Background: Surgery for patients with chronic pancreatitis (CP) is recommended when medical and endoscopic treatments fail in the Japanese practice guidelines. However, the optimal timing of surgery is not mentioned.

Purpose: To investigate the optimal timing of surgery for CP.

Methods: Postoperative outcomes were compared between patients undergoing early surgery (preoperative interval less than 5 years, N = 30), and those undergoing late surgery (interval of 5 years or more, N = 20). All patients underwent longitudinal pancreaticojejunostomy, from January 2005 to April 2016 at our institution.

Results: There were no significant differences in patients' background or perioperative outcomes. Thirty-eight patients were analyzed one year after surgery (Early group: 20, Late group: 18). Nutritional status improved in both groups, and there were no significant differences between the two groups. Pain was also significantly improved in both groups. There was no new onset of diabetes mellitus or pancreatic cancer during the follow up period.

Conclusion: Regardless of preoperative interval, surgical intervention was effective for patients with CP. Early surgical intervention may improve QOL by reducing disease duration.

An 83-year-old male was noted to have an elevated serum amylase level. Contrast enhanced CT scan revealed a heterogeneous mass in the head of the pancreas. The lesion was diagnosed as a solid pseudopapillary neoplasm (SPN) by EUS-FNA. We performed a subtotal stomach-preserving pancreaticoduodenectomy and lymph node dissection. Macroscopically, the tumor was 40×30×25mm, composed of blood, cysts and necrotic tissue. The histological findings included solid and partial pseudopapillary structures. Immunohistochemical staining was positive for beta-catenin and vimentin and partially positive for CD10. There was no staining for chromogranin or progesterone receptor. The final diagnosis was SPN. The patient is doing well and has no evidence of recurrence 2-years postoperatively. The number of male patients with SPN has been increasing recently, but there are no patients reported to date with SPN older than age 80. We believe that this patient is the oldest male yet reported with SPN.

The patient is a man in his 70s. Elevated serum Elastase1 and dilatation of the main pancreatic duct were detected on routine medical evaluation and he was referred for farther examination. A dynamic CT-scan and MRI showed an inhomogeneous 20mm mass in the pancreatic uncus with mild contrast enhancement. Pancreatic ductal adenocarcinoma was suspected. Pancreatic acinar cell neoplasm or neuroendocrine neoplasm were also considered and pylorus preserving pancreaticoduodenectomy was performed. The histopathological findings showed a papillary proliferation associated with nuclear atypia in the stenotic area of the main pancreatic duct. No cell invasion was seen beyond the pancreatic duct. The pathological diagnosis was a high-grade pancreatic intraepithelial neoplasm. The mass seen on the CT-scan was composed of marked fibrosis with invasion of fat tissue. The postoperative course was uneventful. Local fatty changes and atrophy of the pancreatic parenchyma were recently described as characteristic of early-stage pancreatic ductal adenocarcinoma, as seen in this patient. We report this patient with a literature review of the molecular mechanisms of fibrotic change.

A 59-year-old asymptomatic woman was found to have a cystic mass in the tail of the pancreas during a periodic health examination and was referred for further evaluation. A 5 × 3cm multilocular lesion was seen on contrast-enhanced computed tomography scan. The central part of the lesion was solid and deeply enhanced in the early phase and surrounded by larger multi-lobed cysts. The lesion was also recognized to have multi-lobed cysts with high intensity on T2-weighted images of MRI and MRCP. Intra-cystic nodules and a honeycomb-like area were seen on endoscopic ultrasound imaging. One of the pancreatic cysts appeared to communicate with the main pancreatic duct using endoscopic retrograde pancreatography. Cytology of the pancreatic fluid did not show malignant cells. Distal pancreatectomy and splenectomy was performed. Histopathological evaluation showed a serous cystic neoplasm (SCN, microcystic type) and intraductal papillary neoplasm (IPMN, gastric type) located next to each other. Synchronous pancreatic SCN and IPMN are extremely rare. This paper reports our experience together with a review of the literature and comment.

A 47-year-old man presented with a mass in the pancreatic tail diagnosed by transabdominal ultrasonography. A contrast-enhanced CT scan showed a 15mm mass with central calcifications which gradually enhanced from early to late phases. Based on endoscopic ultrasonography imaging, the mass was hyperechoic mainly in the central area despite the margin being hypoechoic. Based on imaging studies, a solid-pseudopapillary neoplasm (SPN) and pancreatic neuroendocrine tumor were considered in the differential diagnosis. Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) was performed, followed by hematoxylin-eosin staining and immunostaining, to definitively establish the diagnosis of SPN. We performed a distal pancreatectomy, and the mass was histologically confirmed to be an SPN from the resected specimen. In this patient, diagnosis using imaging studies alone was inconclusive since the mass had an atypical internal echo by ultrasonography. Therefore, EUS-FNA played a relatively important role in the preoperative diagnosis of SPN for this mass lesion with atypical ultrasonographic findings.

We describe a patient with neoplastic aneurysms which developed in areas of pancreatic choriocarcinoma during chemotherapy. A 43-year-old female presented with irregular metrorrhagia. CT scan demonstrated a 2.5cm mass in the head of the pancreas and multiple lesion in the lung, liver, adrenal gland and lumber vertebra. The pancreatic tumor enhanced peripherally in the arterial phase and enhanced similar to the surrounding parenchyma of the pancreas in the delayed phase. We performed a lumber vertebra biopsy and diagnosed multiple organ metastases from choriocarcinoma, histologically.

EMA/CO chemotherapy was used to treat this patient for advanced choriocarcinoma. Neoplastic aneurysms developed in the pancreatic lesion of the choriocarcinoma while receiving chemotherapy. Preventive coil embolization was performed on the pancreatic aneurysms. After preventive coil embolization, EMA/CO chemotherapy was continued. Consequently, the EMA/CO chemotherapy was effective and complete remission was obtained.

Pancreatic lesions of choriocarcinoma are extremely rare, however choriocarcinoma result in neoplastic aneurysm formation in the primary and metastatic lesions.

It is necessary to observe the clinical course of pancreatic choriocarcinoma carefully whether strongly stained areas in the tumor progress to neoplastic aneurysms. Chemotherapy should be given to patients with choriocarcinoma while considering the treatment for the aneurysm.

A 50s man underwent pancreaticoduodenectomy for extrabiliary cancer and 19 months after surgery presented with a fever. Serum hepatic and biliary enzyme levels gradually increased. DIC-CT scan showed intrahepatic stones in the left hepatic ducts. He was successfully treated with fasting and antimicrobial agents and then underwent endoscopic retrograde cholangiopancreatography. Biliary lithotripsy was performed and the pancreatic stent dislocated into the intrahepatic bile duct.

A 50s woman underwent pancreaticoduodenectomy for intraductal papillary mucinous adenoma. Six months after surgery, she presented with abdominal pain. CT scan showed an enlarged pancreas. She was treated successfully with fasting and ulinastatin and endoscopic retrograde pancreatography was performed. The pancreatic stent became dislocated.

Based these findings, we conclude that dislocation of the pancreatic duct stent may be a long-term complication. Based on an individualized approach, a pancreatic duct stent may not be necessary when performing pancreaticoduodenectomy.

An 81-year-old woman presented with epigastric pain. A tumor in the pancreatic head was found and she was referred for further evaluation and treatment. Contrast enhanced computed tomography scan showed a hypovascular 1.5cm mass in the pancreatic head. We diagnosed resectable pancreatic cancer, cT3 cN0 cM0 cStage IIA (General rules for the study of pancreatic cancer, Japan Pancreas Society 7^th Edition). We did not perform PET-CT or fine needle aspiration preoperatively and performed a subtotal stomach-preserving pancreatoduodenectomy. Histopathological examination failed to reveal malignancy, but revealed a xanthogranulomatous inflammatory tumor (xanthogranulomatous pancreatitis) of the pancreatic head. Xanthogranulomatous inflammatory tumor is extremely rare and difficult to differentiate from pancreatic cancer. Herein, we report a patient with xanthogranulomatous inflammatory tumor of the pancreatic head mimicking a pancreatic cancer, and summarize 27 previously reported cases.

A 54-year-old man with cancer of the pancreatic body underwent distal pancreatectomy. Chemotherapy was given as second-line treatment for local recurrence and distant metastases. He underwent three courses of FOLFIRIOX (oxaliplatin, irinotecan, fluorouracil and levofolinate calcium regimen) without difficulty. During the fourth course, he developed severe systemic blisters, abdominal pain, and back pain. Varicella was diagnosed based on the varicelliform rash. Acyclovir was given following hospitalization. Fever, hepatic dysfunction and disturbance of consciousness subsequently developed. Varicella zoster virus (VZV) was detected in the cerebrospinal fluid and disseminated VZV infection diagnosed. His condition improved with supportive care including antiviral therapy, steroids, as well as transfusion. The VZV infection resolved. Varicella is known to be aggravated in patients who are in an immunosuppressed state with leukemia or after transplantation. However, reports of varicella infections during chemotherapy for solid tumors are rare. It is necessary to be aware of the potential for such patients to develop a viral infection when they are undergoing chemotherapy for solid tumors.

The patient was a 77-year-old man who underwent distal pancreatectomy and splenectomy for intraductal papillary mucinous neoplasm (IPMN) at another institution 8 years previously. CT scan 7 snd 6 years previously showed no abnormalities. CT scan 3 years before revealed dilatation of the main pancreatic duct with multiple cystic lesions. Recurrent metachronous IPMN was suspected, and surgery was recommended but follow-up alone was conducted in accordance with the patient's wishes. CT 2 and 1 year previously showed enlargement of the cystic lesions. CT examination at presentation showed that multiple cystic lesions had become larger. Mural nodules were identified in the pancreatic body by endoscopic ultrasonography examination and remnant pancreatectomy performed. The patient's postoperative course was uneventful, and he was discharged 28 days postoperatively. The pathology results showed IPMN with high grade dysplasia, and metachronous recurrence diagnosed based on the absence of continuity with the previous lesion and multicentric pattern. This is a report of the natural history of metachronous recurrence after IPMN resection with imaging studies for 3 years.