Carcinoma of the pancreas is the fourth leading cause of death from cancer of the digestive organs in Japan, 1978. There has been a steady rise in the rate of death due to thismalignancy for some time. Early diagnosis has not been possible, and to date therapy has not altered the disease process.
The availability of multiple-imaging modalities and combined radioimmunoassay methods has added new diagnostic information, but their use and correlation has not yet been opti-mized for the evaluation of pancreatic cancer. Consequently, interpretation is less specific than in disease of other abdominal organs.
Clinicians still debate the efficacy of pancreatic nuclear imaging. A normal pancreatic scan effectively rules out pancreas disease with 90-95% certainty. On the other hand, an abnormal pancreatic scan is non-specific and may represent carcinoma with 85.5% certainty.
The evaluation of suspected pancreas carcinoma remains a difficult and perplexing problem. The optimal approach, combining clinical, imaging and clinico-pathologic data has not yet been defined.
Therefore, author have summerized our approach, using multiple imaging modalities and combined radioimmunoassay methods. The greatest hope for non-invasive diagnosis lies in thefuture development of organ and pathology-specific radionuclide-labeled agents that provide functional as well as anatomic information.

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ERCPs were performed in 444 cases. In well opacified 365 pancreatograms, the abnormal changes were morphologically studied. The results were as follows:
1) Incidence of abnormal pancreatogram, normal pancreatogram, insufficient opaci-fication and no visualization was 27.5%, 54.7%, 1.1% and 16.7%, respectively.
2) The “rat-tail”like stricture of main pancreatic duct (m. p. d.) and “long and tight irregularity”were the most characteristic signs in pancreatic cancer (P. C.).
3) ‘Long but not tight irregularity’;was due to pancreatitis.
4) In 11 cases of ‘m. p. d. obstruction’, incidence of P. C. was 72.7%. Mode of ob-struction in P. C. differed from that in other diseases.
5) ‘Partial stricture with proximal beaded changes’was recognized in 11 cases. Inci-dence of P. C. was 63.6%. Degree of stricture in P. C. was higher than that in chronic-pancreatitis.
6) One case of P.C. showed ‘partial stricture with proximal dilatation’.
7) One third cases with ‘partial stricture with no dilatation’was P. C. This changes was not diagnostic sign.
8) Three out of 8 cases with ‘m. p. d. dislocation’was P. C.
9) Other changes in c. b. d. were ‘rigidity’, ‘slight beaded sign’, ‘smooth dilatation’, ‘radiolucent filling defect’and ‘cyst formation’. It may be true that all the changes are the indication of benign conditions.
10) ‘Partial absence of lateral branches’was shown in two cases. One was P. C. and the other was carcinoma of common bile duct. In the former, ‘dislocation of m. p. d.’was ac-companied.
11) ‘Multiple micro cyst’, ‘partial parenchymography’, ‘irregular and rigid branches’and ‘dilated branches’were the signs of benign conditions.
12) The cause of unsuccessful cannulation was the deformity of duodenum. The de-formity was probably due to tumor infiltration.
13) Pancreaticoduodenectomy was successful in one case out of 31 with P. C.
14) A rare case was presented. In this case, unresectable pancreatic tumor was con-firmed at operation. No changes was recognized in its pancreatogram.

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Recently endoscopic retrograde cholangiopancreatography (ERCP) is developed much as one of the special examinations of the biliary tract. But ERCP in children have not been carried out, because of their particularity.
Now, we performed this examination to two children under general anesthesia with nasal tracheal intubation with good results, and we discussed a few problems about ERCP in children.
ERCP was originated first by Doubilet in 1951, then Hirschowitz observed the duodenum and Vater's papilla by using fiberscope in 1958, and McCune et al. succeeded retrograde pancreatography in 1968.
In Japan, there were many reports about ERCP by Ohi and Takagi in 1969. In the next year other reports were published by Shindo, Ogoshi and Fujita. Moreover, many kinds of diagnostic methods and therapies have been contrived to nowadays. But there is no report concerning ERCP in children without Uragami's two cases.
We examined ERCP in two cases by using Olympus JF-B₃ (for adults) under general anesthesia with nasal tracheal intubation;(One was a 6-years-old female, who was sus-pected congenital choledochal delatation, and her body weight was 22 kg and height was 124.5 cm. Another case was a 7-years-old male, who was suspected traumatic pancreatic cyst, and his body weight was 23 kg and height was 119 cm).
The problems of this examination depend on the type of fiberscope and the cooperation of the children. Concerninng the type of fiberscope, we hope that a new and skillful type beneficial for children, but we know that we can examine children by means of the popular type of fiberscope for adults.
When we use the popular type of fiberscope for adults to children, we must know deservedly the technical limitation, in which the children are required elder than age of 6, heavier than 20 kg body weight and higher than 110 cm height.
Another problem is “anesthesia”. General anesthesia with nasal tracheal intubation is necessary to children for their particularity by all means, thus the operation of fiberscope will be easier, then the safety and effective examinations will be carried out.

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A linear-array real-time electronic scanner of ultrasound has some advantages in per-formance compared with the conventional contact scanner. It can demonstrate small lesions or thin ductal structures easily shifted by respiratory movement or circultory pulsation.
Concerning the pancreas, main pancreatic duct can be reliably demonstrated using the real-time scanner in addition to the parenchymal echogram.
Using a specially desighed linear-array real-time electronic transducer for puncture, percutaneous aspiration biopsy of the pancreas and percutaneous pancreatic ductography (PPD) were performed with a high rate success.
Percutaneous aspiration biopsy of the pancreas provided a cytological proof of ade-nocarcinoma for 24 of the 30 patients with carcinoma of the pancreas. There was no false positive proof of malignant cell in the 4 patients with chronic pancreatitis who underwent procedure.
PPD was successful in 14 of the 17 patients with disease of the pancreas in whom, the pancreatic duct proximal to the obstruction could not be opacified by ERCP. A cytological study of the pancreatic juice revealed adenocarcinoma in one of the 6 patients.
No serious complications occurred either during or after the procedure.

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Pancreatitis is an important disease to differentiate patients with acute abdomen on emergency. Present study was conducted to know localization, incidence and pathogenesis of 40 patients with acute pancreatitis who were admitted to Iwakuni National Hospital from 1970 to 1978. Patients with pancreatitis were found to visit our hospital from wide area surrounding Iwakuni City;eastern part of Yamaguchi prefecture, Otake City in Hiroshima prefecture and Muikaichi-cho in Shimane prefecture. Average number of patients was 4.4 in each year, ranging two to nine. 23 cases were admitted through emergency clinic and 17 were hospitalized through ordinary out-patient clinic. Operation was performed in 11 cases of pancreatitis. Pathogenesis of the disease in Iwakuni area was demonstrated as 37.5% of biliary tract stone, 20% of alcohol and 32.5% of unknown etiology. Predominance of biliary tract stone in Iwakuni area was contrast to whole Japan study indicating gallstone and alcohol in a same degree as a pathogenesis of pancreatitis.
Report of Cases
Case 1;A 25-years-old female came into first pregnancy with two-year history of biliary colic. On six months' pregnancy, she was admitted to Iwakuni National Hospital com-plaining of severe abdominal pain. Twenty days after admission, she had another episode of severe abdominal pain indicating acute pancreatitis. Conservative therapy was performed. On ten months' pregnancy, she underwent Cesarean section and cholecystectomy which resulted in survival of mother and baby.
Case 2;A 40-years-old male, a heavy drinker, had first admission with a chief com-plaint of abdominal pain. Pancreozymin-secretin test revealed slightly depressed pancreatic function. He continued drinking after discharge and was admitted again with severe ab-dominal pain. As serum and urinary amylase levels were both within normal range, laparotomy was performed and acute hemorrhagic pancreatitis was diagnosed. He stopped drinking, then pancreatic function became normal six months after discharge.
Acute pancreatitis is one of the important disease for the differential diagnosis of acute abdomen. As its correct diagnosis is often difficult, both surgeon and internist should cooperate and study how to manage the disease. One third of patients with acute pancre-atitis in Iwakuni area had gallstone, suggesting the nessecity of early cholecystectomy in cases of biliary colic.

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Twenty one patients with chronic pancreatitis were treated in our department from 1966 to 1979, and 20 of 21 patients were operated and followed. Only 3 of 20 patients had a direct procedure performed on the pancreas, such as latero-lateral pancreatico- jejunostomy, pancreatectomy of body and tail and transduodenal pancreaticoplasty. Of 11 patients sub-jected to biliary tract, 3 had choledochoduodenostomy, 3 had cholecystectomy with common bile duct exploration, 2 had choledochojejunostomy, 2 had cholecystectomy only, 1 had cholecysto-gastrostomy. Of other 6 patients, 4 had pancreatic cyst resection, 2 had explo-ratory laparotomy. Among surgical procedures we performed, operation on the biliary tract was the most effective. Among various causes of pancreatitis, biliary pancreatitis was the best indication for surgical treatment.

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The serum lipase and amylase activities of forty patients with chronic pancreatitis were observed for more than six months and were studied relation to their symptoms. Control groups consisted of forty patients with digestive diseases excluding the other pancreatic diseases, biliary tract diseases, severe bowel, hepatic diseases and twenty eight normal volunteers.
There was significant difference between the mean values of those two enzyme activi-ties of chronic pancreatitis group and the mean values of control groups.
Of the patients with chronic pancreatitis, those enzyme activities were significantly higher in severe, prolonged cases than in mild cases.
In 246 periods of relapse and remission in the course of forty chronic pancreatitis patients, lipase activity increased in 86% of the relapsing periods and decreased in 63% of remission periods.
Inversity between the course of serum lipase and the course of amylase activities was seen in mild cases.
In pancreozymin and secretin tests, at least one of two enzyme activities increased in more than 3/4 patients with chronic pancreatitis.
Normal volunteers showed diversed tendency between before and after ingestion of alco-holics and fatty foods in lipase activity.
Therefore serum lipase activity would be one of the useful markers for prognosis of chronic pancreatitis and precaution should be made before serum lipase examination.

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We have carried out the aspiration biopsy of the pancreas in 17 cases based on the technique of the aspiration biopsy for the mammary gland.
Results obtained were as follows:
1) After enough mobilization of the pancreas, fine needle should be inserted into the tumor mass.
2) Incisional biopsy occasionally causes bleeding or pancreatic fistura formation, while aspiration biopsy is satisfactory.
3) In the case of the pancreatic tumor associated with chronic pancreatitis, biopsy in many places of the pancreas should be done.
4) Aspiration biopsy seems to be better than incisional biopsy for the diagnosis of the pancreatic carcinoma.
5) The diagnostic acurracy of the aspiration biopsy was 43/49 in mammary diseases while that was 14/17 in pancreatic diseases.

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A synthetic peptide, N-benzoyl-L-tyrosyl-P-aminobenzoic acid (BT-PABA) was orally administered to 10 controls and 25 patients for the exocrine pancreatic function test (PFD test). The BT-PABA is specially cleaved by pancreatic chymotrypsin and releases P-aminobenzoic acid (PABA) which is absorbed from the intestines, conjugated in the liver and excreted in the urine.
In the control group a mean of 88.46±6.76% (M±SD) of the PABA was excreted over a period of six hours. The recovery rates of PABA in chronic pancreatitis, suspected chronic pancreatitis, cholelithiasis, cases of partial pancreatectomy were 56.76±24.30%, 71.30±13.53%, 71.22±10.71%, and 42.16±10.90% respectively. These values were statistically significant as compared with that of the control group.
The PFD test is simpler and more comfortable to the examinees than the PS test and is useful in the diagnosis of exocrine pancreatic insufficiency, especially in chronic pancre-atitis. More studies will be required to diagnose chronic pancreatitis with mild pancreatic dysfunction.

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The prognosis of acute pancreatitis is severe, particularly in case accompanied by pancreatic encephalopathy.
We experienced a case of such severe pancreatic necrosis.
A 45-years-old businessman was admitted because of epigastralgia which had begun from a month ago and had been increasing gradually in severity.
He was operated 24 hours after admission.
The operativc findings were as follows:
A remarkably edematous and nodular appearance of the pancreas and fat necrosis of almost all the pancreas.
The six gummy drains were left after lavage of the peritoneal cavity.
The postoperative course was very stormy.
Hallucination due to Pancreatic encephalopathy developed on the second postoperative day, which was improved gradually by treatment with trasyrol and chlorpromazine.
IVH was applied from the 6th postoperative day to the 17th postoperative day.
Feeding by month begun on the 14th postoperative day.
He left the hospital in good health on the 60th postoperative day.

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