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Background: Insulinoma is the most common neuroendocrine neoplasm of the pancreas, characterised by hypoglycaemic symptoms. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and ethanol ablation (EUS-EA) are novel methods for treating insulinoma. We aimed to perform a systematic review to assess the efficacy and safety of EUS-guided ablation techniques for pancreatic insulinomas. Methods: We systematically searched for articles detailing EUS-guided ablations of insulinomas. We performed a qualitative analysis and summarised data on the efficacy and safety of EUS-RFA and EUS-EA techniques. Results: In total, we identified 35 case reports and case series describing 75 patients with insulinomas treatment with EUS-guided ablation. Twenty-seven patients were treated with EUS-RFA, 47 patients with EUS-EA, and 1 patient received EUS-EA and EUS-RFA in the same session. In total, 84 insulinomas were ablated (EUS-RFA: 31, EUS-EA: 53). Most insulinomas were in the head of the pancreas (40%). The clinical success rate for EUS-guided ablation techniques was 98.5%. The median glucose level was 1.95 (Q1-Q3: 1.69–2.13) mmol/L before ablation compared to 6.20 (Q1-Q3: 5.30–7.05) mmol/L after treatment. The median insulin and C-peptide levels before and after RFA/EA were 230 (Q1–Q2: 120–257) pmol/L and 41 (Q1–Q2 35–42) pmol/L; 2077 (Q1–Q2 1644–2459) pmol/L and 819 (Q1–Q2 696–1072) pmol/L, respectively. There were eleven adverse events: seven abdominal pain, two mild acute pancreatitis, one necrotising acute pancreatitis and one local hematoma. All patients recovered, and there were no periprocedural deaths. Conclusions: EUS-guided ablation of insulinoma seems to be a safe and effective treatment and is an alternative to surgical resection in selected cases.

Common bile duct stones (CBDS) are estimated to be present in 10–20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.

IntroductionWe describe the development of nurse delivered advanced upper GI therapeutic endoscopy service, which has ensured timely and efficient access to urgent and elective therapeutic procedures.MethodsWe utilised the HEE accelerated Clinical endoscopist training programme to train a nurse in diagnostic upper GI endoscopy. Training commenced Apr ‘16 with JAG accreditation in diagnostic OGD achieved Oct ‘16. From ’17 we began regular weekly therapeutic training lists, initially in observer role but progressing to hands on training (on top of the 4 job planned independent diagnostic lists/week + other duties). The Clinical endoscopist attended a weekly specialist upper GI clinic with a consultant gastroenterologist, progressing to an allocated patient list after 6 months. This training was supplemented with regular attendance at MDTs, national conferences and external courses as well as a Master’s Degree in Advanced clinical practice.Over a 4 year period, competency was attained in multimodal assessment of Barrett’s oesophagus, HALO radiofrequency ablation, endoscopic mucosal resection, pneumatic dilatation of oesophageal strictures, placement of oesophageal stents, the assessment and multi-modal treatment of emergency upper GI bleeding (and delivery of daily inpatient emergency endoscopy lists), and placement of percutaneous endoscopic gastrostomy feeding tubes. Furthermore the Clinical endoscopist is “train the trainer’s” accredited and is a now major provider of upper GI endoscopy training to SpRs and consultants in our unit.ResultsNo. of independent lists delivered over the most recent 12 month period: Therapeutic OGD RFA Inpatient OGD lists RFA list shared with trainer Number of lists 26 6 94 15 TOTAL: 126 independent therapeutic/inpatient lists and 15 continued training listsCompared to a gastroenterology consultant’s endoscopy commitment, this is the equivalent of 3 endoscopy lists per week over 42 weeks i.e. approximately the total amount of endoscopy that a consultant is contracted to deliver in a year.Procedures performed in same time period: Number of Procedures : 737 Therapeutic Totals Number Argon plasma coagulation (APC) 28 Variceal Banding 6 Gold Probe/electrocoagulation 12 Injection – adrenaline 13 Endoclip placement 4 Endomucosal resection (EMR) supervised in room 10 HALO radiofrequency ablation 16 Stricture dilatation with balloon 41 Injection – botulinum toxin 4 Hot snare polypectomy (gastric) 3 Nasojejunal tube placement 16 PEG placement/removal 2 Oesophageal Stent placement9 Video Capsule placed 2 ConclusionsWe have shown that with the appropriate structured training, mentoring and clinical governance, nurse endoscopists can successfully and safely deliver an independent upper GI therapeutic service.

IntroductionEndoscopic biliary drainage is effective in 90 percent of all attempted cases of biliary strictures and 80 percent of malignant biliary strictures. It carries lower morbidity compared to surgical and radiological approaches. Our aim is to review our practice of biliary self-expandable metal stents (SEMs) insertion in a high endoscopy volume district general hospital looking into stent related complications and benign biliary stricture remodelling.Methods185 endoscopic retrograde cholangiopancreatography (ERCP) with biliary SEMs insertion were performed in 166 patients at the Royal Bournemouth Hospital between January 2010 and November 2016. We retrospectively reviewed the indications of biliary SEMs insertion, early and late stent related complications. Early complication is defined as adverse events and stent occlusion or migration within the first 7 days of stent deployment.ResultsOut of 185 ERCPs, 153 were done in 142 patients with malignant strictures, 27 done in 19 patients with benign strictures and 5 done for 5 patients with indeterminate strictures. 122 uncovered SEMs(UCSEMs) were inserted in malignant strictures whereas 30, 22 and 4 fully covered SEMs(FCSEMs) inserted in malignant, benign and indeterminate strictures respectively. Early complications from SEMs insertion include biliary infection (3.24%), pancreatitis (1.08%), bleeding (1.08%), perforation (0.54%), and failure of initial ERCP requiring repeat procedure (1.08%) across all biliary strictures. Rate of stent dysfunction in UCSEMs, FCSEMs and combined plastic and FCSEMs were 17.1%, 37.5% and 33.3% respectively. 12 out of 17 patients had benign strictures remodelled, with mean time from index ERCP to remodelling being 50.5 months (range 21.1–137.8 months). Benign stricture remodelling rate were 100% (4/4) in stone disease, 100% (1/1) in post-cholecystectomy related stricture and 58.3% (7/12) in chronic pancreatitis.Abstract PTH-037 Table 1Patient baseline characteristics Malignant (n= 142) Benign (n= 19) Indeterminate (n= 5) Mean age (range) 77 (44–101) 55 (28–95) 84 (78–89) Male gender, n(%) 84 (59.1%) 15 (78.9%) 1 (20%) No. of ERCPs prior8. 09. 110. 211. 312. 413.≥5 90427102 283303 311000 Mean no of days between last and current ERCP, n(range) 113 (4–963) 164 (9–1325) 58 (34–82) n=number of patientsAbstract PTH-037 Table 2Adverse events Malignant (n= 153) Benign (n= 27) Indeterminate (n= 5) Early14. Biliary infection15. Pancreatitis16. Bleeding17. Perforation18. Repeat ERCP within 7 days19. Others 622122 000001 000000 Late20. Stent occlusion21. Stent migration22. Biliary infection but patent stent on ERCP 25101 080 010 n=number of ERCPsAbstract PTH-037 Table 3Stent dysfunction in malignant strictures Malignant (n= 153) FCSEMs (n= 30) FCSEMs+ plastic* (n= 1) UCSEMs (n= 122) Stent occlusion 5 0 20 Stent migration 8 1 1 n=number of ERCPs* plastic stent inserted for anchoring purposes to prevent stent migrationAbstract PTH-037 Table 4Stent dysfunction in benign strictures Benign (n= 27) FCSEMs (n= 22) FCSEMs+ plastic* (n= 5) UCSEMs (n= 0) Stent occlusion 0 0 0 Stent migration 7 1 0 n=number of ERCPs* plastic stent inserted for anchoring purposes to prevent stent migrationConclusionsOur data appears comparable to larger studies. In our cohort there is a clear contrast in stent dysfunction between FCSEMs and UCSEMs. Biliary sepsis post SEMs insertion seems higher than the published European data and this probably reflects the change in practice in our hospital for advocating against antibiotic prophylaxis. Plastic stent within FCSEMs did not significantly reduce the risk of stent migration.

Abstract IntroductionInterventional angiography is increasingly utilized in trauma management for various injuries. Despite published guidelines by the Eastern Association for the Surgery of Trauma on the use of angiography, limited data exist on factors associated with outcomes in angiography procedures. This study examines factors associated with survival to hospital discharge in trauma patients undergoing angiography with or without embolization across US trauma centers.Materials and methodsThis retrospective observational study used the National Trauma Data Bank 2017 dataset and included adult trauma patients who underwent conventional angiography with or without embolization. A bivariate analysis was done to compare patients’ characteristics by outcome (survived/died), followed by a multivariable logistic regression analysis to determine factors associated with survival to hospital discharge after adjusting for important confounders.ResultsIn the included sample of 4242 patients, median age was 41 years and male gender was predominant (72.6%). Overall mean time to angiography was 263.77 ± 750.19 min. Factors positively associated with survival included treatment at large facilities with over 401 beds (OR = 2.170; 95% CI, [1.277–3.685]), helicopter ambulance/fixed-wing transport (OR = 1.736; 95% CI, [1.325–2.275]), mild Glasgow Coma Scale (OR = 7.621; 95% CI, [5.868–9.898]) and moderate Glasgow Coma Scale (OR = 3.127; 95% CI, [2.080–4.701]), SBP ≥ 90 (OR = 1.516; 95% CI [1.199–1.916]), and spleen as embolization site (OR = 1.647; 95% CI [1.119–2.423]).ConclusionThis nationwide study identified variables associated with survival in trauma patients who underwent angiography. These variables can serve in creating standardized risk stratification tools that could be incorporated into evidence-based guidelines for angiography candidates.

The burden of cardiovascular diseases is predicted to escalate in developing countries. We investigated the descriptive epidemiology, practice patterns, and outcomes of patients hospitalized with acute coronary syndromes (ACS) in African, Latin American, and Middle Eastern countries. In this prospective observational registry, 12,068 adults hospitalized with a diagnosis of ACS were enrolled between January 2007 and January 2008 at 134 sites in 19 countries in Africa, Latin America, and the Middle East. Data on patient characteristics, treatment, and outcomes were collected. A total of 11,731 patients with confirmed ACS were enrolled (46% with ST-elevation myocardial infarction [STEMI], 54% with non–ST elevation–ACS). During hospitalization, most patients received aspirin (93%) and a lipid-lowering medication (94%), 78% received a β-blocker, and 68% received an angiotensin-converting enzyme inhibitor. Among patients with STEMI, 39% did not receive fibrinolysis or undergo percutaneous coronary intervention. All-cause death at 12 months was 7.3% and was higher in patients with STEMI versus non–ST elevation–ACS (8.4% vs 6.3%, P < .0001). Clinical factors associated with higher risk of death at 12 months included cardiac arrest, antithrombin treatment, cardiogenic shock, and age >70 years. In this observational study of patients with ACS, the use of evidence-based pharmacologic therapies for ACS was quite high, yet 39% of eligible patients with STEMI received no reperfusion therapy. These findings suggest opportunities to further reduce the risk of long-term ischemic events in patients with ACS in developing countries.

To evaluate the daily practice of pediatricians, physician-perceived reasons for unsatisfactory effects of treatment, and unmet needs in the management of acute pain and/or fever. This was a multinational (n=13), multicenter, non interventional, cross-sectional study conducted in Latin America, Africa, and the Middle East in children under 16 years of age with fever (defined as a central body temperature ≥38°C) and/or acute pain (defined as pain lasting ≤6 weeks). Data were collected during a single visit using a structured physician-administered questionnaire and case report forms. A total of 2125 patients were recruited by 178 physicians between September 2010 and September 2011. From the 2117 analyzed patients, 1856 (87.7%) had fever, 705 (33.3%) had acute pain, and 446 (21.1%) had both. Of 1843 analyzed patients with fever, 1516 (82.3%) were previously prescribed a pharmacological treatment for the management of fever concomitantly with a non pharmacological approach, while 1817/1856 patients (97.9%) were currently receiving a prescribed pharmacological treatment for fever. Paracetamol/acetaminophen was the most commonly prescribed antipyretic medication during both previous (70.8%) and current (64.1%) consultations. With regard to acute pain management, 67.2% of the patients received previous and 93.9% received current treatment for pain. The most frequently prescribed analgesic during previous consultations was paracetamol/acetaminophen (53.7%), and the current most commonly prescribed analgesics were non steroidal anti-inflammatory drugs (55.2%). Treatment patterns for patients with both fever and acute pain were similar. Overall, 53.4% of the physicians reported poor treatment compliance as a reason for the unsatisfactory effect of the pain/fever treatment, and the most common unmet need was the availability of new drugs (according to 63.5% of the physicians). Adequate management of fever was observed; however, due to the complex etiology of pediatric pain, better evaluation and management of pain in pediatrics is necessary.