Background: The impact of the factor associated with a hepatic duct margin positive for cancer cell invasion and how to manage post-operative patients with residual tumor-positive status are still under debate.
Methods: The association between overall survival (OS) and pathologic variables, especially for hepatic ductal margin status, determined after surgical resection for middle and distal bile duct cancer was assessed retrospectively for 57 patients from 1987 to 2007.
Results: The estimated 5-yr survival rate of all resected cases was 33.3%. Survival was impacted by R (residual tumor) status; R0 cases (n=36) had better prognosis than R1 cases (n=21, 5-yr survival rate; 44.5% vs. 0%, p<0.05). Multivariate analyses revealed that the factor associated with poor prognosis was hepatic ductal margin status (H.R. 3.27, 95% C.I. 1.003-10.663, p=0.0495).
Conclusions: In the treatment of middle and distal bile duct cancer, it is important to secure a negative ductal margin. Surgeons should make efforts to obtain a negative ductal margin. Postoperative adjuvant treatment might have a significant role in the prolongation of survival even if the patient was pathologically diagnosed as R1.

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Endoscopic access to the biliary system is challenging in patients with surgically altered anatomy, here we reported our experience of endoscopic billiary intervention using double balloon enteroscopy (DBE).
Three patients with Roux-en-Y reconstruction and 2 patients with Billroth-II gastrojejunostomy were treated for pancreatobilliary disorder. We successfully performed endoscopic retrograde cholangiopancreaticography (ERCP) in all cases, and therapeutic procedures using "Short" DBE (EC450-B15, Fujinon, Japan). DBE and ERCP were performed by specialists of each procedure.
No major complication occurred, including recurrent cholangitis during the observation period (average, 8 month).
Endoscopic intervention using DBE is very beneficial strategy in patients with reconstructed gastro-intestinal anatomy.

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This study is aimed to investigate the effects of biliary drainage (BD) on hepatic microcirculation and Kupffer cell activity in obstructive jaundice (OJ). Common bile duct ligation and division was performed on C57BL/6 mice to induce OJ. One and 2 weeks after surgery, some mice underwent BD. Sinusoidal perfusion, leukocyte rolling and sticking in the postsinusoidal venules, and diameters of sinusoids containing blood flow were evaluated using intravital microscopy. Kupffer cell phagocytic activity was estimated by the ratio of Kupffer cells that phagocytosed fluorescent-labeled particles to sinusoids containing blood flow. BD significantly increased sinusoidal perfusion, but not sufficiently compared with controls. Number of rolling leukocytes and sticking leukocytes significantly decreased, however, diameters of sinusoids were still reduced associated with increase in Kupffer cell phagocytic activity after BD. These data suggest that leukocyte-endothelial cell interaction is ameliorated, but Kupffer cells are still activated to impede hepatic microcirculation in the early phase after BD.

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To clarify the prognostic significance of ductal resection margin status, characteristics and outcome were retrospectively analyzed in 75 patients with extrahepatic cholangiocarcinoma who underwent surgical resection. Residual tumor was histologically observed in 16 patients, of whom, 8 had positive ductal margin, 4 had positive dissected periductal structures margin, 2 had both, and 2 were considered to have undissected positive nodes. With respect to the gross tumor appearance, 4 of 9 (44%) patients with flat type tumor showed positive ductal margin. Univariate analysis of all patients underwent resection revealed that the depth of tumor invasion, lymph node metastasis, and pathological stage were the prognostic factors, while the ductal margin status was not. In the selected patients with negative nodes and negative dissected periductal structures margin, however, the ductal margin status was found to be a prognostic factor. Clearance of ductal margin seems to be less important in patients who have lymph node metastasis or whose dissected periductal structures margin can not be cleared from cancer.

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This study aimed to evaluate the usefulness and safety of laparoscopic cholecystectomy (LC) for benign gallbladder disease in elderly patients. Between March 1992 and December 2008, 1257 patients who underwent LC were included in the study. They were divided into two groups: those under age 65, and those aged 65 and older. The incidence of underlying disease and gallbladder inflammation was higher in elderly than in younger patients. The mean operating time was significantly longer, and blood loss was significantly higher in elderly than in younger patients. No significant differences were observed between the two groups' incidence of postoperative morbidities or length of hospital stay. These findings suggest that LC can be performed safely as a minimally invasive procedure in elderly patients, although it requires both careful selection of patients and appropriate surgical techniques.

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Biliary tract carcinoma (BTC) is a lethal malignancy. This is essentially attributed to slow carcinogenesis under the complex of pathological circumstances and to asymptomatic growth of BTC infiltrating the surrounding structures in varying routes. The disease is therefore usually detected at an advanced stage with a high frequency of distant organ metastasis. To date, conventional chemotherapy and radiation therapy have been notably ineffective against BTC. For improved treatment outcome of BTC and its prolonged survival, there is now a real and urgent need to focus on developing novel and potent therapeutic strategies aimed at exploiting select molecular targets associated with tumor proliferation, invasion and/or metastasis that would impact in a significant way on clinical outcome. The outcome of recent studies, by the analysis of BTC cells, BTC animal models, and clinical specimens of BTC patients, has revealed in detail the molecular mechanism of carcinogenesis and tumor progression of BTC, and has exploited select molecular targets that would impact in a significant way on clinical outcome. In the U.S.A. and European countries, there have been reported only a few clinical phase II trials against BTC using anticancer drugs targeting growth factor receptors. In the near future, development of new molecular targeting drugs with potent efficacy against BTC and randomized clinical trials of these drugs are urgent and essential for the treatment of patients with BTC.

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FDG-PET has high detectability of biliary malignancies. It is not sufficient for regional lymph node staging, but may reveal distant metastases missed by other imaging modalities. Moreover, it is also useful for detection of recurrent and metastatic diseases. Thus, FDG-PET staging has an important impact on selection of adequate therapy. However, It is not always able to differentiate a malignancy from other diseases. SUV analysis is one of the useful prognostic predictors of biliary carcinoma for overall survival. This information may assist conventional clinical staging and the guiding of treatment strategies before postoperative pathological assessment. The combined information of PET and other imaging modalities enhances the diagnostic confidence in lesion characterization.

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We report a very rare case of cancer of the remnant cystic duct after cholecystectomy. A 60s-years-old woman was admitted for the stone in the common bile duct who was followed for diabetus mellitus and chronic hepatitis C. She underwent cholecystectomy for gallbladder stone at thirty-four years old. ERCP showed that there is no stone in the common bile duct and the remnant cystic duct was detected and a filling defect of right side of the upper bile duct. Biopsy specimen of the wall of the upper bile duct was adenocarcinoma. Abdominal angiography revealed the cystic artery from the right hepatic artery and tumor stain. We diagnosed cancer of the remnant cystic duct and extrahepatic bile duct resection was performed. The resected specimen revealed tumor was located in the remnant cystic duct and invaded the upper bile duct. The tumor consisted of moderately differentiated adenocarcinoma. We diagnosed cancer of the remnant cystic duct finally. The patient is alive nine months after surgery without recurrence.

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A 53-year-old man complaining of general malaise and brown urine was admitted to the hospital. Laboratory data showed the elevation of hepatobiliary enzymes. Abdominal ultrasonographic examinations revealed hypoechoic mass in the S4 area of the liver and dilatated left intrahepatic bile ducts. Abdominal CT also revealed a low density mass which was well-defined in the left lobe of the liver. The mass was not enhanced. We speculated hilar cholangiocarcinoma and performed endoscopic retrograde cholangiography (ERC). ERC showed a filling defect in the superior bile duct and the junction department of the right and left hepatic duct. The bile cytodiagnosis was class IIIa, but hilar cholangiocarcinoma was not completely excluded by imaging study. We underwent extended left hepatectomy and excision of the extrahepatic bile duct. The resected specimen showed a yellowish white tumor in 3×2 cm diameter. Pathological findings revealed hyperplasy of the fiberization with lymphoplasmocytic infiltration. Because there were no malignant cells in a tumor and a bile duct by pathological findings, inflammatory pseudotumor was diagnosed. The invasive inflammatory cells were IgG positive cells, but IgG4 positive cells was not found by the immunohistochemistry and blood IgG4 was 104 mg/dl(4.8∼105 mg/dl).

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EUS plays a central role in the decision-making process of the treatment of duodenal papillary cancer. One of the important roles is to diagnose the depth of tumor invasion both into the duodenal wall and the pancreas. In addition, whether malignant or benign of enlarged lymph nodes still remains a very important issue to determine the tumor clinical stage. EUS in combination with cutting-edge ultrasonographic procedure such as contrast-enhanced EUS may be promising in the near future.

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For CT diagnosis of the periampullary region, it is essential to perform multiphase contrast-enhanced examinations with collimation of 1.25 mm or less and reconstruct axial images as well as high-resolution multiplanar reformatted images with a 2-3-mm slice thickness. These images make it possible to depict small anatomic structures such as the pancreatic and intrapancreatic bile ducts and pancreaticoduodenal arterial arcade. Furthermore, the examinations permit the visualization of the area showing less contrast enhancement between the pancreatic head and duodenum in pancreatic-phase images, what is assumed to correspond to the area of the ducts surrounded by the sphincter of Oddi. In the patients with ampullary neoplasms presenting with dilatation of the pancreatic and/or bile ducts, the most valuable role required for CT is to determine the absence of other disorders such as pancreatic cancer and bile duct cancer. However, since it is impossible to identify the common channel, the muscularis propria of the duodenal wall, and the sphincter of Oddi on CT, the role in local staging of ampullary tumor is limited. Since ampullary tumors have a relatively good prognosis, it is also required to pay enough attention to side effects associated with radiation exposure and contrast media in CT examinations.

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For MR evaluation of carcinoma of the biliary system, MR cholangiography (MRC) and 3D dynamic study are the two main sequences to be used, both of which are based on excellent contrast resolution. Usually, overall view of the whole biliary system is first obtained with MRC, and then, conventional MR sequences including 3D dynamic study are applied to scrutinize the pathologic sites (stenosis, obstruction, etc) as observed on MRC. Both 3D and 2D MRC may be used. Dynamic study is to be obtained with fat suppression and along the plane with which the target lesion is best visualized. Diffusion-weighted image is a novel and promising tool, however, its validity is yet undetermined. In gallbladder carcinoma, delayed subserosal enhancement on the dynamic study may be a useful sign to suggest subserosal invasion of carcinoma, which would make MR superior to MDCT. In bile duct carcinoma, MR may provide more useful information for lesion characterization than MDCT. MR/MRC is a useful modality to assess carcinoma of the biliary system and should be used in addition to MDCT.

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