Pancreatic neuroendocrine tumors, relatively rare cancers, mostly arise in the pancreatic parenchyma with infrequent involvement of the main pancreatic duct. Now and then, however, case reports have been published on pancreatic neuroendocrine carcinoma in which the main pancreatic duct is obstructed by tumor cells with severely fibrous stromal cells. Here, in this paper, we report a case of pancreatic neuroendocrine carcinoma with obstruction of the main pancreatic duct. A 59-year-old man complained of right upper abdominal pain. Magnetic resonance cholangiopancreatography and fat-suppressed T1-weighted magnetic resonance imaging showed gallbladder stones, a low-intensity-area measuring 8 mm in diameter in the pancreatic body, and club-shaped dilatation at the distal end of the pancreatic duct. The patient was thus diagnosed with a tumor in the pancreatic body and cholecystolithiasis, and underwent distal pancreatectomy and cholecystectomy. HE-staining showed tumor cells with eosinophilic cytoplasm and nuclear atypia. The infiltrative growth of the cells with severe fibrosis caused stenosis of the pancreatic duct. Based on the positive results of immunohistochemical staining for chromogranin A and synaptophysin and the Ki-67 index, the tumor was finally identified as pancreatic neuroendocrine carcinoma. The patient has been under follow-up with no additional treatment for >3 years since the surgery, without evidence of tumor recurrence.

　　Among visceral artery aneurysms, those arising in the region of the pancreatic duodenal artery due to celiac artery stenosis are rare. We report a surgical case with stenosis caused by dissecting celiac artery aneurysms and multiple aortic aneurysm rupture in the pancreaticoduodenal region. A 72-year-old man with a history of distal gastrectomy for gastric cancer was carried into our hospital by ambulance for acute abdominal pain. CT scans showed dissected aneurysms of the root of the celiac artery and hepatic artery as well as massive retroperitoneal hematoma around the pancreaticoduodenum and intraperitoneal hemorrhage. Arteriography of the superior mesenteric artery revealed multiple aneurysms of the pancreaticoduodenal artery that might have caused rupture. In the late phase, retrograde flows in the gastroduodenal, hepatic, celiac, and splenic arteries from the pancreaticoduodenal artery were contrast-enhanced. Because it was thought that transcatheter arterial embolization or surgical aneurysmectomy for pancreaticoduodenal aneurysms could prevent blood flow in all circulating branch arteries of the celiac artery, leading to extensive organ ischemia, the gastric pouch, spleen, entire pancreas, and gallbladder were resected. The patient has been doing well.

Kinki University School of Medicine introduced clerkships for undergraduate clinical training in 1999. Clinical clerkships are performed for the first 8 weeks of the sixth academic year. In 1999 and 2000 we conducted questionnaire surveys asking students about this system. The teaching staff encourages students to participate extensively in clinical situations, which reflects the consensus about this system. We also performed similar surveys of nurses and teaching staff. Clinical clerkships did not increase the incidence of problems between patients and medical staff. Many students felt their motivation to be a physician was increased. Although the findings of these questionnaire surveys indicate that our clerkship system works successfully, they also revealed some problems for sixth-year students. Although we recognize the significance of this system for undergraduate clinical training, further improvement is required.