A 27-year-old woman presented at 20 weeks gestation with upper abdominal pain. Laboratory tests revealed elevated pancreatic enzymes with prominent hypertriglyceridemia. Severe acute pancreatitis was diagnosed, and she was treated with aggressive fluid administration. Although respiratory deterioration and disseminated intravascular coagulation developed, she recovered successfully with strict lipid restriction and adequate fluid management. She was discharged on day 18. Walled-off necrosis was detected by MRI, but there was no sign of bacterial infection. She safely delivered twins by cesarean section at 36 weeks gestation. Serum triglyceride levels remarkably improved after delivery, but abnormalities in lipoprotein levels persisted. Thus, her marked hyperlipidemia was likely caused by a genetic predisposition in addition to pregnancy. Pregnancy affects lipid metabolism and can be a cause of acute pancreatitis. In this patient, collaboration with gastroenterologists and obstetricians helped to achieve successful outcomes for both mother and babies.

The patient is a 33-year-old woman. Eight weeks after the birth of her first child, she visited her family doctor because she found a mass in the right upper quadrant of her abdomen. A cystic tumor was found in the pancreatic head, and she was referred for further investigation and treatment. Abdominal computed tomography scan showed an 8cm cystic lesion in the pancreatic head, with a faint contrast effect on the cyst septa. Magnetic resonance imaging showed a multilocular cystic lesion. Considering the possibility of a solid pseudopapillary neoplasm or a pancreatic serous cystic neoplasm (SCN) in the differential diagnosis based on gender, tumor size, and imaging findings, malignant disease could not be ruled out and a subtotal stomach-preserving pancreaticoduodenectomy with D1 lymph-node dissection were performed. The histopathological diagnosis was serous cystadenoma with intracystic hemorrhage. Intracystic hemorrhage in a SCN is an extremely rare condition, and may be difficult to diagnose due to varied imaging findings. An SCN larger than 4cm has an increased risk of containing malignancy and resection should be considered.

A 64-year-old male with jaundice was admitted. A contrast enhanced abdominal computed tomography (CT) scan revealed a low-density mass in the pancreatic head. The right and left hepatic artery (LHA) originated independently from the superior mesenteric artery. In addition, the gastroduodenal artery (GDA) originated from the LHA superior to the pancreas. The patient underwent pancreatoduodenectomy (PD) for pancreatic cancer. The GDA was correctly identified and the LHA was preserved without injury. Variations in the anatomy of the hepatic arteries have been classified by Michels and Hiatt. However, this anomaly was not defined in these traditional classifications, and is considered to be extremely rare. When performing a PD associated with hepatic artery and/or GDA variations, detailed preoperative evaluation of the relationship between the aberrant arteries and pancreas by three-dimensional CT scan visualization is essential.

A 61-year-old male was referred with the sudden onset of abdominal fullness for further examination and treatment. Enhanced computed tomography scan revealed a multi-cystic lesion from the pancreas tail to the spleen, with extravasation of contrast medium to the intraabdominal space. Emergent angiography with embolization of the extravasating artery was performed. Instead of hemostasis only by embolization, we considered that there was a high risk of rebleeding. Thus, we planned surgery to establish complete hemostasis 3 days after embolization. Distal pancreatectomy with lymph node dissection was performed. In addition, concomitant resection of the left transverse colon was needed due to involvement of the tumor. Pathological diagnosis revealed anaplastic carcinoma of the pancreas with invasion to the transverse colon and spleen. Rapid growth of the tumor caused rupture of the tumor with intraabdominal hemorrhage as the presenting symptom. Anaplastic carcinoma of the pancreas presenting with intraabdominal hemorrhage is rare. This mechanism is reasonable due to the rapid and aggressive growth of anaplastic carcinoma. Prompt planning of a treatment strategy is needed in the treatment of patients with intraabdominal bleeding.

The patient is a 73-year-old man who underwent distal pancreatectomy (D2 dissection) for cancer in the tail of the pancreas. Pathological examination showed T3N0M0 Stage IIA (JPS 7th) and T2N0M0 Stage IB (UICC 8th). S1 was administered as adjuvant chemotherapy for 6 months. Thirty-four months after pancreatic resection, serum CEA and CA19-9 were elevated and computed tomography scan revealed an ascending colon tumor. Colonoscopy showed thickening of the wall and stenosis of the ascending colon, but there was no change in the mucosal surface and biopsy did not reveal any malignant findings. The patient underwent right hemicolectomy (D2 dissection, and sampling of LN 223) and limited liver resection. Pathological examination revealed a metastasis to the ascending colon of pancreatic cancer, together with immunohistochemical findings showing CK7 positive and CK20 negative. He has been alive without recurrence for 67 months after pancreatectomy (33 months after colectomy). We summarize the previous reports and this patient's history since pancreatic cancer metastasis to the colon is very rare. Immunohistochemistry results showing CK7 and CK20 positive were useful to confirm the diagnosis. In previous reports of colon metastases from pancreatic cancer, 57% of patients had metastases to colonic lymph nodes.

The patient is a female in her 70s referred for further workup after dilatation of the main pancreatic duct was seen on abdominal ultrasonography performed to evaluate cardiac orbital pain. Contrast-enhanced computed tomography scan showed an approximately 15mm contrast-enhancing mass in the pancreatic head. EUS-FNA was performed and revealed spindle-shaped cells, pleomorphic cells of unequal size, and atypical cells with osteoclast-like giant cells. These atypical cells were CD68 (KP-1) positive by immunostaining and diagnosed as anaplastic carcinoma of the pancreatic head. Pylorus preserving pancreaticoduodenectomy was performed. Histopathologic examination of the surgical specimen showed mainly pleomorphic cells, but also spindle-shaped cells and osteoclast-like giant cells, leading to the diagnosis of pT1c pleomorphic cell type anaplastic carcinoma TS1. The patient is currently alive and recurrence-free 9 months after resection. This patient had anaplastic carcinoma TS1 definitively diagnosed by preoperative EUS-FNA and resected.