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Video Video 1 Pursuit of a pancreatic mass: autoimmune pancreatitis mimicking pancreatic cancer. EUS features of autoimmune pancreatitis in an older man who presented with obstructive jaundice and pancreatic mass.

COVID-19 brings vulnerability, uncertainty, complexity, and ambiguity to endoscopy education. The opportunities for fellows to hone their skills and prepare for independent practice may become limited. To optimize and improve their learning opportunities, we will need to adapt contemporary methods of learning: ML and SBML. These methods allow for structured training by deliberate practice with feedback. We need to require learners to demonstrate mastery of endoscopic skills on the simulators prior to performing procedures in clinical care. In doing so, we ensure safety and deliver quality treatment for our patients. The collective enthusiasm observed among the trainees, their interest to learn endoscopy through virtual SBML, and the rewarding outcome witnessed as never before, lends support to wide-spread renewal of endoscopy training methodology in the post-COVID era.

The prevalence of pancreatic cystic lesions (PCLs) has increased recently due to the increased use of cross-sectional abdominal imaging and the ageing global population. Current diagnostic techniques are inadequate to distinguish between PCLs that require surgery, close surveillance, or expectant management. This has resulted in increased morbidity from both inappropriately aggressive and conservative management strategies. Needle-based confocal laser endomicroscopy (nCLE) has allowed microscopic examination and visual delineation of the surface epithelium of PCLs. Landmark studies in this decade have correlated nCLE and histological findings and identified characteristics differentiating various types of PCLs. Subsequent studies have confirmed the high diagnostic yield of nCLE and its diagnostic utility in PCLs with an equivocal diagnosis. Moreover, nCLE has been shown to improve the diagnostic yield of PCLs. This will help avoid unnecessary pancreatic surgery, which carries significant morbidity and mortality risks. The early detection of high-grade dysplasia in PCLs will provide early surgical treatment and improve outcomes for pancreatic cancer. Despite the high upfront cost of nCLE, the improved diagnostic accuracy and resultant appropriate management have resulted in improved cost effectiveness. Refining the procedure technique and limiting the procedure length have significantly improved the safety of nCLE. A structured training program and device improvements to allow more complete mapping of the pancreatic cyst epithelium will be crucial for the widespread adoption of this promising technology.

The over-the-scope clip is safe and efficacious and has become the preferred device of choice for the treatment of complex gastrointestinal bleeding, perforation, and gastrointestinal leaks. With its widespread adoption in clinical practice, information on complications associated with over-the-scope clip use is emerging. Nonetheless, the overall complication rate is still very low. Most of the reported complications have been related to the technique rather than the actual device and could likely be prevented with proper technique. In this article, the authors summarize the complications associated with over-the-scope clip use and provide guidance on safety measure to mitigate them.

Training practicing physicians to adopt new technology may be difficult because most endoscopy training is given during fellowship training. As such, the adoption of new technology in gastroenterology is typically slow. We designed our course to train our cohort of practicing physicians using flipped learning, a pedagogical approach in which instructional cognitive content is delivered to the individual instead of the group, usually through online platforms and outside of the classroom. We describe our methods and results of the training courses on the techniques of clipping over the scope for gastrointestinal bleeding and endoscopic balloon dilation.

Background This systematic review was performed to assess the clinical utility of the Sendai Consensus Guidelines (SCG) and Fukuoka Consensus Guidelines (FCG) for intraductal papillary mucinous neoplasm (IPMN). Methods A computerized search of PubMed was performed to identify all the studies which evaluated the SCG and FCG in surgically resected, histologically confirmed IPMNs. Results Ten studies evaluating the FCG, 8 evaluating the SCG and 4 evaluating both guidelines were included. In 14 studies evaluating the FCG, out of a total of 2498 neoplasms, 849 were malignant and 1649 were benign neoplasms. Pooled analysis showed that 751 of 1801 (42%) FCG+ve neoplasms were malignant and 599 neoplasms of 697 (86%) FCG−ve neoplasms were benign. PPV of the high risk and worrisome risk groups were 465/986 (47%) and 239/520 (46%) respectively. In 12 studies evaluating the SCG, 1234 neoplasms were analyzed of which 388 (31%) were malignant and 846 (69%) were benign. Pooled analysis demonstrated that 265 of 802 (33%) SCG+ve neoplasms were malignant and 238 of 266 SCG−ve (90%) neoplasms were benign. Conclusion The FCG had a higher positive predictive value (PPV) compared to the SCG. However, the negative predictive value (NPV) of the FCG was slightly lower than that of the SCG. Malignant and even invasive IPMN may be missed according to both guidelines.

Background/aim: Pancreatic cystic lesions are increasingly diagnosed from cross-sectional imaging done for other indications. The challenge lies in the ability to correctly identify the high-risk individuals for resection surgery, which carries high morbidity and mortality. Unfortunately, present diagnostic techniques are suboptimal. Needle-based confocal laser endomicroscopy (nCLE) has been designed to bridge this diagnostic gap. We aim to assess the feasibility and safety of nCLE in the assessment of pancreatic cystic lesions. Methods: We prospectively recruited patients referred for assessment of pancreatic cystic lesions from August 2014 until July 2015. All pancreatic cystic lesions were examined with nCLE miniprobe via endoscopic ultrasound followed by fine-needle aspiration. Information regarding the cysts (morphology, location, fluid analysis etc.) was documented. Adverse event was recorded. Results: Fourteen patients were recruited, six were male with a mean age of 66.5 (range 48–80) years. Only 12 completed nCLE examination of the pancreatic cystic lesions. nCLE imaging was successful in 83.3% (10/12). Average nCLE imaging duration was 5 min 18 s. There was one (10%) adverse event. nCLE impressions were correct in eight cases (five malignant and three benign) compared with final diagnosis. Three patients underwent surgery, histology showed ductal adenocarcinoma, pancreatic neuroendocrine tumor and gastric-subtype of intraductal papillary mucinous neoplasm. The sensitivity and specificity of the nCLE impression when compared with final diagnosis were 83.3% and 75% respectively. The accuracy of nCLE was 80%. Conclusion: Our results have demonstrated that nCLE assessment of pancreatic cystic lesions is safe and feasible. It may complement the existing diagnostic modalities to improve diagnostic yield.

Training practicing physicians to adopt new technology may be difficult because most endoscopy training is given during fellowship training. As such, the adoption of new technology in gastroenterology is typically slow. We designed our course to train our cohort of practicing physicians using flipped learning, a pedagogical approach in which instructional cognitive content is delivered to the individual instead of the group, usually through online platforms and outside of the classroom. We describe our methods and results of the training courses on the techniques of clipping over the scope for gastrointestinal bleeding and endoscopic balloon dilation.

The over-the-scope clip is safe and efficacious and has become the preferred device of choice for the treatment of complex gastrointestinal bleeding, perforation, and gastrointestinal leaks. With its widespread adoption in clinical practice, information on complications associated with over-the-scope clip use is emerging. Nonetheless, the overall complication rate is still very low. Most of the reported complications have been related to the technique rather than the actual device and could likely be prevented with proper technique. In this article, the authors summarize the complications associated with over-the-scope clip use and provide guidance on safety measure to mitigate them.

Objectives: Antibiotic therapy and percutaneous drainage have been the first-line treatments for liver abscesses. However, percutaneous drainage of abscesses may be challenging in difficult-to-access locations such as the caudate lobe. The aim of this review was to determine the indications, technical feasibility and efficacy of endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses. Methods: A literature review of original articles, abstracts, case series and case reports describing endoscopic ultrasound-guided liver abscess drainage was performed. The indications, techniques and complications associated with endoscopic ultrasound-guided drainage were reviewed. Results: A total of 15 studies were identified. The main indications were failed antibiotic therapy and difficulty in gaining percutaneous access. The technique involved identification and puncturing of an abscess under endoscopic ultrasound guidance followed by placement of a prosthesis via a guide wire. The technique was 97.5% successful with no major complications reported. Conclusion: Endoscopic ultrasound-guided drainage was feasible and safe and allowed complete drainage of liver abscesses not accessible by percutaneous drainage.

Background EUS gastrojejunostomy (GJ) is emerging as an alternative novel technique in patients with symptomatic gastric outlet obstructions (GOO) who have advanced malignancy. Recent studies have shown that the EUS-guided approach has less adverse events and is more cost-effective compared to laparoscopic GJ. We share our experience of 5 patients who underwent EUS Guided GJ with favourable outcomes. Methods 5 patients with symptomatic gastric outlet obstruction underwent EUS-guided GJ interventions from May. 2017 to Nov. 2017. Patients were informed of the potential risks and informed consent was taken. Technical success was defined as successful deployment of lumen apposing metal stents (LAMS); while clinical success was the ability to tolerate diet. Results Median age was 61.5 (Range 53–83) years. GOO was secondary to advanced pancreatic malignancy (4) and duodenal malignancy (1). Two patients had altered anatomy from previous post bilroth gastrectomy and Roux-en-Y hepaticojejunostomy. For all five patients with GOO, LAMS 15 mm diameter with electrocautery-enhanced delivery system was used to create the GJ anastomosis. Identification of the distal jejunal limb was done with an inflated balloon catheter and this was use as a target for direct puncture with a 19G needle. All five interventions had technical success with median procedure time of 80 min (38–163 range). All stents were dilated up to their corresponding diameters. Duration of stay after procedure was 3–7 days and there were no adverse events post procedure such as bleeding or perforation. There were no stent migrations and stents were left in place for the rest of their life expectancy. One patient developed intermittent vomiting four weeks after stent deployment. This was possibly secondary to proximal stomach deployment, as repeated endoscopy showed a patent stent. The rest of the patients had clinical success and could tolerate diet on discharge. Range of follow up time was 1-6 months and at time of analysis GOO did not recur in all 5 patients. Three patients died due to disease progression with no symptoms of GOO prior to terminal event. Conclusions EUS guided GJ is a novel procedure with favourable outcomes in patients with symptomatic GOO.

AIM To evaluate factors that influence the diagnostic accuracy of endoscopic ultrasound (EUS)-guided tissue acquisition for lymph node enlargement in the absence of an on-site pathologist. METHODS A retrospective analysis of patients who underwent EUS-guided tissue acquisition for the pathological diagnosis of lymph node enlargement between April 2012 and June 2015 is reported. Tissue acquisition was performed with both cytology and biopsy needles of different calibers. The variables evaluated were lymph node location and size, number of passes and type of needle used. Final diagnosis was based on surgical histopathology or, in non-operated cases, on EUS-guided tissue acquisition and imaging assessment with a minimum clinical follow-up of 6 mo. RESULTS During the study period, 168 lymph nodes with a median size of 20.3 mm (range 12.5-27) were sampled from 152 patients. Ninety lymph nodes (53.6%) were located at mediastinum, and 105 (62.5%) were acquired with biopsy needles. The final diagnosis was benign/reactive origin in 87 cases (51.8%), malignant in 65 cases (38.7%), and lymphoma in 16 cases (9.5%). The sensitivity, specificity, positive predictive value and negative predictive value for the detection of malignancy were 74.1%, 100%, 100% and 80.6%, respectively. The overall accuracy was 87.5% (95%CI: 81.7-91.7). No variables were independently associated with a correct final diagnosis according to the multivariate analysis. CONCLUSION EUS-guided tissue acquisition is a highly accurate technique for assessing lymph node enlargement. None of the variables evaluated were associated with diagnostic accuracy.

Introduction Weekend admissions have been associated with higher mortality. For upper gastrointestinal haemorrhage (UGIH) some studies show significantly increased mortality and less early endoscopy while the UK UGIH audit reported no difference. We studied whether out of hours (OOH) admissions were sicker and/or had higher mortality. Methods Prospective study over 12 months (from March 2014) from 2 UK and 2 international centres. Admission time, demographics, pulse, BP, lab results, endoscopy findings, further procedures and 30 d mortality were recorded. 3 pre-endoscopy scores (Glasgow Blatchford (GBS), AIMS65 and admission Rockall scores) and 2 post-endoscopy scores (PNED and full Rockall scores) were determined. Chi-squared, Fisher’s exact and Kruskal-Wallis tests were used as appropriate. A two-tailed significance level of 5% was used. Results 2118 pconsecutive atients, 60% male, median age 66 years were seen. There were no significant differences in mortality, need for endoscopic therapy, surgery/embolisation or rebleeding in both UK and non-UK centres. There were no differences in comorbidity, mean ASA 2.3, pulse or BP although weekday admissions had a lower Hb (110 g/l vs 118 g/l (weeknight) vs 117 g/l (weekend) p 2118 consecutive patients admitted March 2014-March 2015 from Glasgow (600), Truro (544), Odense (541) and Singapore (433). Data shown are mean [95% CI] or number (%). Conclusion There is no difference in mortality in patients admitted with UGIH OOH compared to weekday admissions. The severity of UGIH was not related to time of admission. Similar findings were noted in the 2 UK centres and internationally. Disclosure of Interest None Declared

Biliary stricture is a rare sequela of biliary tuberculosis (TB) infection. Early recognition with prompt treatment can result in complete resolution. A 56-year-old man was diagnosed with biliary TB after analysis of bile from ERCP showed positive results for TB. Bile duct brushings were inconclusive. Despite completing 7 months of anti-TB treatment, the patient’s liver function test results were still abnormal. MRCP showed dilated intrahepatic ducts with a stricture at the hilar bifurcation