Perioperative glycemic and nutritional management improves quality of life and improves a patient's prognosis. We retrospectively reviewed 32 patients who underwent total pancreatectomy (TP) performed from January 2008 to January 2020. We evaluated blood glucose and nutritional status preoperatively and at one year postoperatively and analyzed the relationship with surgical outcomes. Of 32 patients who underwent TP, 16 were one-stage TP and 16 were two-stage TP. Of 48 lesions, 38 were intraductal papillary mucinous neoplasms and invasive pancreatic ductal carcinoma. The 5-year survival rate was 60%, with no significant difference between one-stage and two-stage TP. The mean preoperative HbA1c was 6.7% which significantly increased to 7.7% postoperatively. The prognostic nutritional index (PNI) was 47.8 preoperatively which significantly decreased to 43.0 postoperatively. In univariate analysis of prognostic factors, one year postoperative neutrophile-lymphocyte ratio, preoperative platelet-lymphocyte ratio, and one year postoperative PNI were identified as significant factors. Multivariate analysis showed that postoperative PNI was a significant prognostic factor. The prognosis was significantly worse in the group with PNI <40.5. The prognosis was significantly improved in patients who received high-titer pancreatin. Since TP completely eliminates pancreatic endocrine and exocrine function, concurrent administration of insulin and exocrine replacement therapy based on a correct understanding of the pathological condition is important.

A 71-year-old man with epigastric pain was diagnosed with a pancreatic arteriovenous malformation (AVM) concomitant with acute pancreatitis and was brought to radiology for transcatheter arterial embolization (TAE). Computed tomography scan revealed abnormally dilated vessels in the pancreatic body and tail and a pseudocyst surrounding the tail of the pancreas. Angiography revealed an AVM across the entire pancreas, and TAE was contraindicated. Acute pancreatitis was treated non-operatively, and a pancreatic drain inserted due to stenosis of the main pancreatic duct. However, the patient remained refractory to this course of treatment for 6-months and was referred for surgical intervention. Distal pancreatectomy was performed, and the postoperative course was uneventful. No recurrence has occurred 4 years postoperatively. Surgery may be an effective therapeutic strategy for patients with pancreatic AVMs concomitant with acute pancreatitis.

We report a patient with a mixed acinar-neuroendocrine carcinoma and review of the literature. A 57-year-old man was referred for a cystic lesion in the pancreatic body for further evaluation. Contrast-enhanced computed tomography (CT) scan showed a 17mm mass with a cystic component. On CT scan 3 years later, the tumor with its cystic component had enlarged to 23mm. Magnetic resonance imaging showed a tumor with the central cystic component having a high signal intensity in T1- and T2-weighted images and the margin of the tumor had reduced diffusion. Endoscopic ultrasound depicted a solid mass with a central cystic component. This tumor was suspected to be a solid pancreatic tumor with cystic changes as seen with neuroendocrine tumors or acinar cell tumors. The tumor was resected and pathologically diagnosed as a mixed acinar-neuroendocrine carcinoma. The cystic component in the center of the tumor may have resulted from necrosis and hemorrhage. The components of the neuroendocrine neoplasm and acinar cell carcinoma were located near the cystic component and the periphery, respectively. This case strongly suggests a mechanism for mixed acinar-neuroendocrine carcinoma development.

Intraductal papillary mucinous neoplasms (IPMN) are known to cause fistulas to other organs such as the bile duct and duodenum. Development of a fistula from an IPMN into the bile duct often causes obstructive jaundice. We report a patient who underwent endoscopic nasobiliary drainage (ENBD) and radical resection after resolution of jaundice with regular tube lavage. An 84-year-old man presented with recurrent fevers. Based on detailed examination, he was diagnosed with obstructive jaundice caused by a fistula from an IPMN into the bile duct. Endoscopic placement of a plastic biliary stent failed to resolve the jaundice, the patient's condition worsened, and he was referred to our hospital. We replaced the plastic stent with an ENBD tube and performed lavage regularly to prevent obstruction. After resolution of the jaundice, we performed a pylorus-preserving pancreaticoduodenectomy. Based on pathological findings, the lesion was diagnosed as an intraductal papillary mucinous carcinoma. After surgery, the patient was discharged with no complications. One year postoperatively, there is no evidence of recurrence.

A 76-year-old man developed septic shock six days after undergoing SSPPD-II-A-1 for IPMC. He was diagnosed with diffuse peritonitis due to a POPF and emergent reoperation with peritoneal lavage and drainage was necessary. We drained fluid collection spaces and performed a peri-pancreatojejunostomy with a jejunal limb. Although inflammation improved gradually, significant leakage of pancreatic secretions from the peri-pancreatojejunostomy continued. An enteral nutrition catheter was placed in the jejunal limb by IVR for enteral feeding on postoperative day 27. Direct drainage of the main pancreatic duct via the jejunal limb succeeded on postoperative 37, and the leakage of pancreatic secretions from the peri-pancreatojejunostomy gradually decreased. The patient made steady progress and was discharged on postoperative day 92.

A patient with a critical grade C POPF successfully treated by reoperation and direct drainage of the main pancreatic duct by interventional radiology is presented.

A 74-year-male was seen for detailed examination of a gallbladder tumor. We diagnosed the tumor as adenomyomatosis. Coincidentally, contrast-enhanced computed tomography (CT) scan showed a 20mm mass with poor enhancement in the pancreatic tail. The tumor showed high intensity on T1 and T2-weighted MRI images. EUS showed a hypoechoic solid tumor with calcifications in the pancreatic tail. A 6mm hypoechoic solid tumor not detected by CT scan or MRI was found by EUS. We performed EUS-FNA using a Franseen needle for both lesions. Pathological findings including immunohistochemistry suggested the tumors were solid-pseudopapillary neoplasms (SPN). Cholecystectomy and distal pancreatectomy were performed. Pathological findings of the resected pancreatic lesions showed SPN. Some cases of metachronous multiple or recurrent SPNs have been reported, but multiple synchronous SPNs are rare. Since one of the two lesions was detected only by EUS in this patient, EUS is a useful modality for the preoperative diagnosis of SPN.