The percentage of Japan's total population aged 65 and over is 29.0%. This is the so-called "super-aging society. " Pancreatic diseases such as acute pancreatitis, chronic pancreatitis, pancreatic cancer, and autoimmune pancreatitis are observed even in the elderly. It has been pointed out that screening tests are difficult because subjective symptoms manifest differently in elderly and non-elderly people, and testing is limited by underlying diseases and medications. On the other hand, due to advances in medical technology in recent years, the target age group for pancreatic diseases, including surgery and chemotherapy, is increasing, and the significance of safely and reliably diagnosing elderly patients is increasing. It is important to thoroughly understand the physiological changes in the pancreas associated with aging, determine the suitability of tests, and then select minimally invasive and safe screening tests and methods of diagnosis for the elderly.

Japan is said to be the world's most aging society, with over 29% of the population aged 65 and over. Many clinical studies and national survey studies in Japan show that the age at onset of acute pancreatitis is gradually increasing. In the real world, there are actually many elderly patients with acute pancreatitis. In the elderly, the most common cause of acute pancreatitis is gallstone pancreatitis, which tends to develop into severe pancreatitis and has a high mortality rate. Many high-quality clinical studies have been reported regarding the indications for endoscopic intervention for gallstone pancreatitis and the timing of cholecystectomy. This review summarizes the evidence regarding the characteristics and management of pancreatitis in the elderly.

As we enter the era of the super-aging society, the demand for medical care for the elderly in the treatment of chronic pancreatitis is steadily increasing. The latest nationwide survey in Japan revealed that 17.6% of patients with chronic pancreatitis are aged 75 years or older, and that the etiology of chronic pancreatitis in the elderly is less frequently alcoholic and more frequently idiopathic. Chronic pancreatitis in the elderly is often painless, and pancreatic exocrine dysfunction should be noted. In terms of treatment, from the viewpoint of complications such as frailty, sarcopenia, and osteoporosis, it is important to provide adequate pancreatic enzyme replacement therapy and dietary guidance without fat restriction for patients in the uncompensated phase. The management of malignant tumors including pancreatic cancer is often necessary in elderly patients with chronic pancreatitis. In addition to these characteristics of chronic pancreatitis in the elderly, careful and individualized medical care is required, taking into account physiological changes associated with aging, multiple comorbidities, adverse events associated with drug therapy, and social factors that are specific to the elderly.

Pancreatic cancer is a disease that is more likely to affect older adults and is therefore on the rise in Japan's hyper-aged society. In older patients with pancreatic cancer, surgical resection may not be indicated even when the disease is still oncologically speaking resectable, because surgical resection is too invasive to tolerate. Recently, minimally invasive procedures such as laparoscopic pancreatectomy have been developed and are expected to become more and more popular forms of surgical resection in older patients. Radiotherapy may be indicated even in older patients with pancreatic cancer because of its safety, but its efficacy is limited. Techniques that increase the radiation dose to the tumor while reducing the dose to normal tissue by irradiating from multiple directions, as well as proton beam and carbon-iron beam radiotherapy, are expected to have more efficacy while maintaining safety. Systemic chemotherapy can be applied for older patients using gemcitabine plus nab-paclitaxel, gemcitabine alone, and S-1 alone. The indication for any of these treatment modalities should be based on a geriatric assessment that includes not only age but also major organ function and comorbidities.

The incidence of pancreatic neuroendocrine neoplasms (PanNENs) has been increasing worldwide due to improved disease recognition and advances in diagnostic modalities such as computed tomography and endoscopic ultrasound. The number of older adult patients with PanNENs is expected to increase in Japan's rapidly aging society. Therefore, it is important to establish treatment strategies for older adult patients. The only curative treatment for PanNENs is surgical resection, which can be safely performed in older adult patients when selected appropriately. Depending on age, comorbidities, and tumor size, nonsurgical management, such as observation and systemic therapy, should also be considered. Systemic therapies, including somatostatin analogs, targeted therapies, cytotoxic chemotherapy, and peptide receptor radionuclide therapy, are available for patients with unresectable or metastatic pancreatic neuroendocrine tumors (PanNETs). When administering these therapies to older adult patients with PanNETs, it is important to balance the treatment, and the adverse events which can be linked to it, with the patient's comorbidities and cognitive function. Further studies on older adult patients with PanNETs are warranted to establish an optimal treatment strategy.

Geriatric syndrome is a concept for the onset of symptoms and disorders peculiar to the elderly due to age-related decline in physical and mental functions, or the very wide range of physical and mental symptom that are highly prevalent in the elderly. Japan has been a "super aging society" since 2007. In the clinical practice of pancreatic diseases treatment there is more need to treat the elderly than 20 years ago. Therefore we must consider the characteristics of the elderly patient. This review provides a general understanding and recent findings on clinical practice for pancreatic disease treatment related to geriatric syndrome.

In Japan, the elderly population is constantly increasing. An increasing number of geriatric patients equals an increasing number of comorbidities for physicians to consider. Frailty, advanced multimorbidity, uncertainty, geriatric syndromes and polypharmacy are particular problems when considering palliative care for the elderly. When considering palliative care for elderly patients with pancreatic disease, it is necessary to assess their functioning, bearing in mind the characteristics and problems associated with aging. To deal with these issues multidisciplinary teams need to work together to provide support, paying particular attention to the characteristics of pancreatic disease.

Japan became the first country in the world to enter the super-aged society in 2007, and reform of the healthcare system and welfare policies is now an urgent issue. The elderly with geriatric syndromes and numerous chronic diseases can easily have serious and complicated conditions. In general, medical care has been focused on 'cure-seeking medical care' for single diseases, but a paradigm shift is needed to 'cure- and support-seeking medical care' for the elderly, with an emphasis on quality of life. In addition to 'preventive medicine', it will also be necessary to develop 'preemptive medicine', which starts at a stage before a disease or disorder occurs. This will require the development of new predictive measures and diagnostic methods that integrate novel biomarkers, genomic, proteomic and metabolomic analysis, and analysis of other clinical information, etc. Although ageing care research has progressed dramatically in recent years, it has not been sufficient in the field of Pancreatology. In the future, new knowledge about ageing will be accumulated through various approaches, so that evidence-based medical care can be provided to elderly patients with pancreatic diseases.

A 73-year-old woman presented with a cystic lesion measuring 18mm in diameter in the pancreatic tail on plain CT. The cyst diameter had doubled in nine years. A Contrast-enhanced MRI showed a smooth and enhanced cyst-wall measuring 2mm in thickness, with Endoscopic Ultrasound (EUS) revealing a septal structure, but no mural nodules. The patient was followed without treatment because the cyst was small and no mural nodules were observed. However, the cyst size continued to increase, reaching 30mm × 35mm at 18 months. Thus, distal pancreatectomy was performed due to a suspected mucinous cystic neoplasm (MCN). A postoperative pathohistological examination revealed the cyst to be mostly lined with a monolayer of cuboidal mucinous-epithelium, but it was partly covered with a columnar mucinous-epithelium without atypia. Neither communication with the pancreatic duct nor ovarian-like stroma was identified, leading to a diagnosis of a simple mucinous cyst (SMC). It was difficult to distinguish this cystic mass as a SMC preoperatively because it mimicked MCN with an enhanced thick-wall and a septal structure, and had been increasing in size over time. SMCs have only recently been defined as a type of mucinous cystic lesion that should be differentiated from MCN. SMC should be considered as a possibility when diagnosing MCN-like pancreatic cysts.

Case: The patient was a 55-year-old female. A tumor of the pancreatic tail was found during a medical examination, and a laparoscopic distal pancreatectomy was performed at our hospital. Histological examination revealed the diagnosis of a pancreatic neuroendocrine tumor (PanNET) grade 3 (G3) (Ki-67 index: 20-30%). Seven months after the initial surgery, bile duct dilatation and abnormal liver functions〔aspartate aminotransferase (AST): 171U/l, alanine transaminase ALT: 86U/l〕were observed, and upper gastrointestinal endoscopy was performed for further examination, showing a papillary reddish tumor with a white coat protruding from the papilla of Vater. Considering the possibility of local recurrence of PanNET G3, although not typical, the patient underwent a remnant total pancreatectomy. Histologically, immunohistochemical stains were positive for synaptophysin and chromogranin A, and the Ki-67 index was around 30-40%, indicating that this tumor was a recurrence of the PanNET G3. The patient is alive without any recurrence at 24 months after the second surgery.