We investigated patients with difficulty in selective cannulation to the bile duct using precut papillotome. Patients with failure of the selective cannulation to the bile duct after conventional attempts were defined as difficult cases using precut papillotome with triple lumen consecutive 13cases. Both presence of the periampular diverticula and long narrow distal segment in difficult cases were evaluated to compare those of conventional EST cases (n=23). There were no periampular diverticula in difficult cases. The length of the narrow distal segment in difficult cases is significantly longer than that with conventional EST cases, therefore, long narrow distal segment plays an important role in difficult cases. Precut papillotomy using triple lumen sphincterotomy increased the success rate of therapeutic procedure at the duodenal papilla (our success rate 92.3%). We believe this precut technique is safer promising procedure after failed convention al attempts when performed by endoscopists with skilled hands.

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We reviewed pre-operative diagnosis of 8 cystic duct carcinomas. The patients were all men and average age was 67.5. Two cases satisfied the Farrar's diagnostic criteria and 6 satisfied it in a broad sense. Although it was difficult to identify the tumors by US, US revealed enlargement of the gallbladder in 75%, sludge or debris in 63%. CT revealed the tumor itself or unilateral wallthickness of cystic duct in 63%. We emphasize EUS revealed the tumors in 7 of 8 cases (88%), and enabled us to recognize the spatial relationship between tumor and the surrounding organs. ERC revealed stenosis with oppression and axis distortion in all the 6 cases, which satisfied the broad criteria. IDUS revealed the tumor itself in 88%. IDUS could not determine the tumor localization in 2 cases because of the massive extension of the tumors to bile duct. In conclusion, diagnostic EUS and IDUS imaging was effective for pre-operative diagnosis. Overall pre-operative diagnostic accuracy for cystic duct carcinoma was 88%.

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In the field of the biliary disease, ultrasound examination (US) is useful not only to pick up the lesions, but also to make a further diagnosis. In this lecture, the findings and readings as for gallstones, gallbladder polyps, adenomyomatosis, gallbladder cancer were described. Normal gallbladder wall is visualized as three layers (high-, low-, high-echo) by US. The first high echo layer shows marginal echo, the second shows mucosa, muscle layer, and superficial part of subserosal layer, and the third shows subserosal layer, respectively. To make a further diagnosis, understanding which layer of the gallbladder wall is mainly occupied by the lesion is mostly needed.

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Multidetector-low computed tomography (MDCT) not only allows routine examinations in a shorter time but also can be used to process to display images in three-dimensional and multiplanar formats. This noninvasive technique simplifies the diagnostic strategy for biliary diseases and reduces the need for other invasive staging methods.

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MRCP is useful to identify not only morphological changes, but also functional changes of the pancreaticobiliary diseases. Pancreatobiliary reflux similar to that seen in patients with pancreaticobiliary maljunction can occur in patients with a normal pancreaticobiliary junction and this may be associated with carcinoma of the gallbladder.

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The pancreas is uncommon site for metastasis from cancer of the papilla of Vater. We herein present a rare surgical case of a metachronous metastasis developing in the remnant pancreas after a pancreatoduodenectomy for cancer of the papilla of Vater. A 55-year-old woman had undergone pylorus-preserving pancreaticoduodenectomy for cancer of the papilla of Vater (TNM: Stage II). During the follow-up period, CA 19-9 increased to 141.2 U/mL (normal range: 0-37) 19months after the resection. Abdominal and chest CT disclosed a solid mass measuring 10 mm in size in the tail of the remnant pancreas without any other distant metastasis. These findings were considered to represent an isolated pancreatic metastasis from cancer of the papilla of Vater. The patient underwent distal pancreatectomy with splenectomy. Histologically, the tumor consisted of a well-differentiated tubular adenocarcinoma, the same diagnosis as that of the first tumor with no involvement of pancreatic ducts. Based on these histological findings, the pancreatic tumor was diagnosed as a metastasis from cancer of the papilla of Vater. To our knowledge, this case is the first report of a resection for pancreatic metastasis from cancer of the papilla of Vater after a pancreaticoduodenectomy.

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The subject, a 55-year-old woman received pylorus-preserving pancreatoduodenectomy for the treatment of a cancer of the duodenal papilla. The rupture of a hepatic artery aneurysm, as a postoperative complication, was treated with an embolization procedure, which was followed by a small amount of blood found several times in the drained fluid. A hemorrhage from the portal system was suspected but the spontaneous hemostasis occurred during the subsequent period. An abdominal CT indicated occlusion of the main portal system and the subsequent development of collateral circulation, which caused melena. Due to obstruction of the portal system and portal hypertension, a hemorrhage from the superior mesenteric varices was suspected. During the past two years, the patient has repeatedly hospitalized due to melena. In September 2003, since the episode of melena has occurred on a daily basis, the patient was transferred to our hospital. Transcutaneous transhepatic portography indicated a complete closure of the portal trunk and the evident development of collaterals into and away from the liver. Detecting that the stenotic region was hard and affected the entire luminal periphery, the section was dilated by using a cutting balloon, followed by the placement of 2 SMART Stents in a “stent-in-stent” fashion.
The residual collateral away from the liver was embolized by using a sclerosing agent. The stent patency has been maintained for 24 months after the procedure with no development of melena. Aggressive interventional radiology may be indicated even when an obstruction has existed for several years.

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We reported a case of carcimona of the papilla of Vater which visualized typical lymphatic spread pattern. The patient was a 80-year old man who has been treated for hypertension. He was pointed out liver damage incidentally. Duodenoscopy showed ulcerative tumor in the papilla of Vater and biopsy specimen from tumor revealed poorly differenciated adenocarcimona. Pylorus preserving pancreatoduodenectomy was performed. Resected specimen was cut same as computed tomography plumb in a body axis and consecutive serial sections were made. Histopathologically, lymphatic emboli were observed diffusely in retropancreatic region along posterior superior and posterior inferior pancreatoduodenal arteries and anterior inferior pancreatoduodenal artery. However, no lymphatic embolus was observed in the superior anterior region of the pancreatic head. This case is considered to be extremly valuable to understand the lymphatic basin of carcimona of the papilla of Vater.

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A 74-year-old man exhibited obstructive jaundice and underwent PTBD at a nearby hospital. After he was admitted to our hospital, examinations revealed that the jaundice was caused by a hepatic artery aneurysm with its neck at the junction of the proper and common hepatic arteries. Since severe stenosis of the main portal vein was also found, there was a concern that embolization of hepatic artery could induce dearterialization and corresponding failure of the liver. Therefore, equipments for portal vein arterialization were also provided at the procedure. Transcatheter arterial embolization using steel coils were performed on the proper and common hepatic and proximal gastroduodenal arteries, which respectively were the vessels proximal and distal to the lesion. The procedure was successful with no post-op liver failure. The aneurysm was reduced and the biliary stenosis was relieved. So far as 15 months follow-up, the patient is showing favorable clinical course with no recurrence of the obstructive jaundice.

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We herein reported a case of carcinoid tumor arising in the papilla of Vater, performed transduodenal local resection. A 49-year old male presenting high gamma-glutamyl transpeptidase level on the periodical health check and admitted to our hospital. Ultrasonography showed dilatation of the common bile duct. Computed tomography also revealed dilatation of the common bile duct and protruding lesion into the duodenal lumen on the papilla of Vater, however any swollen lymph nodes nor invasion into the surrounding tissues was not disclosed. Endoscopic ultrasonography demonstrated well defined homogenous low echoic tumor on the papilla of Vater,1.7 cm in size and the biopsy specimens taken from the swollen papilla revealed carcinoid tumor. We performed transduodenal local resection and the papilloplasty with regional lymph nodes sampling. Histopathologic examination revealed carcinoid tumor of the papilla of Vater. Lymph node metastasis, vascular and lymphatic permeation, perineural invasion, mitosis of the nucleus were not revealed. Atypical grade of the tumor cells and positive rate for Ki-67 staining were very low and the surgical margin was negative. Patient is alive and well without recurrence,11 month after the operation.

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There are few reports of adenosquamous carcinoma of the extrahepatic biliary tract. We experienced two cases of adenosquamous carcinoma of the extrahepatic biliary tract. First case is 62 years old with adenosquamous carcinoma from middle to lower part of common duct. Second case is 78 years old with adenosquamous carcinoma from middle to upper part of common bile duct. We reported clinicopathological findings of two cases.

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A 71-year-old woman was conducted transcatheter embolization against hepatocellular carcinoma. Diagnostic imaging, including ultrasonography and computed tomography was conducted every two or three month. Ten months later, the wall in the fundus of the gallbladder showed a irregular thickness. Cholecystectomy was performed and histological diagnosis was xanthogranulomatous cholecystitis. We report a case of xanthogranulomatous cholecystitis in which suffering process was successfully observed.

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A 37-year-old man on abdominal CT had a poorly enhanced and uncertain area at segment 2 of the liver with invasion to hilar portion. Abdominal angiography revealed irregular encasement at from proper hepatic artery to right hepatic artery and stiffness of the wall of the portal vein with obstruction of the left branch. Under the diagnosis of intrahepatic cholangiocarcinoma originated from segment 2 with invasion to hepato-duodenal ligament, extended left lobectomy including caudate lobe and complete en bloc resection of hepatoduodenal ligament was performed. Lymph node dissection was performed level 2 including lymph node along lesser curve of the stomach. After resection of artery and portal vein, arterioportal shunt (APS) was formed. Macroscopically, the tumor measured 5.2×3.2 cm in diameter invaded to hilar portion and caudate lobe. Cancer cell invaded to the inner wall of main route of the portal vein and to the surgical margin of the vessel at hepatic side. Moreover lymph node metastasis was recognized extremely including lymph node along lesser curve of the stomach. Because abdominal angiography at 16 days after the surgery revealed intrahepatic artery through the anastomosis from elevated jejunum, APS with patency was blocked. This case has now been followed for 1 year with no evidence of recurrence.

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