Although obesity has been thought to be a prognostic factor for acute pancreatitis, there is a difference in the contribution among the races. We studied the relationship between the prognosis of severe acute pancreatitis (SAP) and body mass index (BMI).
We retrospectively investigated 139 patients with SAP (median age, 52 years old; 106 male and 33 female patients) who were admitted to Showa University Hospital from November 2002 through December 2010. Among 139 patients with SAP, those of BMI less than 25kg/m² comprised 64.7%, those of BMI 25-30kg/m² did 25.2%, and those of BMI more than 30kg/m² did 10.1%. There were significant differences in administered fluid volume in the early phase, PaO₂/FIO₂, age, abdominal circumference, HbA1c, and the rate of metabolic syndrome between patients of BMI less than 25 or 30kg/m² and those of BMI more than 25 or 30kg/m². Complications, total hospital stay and mortality for SAP did not differ significantly between patients of BMI less than BMI 25 or 30kg/m² and those of BMI more than BMI 25 or 30kg/m². Obese patients were younger and had more respiratory disturbance than non-obese patients. However, there was no relationship between obesity and the prognosis of SAP.

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Impact of obesity on severe acute pancreatitis was reviewed. BMI (Body mass index) was used for analysis in most reports. Recently, some authors studied the relationship of visceral and subcutaneous fat area based on computed tomography, and the course of acute pancreatitis. Most reports showed that obesity may have effects on the severity of acute pancreatitis and development of complications. In most western reports, a high value of BMI was a significant predictive factor for severe pancreatitis and the development of systemic complication such as respiratory failure, but, this was not true of Japan. However, a high value of visceral fat area may have effects on the severity of acute pancreatitis and development of complications. For the future, more detailed analyses, using images of early onset, are needed to determine whether abdominal obesity or subcutaneous obesity have an effect on severity of acute pancreatitis.

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Excessive alcohol consumption is a major cause of both acute pancreatitis (AP) and chronic pancreatitis (CP). This study aimed to clarify the alcohol consumption habits in patients with alcoholic pancreatitis in Japan. A questionnaire was created to assess (1) the number of patients with AP and CP between April 1^st, 2008 and March 31^st, 2009, and (2) the alcohol consumption in patients with alcoholic pancreatitis treated between April 1^st, 2006 and March 31^st, 2009. The questionnaire was mailed to heads of the 1295 departments of gastroenterology in hospitals certified by the Japanese Society of Gastroenterology. Detailed information regarding alcohol consumption was collected from 316 patients with alcoholic AP (268 males and 48 females) and 528 patients with alcoholic CP (481 males and 47 females). Female patients develop alcoholic pancreatitis at a younger age, with shorter duration and smaller cumulative amounts of alcohol consumption than male patients. Compared to those who achieved complete abstinence, continued drinking as before increased the risk of recurrence within 2.1 years to 6.2-fold. Our results suggested gender differences in patients with alcoholic pancreatitis. Continued alcohol drinking led to the recurrence of pancreatitis.

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Chronic pancreatitis is an irreversible and progressive disease that causes abdominal pain, malabsorption, and pancreatic diabetes. Risk for pancreatic cancer is high in these patients and has a poor prognosis. Although lifestyles, such as drinking, tobacco, and high-fat diet strongly affect the pathogenesis of chronic pancreatitis, these are less so recognized as risk factors of chronic pancreatitis, partly because the lack of a classification system involving the lifestyle factors. Lifestyle guidance, which has not been proven as scientifically true, makes it difficult to verify the causational relationships between lifestyle and prognosis, and the efficacy of abstinence and lifestyle guidance as therapy for patients with chronic pancreatitis. Modification and validation of a classification system and validation of lifestyle guidance will shed light on the clinical practice in patients with chronic pancreatitis. In this report, we elucidated the problems and provision of recent guidance for abstinence and lifestyle habits in chronic pancreatitis.

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Low concentrations of ethanol (0.3-30mM) directly augment pancreatic ductal fluid secretion stimulated by physiological (1pM) and pharmacological (1nM) concentrations of secretin, which appears to be mediated by the activation of both the intracellular cAMP pathway and Ca²⁺ mobilization. Lower concentrations of ethanol in the stomach stimulate gastric acid secretion. When gastric acid enters the duodenum, it stimulates pancreatic fluid and bicarbonate secretion by releasing secretin from the duodenal mucosa. In the presence of 1mM ethanol (a concentration observed after normal alcohol consumption), a physiological concentration of secretin (1-10pM) causes a significant increase of pancreatic fluid secretion from interlobular ducts. In the presence of highly viscous pancreatic juice, protein plug, or intraductal stones, ethanol-induced fluid hypersecretion would elevate the intraductal pressure in the proximal part of the duct, leading to edema formation around acini.

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Tobacco smoking is not only a risk factor for pancreatic cancer but also for various perioperative complications. However, the effects of smoking during the perioperative period of pancreatic cancer have been not reported. Therefore, we performed an analysis of the relationship between smoking and the perioperative course of pancreatic cancer. Between April 2005 and March 2011, 96 pancreatic cancer patients underwent pancreatic resection in Kumamoto University Hospital. Seventeen parameters were analyzed. Smoking was a significant risk factor for surgical site infection, but did not influence circulatory, brain, or respiratory complications, the period of hospitalization, or prognosis. We review the influence of smoking in pancreatic cancer patients during the perioperative period.

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BACKGROUND: The number of patients diagnosed with diabetes mellitus (DM) is increasing year by year, and approximately one out of five adults may have diabetes. DM is well known to be a risk factor for pancreatic cancer. If we could clearly identify more high risk individuals among this population, it could lead to early detection and treatment of pancreatic cancer. AIM: To identify biomarkers of pancreatic cancer in diabetic patients. METHODS: We examined the clinical features of 39 pancreatic cancer patients with DM. RESULTS: Many pancreatic cancer patients with DM had smoked and had family history of cancer. Their blood glucose controls had worsened, and experienced body weight loss 1 year before they were diagnosed with pancreatic cancer. None of patients within a 2-year history or newly diagnosed with DM had family history of DM, so they were supposed to be pancreatic diabetes. CONCLUSIONS: Diabetic patients with an aggravation of DM and body weight loss, or newly onset diabetic patients without family history of DM are suspect to have pancreatic cancer and should be screened accordingly.

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No less than 56% cases of pancreatic cancer with long duration type 2 diabetes (DM) failed to show any clinical symptoms at the time of diagnosis. This rate was statistically significantly higher than that in cases with usual pancreatic cancer (12%). The better cases in usual pancreatic cancer, with regards to clinical stage, radical resection rate, and overall survival, were found to be more significantly frequent in cases without any symptoms. Whereas a similar tendency was found in each of the stated categories, there was not statistically significant difference in cases with DM. To discover the disease as early as possible, and improve the prognosis, imaging and diagnostic examinations should be performed regularly during following up of patients with type 2 diabetes mellitus.
A prospective study with a larger population is warranted to confirm our recommendation as sample size of the cases with DM was small.

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OBJECTIVE: We conducted a retrospective investigation to establish efficient screening for pancreatic cancer in patients with diabetes.
METHOD: Of 287 pancreatic cancer patients, 68 patients who already had underlying diabetes at the time of diagnosis of the pancreatic cancer were included in this study. These 68 patients were divided into two groups: Diabetes-related diagnosed group (Group 1), in which the pancreatic cancer was detected by diagnostic imaging at the time of worsening of diabetes, and the Diabetes-non-related diagnosed group (Group 2), in which the pancreatic cancer was diagnosed independently from diabetes. Clinical factors were compared between in the two groups.
RESULTS: There were 34 cases in the Group 1 and 34 cases in the Group 2. There were no significant differences in the levels of symptoms, tumor markers, or tumor size between two groups. Mean HbA1c was significantly higher in the Group 1 (10.0±1.9% vs. 8.6±2.1%, p=0.006). The surgical resection rate was also significantly higher in the Group 1 (41.1% vs. 18.0%, p=0.02).
CONCLUSION: Intensive examination such as diagnostic imaging might be effective for early detection of pancreatic cancer in diabetic patients with elevated HbA1c greater than 10%.

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The establishment of high-risk groups and proactive approaches are important for early detection of pancreatic cancer. In this study, we carried out a detailed analysis of pancreatic cancer patient backgrounds and clinical characteristics to investigate the related risk factors and issues. Subjects were 153 patients with pancreatic cancer who were treated at our hospital between July 2003 and February 2011. The control group comprised 153 individuals matched for sex and age who tested positive for fecal occult blood during the same period. An investigation of the sex ratio among pancreatic cancer patients showed that lesions of the head of the pancreas were characteristically more frequent in women than in men. In terms of the principal complaint on initial examination, back pain and loss of appetite tended to be more common in advanced cases. In comparison with the control group, men had a significantly higher frequency of a previous history of a different cancer, as well as a higher tendency toward diabetes. The breakdown of previous different cancer types among men revealed a high frequency of gastrointestinal cancer, including 10 cases of gastric cancer and 5 of colorectal cancer. This suggests that men with a previous history of a different cancer, chiefly gastrointestinal cancer, may comprise a potential new risk group.

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[in Japanese]

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Pancreatic tumors with combined exocrine and endocrine features are rare. Most of the reported cases are classified as mixed exocrine and endocrine carcinoma of the pancreas. We retrospectively reviewed three cases of pancreatic tumors with combined exocrine and endocrine features that underwent surgical resection. Two cases had multiple concomitant tumors that contained isolated exocrine and endocrine characteristics simultaneously, and one case had mixed tumors. In the multiple concomitant cases, EUS images showed neuroendocrine tumors as well-defined, round, regular, low echoic masses and enhanced CT showed late enhancement in the ductal cell carcinoma. In the mixed tumor case, EUS images showed an irregular low echoic mass with high echoic parts and enhanced CT showed enhanced parts in early phase. It is important to keep in mind that there may be multiple lesions present in cases of pancreas tumors, and should therefore perform exams accordingly.

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Objective: To assess the cost-utility of chemotherapy for patients with unresectable pancreatic cancer, we compared two regimens containing either gemcitabine (GEM) or S-1.
Methods: We developed a decision tree reflecting the clinical processes of unresectable pancreatic cancer patients. We calculated the probabilities of endpoint and life-months gained based on clinical trials. To estimate the costs, we analyzed medical records of inpatients with unresectable pancreatic cancer treated with GEM or S-1. Utility score was measured for physicians using the EuroQol 5-Dimension. Sensitivity analysis was used to check the robustness of the results.
Result: In the GEM group and S-1 group, costs were 1,636,393 and 985,042 yen, and quality adjusted life months (QALM) was 3.79 and 7.18 months, respectively. Thus, the cost-utility ratio was calculated to be 431,766 and 137,192 yen/QALM, respectively, and the incremental cost utility ratio was -202,913yen/QALM. The sensitivity analysis showed that this finding was definitely robust.
Conclusion: Our findings suggest that the S-1 regimen could increase QALM with less cost than the GEM regimen, and that the S-1 regimen is considered a markedly cost-effective treatment.

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A 78-year-old man had undergone laparoscopic cholecystectomy for cholecystolithiasis at another hospital. Preoperative magnetic resonance imaging incidentally revealed an 18mm mass lesion in the pancreatic body. After the operation, he was referred to our hospital for further examination and treatment of the pancreatic mass. On admission, he was afebrile and asymptomatic. Contrast-enhanced computed tomography showed a 22mm mass lesion in the pancreatic body which was mildly enhanced. Positron emission tomography-computed tomography scan showed no fluorodeoxyglucose uptake in the mass. Endoscopic ultrasonography showed a hypoechoic irregular mass. On the basis of the findings from the imaging series, he was likely to have a solid pancreatic neoplasm, therefore surgery was performed. Histological examination revealed fat necrosis with xanthogranulomatous inflammatory (XGI) change. XGI of the pancreas is an extremely rare condition. Herein, we report a case of XGI of the pancreas mimicking a pancreatic neoplasm.

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A 69-year-old male with chronic renal failure, due to diabetic nephropathy, had received maintenance dialysis (twice/week) since July 2008. Multiple liver tumors were seen in routine abdominal ultrasound, and diagnosed as carcinoma of tail of pancreas with multiple liver metastases on CT. The patient was admitted to the Gastroenterology unit of our hospital in April 2009, and single GEM chemotherapy was started together with hemodialysis. Gemcitabine (1000mg/m²×3 times/month) was given on Monday evening, and hemodialysis was performed on Tuesday and Saturday to remove gemcitabine metabolites. Extension of dosage interval, dosage adjustment, and drug withdrawal were required due to pancytopenia and fever occurring after the administration of gemcitabine. Furthermore, blood transfusion and percutaneous transluminal angioplasty (PTA) were given for shunt failure due to severe anemia and low blood pressure. One and a half months after treatment, CT showed stable disease (SD) and also there was reduction in serum CA19-9, the patient was discharged from hospital and continued treatment as outpatient follow-up till June 2010, when the patient expired. Although there is continued hemodialysis in patients due to an increase in aging populations and lifestyle related diseases, reports on antineoplastic agents are still very rare.

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The patient was a 78-year-old man who had a pancreaticoduodenectomy for main duct intraductal papillary mucinous carcinoma (IPMC) in January 2010. A blood analysis in September 2010 showed the progression of anemia and increased tumor marker; a bleeding tumor at the pancreaticogastrostomy portion was identified by gastric endoscopy. We performed total resection of the remnant pancreas combined with partial gastrectomy and splenectomy. Histopathological diagnosis was IPMC. This diagnosis suggested that the tumor was likely to be a local recurrence or multiple metachronous lesions. Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing tumor which contains various histological types from benign tumors to malignant tumors. The prognosis of invasive IPMC is better than that of ordinary typed pancreatic cancer. As patients with IPMN have the possibility of local recurrence, multicentric occurrence in the remnant pancreas, occurrence of ordinary-typed pancreatic cancer, and extrapancreatic cancer, we should follow-up these patients carefully.

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