Duodenal papilla is one of the important places among the body physiologically and morphologically, because bile and pancreatic juice are excreted into the duodenum via its narrow orifice.
There are various pathological conditions in the duodenal papilla, such as so-called overreplacement of ampullary mucosa, parapapillary diverticula, papillitis, and ampuilary carcinoma occurred.
In this article, some topics mentioned above were described.

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After surgical resection, cancer of the papilla of Vater slows better prognosis than that of pancreatic head and extrahepatic bile duct. Recently, papillectomy has been accepted as an endoscopic treatment for an adenoma of the papilla of Vater. However, some problems to be solved still remain such as differential diagnosis of the papillary tumors, cancer staging, indication for endoscopic papillectomy and prevention of complications. In this paper, the author discussed these problems with special references to endoscopic procedures.

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We have two endoscopic methods to access bile duct from duodenal papilla. Endoscopic sphincterotomy (EST) was initially proposed for the treatment of post surgically retained calculi in the common bile duct. According to developments of the instrumentation and technique, EST has become a. widely accepted treatment for common bile duct stones, In 1983, endoscopic papillary balloon dilation (EPBD) was proposed, and accepted for choledocholithiasis especially in Japan. An analysis of the recent literature on randomized controlled trials of EST and EPBD shows its indication. On the basis of lower rates of bleeding, EPBD should be preferred in patients with coagropathy or a partial gastrectomy with Billroth II reconstruction. Long-term follow up on randomized controlled study is necessary to confirm which is preferable for treatment of choledocholithiasis.

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It is mandatory to have precise knowledge of topographical anatomy for treatment of diseases of the duodenal papilla. The connection between the duodenum and the pancreatic parenchyma is generally loose except for the portion surrounding the minor papilla. The vascular supply to the duodenum and the major papilla derives from the anterior and posterior arterial arcades. Severance of 3 pairs of anterior and posterior duodenal branches is necessary for dissection of the major papilla from outside the duodenal wall.
Common bile duct stones and choledochal cyst are new treated not by surgical intervention but by interventioal endoscopy. Surgery is still indicated for adenoma of the duodenal papilla. The tumor of the papilla that causes obstructive jaundice should be considered invasive and be managed by surgery such as pylorus-preserving pancreatoduodenectomy.
Such knowledge of anatomy and surgical techniques helps perform pancreas-sparing duodenectomy for duodenal trauma and duodenal polyposis.

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A 70-year-old female was admitted to our hospital in order to exam the gall bladderlesion. US, CT, and EUS revealed early cancer in the body-fundus of the gall bladder. Cholecystectomy and extra-hepatic bile duct resection were performed. Resected specimens disclosed early cancer in the body-fundus of the gall bladder. However, microscopic examinations revealed early papillary adenocarcinoma in the body-fundus and the cystic duct, as well as in the middle portion of the common bile duct, which could not be observed with the imaging techniques or inspection of the specimens. Those three lesions were separated one other, considering that synchronous, separate tumor growing occurred. When we encounter the gall bladder cancer, multiple lesions of the biliary tract should be suspected.

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A 31-years old man was admitted to Nagoya University Hospital with melena and anemia. An upper gastrointestinal endoscopic examination showed an elevated lesion mimicking submucosal tumor adjacent to the major papilla. The tumor was diagnosed to be carcinoid from bioptic specimens. We perfomed pancreatoduodenectomy and the histological examination revealed a gangliocytic paraganglioma.

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A rare case of polyp type of cancer of papilla of Vater is reported herein. A 75 year-old woman had her bile duct dilatation checked by abdominal US in a routine medical checkup, resulting in a discovery of a 3×2.5 cm polyp tumor originating from papilla of Vater. There was no abnormal data in biochemical or serum tumor marker level. She had a history of renal cancer and diabetes mellitus. Histological examination from biopsy specimen confirming a well differentiated adenocarcinoma lead to a diagnosis of polyp type of cancer of papilla of Vater. Pylorus preserving pancreaticoduodenectomy was perfomed on November 6,2003. From pathological examination of excised specimen, no lymph node metastasis was observed and the invasion depth was up to proper muscle of Oddi. Macroscopically, polyp type of cancer of papilla of Vater is rare. Although various minimal invasive surgeries are applied to cancer from pancreatoduodenal lesion, there is no standard technique except pylorus preserving pancreaticoduodenectomy. Case accumulation of polyp type of cancer of papilla of Vater is desired for establishing the treatment.

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A 68-year-old woman who was diagnosed as dermatomyositis developed common bile duct cancer. It is well known that patients with dermatomyositis often complicate malignant tumor, but rarely cholangiocarcinoma. We recommend patients with dermatomyositis undergo annually systemic examination such as abdominal US, CT and endoscopy including tumor marker to be found malignant tumor.

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The patient was an eighty-year-old man. He was admitted to our hospital for treatment of bile duct stone. MRCP showed a bile duct stone in the lower bile duct, and slight dilatation of the bile duct and the cystic duct. After EST and removal of the bile duct stone, ERCP using balloon catheter was performed; however, it did not show the cystic duct. EUS was performed with a possible diagnosis of cystic duct lesion. A low-echoic lesion was observed inside the cystic duct; while cystic duct tumor was suspected, a diagnosis of debris could not be excluded. For differential diagnosis of tumor and debris, contrast-enhanced EUS was performed; it revealed a signal of blood flow inside the lesion, and the lesion was diagnosed as cyctic duct tumor. At POCS, granular changes of mucosa was observed around the bifurcation of the cystic duct. It was finally diagnosed as papillary-type cyctic duct tumor, and resection of the cystic duct and the bile duct were performed. The resected specimen was an elevated papillary lesion, measuring 19 mm×18 mm, and occupying nearly entire lumen of the cystic duct. Pathologically it was expanded papillary-type, C, Pap, pT₂ (ss, pHinf₀, pBinf₀, pPv₀, PA₀), n₀, m₀, fStage II.

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Peribiliary cysts are characterized by cystic dilatation of extramural glands in the bile duct. Liver cirrhosis, systemic infection, and polysystic kidney disease are the main underlying conditions. They have been speculated that circulatory failure caused by the interference of blood flow through the portal vein causes morphological change in extramural glands around the bile duct. A71-year-old man with hepatitis B was diagnosed as having cholangiocarcinoma. He was admitted to our hospital to detect the cause of the findings (we suspect cholangiocarcinoma). Percutaneous transhepatic cholangiography (PTC) showed stenosis of the left hepatic bile duct following the dilated peripheral duct. Comuputed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed cystic or beaded dilatation-like lesions of the left intrahepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed some filling defects (their surface were smooth) between the left and right hepatic duct and the second-order branch of the bile duct and lower common bile duct. In recent years, intraductal ultrasonography (IDUS) has been widely used for the diagnosis of various hepatohiliary and pancreatic disease. IDUS only showed the intrahepatic and extrahepatic bile duct was pressed directly by surrounding multiple cysts. Based on these imaging studies, he was diagnosed as having multiple Peribiliary cysts. We experience IDUS is useful technique for the diagnosis of Peribiliary cysts.

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Among benign tumors of the gallbladder, inflammatory pseudotumor has rarely been reported. An 88-year-old man with fever and right hypochondralgia was admitted. Previously he had suffered from chronic renal failure and renal anemia. Laboratory data on admission revealed anemia and renal disorder. Adominal ultrasonography revealed swelling of the gallbladder, debris, thickening of the gallbladder wall, and dilatation of the intrahepatic bile duct. Computed tomography showed swelling and thickening of the gallbladder wall. Magnetic resonance cholangiopancreatograhy visualized stenosis of the common bile duct and dilatation of the intrahepatic bile duct. On operation, an elastic soft mass of the neck of the gallbladder was involved in the common bile duct. Biliary tract reconstruction and cholecystectomy were performed. Histopathologically, infiltration of inflammatory cells, proliferation of fibrosis, and granulation with increase of small vessels were recognized. No malignancy was confirmed and inflammatory pseudotumor of the gallbladder was diagnosed. The patient died due to renal failure two months after the operation.

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