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In addition to surgery, procedures for patients with pancreatolithiasis are developing; therefore, establishing practical guidelines for the management of pancreatolithiasis is required.Three committees (the professional committee for asking clinical questions (CQs) and statements by Japanese endoscopists, the expert panel committee for rating statements by the modified Delphi method, and the evaluating committee by moderators) were organized. Eight endoscopists and a surgeon for pancreatolithiasis made the CQs and statements from a total of 694 reports of published literature by PubMed search (from 1983 to 2012). The expert panelists individually rated these clinical statements using a modified Delphi approach, in which a clinical statement receiving a median score greater than 7 on a 9-point scale from the panel was regarded as valid.The professional committee made 3, 7, and 10 CQs and statements for the concept and pathogenesis, diagnosis, and treatment, respectively. The expert panelists regarded them as valid after a 2-round modified Delphi approach.After evaluation by the moderators, the Japanese clinical guidelines for pancreatolithiasis were established. Further discussions and studies for international guidelines are needed.

According to the international consensus guidelines 20121 for the management of intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms of the pancreas, main duct IPMN (MD-IPMN) and branch duct IPMN (BD-IPMN) are significantly different with regard to the prevalence of carcinoma, and therefore, the classification has prognostic implications. When MD-IPMN is diagnosed in a patient, surgical treatment should be considered. In BD-IPMN, however, it is important to differentiate low-grade dysplasia from high-grade dysplasia (carcinoma in situ) or ordinary invasive pancreatic ductal adenocarcinoma (PDAC) to avoid excessive surgery. The presence of mural nodules (MNs) has reportedly been the most important factor for predicting malignancy and determining the indication for surgery of BD-IPMN. However, there is a paucity of data on the morphological and histologic changes in patients with BD-IPMN with MNs during follow-up. The aim of this study was to evaluate long-term follow-up results of patients with BD-IPMN who had MNs on initial imaging in a retrospective multicenter series for better management of patients with BD-IPMN.

There have been only a few reports on follow-up results of serous cystic neoplasm (SCN) of the pancreas. The frequency of malignancy and surgical indication of SCN are not determined yet.In this multi-institutional study of the Japan Pancreas Society, a total of 172 patients with SCN were enrolled. The mean follow-up period was 4.5 years. Surgical resection was performed in 90 patients, whereas the remaining 82 were simply observed.Of all patients, 20% were symptomatic. The tumor was located in the pancreatic head (39%), body (35%), and tail (22%). The mean diameter of the tumor was 4.1 cm. None of the patients showed distant or lymph node metastasis except for liver metastasis found in 2 patients (1.2%). No patient died during the follow-up. The preoperative diagnosis did not correctly identify SCN in 57 (63%) of 90 resected cases. A honeycomb appearance, which is one of the most characteristic findings of SCN, could be diagnosed better by endoscopic ultrasonography than by other imaging diagnostic modalities.Surgical resection should be considered only when clear distinction from other surgical diseases is difficult, when symptoms or mass effects are present, and when the tumor size is large.

The aim of this study was to elucidate the clinicopathological features and prognosis of mucinous cystic neoplasms (MCNs).We performed a multi-institutional, retrospective study on a collected series of patients with MCN pathologically defined by ovarian-type stroma. Clinicopathological features and prognosis were investigated.Mucinous cystic neoplasm was confirmed in 156 cases, including 129 adenomas (82.7%) and 21 noninvasive (13.4%) and 6 invasive carcinomas (3.9%). Patients with MCN were exclusively women (98.1%) with the mean age of 48.1 years. All but 1 MCN were in the pancreatic body/tail region with a mean size of 65.3 mm. Communication between the cyst and the pancreatic duct was found in 18.1%. The 3-, 5-, and 10-year survival rates were 97.6%, 96.6%, and 96.6%, respectively. A significant difference in the survival rates was observed between adenomas and carcinomas and between minimally invasive carcinomas and invasive carcinomas. Cyst diameter and presence of mural nodule were predictive of malignant MCN.Mucinous cystic neoplasm is a rare but distinctive pancreatic cystic neoplasm with a favorable overall prognosis. All MCNs should be resected to prevent malignant changes but can be observed for an appropriate time when the lesion is small without the presence of mural nodules.

Since its development, endoscopic retrograde cholangiopancreatography (ERCP) has been playing a major role in the diagnosis of pancreatic diseases. The recent development of magnetic resonance cholangiopancreatography has accelerated the shift in the role of ERCP toward more therapy-oriented applications. In the diagnosis and treatment of curable pancreatic cancer, however, ERCP remains the mainstay of imaging modalities. ERCP is not simply a method with which to obtain x-ray images of the pancreatic duct. Collection of pure pancreatic juice, transpapillary biopsy/brush cytology of the pancreatic duct, intraductal ultrasonography, and peroral pancreatoscopy are all performed based on the ERCP technique. Endoscopic ultrasonography (EUS) has a high spatial resolution and provides tomographic images of the pancreas and its neighboring organs. EUS is now widely used in evaluation of the local extent of pancreatic cancer and the differential diagnosis of cystic lesions of the pancreas. EUS-guided fine needle aspiration biopsy/cytology is performed to obtain a histologic diagnosis before beginning chemotherapy. Although the number of pancreatic cancer patients who are candidates for surgery is limited at present, there is an increasing need for ERCP-based techniques in both the diagnosis and treatment of pancreatic neoplasms.

患者は78歳の男性.黄疸を主訴に当科へ紹介となった.腹部超音波検査では，膵頭部に辺縁不整な低エコー腫瘤が指摘された.肝外，肝内胆管拡張，および肝内に多数の低エコー腫瘤を認めた.胆道ドレナージを目的にERCPを試みたが，癌浸潤に伴う十二指腸狭窄にて不成功で，胃内から肝外胆管を標的胆管として，超音波内視鏡ガイド下胆道ドレナージ（ESBD：Endosonography-guided biliary drainage）を施行した.肝転移により手術適応無く，減黄後gemcitabine化学療法を導入した.その後，十二指腸狭窄が増悪し食事摂取が困難となったために，内視鏡下に十二指腸ステント留置を行った.内視鏡治療により良好なQOLが得られたが，初診から約6ヶ月後に原病死となった.化学療法の進歩した現在，全身状態の改善をめざした悪性胆道·消化管狭窄に対する内視鏡的interventionは，積極的に試みるべきと考えられた.