Ji, Hyun

INTRODUCTION: We recently developed a fluorescence in situ hybridization probe set for evaluating suspicious biliary and pancreatic duct strictures (PB-FISH). We aimed to determine whether PB-FISH results in biliary brush cytology specimens are associated with outcomes of patients with cholangiocarcinoma (CCA). METHODS: We performed a retrospective study of patients with CCA tested by PB-FISH from January 2015 to August 2018. CCA was stratified by primary sclerosing cholangitis (PSC) into those with (PSC CCA) or without PSC ( de novo CCA). PB-FISH results were categorized as polysomy (gain of multiple loci), nonpolysomy (single locus gain, single locus gain with 9p21 loss, homozygous 9p21 loss, tetrasomy), and disomy (no abnormalities). Overall survival (OS) was estimated using Kaplan-Meier methods and compared between the PB-FISH results using log-rank tests. Cox models were adjusted for age, sex, CA 19-9, cytology results, source of brushing sample, and treatments. RESULTS: Characteristics of 264 eligible patients (median age 60.4; range 18–92) were comparable for patients with PB-FISH polysomy vs nonpolysomy vs disomy. The median OS was similar between disomy, nonpolysomy, and polysomy in the overall population (22.7 vs 22.7 vs 20.3 months, respectively). For de novo CCA, both polysomy and nonpolysomy were associated with worse OS compared with disomy (polysomy: hazard ratio [HR] = 2.09, 95% confidence interval [CI] = 1.14–3.83; nonpolysomy: HR = 2.4, 95% CI = 0.54–2.46; P = 0.027). For PSC CCA, neither polysomy nor nonpolysomy were significantly associated with worse OS (polysomy: 0.90, 95% CI = 0.47–1.75; nonpolysomy: HR = 1.78, CI = 0.71–4.49; P = 0.27). DISCUSSION: PB-FISH alterations are associated with worse survival in de novo CCA, though statistical significance was lost when adjusting for confounding variables.

INTRODUCTION: Necrotizing pancreatitis is a serious complication of acute pancreatitis with high morbidity and mortality. We present a case of a 58 year old male diagnosed with necrotizing pancreatitis after cardiopulmonary bypass surgery and exposure to sulfamethoxazole-trimethoprim (TMP/SMX). CASE DESCRIPTION/METHODS: A 58 year old man presented with one week of jaundice and dyspnea. His history is significant for a recent cardiac surgery with coronary artery bypass grafts (CABG) and aortic valve repair (AVR) with a prolonged cardiopulmonary bypass time (CPBT) aortic cross-clamp time (ACCT). After the surgery, he was prescribed a course of TMP/SMX for an unknown indication. On assessment, he denied any other symptoms and had no history of alcohol use. He was hemodynamically stable with physical examination notable only for generalized jaundice. Lab findings were significant for hemoglobin 6.2 g/dL, WBC 19 × 10(9)/L, K 5.8 mmol/L, BUN 82 mg/dL, Cr 2.82 mg/dL, total calcium 6.7 mg/dL, serum glucose 110 mg/dL, total/direct bilirubin 8.7/6.8 mg/dL, alkaline phosphate 503 U/L, ALT 343 U/L, AST 640 U/L, lipase 540 U/L, and triglycerides 212 mg/dL. CT of the abdomen showed acute necrotizing pancreatitis. He was treated with fluid resuscitation and antibiotics. ERCP was deferred as his cholestasis was thought to be due to extrinsic compression. His course was complicated by hemorrhagic conversion, acute renal failure, shock liver and gastric ischemia. Ultimately, he expired on hospital day 20. DISCUSSION: Drug-induced pancreatitis accounts for 0.1-2% of cases of acute pancreatitis. Although TMP/SMX is classified as a potential cause of pancreatitis, the data is sparse with limited reported cases and a broad latency period ranging from 3 days to 20 years. Acute pancreatitis has also been described as a complication of cardiac surgery with an incidence of 0.4% per prior report. Notably, many of these patients are often asymptomatic, which makes early diagnosis of utmost priority. Factors that increase the risk of developing pancreatitis include prolonged CPBT/ACCT and combined CABG and valve repair, possibly related to splanchnic ischemia. Given that our patient with a recent cardiac surgery received a culprit antibiotic within several weeks of presentation, it is unclear whether TMP/SMX, cardiac surgery, or a combination caused our patient's episode of acute pancreatitis. Although rare, each of these factors should be considered when determining the cause of pancreatitis.