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ObjectiveNeedle knife fistulotomy (NKF) has traditionally been employed as a second-line technique for biliary access. There is emerging evidence in favour of its early use and as a primary cannulating technique. The aim of this study was to analyse the outcomes of a decade’s worth of experience in early and primary NKF. We present the largest UK single centre, single-operator experience on the use of early and primary NKF in endoscopic retrograde cholangiopancreatography (ERCP).MethodsAll patients at a tertiary centre who had either primary NKF or early NKF between January 2013 and December 2023 were selected for analysis. The main outcomes of successful biliary cannulation, papilla morphology and complications were analysed.ResultsA total of 329 cases of early or primary NKF were identified. The successful cannulation rate was 88.5% on the index procedure and 92.7% following repeat attempt. PEP rate was 2.4%, bleeding 0.3% and perforation 0.3%. Haraldsson type 3 papillae were best suited for NKF with 95.6% biliary cannulation rate (p=0.01) and 1.8% pancreatitis (p=0.86). NKF in ERCP for choledocholithiasis had higher rates of biliary cannulation at 93.9% (p<0.001) and lower rates of pancreatitis at 0.9% (p=0.01) compared with other indications. Primary NKF had a 93.5% biliary cannulation rate with no complications.ConclusionEarly and primary NKF is safe and effective, especially when used on patients with favourable characteristics. These characteristics include Haraldsson type 3 papillae and stone disease.

IntroductionEvidence on the safety of doses for conscious sedation in ERCP is currently lacking. The recent BSG guidelines suggest minimal to moderate sedation in level 1–2 ERCP. More complex ERCPs or combined endoscopic ultrasound (EUS) and ERCP procedures require deep sedation or general anaesthetic. The previous JAG guidance suggests no more than 2mg Midazolam and 50µg Fentanyl for patients aged 70 or above and no more than 5mg Midazolam and 100µg Fentanyl for patients under age 70. This recommendation has been extrapolated from diagnostic endoscopy. For the more complex cases, the availability of deep sedation is often unavailable for endoscopy in most centres. We aim to examine our practice of adopting a dual sedationist-endoscopist model for conscious sedation. We aim to establish safety profile of using sedation beyond the previous recommendations and its impact on endoscopic performance.MethodRetrospective review of all ERCP from September 2022 to September 2023. Doses of Midazolam and Fentanyl were reviewed in accordance to patients’ age group. Cases that required repeat endoscopy were reviewed for the cause and cases requiring reversal agents for sedation were identified. Further analysis was done on patients who had combined EUS-ERCP. The standards for meeting sedation recommendations was adapted from Joint Advisory Group (JAG) Guide to Meeting the Quality and Safety Standards. Sedation was administered in small increments (1mg for Midazolam and 25µg for Fentanyl) and titrated to response while monitoring oxygen saturations and heart rate during the procedure by either the trainee or trainer while the other performs the endoscopy.Results497 cases of ERCP done with conscious sedation between September 2022 to 2023. All were done with Fentanyl and Midazolam. Doses for cases which exceeded recommendations for Midazolam were 45.1% (n=224) and Fentanyl were 68.8% (n=342). The median dose of Midazolam was 3.3mg and Fentanyl was 100µg for all ages. There were 168 cases for combined EUS-ERCP, 162 cases were done under conscious sedation. The median dose of Midazolam was 4mg and Fentanyl was 125µg. 2 combined procedures (1.2%) could not be completed due to intolerance. 4 cases (0.8%) of ERCP required repeat under deep sedation and was incomplete due to inadequate tolerance. One patient (0.2%) needed reversal agents for respiratory depression. The highest dose recorded was Fentanyl 400µg and 10mg Midazolam with no adverse events.ConclusionThe use of conscious sedation is safe when given in small increments with close monitoring. The doses should be tailored to each individual and their response. The dual sedationist-endoscopist model is effective as there is low rate of failure (0.8%) from intolerance as sedation is given proactively as opposed to reactively. Furthermore, combined EUS-ERCP procedure can also be done effectively under conscious sedation in our experience.

IntroductionERCP carries risks of pancreatitis, perforation and bleeding. Extensive studies have been carried out in a bid to reduce these risks and to modify procedural related risk factors to minimise the risk of pancreatitis. One of these methods is utilising the needle knife fistulotomy (NKF) early into gaining biliary access.MethodsAll the cases with NKF, either early or primary, during ERCP by a single operator over a ten-year period from January 2013 to December 2023 were identified. The notes and endoscopy reports were reviewed for:rate of biliary cannulation in initial ERCP and subsequent attempts for failed procedures following NKFpapillary morphology (according to Haraldsson classification) and associated biliary cannulation ratecomplication rate of ERCP where NKF was attemptedResultsThere were 329 cases of ERCP had NKF done by a single operator. There was 298 cases of early NKF and 31 cases of primary NKF. The overall biliary cannulation rate was 88.5% (n=291) on first attempt ERCP with NKF. Among the unsuccessful first ERCPs (n=38), 17 patients were brought back for re-attempt ERCP and success rate was 82.4% (n=14). The cumulative biliary cannulation rate is 92.7% (n=305). The success rate was the highest in bulged papillae (Haraldsson Type 3) at 96.5% with the lowest complication rate at 1.8%, all of which were pancreatitis. There were 31 cases of primary NKF with 93.5% (n=29) biliary cannulation with no complications. Most cases of primary NKF was done on bulged papilla (n=19) all of which were successful in biliary cannulation. The complication rate of NKF was 3.0% (n=10). Post-procedure bleeding was at 0.3% (n=1) and 0.3% (n=1) for perforation. The rate of pancreatitis was 2.4% (n=8). The mortality rate in this study was 0.3% (n=1) from severe pancreatitis.ConclusionsIn difficult ERCP, NKF is effective in in experienced hands, as evidenced by 88.5% biliary cannulation rate on first attempt. After a failed initial ERCP, repeat ERCP should be re-considered as supported by 82.4% success rate on second ERCP following initial NKF, alongside a cumulative success rate of 92.7%. In suitable cases, primary NKF should be considered as there is a 93.5% success rate and no complications in our small group of patients. Analysis of papillary morphology showed that bulged papillae (Haraldsson Type 3) had the most success with 96.5% cannulation rate and 1.8% complication rate, all of which were pancreatitis. NKF is a safe modality in experienced hands with low rates of complications (3.0%) and specifically pancreatitis (2.4%).

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) should only be reserved for cases with appropriate indications, as it carries significant risks. Due to the risk of cholangitis, common bile duct (CBD) stones require extraction. However in practice there are usually delays between diagnostic imaging and intervention with ERCP. During this delay, stones can be passed spontaneously, rendering the need for ERCP obsolete. Endoscopic ultrasound (EUS) has been demonstrated to be accurate in diagnosing CBD stones. When spontaneous passage of stone is clinically suspected, EUS could be utilized in a single session immediately prior to intervention to confirm the necessity of intervention. We aim to study the reduction of unnecessary ERCP cases since the introduction of a single session EUS-ERCP in low risk stone cases in our unit.MethodsRetrospective data analysis was done on all ERCP in University Hospital North Midlands in the year 2015 and 2021 for stone disease. Clinically unnecessary ERCP cases were identified from this and defined as ERCP that revealed no stones or did not improve liver enzymes following the procedure. Comparison was made between the practice before (year 2015) and after (year 2021) the introduction of single session EUS-ERCP for low risk stone disease. Single session EUS-ERCP for stone disease were also analyzed for the number of cancelled ERCP due to normal EUS and number of cholangitis cases following cancellation.ResultsIn 2015, there was a total of 402 ERCP cases done for stone disease. 27 (6.7%) of these procedures were clinically unnecessary. In 2021, there was a total of 327 ERCP cases done for stone disease. 4 (1.2%) procedures were clinically unnecessary. There were 185 of single session EUS-ERCP for low risk cases, 92 (49.7%) had cancelled ERCP due to normal EUS. 3 patients (3.3%) were readmitted with cholangitis following cancellation of ERCP.ConclusionSingle session EUS-ERCP in low risk stone disease significantly reduced the rates of unnecessary ERCP. This allows for better allocation of resources in endoscopy for patients who needs intervention and reduces the risk of complications that patients would have otherwise been subjected to.

IntroductionERCP and combined EUS-ERCP require tailored sedation. The BSG recommends deep sedation or general anaesthesia for complex cases. However, limited access to deep sedation in UK centres, often necessitates conscious sedation within JAG dose limits (<2 mg Midazolam and <50 μg Fentanyl for patients ≥70 years; <5 mg Midazolam and <100 μg Fentanyl for those <70 years).AimsEvaluation of a dual sedationist-endoscopist model for conscious sedation in ERCP and combined EUS-ERCP, focusing on the impact of exceeding JAG-recommended doses on patient safety and procedural outcomes.MethodsA retrospective review of 1,040 ERCP cases performed from September 2022 to September 2024 was conducted, including 346 combined EUS-ERCP cases. Sedation doses of Midazolam and Fentanyl were recorded and analyzed by age group. Doses were titrated in small increments (1mg Midazolam, 25μg Fentanyl) by either the trainee or trainer administering sedation while the other performed the endoscopy, with continuous monitoring of oxygen saturation and heart rate. Cases requiring repeat endoscopy, as well as those needing reversal agents due to sedation-related respiratory depression were reviewed.ResultsThe study revealed that 47.85% of cases received higher than recommended doses of Midazolam, and 74.35% exceeded the recommended Fentanyl dose. The highest doses administered were 13 mg of Midazolam and 500 μg of Fentanyl, yet the model achieved a 99.9% procedure completion rate with only 0.1% requiring respiratory depression reversal, underscoring its safety. Patients under 70 generally received higher doses of both Midazolam (median 5mg) and Fentanyl (median 175 μg), compared to those over 70, who received lower doses (3 mg of Midazolam and 100 μg of Fentanyl). These age-related differences in sedation requirements did not affect the overall safety of the model. Even for complex procedures such as combined EUS-ERCP (including EUS biliary drainage), the sedation approach was well tolerated, with minimal adverse outcomes. Despite exceeding recommended limits, the dual sedationist-endoscopist model demonstrated its capacity to safely manage high-risk cases, particularly in settings with limited access to deep sedation. These findings suggest that this model provides a reliable and effective solution for ERCP sedation, offering a high success rate with minimal complications, even when the maximum recommended sedation doses are surpassed.ConclusionsThe dual sedationist-endoscopist model for conscious sedation in ERCP is both safe and effective, even with doses exceeding conservative recommendations. This model allows for successful completion of complex ERCPs, including combined EUSERCP procedures, without increased sedation-related complications.

A 60-year-old man with a history of heart transplant and renal failure on dialysis was referred for an OVESCO clip to a post appendicectomy stump leak. He had a radiologically placed external drain to a collection which was actively draining faecal matter. The leak failed to close with several weeks of conservative management. Endoscopic management was favoured as initial management due to his anaesthetic risk factors.The fistula site was identified at the appendix stump and confirmed on fluoroscopy with wire passage and contrast extravasation. The OTSC Twin Grasper was put down the working channel in an attempt to draw the two edges of the fistula into the cap. Unfortunately, this caught on the OVESCO string and the string was sheared in the working channel.A grasper and biopsy forceps were used in attempt to grab the slack end of the string and release the clip but neither were able to grip sufficiently. The procedure was abandoned and a further reattempt was scheduled.This time the fistula was easily identified and OVESCO clip successfully deployed. Fluoroscopy confirmed no contrast leak and methylene blue was sprayed in the caecum to aid in confirmation of closure. The patient recovered well and drain output stopped with no methylene blue seen. He was discharged soon after.Video link: OVESCO COLONIC_BSG_FINAL (vimeo.com)

IntroductionAn 80 year old man was diagnosed with an advanced distal oesophageal adenocarcinoma. He was referred for a palliative oesophageal stent due to marked dysphagia. An initial attempt at stent insertion was curtailed by an unexpectedly complex, incarcerated hiatus hernia which was not highlighted on the CT report. As there was tight angulation of the hiatus hernia just below the gastro-oesophageal junction (GOJ) and concerns of stent impaction, the procedure was abandoned.Following review, a repeat attempt was arranged as he had few other options for nutrition.During the repeat attempt, a nasoendoscope was used to traverse the tumour and carefully navigated through a loop in the hiatus hernia into the antrum. A stiff amplatz wire was then placed and the distal margin of the tumour at the GOJ was marked with an external paperclip. A 10cm half-covered Citec oesophageal stent was placed with the distal flange deployed immediately below the GOJ. The distal flange was inspected with a nasoendoscope and the stent was then pulled upwards using grasping forceps.Contrast instillation confirmed smooth passage through the stent and hiatus hernia into the gastric body. The patient’s symptoms improved and he was discharged.ConclusionWe demonstrate the challenges in oesophageal stent placement in a patient with a complex incarcerated hiatus hernia and technique modifications.Video link: HH stent_BSG (vimeo.com)

A 50-year-old man was referred to our unit for management of an embedded fully covered oesophageal stent.He was taking doxycycline over many years for acne and was subsequently found to have severe oesophagitis and strictures. He then underwent a series of endoscopic dilatations at his local unit for the benign oesophageal strictures. Following recurrence, a 10cm fully covered Wallflex® oesophageal stent was placed. On attempted removal a few months later there was stricturing above and below the stent and despite balloon dilatation the stent was not able to be freed. A nasogastric tube was placed and he was referred for further management.Initial inspection here showed a dense fibrotic stricture above and below the stent. There was marked granulation tissue ingrowth through the membranous covering. Despite snare resection and APC, the stent could not be removed. A fully covered 10cm ELLA® HV stent was placed overlapping the embedded stent with a view to a re-attempt at removal in 8 weeks.He underwent weekly endoscopies to mobilise the overlapping stent to ensure the proximal flange did not embed. At one of the endoscopies the ELLA stent was replaced due to concern over overgrowth of granulation tissue at the top margin.We report on the various techniques employed for the difficult embedded stent removal.Video link: https://vimeo.com/678668838/a62294c5d5OGD Sept 2020 – Stricture from 20cm- biopsies benignBarium swallow sept 2020- 6cm Upper oesophageal strictureOGD Nov 2020 – Stricture 23-27cm dilated to 12mmOGD Dec 2020 - Stricture dilated to 13.5mm

IntroductionBiodegradable biliary stents (BDBS) have been introduced in the last few years and studies have shown them to be beneficial in the endoscopic treatment of bile leaks1 as it could avoid a repeat ERCP for traditional stent removal. This could be useful in the current climate where access to endoscopy is yet to fully return to pre-pandemic levels. We conducted a multi-tertiary-centre retrospective study looking at outcomes of endoscopic management for post-cholecystectomy bile leaks.MethodsAll ERCPs performed between 01/01/2020 and 31/12/2021 were reviewed and all cases of bile leaks post-cholecystectomy were included. Patient records and endoscopy reports were analysed.ResultsA total of 52 patients (median age 56.5 ± 19y, 30 females) with post-cholecystectomy bile leak were referred for ERCP. Treatment included endoscopic sphincterotomy (ES) alone (6); plastic stent (PS) alone (13) or with ES (22); metal stent (SEMS) alone (1) or with ES (1); BDBS with ES (9). ES alone with duct clearance was performed in cases where no high grade leak was seen, minimal drain output and choledocholithiasis was deemed to be the cause of the leak.All patients with temporary stent placement had a repeat ERCP for removal apart from one who refused and another who was intentionally not repeated due to frailty. Four patients needed 3 ERCPs for on-going leak but none in the BDBS group. Bile leak resolved in all endoscopically treated patients. No severe complications were observed.ConclusionsBDBS offers a safe and useful alternative to traditional plastic stents for the endoscopic management of post-cholecystectomy bile leaks. Benefits include reducing the risks associated with repeat endoscopy, exposure to hospital environments, redistribution of limited resources and minimising patient cost (time off work, travel and aftercare arrangements). Although our numbers are small, our data indicates the potential cost savings of BDBS.References Siiki, A., Vaalavuo, Y., Antila, A., Ukkonen, M., Rinta-Kiikka, I., Sand, J. and Laukkarinen, J. 2018. Biodegradable biliary stents preferable to plastic stent therapy in post-cholecystectomy bile leak and avoid second endoscopy. Scandinavian Journal of Gastroenterology, 53(10-11), 1376-1380.