Objective:Clinical guidelines for the management of pancreatic cancer were published in 2005 from Japan Pancreas Society. The objectives of this study were to assess how the guidelines have been used by physicians and surgeons and to survey their opinions on it. Methods:A questionnaire was designed and sent to 2,078 doctors mainly of members of Japan Pancreas Society. Results:A total of 168 answers for the questionnaire were obtained, with the responsibility rate being 5.1%. Most of the doctors noticed the guidelines in the medical congress, where the public hearing was carried. Most of the purposes for using the guidelines were determination of the treatment and to order the knowledge of treatment of pancreatic cancer. The guidelines had an influence on their practice in the great majority of doctors although the evidence levels of publications were low and most of the recommendations were graded as C. Answers gave us many useful opinions including requests for revision. Conclusion:This study revealed that the guidelines were utilized by many physicians and surgeons. It also indicated that the publication of the guidelines contributed to their management of pancreatic cancer. There were many useful suggestions for the guidelines which would be reflected at the time of the revision.

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We should understand the pathogenesis of pancreatic exocrine and endocrine insufficiency, and perform replacement therapy for pancreatic steatorrhea by administering pancreatic enzyme preparations. Moreover, adequate insulin therapy by using new insulin preparations will result in good diabetic control. Such replacement therapies for patients with pancreatic insufficiency will improve the quality of life and prognosis.

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The proximal part of the main duct of the dorsal pancreatic bud partially regresses to form the accessory pancreatic duct (APD). APDs were divided into the long type and short type, which showed functionally and embryologically different findings. The patency of the APD determined by dye-injection endoscopic retrograde pancreatography was 43%, and may depend on the duct caliber, course, and terminal shape of APD. The patency of APD in patients with acute pancreatitis was significantly lower. A patent APD may prevent acute pancreatitis as a safety valve by reducing pressure in the main pancreatic duct. As the majority of the exocrine flow is routed through the minor duodenal papilla in pancreas divisum, interrelationships between the poor function of the minor papilla and the increased flow of pancreatic juice caused by alcohol or diet may increase the dorsal pancreatic duct pressure and lead to the development of pancreatitis. Endoscopic therapy is recommended for recurrent pancreatitis associated with pancreas divisum.

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To clarify the characteristics of pulmonary dysfunction (PD) complicating severe acute pancreatitis (SAP), we analyzed 105 patients with SAP. The incidence of PD was 50%. The severity scores on admission and the frequency of necrotizing pancreatitis were significantly higher in patients with PD. Among the blood biochemical parameters on admission, BE, BUN, Cr, BS, LDH, CRP, lymphocyte count, Ca, total protein, and PMN-elastase were significantly different between patients with PD and those without PD. The incidence of infection (48%) and the mortality rate (58%) were significantly higher in patients with PD. Moreover, the incidence of infection (56%) and the mortality rate (68%) were significantly higher in patients with PD together with multiple organ dysfunction syndrome (MODS) compared with PD alone. In patients with PD, the prognostic factors on admission were AST, ALT, total bilirubin, Cr, Ca, and LDH. On admission in patients with PD, early PD, and late PD, the frequency of pancreatic surgery was 47%, 0%, 75%, respectively and the mortality rates were 63%, 10%, 83%, respectively. In PD of every phase, the mortality rates were higher in patients with PD together with MODS. These results suggest that systemic intensive care including a strategy against infection is needed in patients with PD together with MODS.

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A 64-year-old man was referred to our hospital for further investigation of a lesion at the pancreatic body. CT showed swelling of the whole pancreas and a poorly enhanced area in the tail, but did not reveal a lesion in the body. A high IgG4 value and positive anti-nuclear antibody were found serologically. EUS detected a low echoic lesion with an irregular surface (about 15mm in the diameter) at the body. Contrast-enhanced ultrasonography revealed a hypovascular lesion at the body. ERCP showed a segmental stricture of the MPD at the portion of the pancreatic body and abnormal epithelial cells were detected in biopsy specimens. A diagnosis of autoimmune pancreatitis (AIP) with pancreatic ductal cancer was made, and distal pancreatectomy and cholecystectomy were performed. Histopathological examination revealed severe fibrosis and inflammatory cell infiltration in the whole resected pancreas and these cells showed positive staining for IgG₄, but there were no malignant findings. We clinically diagnosed AIP. This is a case report of autoimmune pancreatitis in which we could not exclude pancreatic ductal cancer in the body.

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The patient was a 32-year-old woman who presented with epigastric pain and anemia. Ultrasonography, computed tomography, and magnetic resonance imaging showed a solid tumor measuring 60mm in diameter at the pancreatic body. Endoscopic retrograde pancreatography showed hemosuccus pancreaticus and stenosis of the main pancreatic duct at the pancreatic body. Angiography demonstrated encasement of the splenic artery, obstruction of the splenic vein and no hypervascularity. She underwent distal pancreatectomy with splenectomy and partial resection of the jejunum and portal vein. Histopathological examination revealed a giant cell type anaplastic carcinoma. The tumor had invaded arterial wall of the pancreas. She died of a recurrence of anaplastic carcinoma 14 months after surgery. Anaplastic carcinoma of the pancreas is infiltrative and has a poor prognosis. Our findings suggest that arterial wall failure due to tumor invasion was the cause of the hemosuccus pancreaticus.

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A 36-year-old male who had received an operation for malignant meningioma in 2001 was admitted to a hospital for acute pancreatitis. An abdominal CT scan demonstrated a mass including a calcification at the pancreas body. This calcification was judged to be a benign change due to the chronic pancreatitis. He was admitted to our hospital six months later because the follow up abdominal CT scan demonstrated enlargement of the mass. The pancreatic mass was 5cm in size, and contained calcification. Tumor thrombosis of the portal vein was seen extensively. An operative biopsy was performed because radical operation was considered to be difficult. The tumor consisted of proliferated mesenchymal tumor cells, which were positive for c-kit immunohistochemically. Therefore, the pancreatic tumor was diagnosed as GIST of the pancreas. Despite treatment with STI-571, the tumor enlarged remarkably and the patient died of a rupture of the tumor. By autopsy, the pancreatic tumor was diagnosed as mesenchymal chondrosarcoma. In the review of past specimens, it was concluded that the pancreatic tumor had metastasised from the mesenchymal chondrosarcoma of the dura mater which had been diagnosed as malignant meningioma and removed at the first operation for the brain tumor in 2003. Pancreatic metastases of mesenchymal chondrosarcoma are rare, and only five cases have been reported. Furthermore, to our knowledge, this case of mesenchymal chondrosarcoma was the first to be described that was positive for c-kit.

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A 60-year-old man who was diagnosed as having type 0-IIc gastric cancer was admitted to our hospital because of epigastric pain. Abdominal CT revealed acute pancreatitis with a pseudocyst. Abdominal MRI, CT and endoscopic ultrasoundgraphy showed an unusual mass lesion in the pancreas head. Endoscopic retrograde cholangiopancreatography and cytologic examination didnt allow the diagnosis of adenocarcinoma. However, we could not rule out the presence of a malignant lesion, so pancreaticduodenectomy was performed. The histological diagnosis was pancreatitis with fibrotic tissues and there was no evidence of malignancy. A novel diagnostic modality may be necessary for improving the accuracy of diagnosis in such cases.

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