The first edition of the JPN Guidelines for the Management of Acute Pancreatitis was published in July 2003, and an English version was published in the Journal of Hepato-Biliary-Pancreatic Surgery in 2006 with the aim of receiving comments from many professional clinicians in foreign countries. The guidelines were formulated with the aim of providing practical management advice for achieving better prognoses of acute pancreatitis in Japan under the Japanese health insurance system. The guidelines are composed of evidence-based recommendations and indicate transfer rules for patients with higher JPN scores. Now, four years have passed since the first publication and several new lines of evidence have been reported. The necessity of revising the guidelines according to such new findings had been anticipated before the first publication. And in view of the usefulness of these guidelines, many discussions at various meetings have been held. Current concepts and efforts for the revised edition will be described.

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Evidence-based medicine, which is defined as "the conscientious, explicit and judicious use of the best current evidence in making decisions about the care of individual patients," and "evidence" refers to scientific knowledge about disease risks or treatment effectiveness derived from clinical research. On the other hand, practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances", and are most commonly used as an approach to change physicians' practice behavior. Recent guidelines are developed based on "evidence" with the emphasis on better patient outcomes. For busy clinicians, guidelines are one of the important sources of information for catching up with current medical knowledge so that it can be applied in the clinical practice. Recommendations in the guidelines cannot always apply to all patients, and physicians must make their own decision about which treatment option is best for their patients.

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[Background and purpose] The first domestic edition of "Evidence based clinical practice guidelines for the management of acute pancreatitis" was published in July 2003. And then, we published an English version of the guidelines (JPN guidelines for the management of acute pancreatitis) in February 2006. We will receive global assessments about the JPN guidelines from abroad and are planning further revisions of the contents in the future. [Making JPN guidelines] The chairperson of the JPN guidelines is professor Tadahiro Takada (Teikyo University), and the guidelines have been reviewed as follows. (1) January, 2005: Re-examination working groups discussed the contents of the Japanese edition, notations and recommendations. (2) March 2005: We reviewed the contents, revised them and made new clinical questions. (3) May 2005: English translation. The contents were described in nine papers published in the Journal of Hepato-Bilialy-Pancreatic Surgery. (4) August 2005: Contents of International Edition, notations, recommended methods were reviewed. (5) February 2006: JPN guidelines were published in the Journal of Hepato-Bilialy-Pancreatic Surgery. [Prospective effects] Studies on HPB lesions were the first to be publish in the International edition of the guidelines in Japan. We performed this study with the support of a grant from a science research program of Health Labor and Welfare, Japan. The JPN guidelines will be compared with various international guidelines towards obtaining further improvements in clinical medical care.

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For the diagnosis of acute pancreatitis, the measurement of serum amylase is widely employed and it provides acceptable accuracy. The determination of serum lipase is more reliable, but lipase assay has some problems. A urinary dip stick for trypsinogen-2, with very high sensitivity and specificity, has been developed and it may be an ideal method for the diagnosis of acute pancreatitis. Imaging study is useful for the differential diagnosis of acute abdomen. Ultrasonography is often unhelpful because the pancreas can be visualized in only half of the patients with acute pancreatitis. Pancreatic imaging by contrast enhanced CT is very useful for the diagnosis and stratification of the severity of acute pancreatitis, but the use of contrast media may have undesirable effects on such patients.

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The Japanese criteria for severity assessment (Japanese severity scoring system) are useful for grading the severity of acute pancreatitis. However, the Japanese criteria are cumbersome and complicated. This article reviews issues on the Japanese criteria for severity assessment. The Japanese scoring system is based on 18 prognostic factors of clinical signs, laboratory test data, and CT grade. It is often difficult to evaluate all items in the Japanese criteria during an emergency. There are some tautological factors that show the same clinical condition in acute pancreatitis. Initial fluid replacement directly affects some prognostic factors. The CT grade based on plain CT findings is not reliable to evaluate severity of acute pancreatitis. Although the severity is classified into three categories (mild, moderate and severe) in the Japanese critereia, there is no difference in the mortality rate and therapeutic strategy between mild and moderate acute pancreatitis. New criteria for assessment of the severity are now being developed.

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According to JPN guidelines for the management of acute pancreatitis, a Japanese Ministry of Health, Labour and Welfare Criteria (JMHLW Criteria) score of 2 or more is the criterion for transfer. It is desirable to transfer patients with severe acute pancreatitis (SAP) to a medical institution where monitoring and systemic management are available. Patients with SAP should be cared by full-time physicians specialized in intensive care, endoscopic treatment, radiological intervention, and cholangiopancreatic surgery. The aim of these recommendations is to improve the outcomes and mortality of patients with SAP. In Japan as well as United Kingdom and Europe, practical guidelines for SAP have not been widely introduced and fully accepted. Publication alone of nationally developed and approved guidelines is insufficient to modify the practice of non-specialists. This has implications for the rationale of creating guidelines, and for strategies accociated with their introduction to various clinicians.

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The clinical records of surgical treatments for severe acute pancreatitis were reviewed in the National Survey of Acute Pancreatitis in 2003. Among 549 cases with severe acute pancreatitis, 62 cases were treated surgically. Necrosectomy was performed in 25 cases (35%), and 8 cases had fatal outcomes. Among 25 cases with necrosectomy, the preoperative diagnosis was pancreatic abscess in 7 cases. On the other hand, the mortality rate of the 43 cases which were diagnosed as pancreatic abscess was as high as 23%, being comparable to the mortality of cases whose diagnoses were infected pancreatic necrosis. Moreover, among thirty-one cases initially treated with percutaneous abscess drainage, surgical drainage and necrosectomy were necessary in 7 and 4 cases, respectively. Four of the 20 cases (20%) treated only with percutaneous drainage without operation died. These results strongly suggest that infected pancreatic necrosis is misdiagnosed as pancreatic abscess in a considerable number of cases. We should note that infected pancreatic necrosis is sometimes obscured under the diagnosis of pancreatic abscess, and that surgery should be selected without hesitation when percutaneous drainage is not effective for pancreatic abscess.

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Searching for the etiology of acute pancreatitis is crucial for the treatment as well as the severity assessment. It is particularly important to differentiate gallstone-induced pancreatitis from other causes, because patients with this type of pancreatitis often require the management of biliary disorders. In the JPN guidelines, it is recommended to determine promptly whether it is gallstone-induced or not. And urgent endoscopic treatment is recommended to be performed only in patients suspected to be complicated with biliary duct obstruction or cholangitis. However, the present JPN guidelines do not describe clearly enough how to search for the etiology and what kind of patients have biliary duct obstruction or cholangitis.

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The Evidence-based Japanese Practical Guidelines for Acute Pancreatitis were published in 2003. To evaluate changes in the treatment for and mortality of acute pancreatitis in Japan, the Japanese Society for Abdominal Emergency Medicine Reevaluation Committee for Practical Guidelines for Acute Pancreatitis surveyed members of the Japan Pancreas Society, Japanese Society for Abdominal Emergency Medicine, Japanese Society of Hepato-Biliary Pancreatic Surgery, and Research Committee on Intractable Pancreatic Diseases, Division of Gastrointestinal Diseases, the Ministry of Health and Welfare of Japan. Many of the clinical practices for acute pancreatitis were changed according to the guidelines. The mortality from severe pancreatitis subsequently decreased (10.2% in 2002, and 7.6% in 2004). However, some doctors, even those with expertise in the pancreas, have not seen the guidelines and therefore have not changed their treatment modalities. After evaluating these questionnaires, we are now working on revision of these guidelines. The revised guidelines will be published in March 2007.

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A 57-year-old man was admitted to our hospital due to abdominal pain. At admission, CT grade was IV, TP 5.4 g/dl, and PO₂ (room air) 59.7 mmHg, and the patient was diagnosed as severe acute pancreatitis. The symptoms improved by the administration of protease inhibitors and antibiotics, and the patient was discharged. Follow-up CT showed a multilocular cystic lesion with a solid component in the pancreatic tail. Endoscopic retrograde cholangiopancreatography showed main pancreatic duct dilation and communication with the cyst, and a radiolucent area in the communicating cyst. The patient was diagnosed as intraductal papillary mucinous neoplasm (IPMN), and 3 months after diagnosis, he underwent distal pancreatectomy. Physicians should be cognizant that IPMN involving the main pancreatic duct may cause severe acute pancreatitis.

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A 47-year-old woman was admitted to our hospital because of sudden upper abdominal pain. CT scan demonstrated a cystic lesion of the pancreatic body and ascites. Under the diagnosis of acute peritonitis due to the rupture of the cystic neoplasm of the pancreas, distal pancreatectomy was performed. Histological examination revealed mucinous cystadenoma of the pancreas with ovarian-type stroma. The patient was alive without any evidence of recurrence 5 years after the operation. This is one of several case reports of acute abdomen due to rupture of mucinous cystic neoplasm, the common symptoms of which are abdominal mass and dull pain.

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