Colon Cancer Metastatic to the Biliary Tree.

Metastasis of colon adenocarcinoma is commonly found in the lung, liver, or peritoneum. Common bile duct (CBD) tumors related to adenomas from familial adenomatous polyposis metastasizing from outside of the gastrointestinal tract have been reported. We report a case of biliary colic due to metastatic colon adenocarcinoma to the CBD. Obstructive jaundice with signs of acalculous cholecystitis on imaging in a patient with a history of colon cancer should raise suspicion for metastasis to CBD.

ERCP in pregnancy: is it safe?

BACKGROUND: Although rare, pancreaticobiliary disease during pregnancy can pose a serious risk to both the mother and fetus. Data regarding the relative safety of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy are sparse. METHODS: We performed a retrospective review of 17 ERCP procedures performed at a single tertiary care referral center between January 2005 and April 2009. Records were reviewed for ERCP indication, endoscopic interventions, use and extent of fluoroscopy, postprocedure complications, and pregnancy outcomes including Apgar scores. RESULTS: All procedures were performed without any maternal adverse events immediately or on follow-up. There were no signs of fetal distress during any of these cases, and there were no fetal complications noted upon delivery or at 30-day follow-up per chart review. CONCLUSION: Therapeutic ERCP during pregnancy appears to be safe when performed in experienced hands and with judicious use of fluoroscopy.

Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer.

BACKGROUND: Abdominal wall metastasis after PEG tube placement has been reported in patients with head and neck cancer. The incidence of this occurrence is unknown. OBJECTIVE: Evaluation of the incidence of abdominal wall metastasis as a complication of PEG tube placement in patients with head and neck cancer. DESIGN: Retrospective chart review. SETTING: H. Lee Moffitt Cancer Center and Research Institute, Nutritional Support Services. SUBJECTS: Head and neck cancer patients requiring nutritional support with PEG tube placement. RESULTS: Of the 304 patients with head and neck cancer, 218 had active disease with a viable tumor in the oropharynx or hypopharynx at the time of PEG placement. Two of these patients, both with active disease (0.92%), developed a PEG site metastasis. CONCLUSION: There is a small but definite risk for tumor implantation in the gastrostomy site when using the pull technique in patients with active head and neck cancer. Careful assessment of the oropharynx and hypopharynx before PEG tube placement and the use of alternative techniques for enteral access in patients with untreated or residual malignancy are recommended to minimize this risk. Use of other percutaneous techniques that do not involve traversing the hypopharynx with the catheter may help to prevent tumor translocation. When head and neck cancers metastasize to the gastrostomy site, patient survival appears limited even with extensive resection.

Reduction in the incidence of pancreatitis in patients undergoing sphincter of Oddi manometry: a successful quality improvement project.

OBJECTIVE: Acute pancreatitis is a recognized complication of sphincter of Oddi manometry (SOM). Its frequency of occurrence has been reported in the range of 4 to 31%. In an earlier retrospective study performed at this institution, the incidence of pancreatitis was 9.3% in patients who only had SOM compared with 26.1% in those patients who had SOM and endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy at the same session. On the basis of these data, a quality-improvement project was initiated at two university-affiliated hospitals. This involved performance of SOM without ERCP. If ERCP was required, it was performed at a different session. The purpose of this project was to decrease the incidence of pancreatitis associated with SOM. METHODS: This study involved prospective patient identification and retrospective chart review of patients who underwent SOM without ERCP between May 1998 and December 2000. SOM was performed using a triple-lumen catheter with water perfusion at a rate of 0.25 ml/min using an Arndorfer pneumohydraulic capillary perfusion system. The data recorded included pancreatitis after SOM, pancreatitis after ERCP and sphincterotomy, average days in the hospital after pancreatitis, and time between SOM and ERCP. RESULTS: Forty-one patients were studied. Three (7.32%) patients had pancreatitis after SOM. Five patients subsequently underwent ERCP and sphincterotomy and one (20%) patient had pancreatitis. The overall frequency of pancreatitis after SOM and any subsequent ERCP or sphincterotomy was 4 (9.78%) of 41 (95% confidence interval, 3.9-22.5%). The odds ratio for pancreatitis with ERCP and SOM at the same time compared with the SOM-only strategy was 3.26 (P = 0.05). The average stay in the hospital after pancreatitis ranged from 2 to 4 days, with a mean length of stay of 2.75 days. The time between SOM and subsequent ERCP ranged from 6 to 20 days, with a mean of 10.4 days. CONCLUSION: By adopting a protocol to perform diagnostic SOM, separate from ERCP and sphincterotomy, we were able to decrease the incidence of pancreatitis considerably at our institutions.

Endoscopic ambulatory surgery centers in the academic medical center. We can do it too!

A freestanding ambulatory surgery center (ASC) at an academic institution is an exception rather than the rule. It is a major challenge to the concept of the traditional academic medical center. Advantages and disadvantages are discussed, as well as the detailed planning process beginning with a well executed feasibility study, the hiring of consultants, and financing of the facility. Construction, opening of the facility and operation are not different from other ACSs. However, the integration of teaching and research presents new opportunities. Lessons learned and advice to others are detailed on how the ASC benefitted one specific institution and how it may add value and revenue to other academic medical centers.

Total Parenteral Nutrition During Pregnancy in a Patient Requiring Long-Term Nutrition Support.

BACKGROUND: Total parenteral nutrition (TPN) has been used successfully in preventing intrauterine growth retardation, premature labor, and perinatal morbidity and mortality associated with poor maternal nutrition. Parenteral nutrition support is provided in most instances for short intervals during pregnancy when oral intake is compromised, eg, hyperemesis gravidarum or during complications from comorbid conditions that develop or are exacerbated during pregnancy. Few reports describe continuous parenteral nutrition support from conception through labor and delivery. OBJECTIVE: To support successfully a 19-year-old woman on long-term TPN since age 8 years because of short bowel syndrome complicated by chronic pancreatitis. METHODS: Estimated energy requirements were based on indirect calorimetry and current recommendations for maternal weight gain for optimal fetal growth and development. A strategy was formulated to improve her low maternal weight during early pregnancy. RESULTS: The fetus grew normally throughout pregnancy. There were no significant metabolic or obstetric complications as a result of the parenteral support. CONCLUSIONS: Patients on long-term TPN can conceive successfully and carry a pregnancy to term without any adverse outcome for the mother or the fetus. TPN feeding during pregnancy and recommendations for maternal weight gain are reviewed.