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Background Endoscopic ampullectomy is increasingly performed in patients with familial adenomatous polyposis (FAP)-associated ampullary adenomas. We sought to define the procedure-associated morbidities and long-term outcomes. Methods We performed a retrospective chart review of patients with FAP who underwent endoscopic ampullectomy at two tertiary institutions between 1999 and 2010. The severity of duodenal polyposis was classified according to Spigelman’s classification. Results Of 26 FAP patients who underwent endoscopic ampullectomy, 21 arose in the setting of Spigelman’s stage II duodenal polyposis. Adverse events associated with endoscopic ampullectomy included acute pancreatitis (19.2 %), abdominal pain (7.6 %), and bleeding (3.8 %). The mean resected adenoma size was 0.99 ± 0.34 cm. Three adenomas (12.0 %) contained foci of high-grade dysplasia. Follow-up data were available for 24 patients. The mean follow-up duration was 84.5 ± 36.2 months. Adenoma recurrence was observed in 14 patients (58.3 %; 14/24) at a mean of 38.3 months after initial ampullectomy. Adenomas ≥10 mm recurred more frequently than smaller adenomas (76.9 vs. 36.4 %; p  = 0.002). Positive margins were not associated with higher recurrence rates. No cancers were observed during long-term follow-up. Three patients underwent a Whipple procedure, but none was performed for a recurrent ampullary adenoma. Conclusions Endoscopic ampullectomy in FAP can be performed safely. Because ampullary adenomas frequently recur after endoscopic ampullectomy, close surveillance is essential. Smaller tumors are less likely to recur, suggesting a benefit for early recognition of these lesions.

A 49-year-old man with a family history of diabetes was evaluated because of hypoglycemia. Two hours earlier, he had been found on the floor, obtunded and making nonpurposeful movements. A diagnostic test was performed.

Preoperative biliary stenting is required for patients with obstructive jaundice from pancreatic adenocarcinoma who are receiving neoadjuvant chemotherapy. While in most patients this approach results in durable biliary drainage, some patients develop cholangitis during neoadjuvant treatment. Further, several studies have shown that preoperative cholangitis in patients with hepatobiliary malignancies can result in substantially unfavorable outcomes. The aim of this study was to evaluate the impact of preoperative cholangitis in patients who underwent pancreaticoduodenectomy after completing neoadjuvant chemotherapy. Participants: all adult patients (n = 449) diagnosed with pancreatic adenocarcinoma from January 1st, 2013 to March 31st, 2018 who pursued treatment at the Massachusetts General Hospital were screened. Of these 449 patients, 97 met final inclusion criteria of receiving neoadjuvant chemotherapy with intent to pursue curative surgery. Data were collected via retrospective chart review including baseline characteristics, survival, episodes of preoperative cholangitis, and surgical complications. In patients completing successful pancreaticoduodenectomy surgery, preoperative cholangitis is associated with increased mortality (HR 2.67, 95% CI:1.16–6.13). This finding is independent of postoperative outcomes or tumor recurrence rate. The presence of cholangitis did not impact completion of neoadjuvant chemotherapy (92% vs 85%, p = 0.5) or ability to proceed to surgery (76% vs 75%, p = 1.0). Preoperative cholangitis was not associated with postoperative morbidity (42.1% vs 45.1%, p = 1.0). One episode of cholangitis during neoadjuvant chemotherapy is associated with increased mortality following successful pancreaticoduodenectomy, independent of immediate postoperative outcomes or tumor recurrence. Preoperative cholangitis does not affect ability to pursue neoadjuvant chemotherapy or complete successful surgery. Patients who develop cholangitis during the neoadjuvant chemotherapy treatment phase may reflect a distinct phenotype of patients with PDAC with a complex and more challenging clinical course. •Biliary stenting is often required in patients with pancreatic carcinoma who undergo neoadjuvant chemotherapy.•Despite stenting, some patients develop cholangitis. The impact of which is unclear.•Preoperative cholangitis is associated with increased mortality. Preoperative cholangitis does not affect ability to complete neoadjuvant chemotherapy or successful surgery.•Clinicians should be aware of the detrimental impact of preoperative cholangitis on patients undergoing neoadjuvant chemotherapy.

INTRODUCTION:Opioid use disorder (OUD) has become a public health emergency in the United States. Patients with chronic pancreatitis (CP) are at high risk for opioid dependence due to chronic pain associated with the disease process. We aimed to evaluate the prevalence, impact and predictors of OUD in patients hospitalized with CP.METHODS:A retrospective cohort study was performed using the national inpatient sample (NIS) database from 2005–2014. Patients with a primary diagnosis of CP and OUD were included. OUD-related diagnosis were identified using previously published studies. The primary outcome was to evaluate the prevalence and trend of OUD in patients hospitalized with CP over time. Secondary outcomes were: i) to assess the impact of OUD on healthcare resource utilization, ii) identify predictors of OUD in hospitalized CP patients.RESULTS:A total of 176,857 CP patients were included, and OUD was present in 3.8% of patients. The prevalence of OUD in CP doubled from 2.7% in 2005 to 5.4% in 2014 (Figure 1). Patients with CP who had OUD were found to have higher mean length of stay (adjusted mean difference: 1.2 days (95% CI: 1.1–1.4), P < 0.001) and total hospitalization costs (adjusted mean difference: $1,936 (95% CI: 1590–2282), P < 0.001). Independent predictors of OUD in CP patients were obesity, presence of depression, and increased severity of illness (Table 1).CONCLUSION:OUD related diagnoses are increasing among patients with CP and are associated with increased healthcare resource utilization. Our study identifies an important group of patients at high-risk for OUD whose pain should be carefully managed.Table 1.Multi-variable regression analysis of factors associated with OUD in cases admitted with Primary Diagnosis of chronic pancreatitis. R = Reference category

INTRODUCTION:Pancreatic adenocarcinoma continues to have a high mortality rate. Successful surgical resection (Whipple procedure) of cancer remains the only potential durable cure. In order to improve survival, many patients receive neoadjuvant chemotherapy prior to surgery, which requires biliary stenting in those patients with jaundice. Some patients will develop cholangitis from transient stent obstruction. The impact of preoperative cholangitis on the ability to get surgery is not clear. We investigate the role of cholangitis in patients with pancreatic adenocarcinoma undergoing neoadjuvant chemotherapy.METHODS:We identified all patients of Massachusetts General Hospital (MGH) from 2013 to 2018 who underwent neoadjuvant chemotherapy and received ERCP with metal biliary stenting for jaundice. Chart review was performed to identify patients who had cholangitis. We further determined the rate of successful surgery, time to surgery, and mortality rates. Statistics were performed using the student t-test or Fisher's exact test to establish significance.RESULTS:In total, we identified 97 patients who establish care at MGH to pursue neoadjuvant chemotherapy in preparation for curative surgery. Of these 25 had developed at least one episode of cholangitis within one year of diagnosis, 6 had more than one episode, while 72 did not have any episodes of cholangitis. Whipple surgery was attempted in 76% of the cholangitis-1 group compared to 78% of the non-cholangitis group (P = 1.0). The average time to surgery was 194 days in the cholangitis group and 176 days in the non-cholangitis group (P = 0.40). There was no difference in surgical resection rate or time to surgery between patients with more than one episode of cholangitis compared to the non-cholangitis group. There was no difference between groups in six (P = 0.57) or twelve month (P = 0.56) mortality.CONCLUSION:Our data reveal that cholangitis within a year of diagnosis does not impact the ability of a patient to undergo successful Whipple operation. We propose that aggressive endoscopic biliary endotherapy should be considered, even in patients with recurrent preoperative cholangitis, to assist with completing neoadjuvant protocols in hopes of a curative surgery.

Congenital cytomegalovirus infection is a cause of serious perinatal complications. In this randomized trial involving 399 pregnant women, CMV hyperimmune globulin was found to provide no benefit with respect to congenital CMV infection or perinatal death.

Pregnant women with mild chronic hypertension were randomly assigned to receive medication targeting a normal blood pressure (<140/90 mm Hg) or to receive no treatment unless severe hypertension (>160/105 mm Hg) developed. The incidence of adverse maternal and neonatal outcomes was significantly lower in the active-treatment group, without an increase in low birth weight.

In this follow-up report of a trial of CMV hyperimmune globulin in pregnant women with primary CMV infection, hyperimmune globulin did not improve hearing or developmental outcomes in children at the age of 2 years.