who may have a greater prevalence of CYP2C19 loss-of-function polymorphisms. A single centre retrospective cohort study was undertaken based on a review of medication records and prescription data. Patients prescribed clopidogrel from 2009 to 2012 were followed-up with until December 2012 (median:29 months). The primary outcome was all-cause mortality and secondary outcomes were myocardial infarction (MI), cerebrovascular accidents, and subsequent coronary interventions. Of 12,440 patients prescribed clopidogrel, 62%(n = 7714) were on omeprazole (63.8% Chinese, 13.9% Malay, 12.4% Indian, 10.0% others), and 38%(n = 4726) were not on omeprazole or other proton pump inhibitors (62.6% Chinese, 13.5% Malay, 10.7% Indian, 13.2% others). Mortality after co-prescription occurred in 14.3%(n = 1101) of patients, compared to 6.3%(n = 300) of patients prescribed clopidogrel only. Multivariate analysis using propensity score adjusted analysis showed no significant increase in all-cause mortality with co-prescription (adjusted hazards ratio [AHR] 1.13, [95%CI 0.95–1.35]). Patients on co-prescription had a higher risk of subsequent MI (16% vs 3.8%; AHR 2.03 [95%CI 1.70–2.44]), but not of cerebrovascular accidents (5.0% vs 2.0%; AHR 0.98 [95%CI 0.76–1.27]) or coronary interventions (1.7% vs 0.7%; AHR 1.28 [95%CI 0.83–1.96]). The risk of a subsequent MI was higher in the Malay (AHR 2.43 [95%CI 1.68–3.52]) and Chinese (AHR 2.06 [95%CI 1.63–2.60]) population as compared to the Indian (AHR 1.56 [95%CI 1.06–2.31]) population. In conclusion, the use of clopidogrel with omeprazole is associated with an increased risk of MI, but not mortality or stroke, in this multi-ethnic Asian population. These risks appear to vary among different ethnic groups.

ObjectiveAn international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ.DesignClinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised.ResultsTwenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett’s oesophagus (BO).ConclusionsThis international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.

When performing endoluminal surgery inside the colon using a flexible endoscopic robot, there is a problem of losing visualization and task space due to the collapsing of the surrounding wall. This happens mainly because of the intra-abdominal pressure and peristalsis of the colon. Although insufflation is commonly used for expanding the colon, it does not function when a full-thickness incision is created on the colon wall. To support the collapsing colon and ensure sufficient visualization and task space even with a hole, we developed a deployable colon support structure (CSS) that can be seamlessly adapted to the existing procedures. While the CSS is designed to be small and flexible enough to pass through an endoscopic channel that can be tortuous, it becomes steady enough to hold the collapsing/squeezing colon after being deployed. Also, the CSS is collapsible after task completion, for retraction through an endoscopic channel. Through the ex-vivo and in-vivo studies with a swine, we have successfully demonstrated the feasibility of supporting the colon wall during endoluminal interventions with the CSS. We confirmed that the CSS was easily deliverable and deployable and the created space was large enough to perform surgical tasks using robotic arms. National Research Foundation (NRF) Published version This work was supported by the National Research Foundation (NRF) Singapore under Grant NRFI2016-07

White-light endoscopy with biopsy is the current gold standard modality for detecting and diagnosing upper gastrointestinal (GI) pathology. However, missed lesions remain a challenge. To overcome interobserver variability and learning curve issues, artificial intelligence (AI) has recently been introduced to assist endoscopists in the detection and diagnosis of upper GI neoplasia. In contrast to AI in colonoscopy, current AI studies for upper GI endoscopy are smaller pilot studies. Researchers currently lack large volume, well-annotated, high-quality datasets in gastric cancer, dysplasia in Barrett's esophagus and early esophageal squamous cell cancer. This review will look at the latest studies of AI in upper GI endoscopy, discuss some of the challenges facing researchers, and predict what the future may hold in this rapidly changing field.

The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy., A successful robotic endoscope must provide beyond the basic requirement of a high functioning endoscopic resection tool. It must be demonstrated to be safe, and cost‐effective for its intended clinical application. Training can be best achieved through the synergy of artificial‐intelligence‐guided deep learning systems and virtual reality. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an ideal choice for the application of the robotic endoscope as the triangulation afforded by the device effectively solves the challenges faced when performing NOTES using existing endoscopic equipment.

If a perforation occurs as a result of a flexible endoscopic procedure, suturing through urgent laparoscopy or open surgery may be required to repair the perforation because suturing is normally stronger than closure using existing endoscopic devices. Suturing with stitches and knots, widely adopted in open or laparoscopic surgery, is still not possible in flexible endoscopy. This is because of the confined space of the natural orifice and target area, high levels of motion dexterity and force needed for stitching and knot-tying, and critical size and strength requirements of wound closure. We present a novel flexible endoscopic robotic suturing system that is able to suture gastrointestinal defects without opening up the patient’s body like in open or laparoscopic surgery. This system features a robotic needle driver and a robotic grasper, both of which are flexible, through-the-scope (small in sizes), and dexterous with five degrees of freedom. The needle driver, facilitated by the grasper, enables the surgeon to control a needle through teleoperation to make stitches and knots in flexible endoscopy. Successful in vivo trials were conducted in the rectum of a live pig to confirm the feasibility of endoscopic suturing and knot-tying using the system in a realistic surgical scenario (not possible with existing devices which are all manually driven). This new technology will change the way how surgeons close gastrointestinal defects. NRF (Natl Research Foundation, S’pore) Accepted version

Standard polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection (ESD) are established techniques for the treatment of gastrointestinal tumors. However, resection of submucosal tumors via ESD often results in low rates of microscopically margin-negative (R0) resection and high rates of perforation. Endoscopic full thickness resection (EFTR) overcomes this adverse event and aids in the therapeutic management of complex tumors. Multiple techniques for EFTR have been developed, each with its own advantages and disadvantages. Submucosal tunneling and non-exposed techniques are generally preferable, because the layer of overlying intact mucosa reduces the incidence of intraperitoneal contamination by the gastric fluid and dissemination of the tumor cells. However, adoption of EFTR by endoscopists in clinical practice remains low. The major challenge seems to be the technical difficulty in performing laparoscopic and/or endoscopic suturing using the currently available instruments. We developed a novel robotic endoscopic platform with suturing capabilities to overcome the technical challenges of suturing. This platform allows easy maneuvering and triangulation of the instruments, thus facilitating endoscopic suturing using robotic arms. Our studies have demonstrated that this robotic endoscopic platform with suturing capabilities is an effective and safe method for performing EFTR with endoscopic suturing.

Barrett's esophagus (BE) is a premalignant condition associated with the development of esophageal adenocarcinoma (EAC). Over the past decade, BE and its associated neoplasia has increased in prevalence globally. Current surveillance guidelines aimed to detect and treat BE‐associated dysplasia early in the hope of improving the morbidity and mortality of the condition. However, due to the lack of long‐term data and the proven benefit that surveillance actually improves mortality from EAC, the guidelines of the United States and Europe are slightly different. This review will focus on discussing the surveillance strategy for BE appropriate for the Asian region, taking into account the unique epidemiologic features of this disease in the Asian region., Current surveillance guidelines aim to detect Barrett's esophagus‐associated dysplasia early. However, due to the lack of long‐term data, and proven benefit that surveillance actually improves mortality from esophageal adenocarcinoma, the guidelines coming from the US and Europe are slightly different. This review will discuss the surveillance strategy for Barrett's esophagus appropriate to the Asian region, taking into account the unique epidemiologic features of this disease in the Asian region.

BACKGROUND Gamma-glutamyl transferase (GGT) is associated with the risk of cardiovascular disease (CVD) in the general population. AIM To identify the association of baseline GGT level and QRISK2 score among patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD). METHODS This was a retrospective study involving 1535 biopsy-proven NAFLD patients from 10 Asian centers in 8 countries using data collected by the Gut and Obesity in Asia (referred to as "GO ASIA") workgroup. All patients with available baseline GGT levels and all 16 variables for the QRISK2 calculation (QRISK2-2017; developed by researchers at the United Kingdom National Health Service; https://qrisk.org/2017/; 10-year cardiovascular risk estimation) were included and compared to healthy controls with the same age, sex, and ethnicity. Relative risk was reported. QRISK2 score > 10% was defined as the high-CVD-risk group. Fibrosis stages 3 and 4 (F3 and F4) were considered advanced fibrosis. RESULTS A total of 1122 patients (73%) had complete data and were included in the final analysis; 314 (28%) had advanced fibrosis. The median age (interquartile range [IQR]) of the study population was 53 (44-60) years, 532 (47.4%) were females, and 492 (43.9%) were of Chinese ethnicity. The median 10-year CVD risk (IQR) was 5.9% (2.6-10.9), and the median relative risk of CVD over 10 years (IQR) was 1.65 (1.13-2.2) compared to healthy individuals with the same age, sex, and ethnicity. The high-CVD-risk group was significantly older than the low-risk group (median [IQR]: 63 [59-67] vs 49 [41-55] years; P < 0.001). Higher fibrosis stages in biopsy-proven NAFLD patients brought a significantly higher CVD risk (P < 0.001). Median GGT level was not different between the two groups (GGT [U/L]: Median [IQR], high risk 60 [37-113] vs low risk 66 [38-103], P = 0.56). There was no correlation between baseline GGT level and 10-year CVD risk based on the QRISK2 score (r = 0.02). CONCLUSION The CVD risk of NAFLD patients is higher than that of healthy individuals. Baseline GGT level cannot predict CVD risk in NAFLD patients. However, advanced fibrosis is a predictor of a high CVD risk.

Endoscopic diagnosis of gastroesophageal junction and Barrett's esophagus is essential for surveillance and early detection of esophageal adenocarcinoma and esophagogastric junction cancer. Despite its small size, the gastroesophageal junction has many inherent problems, including marked differences in diagnostic methods for Barrett's esophagus in international guidelines. To define Barrett's esophagus, gastroesophageal junction location should be clarified. Although gastric folds and palisade vessels are landmarks for identifying this junction, they are sometimes difficult to observe due to air entry or reflux esophagitis. The possibility of diagnosing a malignancy associated with Barrett's esophagus1 cm, identified using palisade vessels, should be re-examined. Nontargeted biopsies of Barrett's esophagus are commonly used to detect intestinal metaplasia, dysplasia, and cancer as described in the Seattle protocol. Barrett's esophagus with intestinal metaplasia has a high risk of becoming cancerous. Furthermore, the frequency of cancer in patients with Barrett's esophagus without intestinal metaplasia is high, and the guidelines differ on whether to include the presence of intestinal metaplasia in the diagnosis of Barrett's esophagus. Use of advanced imaging technologies, including narrow-band imaging with magnifying endoscopy and linked color imaging, is reportedly valid for diagnosing Barrett's esophagus. Furthermore, artificial intelligence has facilitated the diagnosis of Barrett's esophagus through its deep learning and image recognition capabilities. However, it is necessary to first use the endoscopic definition of the gastroesophageal junction, which is common in all countries, and then elucidate the characteristics of Barrett's esophagus in each region, for example, length differences in the risk of carcinogenesis with and without intestinal metaplasia.

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are the standard of care in malignant biliary obstruction cases. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used after unsuccessful ERCP. However, the patient’s clinical impact of EUS-BD over PTBD is still not obvious. Therefore, this case series study aims to evaluate the clinical outcomes of patients with advanced malignant biliary obstruction who underwent EUS-BD after failed ERCP. A retrospective database study was performed between January 2016 and June 2018 in patients with advanced malignant biliary obstruction. Patients were consecutively enrolled without randomization. Treatment options consisted of ERCP and PTBD or EUS-BD if ERCP failed. Based on 144 biliary obstruction cases, 38 patients were enrolled; 24 (63.2%) were men. The patients’ mean age was 66.8 ± 12.36 years. The most common cause of malignant biliary obstruction was pancreatic cancer (44.7%). Biliary drainage was achieved by ERCP (39.5%), PTBD (39.5%), and EUS-BD (21.1%). The technical success rate was 86.7% by PTBD and 87.5% by EUS-BD (p = 1.000), while the clinical success rate was 93.3% by PTBD and 62.5% by EUS-BD (p = 0.500). The median survival in patients who underwent PTBD versus those wo underwent EUS-BD was 11 versus 3 months (log-rank p = 0.455). In conclusion, there is no significant advantage of EUS-BD when compared to PTBD in terms of clinical success and survival benefit in advanced malignant biliary obstruction.

Barrett's esophagus (BE), a premalignant condition of the lower esophagus, is increasingly prevalent in Asia. However, endoscopic and histopathological criteria vary widely between studies across Asia, making it challenging to assess comparability between geographical regions. Furthermore, guidelines from various societies worldwide provide differing viewpoints and definitions, leading to diagnostic challenges that affect prognostication of the condition. In this review, the authors discuss the controversies surrounding the diagnosis of BE, particularly in Asia. Differences between guidelines worldwide are summarized with further discussion regarding various classifications of BE used, different definitions of gastroesophageal junction used across geographical regions and the clinical implications of intestinal metaplasia in the setting of BE. Although many guidelines recommend the Seattle protocol as the preferred approach regarding dysplasia surveillance in BE, some limitations exist, leading to poor adherence. Newer technologies, such as acetic acid-enhanced magnification endoscopy, narrow band imaging, Raman spectroscopy, molecular approaches and the use of artificial intelligence appear promising in addressing these problems, but further studies are required before implementation into routine clinical practice. The Asian Barrett's Consortium also outlines its ongoing plans to tackle the challenge of standardizing the diagnosis of BE in Asia.

ObjectiveTo investigate the incidence of gastric cancer (GC) attributed to gastric intestinal metaplasia (IM), and validate the Operative Link on Gastric Intestinal Metaplasia (OLGIM) for targeted endoscopic surveillance in regions with low-intermediate incidence of GC.MethodsA prospective, longitudinal and multicentre study was carried out in Singapore. The study participants comprised 2980 patients undergoing screening gastroscopy with standardised gastric mucosal sampling, from January 2004 and December 2010, with scheduled surveillance endoscopies at year 3 and 5. Participants were also matched against the National Registry of Diseases Office for missed diagnoses of early gastric neoplasia (EGN).ResultsThere were 21 participants diagnosed with EGN. IM was a significant risk factor for EGN (adjusted-HR 5.36; 95% CI 1.51 to 19.0; pH. pylori. Participants with OLGIM II were also at significant risk of EGN (adjusted-HR 7.34; 95% CI 1.60 to 33.7; p=0.02). A significant smoking history further increases the risk of EGN among patients with OLGIM stages II–IV.ConclusionsWe suggest a risk-stratified approach and recommend that high-risk patients (OLGIM III–IV) have endoscopic surveillance in 2 years, intermediate-risk patients (OLGIM II) in 5 years.

Background: This extensive meta-analysis sought to compare the surgical, histological, and oncological outcomes between endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of colorectal polyps, with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world. Methods: Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc, complete resection, margin involvement, resection time, need for additional surgery, complications, and recurrence rate of ESD with EMR. Results: 281,344 colorectal polyps from 21 studies were included. When compared to EMR, the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate, and lower lateral margin involvement and recurrence. ESD led to increased procedural time, need for additional surgery, and perforation risk. No significant difference in bleeding risk was found between the two groups. Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD. Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate, bleeding risk and recurrence. In subgroup analysis, Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4% and 0.0002%, respectively, as compared to perforation risk of 8% and 1%, respectively, in reports coming from rest of the world.Conclusions: This meta-analysis demonstrated increased safety and efficacy of ESD and EMR done in Japan as compared with the rest of the world.

This paper presents a two magnetic sensor based tracking method for a magnetically inflated intragastric balloon capsule (MIBC) which is used for obesity treatment. After the MIBC is swallowed, it is designed to be inflated inside the stomach by approaching a permanent magnet (PM) externally near the abdomen. However, if the balloon inflation is accidentally triggered while the MIBC is still in the esophagus, the esophagus will be damaged. Therefore, to safely inflate the MIBC, we aim to track the MIBC's position along the esophagus and confirm the MIBC passes through. Typically, magnetic sensor based tracking systems tend to be bulky and costly since they involve computationally intensive optimization with many magnetic sensors. To solve those problems, we develop an algorithm that estimates the position of the PM inside the MIBC by using the grid search combined with the dynamically confined search range and search threshold modulation. Our tracking method achieved an average 1D position error of 3.48 mm which is comparable to the up to 4 mm average error for the other magnetic sensor based tracking systems that require more sensors and computational power compared to our system. Nanyang Technological University This research is supported by Nanyang Technological University (Start up Grant M4081419).

Background Hepatocellular carcinoma with biliary ductal invasion is rare and associated with a significantly lower survival rate. Case presentation We present an unusual case of a patient with hepatocellular carcinoma and biliary invasion, who had his diagnosis confirmed by histological analysis from tissue extracted by endoscopic retrograde cholangiopancreatography. An 87-year-old male presented with a 1-day history of right upper quadrant pain and jaundice. His past medical history included recurrent gallstone cholangitis and a previous cholecystectomy. An abdominal CT demonstrated a dilated intrahepatic biliary tree with left proximal intrahepatic hyperdensities, as well as a 3 cm hepatocellular carcinoma. He was initially suspected to have concurrent gallstone cholangitis and a newly diagnosed hepatocellular carcinoma. Endoscopic retrograde cholangiopancreatography and balloon trawling of the intraductal lesions extracted necrotic tumour-like tissue which was histologically consistent with hepatocellular carcinoma. The extraction of the intra-biliary portion of HCC resulted in complete resolution of his jaundice, enabling further treatment with nivolumab, which would not have been possible if the obstruction was not cleared. The patient is currently well and has completed his 6th cycle of nivolumab. Conclusion Obstructive jaundice is an uncommon presentation for patients with HCC. it is key for clinicians to be aware of the possibility of intrabiliary invasion in order obtain an early diagnosis and to reduce any delay in treatment.