Intrapancreatic bile duct stenosis is frequently observed in autoimmune pancreatitis (AIP). However, it is not known whether the cause of stenosis is extrinsic compression due to pancreatic inflammation or bile duct wall thickness due to sclerosing cholangitis. Thus, we analyzed the findings of intraductal ultrasonography in 19 patients which presented intrapancreatic bile duct stenosis. Although bile duct wall thickness is observed in 15 of 19 patients (79%), the cause of stenosis is thought to be extrinsic compression in 11 of 19 patients (58%). Serial cholangiography after corticosteroid therapy showed incomplete remission of intrapancreatic bile duct stenosis in 15 of 16 patients in various degrees. Intrapancreatic bile duct stenosis is considered to be influenced by extrinsic compression rather than bile duct wall thickness. However, the presence of cases that presented with bile duct wall thickness without extrinsic compression suggest that intrapancreatic bile duct stenosis could be caused by sclerosing cholangitis alone.

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Twenty-eight cases with pancreatic body and tail cancer were classified into pancreatic tail (group T: 9 patients) and body (group B: 19 patients) cancer divided at the left edge of the aorta as defined by the UICC. In group T, tumor progression was confined only to the surrounding splenic arteries, however, in group B, tumor progression toward the celiac and common hepatic arteries were observed. The 5-year survival rate of group T (60.0%) was better than group B (11.8%) (p=0.054). In 11 cases of group B, the so-called Appleby's operation was performed. However, there was no difference in the survival rate compared with the usual distal pancreatectomy group, only 2 cases of 5-year survival was observed in the so-called Appleby's operation group. In conclusion, the boundary of pancreatic body and tail at the left edge of the aorta can better reflect the prognosis of pancreatic body and tail cancer.

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We report a rare case of pancreatic cancer, mixed adeno-neuroendocrine carcinoma. A 52-year-old man was admitted to our hospital because of a tumor of the pancreas body. Abdominal Computed tomography showed an unclear mass at artery phase but a well enhanced and unclearly demarcated 25mm tumor at portal phase in the body of pancreas. On magnetic resonance imaging, the lesion demonstrated high signal intensity on a T2-weighted image and diffusion image. On FDG/PET-CT, the tumor showed significantly high SUVmax=9.7. With a diagnosis of pancreatic carcinoma with high malignant potential, we performed a distal pancreatectomy. Histological and immunohistochemical examinations revealed that the tumor consisted of ductal component and neuroendocrine component. The neuroendocrine component corresponded to poorly differentiated neuroendocrine carcinoma, large cell type, based on morphological characteristics. By these findings, the tumor was diagnosed as mixed ductal-neuroendocrine carcinoma according to the current World Health Organization classification system.

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We experienced 6 cases of chronic pancreatitis with calculus exhibiting pus-containing pancreatic juice on endoscopic retrograde cholangiopancreatography (ERCP), along with hyperpyrexia, abdominal pain, and systemic inflammatory response. We defined this disease state as acute obstructive suppurative pancreatic ductitis (AOSPD) based on the similarity to acute obstructive suppurative cholangitis (AOSC). Five of 6 patients with positive pancreatic juice culture for indigenous intestinal bacteria were successfully treated with endoscopic naso-pancreatic drainage (ENPD). The other one case underwent surgery because of difficulty for endoscopic treatment. Thus, in cases of acute exacerbation of chronic pancreatitis with pancreatic calculus and hyperpyrexia, the possibility of AOSPD and the indication of ENPD should be considered.

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We reported herein an extremely rare case of adenocarcinoma arising from the minor duodenal papilla in association with unique pancreatic duct dilatation. The patient was 74 year-old woman, in whom the increased level of the serum CA19-9 (274mg/ml) was pointed out by the medical check-up for anemia. The upper and lower gastrointestinal endoscopy and the CT did not demonstrate any abdominal lesion, but the serum CA19-9 level had been increasing with time. Seven months after the first endoscopy, the lesion, which showed FDG accumulation, was detected around the 2^nd portion of the duodenum by PET. Therefore, upper gastrointestinal endoscopy was performed again, and the type 2 tumor of the duodenum was found. In CT and MR, the prominent dilatation of the pancreatic duct confined to the lower portion of the pancreatic head was disclosed. It took 9 months from the first medical examination to pancreaticoduodenectomy. The tumor was 32mm in diameter and the opening of the accessory pancreatic duct was located in the center of the tumor. Microscopically, the intraepithelial spread of cancer was observed in the accessory pancreatic duct. In this report, we can point out that the minor papilla is easily overlooked by routine endoscopic observation.

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The patient was a 75-year-old woman. She was referred to our department with a diagnosis of neoplastic lesions of the pancreas and liver found after a closer examination for diabetes that was pointed in a preoperative examination of orthopedic surgery. CT shows a cystic lesion of the pancreatic tail from body about 5cm in diameter and a solid space-occupying lesion of the same size in the liver. Distal pancreatectomy and posterior segmentectomy of the liver were performed under diagnoses of mucinous cystadenocarcinoma with hepatic metastasis. Pathological diagnoses were mucinous cystadenoma and invasive ductal carcinoma of the pancreas with hepatic metastasis. The postoperative course was uneventful and the patient had been alive more than 5 years after surgery.
We thought that mucinous cystadenoma coexisting with invasive ductal carcinoma of the pancreas is very rare and the importance of long-term survival with surgery in spite of far advanced cancer with liver metastases in clinical should be reported.

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There have been few reported cases of remnant pancreatic ductal cancer developing after resection of invasive ductal cancer that implicated methachronous multicentric tumorigenesis.
A 67 years old man received a distal pancreatectomy due to pancreas body cancer. Twenty-five months after the surgery, he suffered from obstructive jaundice. Examinations revealed pancreas head cancer and no distant metastasis. Total pancreatectomy was performed and the metachronous invasive cancers of the remnant pancreatic head were surgically removed. Histological finding showed two regions of invasive cancer in the resected pancreas, one was at the caudal region and the other was at the groove region. There was no gross continuity with the lesions. This was a rare case because pancreatic cancer survivors are rare. This implicates two possibilities: 1, recurrence of the pancreas body cancer; 2, multicentric cancer. Additional analysis with molecular biological methods revealed a point mutation of K-ras codon 12 in the second cancer, in both the groove and the caudal portions whereas wild type K-ras was present in the first cancer. This supports a 'multicentric cancer', and 25 months between two surgeries was long enough to indicate the methachronous tumorigenesis.

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A woman in her sixties was admitted to our hospital due to general fatigue and appetite loss occurring 84 days after laparoscopic distal pancreatectomy for autoimmune hemolytic anemia and cystic tumor of the pancreatic tail. During her hospitalization, bilateral pleural effusion suddenly developed and a chest tube insertion was performed. A high level of amylase in the pleural effusion suggested the possibility of pancreatic fistula. Endoscopic retrograde pancreatography showed disruption of the main pancreatic duct at the pancreatic body and pancreaticopleural fistula. Pancreatic pleural effusion was treated with the placement of an endoscopic nasopancreatic drainage tube, fasting, and administration of octreotide acetate and the patient recovered successfully with these conservative managements.
Late-onset pleural effusions after distal pancreatectomy are rarely reported, however, it is important for clinicians to bear in mind that pancreatic pleural effusion could develop long after pancreatectomy in the patients with complicated disease.

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A 42 year-old woman had a cystic lesion in the tail of the pancreas. Abdominal ultrasonography revealed a "cyst-like structure within the cyst" in the same lesion. Because mucinous cystic neoplasm (MCN) is well-known as a "cyst-like structure in the cyst", we could not differentiate this case from MCN having malignant potential. Therefore, we performed a distal pancreatectomy with splenectomy. Histological examination revealed a macrocystic type serous cystadenoma (SCA). SCA usually consist of microcystic lesions, but macrocystic-type SCA is difficult to diagnose and differentiate from MCN. In this report, we present and discuss a case of macrocystic-type SCA with "cyst-like formations within the cyst".

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