Growing evidence indicates that, pathologically, there are different groups in "autoimmune pancreatitis (AIP)". The majority of Japanese cases belong to lymphoplasmacytic sclerosing pancreatitis, which is characterized by dense fibrosis with lymphoplasmacytic infiltrates, periductal inflammation, obliterative phlebitis and numerous IgG4-positive plasma cells. In the west, however, there is another type called idiopathic duct-centric chronic pancreatitis or AIP with granulocytic epithelial lesions, in which, in addition to lymphoplasmacytic infiltrates in the exocrine system, the duct epithelium and lumen are infiltrated by neutrophils. The different prevalence of the latter is probably the best reason why the clinicopathological features of AIP are different between Japan and the West.

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We introduced autologous blood donation(ABD) in pancreaticoduodenectomy for peri-ampullary cancer from September 2002. We classified 135 consecutive patients who underwent pancreaticoduodenectomy from January 2000 to April 2007 into pre-ABD and post-ABD groups. The pre-ABD group consisted of 38 patients from January 2000 to August 2002, and the post-ABD group consisted of 97 patients from September 2002 to April 2007. The patients' backgrounds, frequency of allogenic blood transfusion(ABT), and morbidity were compared in the two groups.
In the patients' backgrounds, only the amount of estimated operative blood loss (EBL) in the post-ABD group was significantly less than that in the pre-ABD group (p=0.0058). And the frequency of ABT significantly decreased from 61% in the pre-ABD group to 35% in the post-ABD group (p<0.0001).
In the result of the multiple logistic regression analysis, we identified the risk factors for requiring ABT was the presence of anemia in the pre-operative period (Hb<11g/dl) and excessive EBL of more than 1270ml.

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The Japanese criteria for the severity assessment of acute pancreatitis were revised. To validate the new severity assessment criteria (new criteria) from the aspect of the clinical course, we categorized patients into 4 groups: patients considered severe by both the heretofore used criteria (previous criteria) and the new criteria, severe group; patients considered severe only by the previous criteria, previous severe group; patients considered severe only by the new criteria, new severe group; and patients considered not severe by both the previous and new criteria, mild group. In each group, the clinical outcomes such as the days to normalization of the serum C-reactive protein, the days to resumption of oral diet, and total hospital stay were investigated. As a result, while no significant differences were observed in the clinical outcomes between the previous severe group and mild group, there were significant differences between the previous severe group and severe group. On the other hand, while no significant differences were observed in the clinical outcomes between the new severe group and severe group, there were significant differences between the new severe group and mild group. These results suggest that the new criteria are pertinent for assessing the severity of acute pancreatitis from the aspect of the clinical course compared with the previous criteria.

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A 78 year-old woman was referred to our hospital for vomiting and abdominal pain. There was a colonic obstruction beside the 8cm-sized cystic mass in the pancreas tail. After reducing the colonic pressure via the anus, we resected the distal pancreas, spleen, part of the colon and stomach, and left adrenal gland. The cystic wall was covered with the adenoma and carcinoma in situ. Carcinoma in situ developed to adenocarcinoma, and then to adenosquamous carcinoma. The diagnosis was pancreas adenosquamous carcinoma, derived from a mucin-producing cystic pancreas neoplasm. It is very rare that pancreas carcinoma is revealed by colonic ileus and mucin-producing pancreas cystic neoplasm leads to pancreas adenosquamous carcinoma. After 5 and a half months from the operation the patient died from cancer recurrence.

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A 57-year old woman was admitted to our hospital complaining of body weight loss. Several imaging modalities showed a huge, round cyst with mural nodules in the tail of the pancreas and a solid tumor in the pancreatic parenchyma adjacent to the cystic lesion. Distal pancreatectomy, splenectomy, left adrenalectomy, resection of the colon, and partial resection of the left kidney were carried out.
Histologically, the cyst wall lacking an ovarian-like stroma was composed of different types of epithelium with moderate to severe atypia. The solid component of the tumor was tubular adenocarcinoma in the pancreatic parenchyma and invasive cancer was found in the cystic wall and extrapancreatic tissue. Regarding the oncogenesis of this case, the following possibilities exist: (1) invasive mucinous cystadenocarcinoma; (2) invasive carcinoma derived from an intraductal tumor; (3) invasive ductal carcinoma of the pancreas with secondary cyst.

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A 59-year-old man was admitted to our hospital because of epigastric pain and elevated amylase levels. Abdominal CT showed a diffuse, enlarged pancreas without dilatation of the pancreatic duct. Magnetic resonance cholangiopancreatography showed a stricture of the lower common bile duct. Endoscopic retrograde cholangiopancreatography showed a diffuse stricture of the intrahepatic bile duct, a smooth stricture of the lower common bile duct, and irregular narrowing of the pancreatic duct in the pancreatic head and body. Based on these findings and elevated IgG4 levels, he was diagnosed as autoimmune pancreatitis with bile duct stricture. The bile duct stricture improved during hospitalization. Moreover, after administration of prednisolone (30mg daily), his symptoms resolved. After discharge from the hospital, the prednisolone dose was tapered off but he was re-admitted because of acute cholangitis. Endoscopic retrograde cholangiopancreatography showed a severe stricture of the upper common bile duct differing from the findings in the first attack. Endoscopic nasobiliary drainage and prednisolone (30mg daily), however, improved his symptoms.

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A 70-year-old male visited Tokai University Hospital complaining of a right palpebral tumor. This skin tumor, which turned out to be malignant, was resected. Because the patient had epigastralgia, abdominal malignancy was surveyed. The serum CA19-9 level was markedly high (18309U/ml) and imaging examinations including US, CT and ERP revealed pancreatic cancer with multiple liver metastases. The pathological findings including immunohistocytochemistry of the skin tumor were similar to those of the liver tumors, suggesting that the skin tumor had metastasized from the pancreatic cancer. The patient was treated with gemcitabine and survived more than 1 year without reccurence of skin tumors. Skin metastasis from visceral cancers, especially pancreas, is relatively rare. Here we present a case with the pancreatic cancer bearing liver and skin metastasis.

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A 68-year-old woman visited our hospital because of jaundice. CT showed an enhanced area measuring 4cm in diameter in the head of pancreas. The tumor had prolapsed from the orifice of the papilla of Vater. Endoscopic biopsy was performed and the tumor was pathologically diagnosed as a non-functioning islet cell tumor.
Pancreaticoduodenectomy was performed. The main pancreatic duct was occupied with the tumor that had prolapsed from the orifice of the papilla of Vater in the resected specimen. The final diagnosis was a non-functioning islet cell tumor.
Usually, endocrine tumors show expanding growth. Although some cases of endocrine tumors showing intraductal growth have been reported, tumors prolapsed from the orifice of the papilla of Vater seem to be very rare. We present a case of a non-functioning islet cell tumor uniquely growing within the lumen of the main pancreatic duct.

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A 60 year old man was referred to our hospital for further treatment of acute severe necrotizing pancreatitis. He was readmitted because of a growing pancreatic pseudocyst 2 months after discharge. We could not detect the pancreatic head mass by abdominal CT scan or endoscopic ultrasonography. Cystgastrostomy was performed for the pancreatic pseudocyst. Six months after operation, a pancreatic head mass 40mm in size with multiple liver tumors was detected by abdominal CT scan. The patient was diagnosed as having pancreatic head cancer with multiple liver metastases and died 9 months after the operation. Acute severe necrotizing pancreatitis caused by pancreatic cancer is very rare. The cause of acute severe pancreatitis should be identified because pancreatic cancer can also be a cause of severe pancreatitis.

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A 71-year-old woman with ischemic colitis was admitted to our hospital for evaluation of a pancreatic tail tumor with splenic infiltration. Endoscopic ultrasonography revealed a heterogenous hypoechoic mass with an irregular, central echogenic area in the tail of the pancreas and a solitary hypoechoic mass within the lumen of the main pancreatic duct(MPD). Endoscopic retrograde pancreatography showed interruption of the MPD in the head of the pancreas. Biopsy of this lesion confirmed a pancreatic neuro-endocrine tumor(NET). A NET with intraductal growth into the MPD and splenic infiltration was diagnosed. The patient underwent curative surgery. Histopathological examination revealed the malignant NET with intraductal growth within the MPD and tumor thrombus within the splenic vein. The patient received no postoperative adjunctive chemotherapy and 11 months after surgery she is alive without recurrence.

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