Background The British Society of Gastroenterology (BSG) recommended that during the COVID-19 pandemic, endoscopy units perform endoscopic retrograde cholangiopancreatography (ERCP) for obstructive biliary pathologies in an emergency. We assessed the local performance of ERCP during the first wave of COVID-19 at our local endoscopy center, in particular the technique to common bile duct (CBD) cannulation. Methodology All ERCP procedures performed from January to June 2020 were retrospectively assessed and compared with procedures performed between January and June 2019 at the Royal Lancaster Infirmary. The indications for ERCP, success rate, and complications were studied separately. Correlation analysis was conducted using Spearman's rank correlation coefficient. The binary logistic regression model was used to compute the factors associated with successful ERCP. Significance was established when the two-sided P-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 25 for Windows (SPSS Inc., Chicago, IL, USA, 2017). Results A total of 281 ERCP were included in this study, with 169 and 112 performed during the first six months of 2019 and 2020, respectively. A statistically significant (0.0087) higher proportion of cases with liver dysfunction presented for ERCP before the COVID-19 outbreak (152, 89.94%). All patients before COVID-19 underwent wire control-assisted ERCP, while 82 (73.21%) received assisted ERCP during the first wave (P < 0.001). There was no statistically significant difference (P = 0.10) in the number of patients who underwent sphincterotomy before and during the first wave of COVID-19, with 97 (57.39%) and 76 (67.85%), respectively. The success rate of ERCP before COVID-19 was relatively high, accounting for 146 (86.39%) patients in contrast to 87 (77.67%) patients during the first wave (P = 0.074). Sphincterotomy ( β = 2.800, P = 0.028) and stent insertion ( β = 0.852, P = 0.046) were statistically significant predictors of ERCP outcomes. There was no statistically significant impact of cholangitis on the success of ERCP ( β = 1.672, P = 0.109). Conclusion The first wave of COVID-19 had a statistically proven negative impact on the expected standards of ERCP performance. Although the complication rate was significantly higher during the first wave case difficulty, the American Society of Anesthesia (ASA) status was not assessed on an individual basis. Both ASA status and case difficulty are now included in our endoscopy selection process. We recommend adding the complexity of cases and ASA to the local and national recording databases. This is a rare study on UK-based hospitals.

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col, based on our experience in initiating Symkevi ® in LT recipients, was to check tacrolimus levels at day 7 and day 14 after initiation and then again at day 28 along with liver function tests (LFTs). Results Kaftrio ® was initiated in 8 LT recipients. Of these patients, six were transplanted for CF-related liver disease (CFLD), one for CFLD and alpha one antitrypsin deficiency (a1-ATD) and one for a1-ATD alone. Four patients (50%) were male and the median age at Kaftrio ® initiation was 30 years (range 24-42 years). All patients had stable LFTs and a tacrolimus level that was within the desired therapeutic range prior to initiation.All 8 patients had stable LFTs following the initiation of Kaftrio ® (table 1). There was a clinically significant rise in tacrolimus level in 4 patients (figure 1) and a tacrolimus dose reduction (of 20-37.5%) was required in these patients. The rise in tacrolimus levels was evident at day 7 and levels returned to therapeutic range within one week of dose adjustment. There was evidence of toxicity (defined as a rise in creatinine from baseline or neurological toxicity) in one patient, most likely secondary to the rise in tacrolimus levels (table 1). Conclusion Our early experience suggests that it is safe to initiate Kaftrio ® in LT recipients. As anticipated, close therapeutic drug monitoring (TDM) of tacrolimus is necessary. We are continuing to monitor these patients to confirm that there are no longer-term effects on liver graft function or tacrolimus levels. Based on the findings of this case series, we recommend LT recipients being initiated on Kaftrio ® have weekly LFT and tacrolimus level monitoring for the first two weeks and then monthly for a further three months, until further data is available on the drug-drug interaction and its implications for tacrolimus dosing.

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