Prognosis of acute pancreatitis (AP) depends on various clinical conditions. The assessment of the severity of AP plays an important role in making a decision on a proper treatment. This study was aimed at clarifying the risk factors for the mortality of AP. A nationwide epidemiological survey was conducted targeting AP patients treated in 2007 in Japan. From this survey, clinicoepidemiological information of 2100 cases, 2055 survival cases and 45 dead cases, was collected from the medical records of the patients. Using univariate logistic regression analysis, we found 7 clinical variables that predicted for the mortality of AP. Age; organ failure during 72 hours of onset; inflammation beyond the lower pole of kidney on CT; hypoenhanced lesion of the pancreas on CT; sepsis; pancreatic abscess; intraperitoneal abscess. Stepwise logistic regression revealed that 3 variables were associated with the mortality of AP: age, organ failure and hypoenhanced lesion of the pancreas on CT. In conclusion, early assessment of these factors for the diagnosis of the severity is crucial in the clinical practice of AP.

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The diagnostic and severity assessment for acute pancreatitis of the Japan Ministry of Health, Labour and Welfare (MHLW) has been used for the diagnosis and the severity judgment of acute pancreatitis in Japan. But in late years, the urinary trypsinogen-2 and the blood procalcitonin (PCT) are reported to be useful in diagnosing acute pancreatitis and levels of these were shown to be elevated in severe cases.
Although trypsinogen-2 was approved in MHLW insurance, its insurance mark was too low for marketing. We can determine levels of trypsinogen-2 similar to a urine test tape, and this would aid the doctors in clinics for the diagnosis/exclusion of acute, especially severe, pancreatitis in 5 minutes. From the viewpoint of early diagnosis/treatment of severe pancreatitis, and improving prognosis, the reevaluation of the insurance mark of the urinary trypsinogen-2 is necessary.
Also, PCT has been approved by insurance for infection, but not for acute pancreatitis. Since it is reasonable to use PCT for the diagnosis severe acute pancreatitis, we hope that PCT would be approved in MHLW insurance for acute pancreatitis.

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In 85 patients with acute pancreatitis (44 with mild and 41 with severe), we evaluated total hospitalization costs with fee-for-service-based (FSB) payment and treatment methods according to severity and reason of severe pancreatitis (S group: determined by prognostic score alone, C group: by CT grade alone, and SC group: by score and CT grade). Mortality did not significantly differ between mild and severe pancreatitis: 0% vs. 7.3% (p=0.108). In the patients with severe pancreatitis, ICU and hospital stays were significantly longer and total hospitalization costs were significantly higher, showing significantly higher number of patients requiring special treatment (mechanical ventilation, renal replacement therapy and percutaneous drainage). In comparison among S (n=7), C (n=16) and SC (n=18) groups, hospitalization costs were higher in C and SC groups than in S group, showing much higher number of patients requiring special treatment in C and SC groups. Based on medical costs and resources, the patients requiring intensive care and/or showing high CT grade should be considered as high severe group.

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Primary imaging for the diagnosis of acute pancreatitis is transabdominal ultrasonography (US). Pulse Doppler study has concluded that increased proper hepatic arterial velocity and decline in pulsatility index of superior mesenteric artery are evident in severe acute pancreatitis. Contrast enhanced US reveals pancreatic hypoperfusion in patients with severe acute pancreatitis. Parametric US image by using perflubutane has a high level of visibility for pancreatic ischemia. Reference CT image of subtraction color map helps identification of ischemic area on the parametric US image. In the early stage of severe acute pancreatitis, diminished intestinal flow volume may occur without vascular resistance augmentation or prolonged intestinal circulation time.

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Initial criteria of severe acute pancreatitis are defined as the presence of systemic complications (organ failure) or local complications (pancreatic necrosis and pseudocyst). In the latest definition of severity of acute pancreatitis, the patient is categorized into three groups according to pancreatic necrosis and/or persistent organ failure (POF); patient with POF into severe acute pancreatitis, patient with pancreatic necrosis and without POF into moderate severe, and patient without pancreatic necrosis and POF into mild. Therefore, to accurately evaluate severity, it is very important to diagnose pancreatic necrosis. In this paper, from a literary perspective, we reviewed the roles of pancreatic necrosis, organ failure, and systemic circulation failure in the early stage of severe acute pancreatitis.

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A large amount of experimental and clinical data providing evidence on the usefulness of continuous regional arterial infusion (CRAI) therapy for severe acute pancreatitis (SAP), including a randomized controlled trial, have been collected since 1996. CRAI therapy, in the early phase of SAP, can reduce the incidence of pancreatic infectious complications and mortality rate in patients with acute necrotizing pancreatitis. CRAI therapy can be applied for patients with SAP in whom contrast-enhanced computed tomography (CECT) shows pancreatic ischemia and/or necrosis in the early stage of SAP.

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Severe acute pancreatitis is the serious disease in which mortality reaches 20%, and having an infection or not greatly affects the prognosis. Prophylactic antibiotics are not necessary for mild acute pancreatitis. Carbapenem antibiotics such as imipenem are recommended with prophylactic antibiotics for by severe acute pancreatitis. But it applications is not standardized in each facility with respect to the starting time or the dosage period. As a result, multidrug resistant bacteria and fungal infections are caused by antibiotic overdose, and these cases become hard to treat. The antibiotical use guidance plan being considered now uses a preventive dose for a maximum of five days, and local administration with an intra-arterial injection is recommended over administration via general injection. It is important to use preventive and therapeutic strategies properly, and the establishment of an optimal protocol is important in combination with enteral hyperalimentation. Future work to address and correct this problem is needed.

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The poor prognosis of severe acute pancreatitis is incurred from late infectious complications. Most of the complications from late infectious are attributed to bacterial translocation. Nutritional management in severe acute pancreatitis has been emphasized since bacterial translocation plays an important role in the manifestation of infections. Several randomized controlled trials have suggested the strong superiority of enteral nutrition, and meta-analyses have shown significant reductions in the incidence of infectious complications and the length of hospital stay. Enteral nutrition results in clinically relevant and statistically significant risk reduction for infectious complications, pancreatic infections, and mortality in patients with predicted severe acute pancreatitis. The obvious usefulness of enteral nutrition is observed in patients starting within 48 hours after hospitalization. We performed a survey of the conference members of JCNT regarding the implementation of enteral nutrition for acute pancreatitis. However, the most common answer about the starting day of enteral nutrition for acute pancreatitis was 7 days (34% of the hospitals that had answered the inquiry questions). In actuality, there are many problems that restrict enteral nutrition, such as disturbance of bowel movement, high levels of pancreatic enzyme, abdominal pain, and nausea at the time of initiation of enteral nutrition. At present, the administration of elemental diets through a jejunal tube is considered to be the best, however, gastric tube tends to be accepted for early enteral nutrition. It is important to consider that the nutritional management of acute pancreatitis should be judged with carefully taking the patient's condition into consideration. Whenever possible, enteral feeding rather than total parenteral nutrition (TPN) is suggested for patients who require nutritional support. NST team support will have a chance to improve the outcome of severe acute pancreatitis.

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A better understanding of the pathophysiology of necrotising pancreatitis and its outcomes as well as improved diagnostic imaging has made it necessary to revise the Atlanta Classification 1992. In the revised classification 2012, the term 'pancreatic abscess' is not used and instead a new concept of walled-off necrosis (WON) has been adopted. WON is a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis (variable amounts of both fluid and necrosis associated with necrotising pancreatitis) and has a well defined inflammatory wall; usually this maturation occurs ≥4 weeks after onset of necrotising pancreatitis. In the revised classification, an important distinction is made between collections that are composed of fluid alone (fluid collections) versus those that arise from necrosis and contain a solid component (necrotic collections): the latter is subdivided into acute necrotic collection (ANC) and WON. Infection of ACN or WON is defined as infected necrosis.

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Pancreatic pseudocyst (PPC)/walled-off necrosis (WON) after severe acute pancreatitis is a typical tardive complication, and, as for the case of a symptomatic WON or infected WON, drainage is required. EUS-guided drainage through the gastrointestinal tract has been widespread and good treatment outcomes for PPC were reported. However, WON contains necrotic debris, and therefore often requires more aggressive therapy such as endoscopic necrosectomy. Drainage using a large bored dedicated metal stent, additional endoscopic drainage technique, and hybrid approach through percutaneous drainage were reported. Owing to the remarkable progress of endoscopic therapy, almost all WON has become treatable by endoscopic therapy alone. However, a wide visual field would be needed if surgery is required for the treatment of WON without the need of endoscopic therapy.

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The Atlanta Classification was revised in 2012 and established four key terms, acute peripancreatic fluid collection (APFC), acute necrotic collection (ANC), pancreatic pseudocyst (PPC), and walled-off necrosis (WON), as local complications in patients with severe acute pancreatitis. According to the new classification, surgical interventions including drainage and necrosectomy, should be clearly differentiated. In this decade, minimally invasive interventions, such as percutaneous drainage and necrosectomy, laparoscopic necrosectomy, and retroperitoneal necrosectomy, have been introduced. The indications and details of the technique for these minimally invasive interventions should be discussed to establish a worldwide consensus.

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BACKGROUND: The aim of this study was to assess the effectiveness of using S-1 as adjuvant chemotherapy after the resection of pancreatic cancer.
METHODS: S-1 was administered orally at the recommended dose (RD; 80mg/m², maximum 120mg/day) twice daily for 14 days, followed by a rest period of seven days to complete one course. Administration was planned to continue at least 6 months (eight courses). The cumulative relative total administered dose rate (RDI), relapse-free survival rate (RFS) and the median overall survival time (MST) was calculated by using the Kaplan-Meier method.
RESULTS: Nineteen patients who had undergone resection of pancreatic adenocarcinoma were enrolled in this study. The planned dose could be administered to 13 patients (68.4%). Although grade 3 anemia occurred in one patient, grade 3 to 4 hematologic adverse events were not observed. The RDI of S-1 was 0.87. The 2-year and 5-year RFS was 42.1% and 26.3% respectively. The MST was 30.1 months.
CONCLUSIONS: Postoperative administration of S-1 at the RD is clinically safe and appears to be a promising method of adjuvant chemotherapy.

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A 66-year-old female patient with resectable pancreatic body cancer had previously received the preoperative gemcitabine-based chemoradiation therapy and a subsequent distal pancreatectomy combined with liver perfusion chemotheprapy. Histopathological assessment of the resected specimen revealed no viable tumor cells (pathological complete response). She received the scheduled postoperative follow-up, and revealed a tumor in the upper lobe of right lung 30 months after the initial pancreatectomy. Because of the absence of the recurrence of pancreatic cancer in sites other than the right lung, the patient underwent a partial resection of the right upper lobe. The diagnosis of the lung metastasis originated from pancreatic cancer was confirmed based on histological as well as immunohistopathological assessments. The patient developed tumor recurrences in mediastinal lymph nodes and carcinomatous pleuritis 6 months after the second surgery, and died 47 months after the initial pancreatectomy and 14 months after the second surgery for the lung metastasis. This case indicates the pathophysiology of a systemic disease even in the case of localized pancreatic cancer, and thus, the therapeutic strategy, based on the fact that the pancreatic cancer is potentially a systemic disease, is needed to improve the surgical outcome of advanced pancreatic cancer.

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A man in his seventies with abdominal pain was admitted to our hospital. He was an alcoholic. Various images showed a pancreatic stone about 5-mm diameter in the pancreatic body and a pancreatic cyst from this locus to the diaphragm. We suspected pancreatic pseudocyst due to acute exacerbation of chronic pancreatitis with a pancreatic stone. Endoscopic retrograde pancreatography (ERP) revealed pancreatic disruption and leakage. We placed a 5-Fr endoscopic nasopancreatic drainage (ENPD) tube in the cyst, and drained the infectious pancreatic juice. We placed a 7-Fr pancreatic stent on the seventh day from ENPD tube placement. The abscess disappeared about 2 months later. We removed the pancreatic stent and have followed up. For pancreatic pseudocysts, which have a connection between cystic lesions and the main pancreatic duct, endoscopic pancreatic stenting is effective.

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A 63-year-old man underwent right nephrectomy and interferon therapy for right renal cell carcinoma (RCC) with lung metastasis in 1999. He had treatments for brain metastases in 2003 and 2004. In 2008, he underwent central pancreatectomy for pancreatic metastasis. In May 2012, follow-up CT studies showed a hypervascular mass in the distal pancreatic remnant. Based on the diagnosis of remnant pancreatic metastasis from RCC without other metastasis, spleen-preserving remnant distal pancreatectomy was performed in July 2012. Histological examination confirmed a clear cell carcinoma compatible with metastasis from RCC. Despite a number of reports describing multiple pancreatic metastases from RCC, literature scarcely exists on repeated pancreatic resections for the disease. Of note in this patient, repeated limited resections of the pancreas could preserve pancreatic parenchyma and the spleen. In conclusion, limited pancreatectomy should always be considered even for patients with the recurrent disease when complete tumor removal is possible.

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A 75-year-old male patient underwent laparoscopic-assisted low anterior resection of the rectum with D3 lymph node dissection. The pathological diagnosis was papillary adenocarcinoma (se, ly0, v2, N0, P0, H0, M0, Stage II). He also underwent right pulmonary surgery for right pulmonary metastasis, and left adrenalectomy for left adrenal metastasis 18 months and 33 months after the primary surgery, respectively. During his follow up, computed tomography scan revealed a tumor 3cm in size in the head of the pancreas 56 months after the primary surgery. After several detailed examinations, with a diagnosis of pancreatic metastasis from the rectal cancer, a pancreaticoduodenectomy was performed 58 months after the initial surgery. The pathological diagnosis was the metastasis to the pancreas from the rectal cancer, because tumor cells were immunohistochemically negative for cytokeratin 7 and positive for cytokeratin 20. There has been no indication of recurrence for 21 months after the pancreatic surgery. Resectable pancreatic metastasis from colorectal cancer is rare, but pancreatic resection may achieve long-term survival in some cases. We present this case with a review of the literature.

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A 55-year-old man was referred to our hospital for further examination of a mass lesion in the pancreatic body. Contrast-enhanced CT scan showed a 5cm pancreatic body tumor on delayed contrast-enhanced on the peripheral lesion without signs of calcification. Endoscopic ultrasonography revealed massive cystic change in the tumor and ventral deviation of the main pancreatic duct. We performed EUS-FNA to differentiate solid-pseudopapillary neoplasm (SPN), neuroendocrine tumor with cystic change and acinar cell carcinoma. The EUS-FNA pathology showed fibrovascular pseudopapillary structure and solid hyperplasia of small tumor cells. Therefore we performed distal pancreatectomy based on the diagnosis of SPN. Male cases of SPN are rare and sometime present different clinical findings from female cases. EUS-FNA is useful for the differential diagnosis of pancreatic tumor in such cases.

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We report a case of anaplastic ductal carcinoma with ossification. A 61-year-old man was admitted to our hospital complaining of hematemesis. CT and MRI showed a sharply demarcated tumor 7cm in diameter at the tail of the pancreas. Hemorrhage, necrosis and calcifications were demonstrated on the inside of the tumor, a neoplasm of the pancreas was suggested and a distal pancreasectomy was performed. The pathological examination revealed that undifferentiated malignant cells with osteoclastic polynuclear giant cells and ossification were present in the tumor tissue. Immunohistochemical studies of tumor cells were positive for vimentin staining. Thus anaplastic carcinoma with osteoclast-like giant cells of the pancreas was diagnosed. Pancreatic neoplasms sometimes contain calcifications, however, it is very rare that ossification is seen in the tumor tissue.

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