We attempted precut sphincterotomy using a standard papillotome to obtain biliary access in patients in whom deep cannulation proved impossible and cannulation of the common bile duct was essential for endoscopic biliary drainage. The incision was begun from the pancreatic orifice, and cutting of the papillary roof was carried out in the same manner as for standard endoscopic sphincterotomy. Next, the common bile duct was carefully searched for using a tapered cannula. Cannulation of the common bile duct was successful in 12 of 18 patients immediately after precut spincterotorny, and was successful in 4 of the 5 patients who underwent repeat ERCP, yielding a total cannulation rate of 88.9%. Though serum amylase levels were elevated in 4 patients, none exhibited symptoms of clinically overt pancreatitis. No complications such as bleeding and perforation were experienced. Precut sphincterotomy using a standard papillotome is a safe and effective method to achieve selective biliary access. In order to use the precut technique safely, however, it is necessary to become skilled in the technique of endoscopic treatment for biliary diseases.

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Clinical features of multiple primary cancers detected for biliary cancer were analyzed. Of the 78patients with biliary cancer who underwent surgery at our department between 1995 and 2002,17patients (22%) were found to have multiple primary cancers. Triple cancer was seen in 4 of these 17 patients. The mean age of the 17 patients was 68.7 years. Males were predominant, with the male-to-female ratio being 16: 1. Multiple primary cancer was synchronous in 7 cases a nd metachronous in 10 cases. The site of biliary cancer was the hilar region and the upper bile duct in 4 cases, the middle bile duct in 1 case, the lower bile duct in 3 cases, the duodenal papilla in 2 cases and the gallbladder in 7 cases. Cancer-affected organs other than the biliary tract were the stomach in 6 cases, the colon and rectum in 6 cases, the liver, and pancreas in 4 cases and other organs in 5 cases. Biliary cancer was resectable in 15 cases (88%). In cases of synchronous double cancer, cancer of the other organs was detected during a detailed examination of biliary cancer. In cases of metachronous double cancer, biliary cancer often developed after resection of preceding gastrointestinal cancer. Our experience with these cases suggests the necessity of bearing in mind the possibility of coexistence with other malignant tumors when treating biliary cancer.

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The patient was a 63-years old male. He was diagnosed with lower bile duct carcinoma, which was treated by pylorus preserving pancreaticoduodenectomy in Novenber 2000. In June 2002 high serum level of tumor markers was pointed out, and abdominal CT revealed liver tumor about 2 cm in diameter in segment 5. The liver tumor was enhanced peripherally by contrast medium, and the tumor invasion into the middle hepatic vein was suspected.
A preoperative diagnosis was made as primary cholangiocellular carcinoma or liver metastasis from the previous bile duct carcinoma, extended right hepatectomy and left hepaticojejunostomy were performed.
Histopathological diagnosis of tumor was the moderately differentiated adenocarcinoma. Because of existence the paracancerous area, and the distinct difference of p53 expression between the first and the second cancer, we diagnosed as heterochronic development of cholangiocellular carcinoma, with mass-forming type arising from B 5. The only 2 cases of heterochronic development of extrahepatic bile duct carcinoma and cholangiocellular carcinoma were reported in Japan. Therefore, the diagnosis of heterochronic development of double biliary carcinomas must be very difficult. The possibility of heterochronic biliary carcinomas should be considered in follow-up.

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We clinicopathologically analyzed 4 patients who had recurrence of biliary tract cancer at periods 5 or more years after initial surgery, and underwent re-resection. The 4 patients consisted of 3 with gallbladder cancer (GBc) and 1 with bile duct cancer (BDc). The initial surgery for GBc was extended cholecystectomy in 2 patients and cholecystectomy alone in 1 patient, and that for BDc was upper and middle bile duct resection with bilateral hepatocholangiojejunostomy. The interval between initial surgery and recurrence ranged from 5 years and 1 month to 6 years and 7months. The symptoms at recurrence were jaundice in the 3 GBc patients, and fever due to cholangitis in the BDc patient. At re-surgery, the GBc patients underwent pancreatoduodenectomy,2 of them with PV resection, and 1 of them with IVC resection. The BDc patient underwent extended right hepatic lobectomy and left hepatocholangiojejunostomy. The mode of recurrence of GBc in the 3 patients was lymph node metastasis, residual cancer in the cystic duct stump, and neural invasion. The mode of recurrence in the BDc patient was residual cancer in the intrahepatic bile duct stump. Although 1 patient had hepatic metastasis, all patients have survived for 1 year and 4 months to 6 years and 8 months after re-surgery.

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A 61-year-old man was admitted to our hospital with complaints of epigastralgia and abdominal distention. Abdominal US and CT showed a cystic lesion between liver and stomach. Biloma due to cholecystitis was suspected. But the location of the cystic lesion was relatively far from a gallbladder. So we could not diagnose biloma with confidence. Abdominal MRI was performed to the purpose of revealing a connection to the cystic mass and a bile duct. MRI showed that the cystic lesion had communication both with the gallbladder and with an intrahepatic bile duct of the left lesion had communication both with the gallbladder and with an intrahepatic bile duct of the left diagnosing biloma before ultrasonography-guided drainage.

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We report a case of gallbladder carcinoma with anomalous pancreaticobiliary ductal union, complicated by metabolic acidosis caused by percutaneous transhepatic biliary drainage (PTBD). A 61-year-old man with obstructive jaundice due to gallbladder carcinoma was admitted with a PTBD catheter already inserted at the previous hospital. Arterial blood gas examination showed metabolic acidosis (pH7.355, HCO₃-15.3 mmol/l, base excess-9.1mmol/l). We concluded that the external drainage of bile and pancreatic juice had caused metabolic acidosis. After a change to internal drainage, pH, HCO₃- and base excess returned to normal. We conducted extended right hepatic lobectomy, pancreatoduodenectomy, right colectomy, and combined resection and reconstruction of the portal vein following percutaneous transhepatic right portal embolization. The postoperative course was uneventful. Metabolic acidosis should thus be recognized as a possible complication of biliary drainage in patients with anomalous pancreaticobiliary ductal union.

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Intraluminal implantation of gallbladder cancer into bile duct is rare. We report a case of gallbladder cancer with intraductal spread curatively treated by hepatopancreaticoduodenectomy. A 59-year-old woman was admitted for upper abdominal pain. Abdominal computed tomography showed tumors in gallbladder and bile duct. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed pancreaticobiliary maljunction and some papillary tumors in the common bile duct. Histopathological diagnosis from biopsy of the tumor was adenocarcinoma.
Hepatopancreaticoduodenectomy was performed for the neoplasms of gallbladder and bile duct. Papillary tumor of the gallbladder showed massive necrosis, viable tumor showed minimal invasion to the muscularis propria.
Tumors of the cystic duct and common bile duct projected into the lumen in papillary polypoid fashion. The neoplastic cells were limited in the mucosal layer without dysplastic lesion. These cells were similar to the cells of gallbladder tumor.

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A 44-year-old man referred to our hospital diagnosed as cholecystitis with cholelithiasis. Ultrasound and CT showed an impacted gallstone and enlargement of the gallbladder. With the diagnosis of acute cholecystitis, percutaneous transhepatic gallbladder drainage (PTGBD) was done. Laparoscopic cholecystectomy was performed on the 13 th day from the inflammation of gallbladder reduced by PTGBD. Bile leakage from the drain was recognized after the surgery, and endoscopic retrograde cholangiography was done and showed bile duct injury during the procedure of PTGBD. Endoscopic nasobiliary drainage (ENBD) was done and the next day, the discharge of bile from the drain disappeared. The patient was recovered five days after the treatment of ENBD. Preceding PTGBD is an effective procedure for acute cholecystitis but unexpected bile duct injury may be occurred. Therefore it was thought that the intraoperative cholangiography was necessary after the PTGBD tube removed. Moreover, ENBD was a useful procedure to postoperative bile leakage by intrahepatic bile duct injury due to the treatment of PTGBD.

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A-60-year-old male had diagnosed as unresectable intrahepatic cholangiocarcinoma (ICC) with dilation of intrahepatic bile duct in left lobe. Angiography showed an encasement of proper hepatic artery (PHA) The reservoir catheter was inserted into PHA for hepatic arterial infusion chemotherapy (HAIC) using 5-FU and CDDP. The jaundice was getting to diminish with a reduction of the dilated right intrahepatic bile duct with HAIC, however, the ICC increased in size and accounted for most of left hepatic lobe. Then, the angiography through the reservoir catheter showed complete obstruction of PHA. He was complicated by sepsis, and died after hospitalization on the 65 th day. Autopsy specified that ICC which was histologically moderately to poorly differentiated adenocarcinoma, occupied the majority of only left lobe. PHA and left portal vein oppacified tumor emboli without dilation of intrahepatic bile duct.

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We encountered a case of alveolar echinococcosis of the liver that was treated by extended left lobectomy with hepatic artery and biliary resection. A 58-year-old woman complained of jaundice and itching, and a hepatic tumor of the left lobe was noted by abdominal US and CT. She was finally diagnosed as having alveolar echinococcosis of the liver by serological tests. Endoscopic retrograde cholangiography showed an obstruction of the left hepatic duct and stenosis of the upper bile duct. Based on these observations, the echinococcosis seemed to extend to the extrahepatic bile duct. She received extended left lobectomy. Echinococcosis lesions extended to the hepatoduodenal ligament, and involved the upper bile duct and proper hepatic artery. We performed resection of the proper hepatic artery and reconstructed it between the right hepatic artery and proper hepatic artery. Bile duct resection and reconstruction (hepaticojejunostomy) was also performed. In conclusion, we succeeded in extended left lobectomy with reconstruction of the hepatic artery in a case of highly extended echinococcosis.

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An 85-year-old female was admitted as acute cholecystitis. After the inflammation composing, the ultrasonography showed multiple variable-sized elevated lesions in the gallbladder. The largest papillary tumor in the neck was 20 mm in diameter. The computed tomography showed mild enhancement of the gallbladder wall. Endoscopic retrograde cholangiopancreatography showed the irregular defects in the gallbladder. Endoscopic ultrasonography (EUS) showed the disorder of the 2 nd layer below the largest papillary tumor. The extended cholecystectomy with regional lymph nodes dissection was perfomed because of her age, complicated diseases, and intraoperative findings. The resected specimen revealed general wall thickning and irregular elevated lesions existed on the whole mucosa. The largest papillary tumor was crowded with rather big grain. Pathological examination revealed well differentiated adenocarcinomas within mucosal layer with superficial spread, except below the largest papillary tumor. Subserosal invasion was minimally detected accompanied by Rokitansky-Aschoff sinus carcinoma.

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