Endoscopic retrograde cholangiopancreatography (ERCP) could activate trypsin in pancreatic acinar cells, resulting in post-ERCP pancreatitis with elevated serum levels of cytokines. Pain associated with acute pancreatic is caused by cytokine expression triggered by activation of trypsin in response to interactions among polymodal nociceptors, the arachidonic acid cascade, and protease-activated receptor-2. The presence of criteria of systemic inflammatory response syndrome (SIRS) correlated significantly with “intense pain” and severe disease. Patients diagnosed with SIRS should be provided with immediate intensive care, including pain control. Abdominal pain due to pancreatitis is provoked by activation of cytokines via trypsin, implying that blockade of trypsin and cytokine activation may control abdominal pain. In patients with post-ERCP pancreatitis with severe abdominal pain, early initiation of continuous intra-arterial infusion of protease inhibitors and adequate pain control may help to control the severity of the disease.

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Mucinous cystic tumors (MCTs) are relatively rare pancreatic tumors. They were defined as tumors containing mucin-producing epithelium, usually supported by ovarian-type stroma (OS). They occur in women and are preferentially located in the body and tail of the pancreas. The mucin-producing epithelium and the cystic character make these tumors easily confused with intraductal papillary-mucinous tumors (IPMTs). Classification and the biological potential of these tumors remain a subject of controversy. In this study, we retrospectively verified the clinicopathological diagnosis in six mucinous cystadenoma (MCA), four mucinous cystadenocarcinoma (MCC) and one invasive mucinous cystadenocarcinoma (IMC) that had been surgically resected. All but one case of MCA had OS and the initial diagnoses were maintained. In four cases of MCC, only one had OS while the others were re-evaluated as intraductal papillary-mucinous carcinoma and pancreatic metastasis, respectively. The IMC case was also re-evaluated as an invasive carcinoma derived from intraductal tumor. Intraoperative diagnosis of MCTs is difficult because of its cystic character. MCTs and IPMTs are different tumors with regard to invasiveness and recurrence. Thus, careful diagnosis is necessary especially to detect atypically clinical and pathological MCTs.

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Acute pancreatitis (AP) is a common abdominal disorder with severity varying from mild to fatal disease. The aim of this study was to analyze a large consecutive series of patients with AP and to identify prognostic factors for hospital mortality. Between January 1995 and December 1998, a consecutive series of 1,131 attacks of AP in 1,088, patients were included in the study. We reexamined the survey sheets and classified AP into mild (38.5%), moderate (21.8%), and severe AP (39.1%) according to the criteria proposed by Intractable Pancreatic Disease Investigation and Research Group of the Japanese Ministry of Health and Welfare. The overall mortality rate was 5.9% while that of severe cases was 13.8%. The severity scores proposed by Intractabe Pancreatic Disease Investigation and Research Group of Japanese Ministry of Health and Welfare were complicated and composed of clinical manifestations, imaging studies of computed tomography and ultrasound, and laboratory data. There was seldom a survey sheet in which the severity scores had been all described, and thus the patients were inadequately evaluated by this soring system. Thus, it was difficult to compare the severity among patients. It was therefore necessary to reduce the number of severity scores but include CRP in order to conveniently and accurately identify the severity of AP. Of 67 deaths' 38 patients (56.7%) were transferred from other hospitals, and 27 patients (40.3%) died within the first 2 weeks, mainly as a result of multiorgan failures including cardiovascular, respiratory and renal failure. Forty patients (59.7%) died after the first 2 week from complications related to infection and DIC. The patients of the former group had mainly idiopathic AP, while those of the latter group had acute exacerbation of alcoholic chronic pancreatitis. The average fluid replacement in the death cases during the first hospital day was 2,788±246 mL and the fluid replacement of 78.9% death cases was less than 3,500 mL per day. Citical issues in patient management include accurate scoring of severity in acute pancreatitis, sufficient fluid replacement at an early stage, and early transfer of patients diagnosed as severe as severe AP to a tertiary hospital.

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A 66-year-old man was admitted to our hospital for further investigation of epigastralgia and back pain. Laboratory data on admission showed elevated hepatic and pancreatic enzymes. Abdominal ultrasonography revealed a dilated main pancreatic duct and a low echoic mass with spotty high echo in the pancreatic head. Endoscopic retrograde pancreatography revealed mucin in the dilated main pancreatic duct. Peroral pancreatoscopy did not reveal fish-egg-like-protrusion in the main pancreatic duct. Abdominal computed tomography showed some enhanced parts of a low-density mass in the pancreatic head, which was recognized as low-and high-intensity mass on T 1- and T 2-WI magnetic resonance images, respectively. Under the diagnosis of invasive mucinous carcinoma originating from intraductal papillary-mucinous tumor, pancreatoduodenectomy was performed. Histopathological diagnosis of the resected specimen showed mainly a mucinous carcinoma, with intraductal papillary-mucinous tumor. Septa with muscular vessels were recognized in the tumor.

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We report a 57-year-old man with invasive carcinoma derived from intraductal papillary-mucinous carcinoma who was successfully treated by surgical excision 7 years after initial diagnosis. Endoscopic retrograde pancreatography conducted when the patient was admitted with acute pancreatitis at 50 years of age, revealed dilatations of the main pancreatic duct the branches with some filling defects. However, he did not undergo any surgical treatment and did not receive any medical treatment. In October 2001, he underwent cholecystectomy and hepatico-jejunostomy at a hospital in Brazil based on the diagnosis of chronic pancreatitis with cystic lesion and obstructive jaundice. Two months later, he was admitted to our hospital for the treatment of pancreatic disease. We performed pancreatoduodenectomy based on the diagnosis of invasive carcinoma of the pancreas. The tumor consisted of dilated pancreatic ducts that were full of jelly-like mucus. The histopathological findings were consistent with invasive carcinoma derived from intraductal papillary-mucinous carcinoma.

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When anaplastic ductal carcinomas of the pancreas are discoverd, the tumors are often very large. They tend to invade locally and metastasize to other organs, and are known to be associated with poorer prognosis than ordinary pancreatic ductal carcinoma. However, we report 3 cases of anaplastic ductal carcinoma of the pancreas associated with survival for more than 10 years after resection. The first case was a 65-year-old male patient who presented with fever of unknown origin. A tumor measuring approximately 10 cm in diameter with enhancement effect was observed in the tail of the pancreas, and distal pancreatectomy and splenectomy was performed. A diagnosis of anaplastic ductal carcinoma of the pancreas, pleomorphic cell type, was made. The patient died of acute myocardial infarction 10 years 1 month after surgery. The second case was a 65-year-old-male patient who presented with typical clinical features of acute pancreatitis. An approximately 6-cm mass with no enhancement effect was observed in the head of the pancreas, and a pylorus-preserving partial pancreatico-duodenectomy (PPPD) was performed. The histopathological diagnosis was anaplastic ductal carcinoma of the pancreas, pleomorphic cell type. The patient remains alive and recurrence-free, 11 year 1 months after surgery. The third case was a 49-year-old man whose initial manifestation was obstructive jaundice and was found to have an approximately 4-cm solid mass in the head of the pancreas. Since the patient had a past history of gastrectomy, pancreatico-duodenectomy was performed. A diagnosis of anaplastic ductal carcinoma of the pancreas, osteoclastoid type, was made, and the patient remains alive and recurrence-free, 11 year 1 months after surgery.

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The patient was a 55-year-old-man who underwent pancreaticoduodenectomy for ductal carcinoma of the pancreas head. At 6 weeks after operation, he was treated with 200 mg/m² of gemcitabine simultaneously with whole liver irradiation to prevent hepatic recurrence. He developed dyspnea and bilateral interstitial edema was noted on the chest X-ray at 26 days after this therapy. Corticosteroid therapy was extremely effective in the treatment of pulmonary failure and he was discharged 41 days after chemoradiotherapy. Gemcitabine is an anti-cancer agent for patients with advanced pancreatic carcinoma, and is commonly used to prevent recurrence. Although 200 mg/m² of gemcitabine used in our patient is low dose for chemotherapy, severe lung injury could occur when this agent is combined with whole liver radiotherapy.

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A 73-year-old male was admitted to our hospital because of appetite loss and body weight loss. Abdominal computed tomography showed a solid hypervascular tumor in the tail of the pancreas with multiple liver tumors. Transpapillary endoscopic pancreatic biopsy and percutaneous transhepatic tumor biopsy were performed. Histopathological examination showed malignant pancreatic endocrine tumor. Because the liver metastases were too numerous to resect, the patient was treated with transcatheter arterial infusion of dacarbazine (DTIC) and doxorubicin (DXR) for the pancreatic tumor and lipiodol-transcatheter arterial chemoembolization for liver metastases. This was followed by initiation of intravenous DTIC therapy. The patient received a total of 23 courses of DTIC and showed marked decrease in the size and number of pancreatic and liver metastases. He has been in good condition without any side effects for more than 2.5 years. DTIC therapy could be potentially useful for unresectable pancreatic endocrine tumor.

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