Three clinical guidelines and large retrospective studies were reviewed regarding a clinical question "Should all MCNs of the pancreas be resected?". IAP guidelines and European consensus statements proposed different treatments for IAP and MCN, while AGA guidelines do not clinically differentiate IPMN and MCN and treat as one entity. IAP proposed resection for MCNs once diagnosed preoperatively, while AGA guidelines and European consensus statements proposed different management for MCN based on the malignant indicators. Malignant predictors include symptomatic factors, tumor markers, cyst size, mural nodule, dilated main pancreatic duct. Some large retrospective studies propose resection for all MCNs and others perform operative indications based on the malignant predictors. In this review, the management of MCN was reviewed based on three clinical guidelines and large retrospective studies.

In recent years, early nasojejunal tube enteral nutrition (NJT-EN) has been recommended. We retrospectively compared the usefulness of nasogastric tube enteral nutrition (NGT-EN) and total parenteral nutrition (TPN) in severe acute pancreatitis (SAP).

The subjects were 96 patients with SAP treated in our department between 2005 and 2013. Recovery time and complications were compared in the TPN group (14 patients), early and middle NGT-EN group (EN started within 8 days after the onset, 30 patients), late NGT-EN group (EN started after 9 or more days after the onset, 35 patients), and TPN(-) EN(-) group (12 patients).

Result, the resumption of oral ingestion was significantly earlier and CHDF enforcement rate was significantly lower in the early and middle NGT-EN group than in the TPN group. There were also significant differences between the early and middle NGT-EN group and late NGT-EN group in the resumption of oral ingestion and CHDF enforcement rate.

Based on the results, early and middle NGT-EN within 8 days after the onset of SAP is recommended to shorten the recovery phase and prevent multiple organ dysfunction.

Contrast-enhanced CT of a 49-year-old woman with back pain revealed a low-density tumor in the pancreas head and multifocal liver metastases. Endoscopic ultrasonography-guided fine needle aspiration of the tumor led to the diagnosis of anaplastic carcinoma of the pancreas. The patient was referred to our hospital for chemotherapy. A combination therapy with 80% doses of gemcitabine and nab-paclitaxel was administered. Follow-up CT after the chemotherapy showed slight reduction of the primary pancreatic tumor and remarkable reduction of liver metastases. Three months after introduction of the chemotherapy, however, the combination therapy had to be changed to monotherapy with S-1 due to appetite loss and decreasing activity of daily living. The patient died four months after the first visit due to general prostration. Autopsy revealed pleomorphic anaplastic carcinoma of the pancreas. Pleomorphic anaplastic pancreas carcinoma is a rare and highly virulent condition, and above all, there have been almost no reported cases that have showed any response to chemotherapy. The partial response described in this report would be instructive in deciding treatment strategy for unresectable pleomorphic anaplastic carcinoma of the pancreas.

A 65-year-old man was admitted to our hospital with mild acute pancreatitis. Contrast enhanced CT and MRI revealed dilatation of the main pancreatic duct as well as the branch ducts at the pancreatic tail. Endoscopic ultrasonography depicted an anechoic region considered as expansion of the branch ducts, and a 10mm hypoechoic region which could not be recognized as a solid tumor. ERP confirmed the main pancreatic duct stenosis and serial pancreatic juice aspiration cytological examination (SPACE) revealed atypical cells. Thus the patient was diagnosed as pancreatic carcinoma, therefore, surgical resection was performed. Histological examination of the surgical specimen revealed that carcinoma in situ was present in the branch duct close to the stenosis of the main pancreatic duct. The hypoechoic region on the endoscopic ultrasonography appeared to represent an indirect image finding of pancreatic carcinoma in situ. Thus, in such instances, SPACE can facilitate the diagnosis of pancreatic carcinoma in situ.

We report a case of pancreatic neuroendocrine carcinoma diagnosed by using EUS-FNA. The patient was a 73 year-old man with a pancreatic body tumor. There was no elevation of CEA and CA19-9. Contrast enhanced CT images showed a pancreatic tumor as a hypovascular lesion of 30mm in diameter with main pancreatic duct dilation. The border of tumor was clear and irregular. The tumor was proximal to the portal vein, common hepatic artery, and gastroduodenal artery. Multiple liver tumors were detected in DWI-MRI. The pancreatic mass was detected as a low echoic lesion whose border was clear and irregular by EUS. We performed EUS-FNA with 22G needle, and the sample led to the pathological diagnosis of small cell neuroendocrine carcinoma. After diagnosis, he received chemotherapy with irinotecan and cisplatin. He died 6 months later due to cancer progression.

Background: Surgery for chronic pancreatitis (CP) is mainly classified into two groups: drainage of pancreatic duct and pancreatectomy. It is important to select the optimal procedure according to the condition of the pancreas. We encountered a CP patient who received subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) with longitudinal pancreatojejunostomy (LPJ) due to severe inflammation at the pancreatic head and duodenum.

Course of treatment: A male in his 40's was admitted to our hospital due to an acute exacerbation of CP. Preoperative examinations revealed calcification of the pancreatic head and cystic lesions with hematoma near the pancreatic head. In addition, a stenotic duodenum with a fistula and calcification in the pancreatic tail were seen. Though Frey's procedure has been selected as the first choice of the surgical therapy for CP in our institution, we selected SSPPD with LPJ in this case because the inflammation of the pancreatic head had extended to the duodenum and the therapeutic effect of Frey's procedure might have been insufficient. Though the patient had postoperative intraperitoneal abscess, it was diminished by drainage. He was discharged without any symptoms.

Conclusion: SSPPD with LPJ can be considerable for cases in which inflammation of the pancreatic head is too severe and the therapeutic effect of Frey's procedure might be insufficient.

A 60-year old man was referred to our department after diffuse pancreatic enlargement was detected with computed tomography (CT) prior to surgery for bladder cancer. Autoimmune pancreatitis (AIP) was strongly suspected due to the findings of diffuse pancreatic enlargement and multiple narrowing in the pancreatic duct. However, histopathological diagnosis via endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) identified a neuroendocrine tumor (NET, Ki-67 index 7%). Somatostatin-receptor scintigraphy, which was performed to find systemic metastases, showed diffuse uptake in the pancreas, as well as a hepatic metastatic lesion and numerous bone metastatic lesions that had not been detected on CT. Subsequent pathological reevaluation determined that the bladder tumor was also an NET. Accordingly, pancreatic NET and systemic multiple metastases were determined to be the final diagnosis.

Herein, we reported two cases of minimally invasive ductal pancreatic carcinoma. The first patient was a 59-year-old woman and the second was 62-year-old woman. Both patients had localized main pancreatic duct (MPD) stenosis of the pancreatic head and dilatation of the upstream MPD, but no mass was detected using endoscopic ultrasound (EUS), enhanced computed tomography, magnetic resonance imaging, and Fluorodeoxyglucose-positron emission tomography examinations. We diagnosed pancreatic carcinoma in situ by endoscopic nasopancreatic drainage (ENPD) and serial pancreatic-juice aspiration cytological examinations (SPACEs). The patients underwent pancreaticoduodenectomy. Histological diagnosis were minimally invasive ductal pancreatic carcinoma in situ for both patients (tumor sizes 0.4×0.3cm and 0.3×0.2cm, respectively) with lymph node metastasis for the first case. When both localized MPD stenosis and dilatation are present, the possibility of an invasive ductal pancreatic carcinoma should be considered, even if a mass or low echoic areas are not detected using EUS. We argue the necessity of ENPD and SPACE in such cases.