Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

Plastic biliary stents do not maintain patency during the time required for most patients to complete neoadjuvant chemoradiotherapy for pancreatic adenocarcinoma. Initially placing metallic stents to palliate malignant obstruction may be a safer and more cost-effective strategy.

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Emphysematous pancreatitis (EP) is a subtype of acute necrotizing pancreatitis (ANP) characterized by the presence of gas in and around the pancreas. While investigators have studied prognostic factors in ANP, less is known about EP. We aimed to determine predictors of mortality and identify changes in management strategies for emphysematous pancreatitis. A PubMed search was performed to identify cases of EP. Data was gathered about patient demographics, clinical findings, laboratory results, radiological studies, procedures, outcomes and mortality. Collected data was analyzed using univariate and multivariate logistic regression analysis. Including a case from our institution, the study cohort included 64 subjects. The overall mortality rate was 32.8% (21/64). On univariate analysis, age (p=.019), hypotension (p=.007), gas outside of the pancreas on CT imaging (p=.003), initial surgical evacuation (p=.007) and the development of multi-organ failure (p=.008) were associated with mortality. On multivariate analysis, only the development of multi-organ failure was found to be an independent predictor of mortality (p=.039). The overall mortality rate of 32.8% for EP is similar to the mortality rates published for ANP. The development of multi-organ failure in EP is strongly associated with increased mortality. Percutaneous and endoscopic approaches have been replacing surgical interventions.

Neuroendocrine tumors (NETs) are uncommon gastrointestinal neoplasms but have been increasingly recognized over the past few decades. Luminal NETs originate from the submucosa of the gastrointestinal tract and careful endoscopic exam is a key for accurate diagnosis. Despite their reputation as indolent tumors with a good prognosis, some NETs may have aggressive features with associated poor long-term survival. Management of NETs requires full understanding of tumor size, depth of invasion, local lymphadenopathy status, and location within the gastrointestinal tract. Staging with endoscopic ultrasound or cross-sectional imaging is important for determining whether endoscopic treatment is feasible. In general, small superficial NETs can be managed by endoscopic mucosal resection and endoscopic submucosal dissection (ESD). In contrast, NETs larger than 2 cm are almost universally treated with surgical resection with lymphadenectomy. For those tumors between 11-20 mm in size, careful evaluation can identify which NETs may be managed with endoscopic resection. The increasing adoption of ESD may improve the results of endoscopic resection for luminal NETs. However, enthusiasm for endoscopic resection must be tempered with respect for the more definitive curative results afforded by surgical treatment with more advanced lesions.

Purpose: Neoadjuvant therapy for pancreatic adenocarcinoma requires referral to multiple specialists before initiating therapy. We evaluated the effect of establishing a multidisciplinary clinic (MDC) for patients with newly diagnosed pancreatic adenocarcinoma on treatment access and time to therapy. Methods:Patients with newly diagnosed pancreatic adenocarcinoma diagnosed and treated at our center were included. Two patient groups were defined: preclinic represented those patients diagnosed before 2008 and MDC represented those patients diagnosed since 2009 who were treated in the newly created MDC and were initially candidates for neoadjuvant therapy. The primary outcomes were days from diagnosis to first treatment (initiation of chemotherapy or external beam radiation), days to completion of all required consultations, and number of visits needed before initiation of therapy.

A pertussis outbreak in a hematology-oncology care unit involved 10 (8.5%) of 117 employees. The source was an employee who contracted pertussis via a family contact. No screened patients contracted pertussis, likely because of isolation measures. Hospitals should consider employee immunization with acellular vaccine in healthcare settings where pertussis has high rates of morbidity and mortality.

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