Explore the vast range of titles available.

IntroductionEndoscopic procedures can be subject to large variability due to patient factors. The turnaround time (TAT) between patients offers a more predictable sequence of events, amenable to a sustainable reduction in time through implemented changes.Our primary aim was to reduce TAT at St.Mary’s Hospital (SM). Our secondary aim was to identify and compare factors leading to TAT delay at SMH and Charing Cross Hospital (CC), both tertiary centres based in London.MethodsClinical observers were used to record TAT and reasons for delay during endoscopy lists at both sites. A TAT was defined as from the point of scope removal from the previous patient to insertion of scope for the next.Results28 TAT were measured at SM during June 2014, with an average TAT of 25 minutes 14 seconds. Nurse-led cannulation was identified as a factor to reduce TAT and partially implemented at SM and CC. From March to May 2015, 44 TAT were recorded at SM (average 20 minutes 49 seconds) and 43 at CC (average 20 minutes 8 seconds), demonstrating a reduction in TAT at SM. Analysis demonstrated significantly more nurse led cannulations in the fastest 20 TAT compared to the slowest 20 TAT (p = 0.01). Endoscopist interruption from non-procedural staff during the TAT also occurred in 25% of TAT across both sites.ConclusionChanges in TAT procedure offer sustainable ways to reduce endoscopy list length. Sources of delay are multifactorial, however nurse-led cannulation has been shown to contribute to faster TAT.Disclosure of InterestNone Declared

BackgroundPeriampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty.AimThis study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events.MethodsProspectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models.ResultsSignificant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation.ConclusionThe presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1.Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/.

IntroductionFormative direct observation of procedural skills (DOPS) in ERCP consist of 27 assessable items located within 7 domains and an overall competence rating. Despite their implementation in 2016, validity evidence remain lacking. We aimed to evaluate DOPS scores to appraise validity and competency development during ERCP training.MethodsThis prospective UK-wide study analysed ERCP DOPS submitted to the JETS e-portfolio between July 2016-October 2018. Reliability was measured using Cronbach’s alpha. DOPS scores were benchmarked using the contrasting groups method to establish consequential validity. The percentage of competent scores were averaged for each item, domain and overall rating and stratified by lifetime procedure count to plot learning curves and provide discriminative validity. Multivariable generalising estimating equations were performed to identify trainee-level predictors of overall procedural competence.ResultsIn total, 818 DOPS submitted from 80 UK centres were analysed. DOPS were completed for 109 trainees (ST–: 26%, ST6: 22%, ST–: 21%, research fellow: 7%, consultant/associate specialist: 24%). 5 items were unassessed in >50% of DOPS and were excluded from Cronbach’s alpha analyses; assessment of the remaining 22 items yielded a statistic of 0.95, indicating high reliability. Attaining competency in 87% of assessed items per DOPS provided the optimal benchmark score (false positive: 10%; false negative: 2%). Competency acquisition occurred in the domain sequence of: ‘pre-procedural’, ‘intubation and positioning’, ‘post-procedural’, ‘endoscopic non-technical skills’, ‘execution of selected therapy’, and ‘cannulation and imaging’ (figure 1). Trainees surpassed the 87% competency threshold after 20–49 procedures (mean: 89%). After 300 procedures, the competency threshold was reached for ‘selective cannulation’ (89%), but not reached for the items of: stenting (plastic: 73%; metal: 70%), sphincterotomy (80%) and sphincteroplasty (56%). On multivariable analysis, lifetime procedure count (P<0.001), easier case difficulty (P<0.001) and lifetime DOPS count >10 (P=0.002) predicted overall procedural competence, but not trainee specialty (P=0.525), grade (P=0.076) or prior gastroscopy certification (P=0.886).Abstract PWE-112 Figure 1ConclusionThis study provides novel validity, reliability and learning curve data in support of ERCP DOPS. Whilst competency in the majority of DOPS items may be attained after 20–49 procedures, this may still be insufficient for selective cannulation and higher-level therapeutic competencies.

The optimal cannulation strategy for patients with acute type A aortic dissections (ATAAD) is unclear. A systematic search was performed to identify all studies comparing aortic and non-aortic cannulation in patients undergoing ATAAD repair. The primary endpoint was overall survival. The secondary endpoints were operative mortality, postoperative stroke, renal failure, renal replacement therapy, paraplegia, and mesenteric ischemia. Pooled meta-analyses with aggregated and reconstructed time-to-event data were performed. Twenty-three studies were included (aortic: 3904; non-aortic: 10,719). Ten-year overall survival was 61.1 ​% and 58.4 ​% for aortic and non-aortic cannulation, respectively (HR 1.07; 95 ​% CI 0.92–1.25; p ​= ​0.38). No statistically significant difference was observed for operative mortality (p ​= ​0.10), stroke (p ​= ​0.89), renal failure (p ​= ​0.83), or renal replacement therapy (p ​= ​0.77). Patients undergoing surgery for ATAAD can undergo aortic cannulation with similar outcomes to those who undergo non-aortic cannulation. •Aortic cannulation is safe in patients undergoing surgery for acute type A aortic dissection (ATAAD).•Overall and operative mortality favor aortic cannulation in ATAAD, though this difference was not statistically significant.•In patients undergoing aortic cannulation for ATAAD repair, female gender was associated with operative mortality.

The choice of an appropriate cannulation technique should be important to increase the possibility of better outcomes in terms of arteriovenous fistulas (AVF) survival and comfort of the patient undergoing hemodialysis. It is a retrospective study and microarray analysis was conducted to identify differentially expressed genes (DEGs) between failing and control access samples. Sixty-four patients who underwent early cannulation (3-4 weeks after AVF creation) were enrolled and divided into two groups: a plastic cannula group (n = 33) and a metal needle group (n = 31). Comparisons were made between the groups regarding complement components, blood flow, access intimal hyperplasia, and inflammatory cell infiltration. (1) AVF failure occurred in 13 patients (20.3%) over a mean follow-up of 241 ± 105 days. (2) Complement B factor (CFB) levels showed significant changes within the first two weeks post-cannulation. (3) Fluctuations in CFB strongly correlated with changes in AVF blood flow during follow-up. (4) CFB variation independently predicted AVF failure, with a hazard ratio of 4.54 (95% CI, 1.21-16.99). (5) The plastic cannula group exhibited significantly lower CFB expression in both blood and outflow access, along with marked improvements in intimal hyperplasia and inflammatory cell infiltration. (6) Compared with the metal needle group, serum from the plastic cannula more significantly induced endothelial cell proliferation and nitric oxide production, with CFB playing a critical role. The alternative complement pathway is significantly activated during initial AVF cannulation, with excessive CFB production contributing substantially to AVF failure. The use of plastic cannulas may improve long-term AVF patency by mitigating endothelial dysfunction and inhibiting inflammatory cell infiltration through suppression of CFB generation.

AimsCombined EUS/ERCP is a practice which offers an opportunity to diagnose and treat biliary pathology within the same sitting.It can avoid unnecessary ERCP and the subsequent complications associated with that procedure. This practice is increasingly performed in tertiary care centres but data is lacking for its safety and success rate in District General Hospitals. Access to deep sedation is restricted in many endoscopy units in the UK. The aim of this study was to evaluate the safety and procedure outcomes of this practice against ERCP alone in a District General Hospital setting.MethodsRetrospective analysis of data was performed for patients who had combined EUS/ERCP versus ERCP alone from April 2020 to April 2023. We evaluated the following: demographics, median sedation dosages, success of biliary cannulation, completion and complication rates.ResultsCombined EUS/ERCP group had 66 patients, 65 cases had conscious sedation and one had Propofol. 55 had stone disease and 11 had strictures. In the same period, 690 ERCP were performed as stand alone procedures, 682 cases had conscious sedation and 8 had Propofol. Group differences were tested with the chi square test and the Student’s t test at a significance level of p<0.05.Abstract P244 Table 1 Combined EUS/ERCP ERCP alone Statistical difference Demographics 27M : 39F Mean Age: 65 301M : 389F Mean Age: 69 NS Biliary cannulation (first ever ERCP) 60/66 (91%) 538/568 (95%) NS Biliary completion rate (stone extraction/stent placement) 60/66 (91%) 407/472 (86%) NS Complications (all procedures) 5/66 (7.75%) 42/690 (6.08%) NS Median Midazolam 5.8 mg (Range 2.5mg - 8mg) 3.4 mg (Range 1 - 9mg) p<0.01 Median Fentanyl 136.1mg (Range 50 - 200mg) 85.3mg (Range 25 - 200mg) p<0.01 ConclusionIn our clinical practice, combined EUS/ERCP had comparative procedural outcomes to stand alone ERCP. However, to achieve these outcomes we needed to use significantly increased incremental dosages of sedation. A recent BSG guideline has advised that combined EUS/ERCP should be considered to be performed under deep sedation. Our experience supports this advice and highlights the increasing need for anaesthetic support within UK endoscopy units.

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%).

To study the effect of early arteriovenous fistula (AVF) cannulation and the usage of plastic cannulas on short- and long-term AVF primary patency. A database of 1,127 access operations from 1 November 2009 to 1 January 2011 was retrospectively analyzed. In total, 765 AVFs used for dialysis with follow-up until 1 December 2015 were included in the study. The period between operation and the initial cannulation, termed first cannulation time (FCT), was classified into intervals of 1-2 weeks, 3-4 weeks, 5-6 weeks, and 7-12 weeks. Primary patency was the interval between AVF creation and the first re-intervention for access dysfunction or thrombosis, the time of measurement of patency or the of its abandonment. The AVF primary patency was 98.1% after 1 year and decreased to 80.1% after 2 years. Among patients using metal needles for the first puncture, those with an FCT of 1-2 weeks experienced significantly decreased AVF primary patency compared to other groups. Conversely, in patients using plastic cannulas at the first puncture, no significant differences were observed among groups with AVF primary patency in 6, 12, and 24 months. FCT and the application of plastic cannulas were significantly associated with primary patency at 12 and 24 months after adjusting for age, sex, hemodialysis (HD) frequency, and HD duration per session. Combination of six variables including age, sex, FCT, application of plastic cannulas, hemodialysis (HD) frequency, and HD duration per session could accurately predict 6-month primary patency with area under ROC curve of 0.89, 95% CI: 0.80-0.99. Early AVF cannulation, within 1-2 weeks of creation, using plastic cannulas, does not increase the risk of access failure and offers an alternative to reduce reliance on catheters.

Background: There has been an increased interest in using antegrade cannulation techniques during surgery for type A aortic dissection. While the utilization of central artery cannulation has been on the rise in recent times, its effectiveness and safety still require thorough examination. This study aimed to explore both the efficiency and safety of central arterial cannulation. Methods: A meta-analysis was conducted on studies that evaluated surgical outcomes when using central artery cannulation (CAC) in comparison to axillary artery cannulation (AXC) or femoral artery cannulation (FAC). Results: 10 retrospective observational studies were included, enrolling 3022 patients (CAC = 1208 vs. FAC = 606; CAC = 1051 vs. AXC = 1119). Among these, 4 articles involved axillary artery cannulation, femoral artery cannulation, and central artery cannulation. Central cannulation was linked to decreased short-term mortality [odds ratio, 0.66, 95% confidence interval (CI) (0.48, 0.89), χ2 = 3.27, p = 0.007; I2 = 0; p = 0.86] compared to femoral cannulation. Additionally, central cannulation was associated with a lower occurrence of temporary neurological dysfunction (TND) [odds ratio, 0.57, 95% CI (0.38, 0.85), χ2 = 0.88, p = 0.006; I2 = 0%, p = 0.83] when compared with femoral cannulation. However, there was no statistical significance in mortality and TND between the central cannulation and axillary cannulation groups. Conclusions: This meta-analysis reveals that central cannulation surpasses femoral cannulation in lowering short-term mortality and the occurrence of TND among patients undergoing surgery for type A acute aortic dissection. However, central cannulation does not exhibit a higher mortality and TND compared to axillary cannulation.

Purpose To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. Methods An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. Results The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. Conclusions These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.