We experienced 32 patients of pancreaticobiliary maljunction without dilatation of the bile duct in 10 years.23 out of 32 patients (71.9%) were diagnosed by ERCP. The other 9 patients (28.1%) were diagnosed only by IDUS, not by ERCP. Malignant changes in the gallbladder was observed in 10 of the 32 patients (31.3%), and the bile duct cancer was seen in 4 patients (12.4%). In 2 cases of gallbladder cancer and 2 of bile duct cancer, maljunction was newly identified by retrospective review of the video tapes of IDUS. In these cases, the length of the commom channel was shorter, and the diameter was thinner than those of the cases diagnosed by ERCP. There is a possibility that quite a few cases with pancreaticobiliary maljunction are not recognized officially. Therefore IDUS should be performed in cases with suspicion by ERCP, cancer of biliary tract, or mucosal thickness of gallbladder, as many as possible to pick up the latent maljunction.

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The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts and regulates the outflow of bile and pancreatic juice. Since the union of the pancreatic and bile ducts is located outside the duodenal wall and the action of the sphincter muscle does not functionally affect the union in pancreaticobiliary maljunction, pancreatobiliary and biliopancreatic refluxes occur, resulting in various pathological conditions in the biliary tract and in the pancreas. Pancreatobiliary reflux could be diagnosed from elevated amylase level in the bile, secretin-stimulated dynamic magnetic resonance cholangiopancreatography, pancreatography via the minor duodenal papilla. Biliopancreatic reflux could be confirmed by operative or postoperative T-tube cholangiography and CT combined with drip infusion cholangiography. Recently, it has become obvious that these refluxes can occur in individuals without pancreaticobiliary maljunction. Biliopancreatic reflux is related to occurrence of acute pancreatitis and pancreatobiliary reflux might be related to biliary carcinogenesis even in some individuals without pancreaticobiliary maljunction. Further clinical study respect to clinical relevance and appropriate management of these refluxes in individuals without pancreaticobiliary maljunction should be performed.

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Cancerous micrometastasis of the lymph nodes generally indicates the lymph nodes with potentially positive metastasis which are diagnosed as those without metastasis by the ordinary pathological investigation. However, there are several problems with regard to the definition, methods for detection, and clinical significance. The first problem is difference of methods for detection, such as serial section methods, immunohistochemical methods, and PCR (polymerase chain reaction) methods, which show the different results. False-positive and false negative reaction may be possible and reproduction of the results are difficult in any of these methods. The second problem is that the reported and investigated cases are few, because of the complicated methods. The third problem is that the definitions of micrometastasis of lymph nodes are not unified. The forth problem is that the significance of lymph node metastasis as the prognostic factor is different among various organs. We confirmed the new method of a serial section method combined with an immunohistochemical method and showed the possibilities of more accurate detection of cancerous micrometastasis of the lymph nodes. Using this method, we investigated the micrometastasis of lymph nodes in cases with hepatic hilar carcinoma. The five year survival after resection in the cases with positive micrometastasis of lymph nodes,31.2%, showed no difference from that of cases with positive lymph nodes metastasis by the ordinal histological detection methods,19.7%, but showed the tendency of worse prognosis than that of cases with negative lymph nodes metastasis by the ordinary methods,57.5%.

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A 68-year-old man was pointed out as having a thickened gallbladder wall by a family doctor and referred to our hospital. Abdominal ultrasonography revealed a segmental type of adenomyomatosis ot the gallbladder and multiple papillary lesions in its neck side lumen. The mucosa of the fundus side was smooth. Abnormal arrangement of the pancreato-biliary ductal system (AAPB) was not shown in MRCP. We conducted cholecystectomy based on the preoperative diagnosis of adenoma or early cancer of the gallbladder. Bile juice amylase level in the gallbladder was very high, which suggested the existence of occult pancreato-biliary reflux (OPBR). Histopathologic examination revealed mucosal carcinoma in situ in the fundus side lumen and hyperplasia in the neck side mucosa. This patient had two risk factors for gallbladder cancer, a segmental type of adenomyomatosis and OPBR, which led to mucosal cancer in the fundus side lumen and hyperplastic mucosa in the neck side lumen.

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A 73-year-old man was found to have two mass lesions along the bile duct. The first one was located aroud intrahepatic bile duct, and the other was in the extrahepatic bile duct. He underwent left lobectomy and choledochectomy based on the clinical and radiological diagnosis of double bile duct cancers. Resected specimens revealed two lesions were histologically continuous by extensive periductal infiltration of carcinoma cells. This report presents a rare bile duct tumor showing two mass lesions and extensive perductal infiltration between them.

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We experienced a case of gallbladder cancer with cholesterosis.
A 71-year-old woman underwent a medical checkup and a protruded lesion of the gallbladder was detected by an abdominal US.
Abdominal US revealed a echogenic lesion, measuring 20mm, with irregular surface at the fundus of the gallbladder.
The protruded lesion was enhanced by administration of contrast medium on abdominal CT.
Under diagnosis of the carcinoma of the gallbladder, she underwent an open cholecystectomy.
The resected specimen showed a 20mm elevated lesion at the fundus of the gallbladder.
Histologically, this was demonstrated to be well differentiated adenocarcinoma associated with cholesterosis, stage I.

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The patient was a 76-year-old female. She became aware of a mass in the upper abdominal area and was referred to and hospitalized at our department with the suspicion of cystadenocarcinoma of the liver. Using the abdominal US, CT, and MRCP, we observed a papillary tumor which was continuous from the common bile duct to the left intrahepatic bile duct. During ERCP, we were able to confirm the dilation of the papillary orifice and mucus excretion. Using a contrast medium, we observed a marked enlargement and a large amount of mucous masses in the bile duct. A mucin-producing papillary tumor was observed by the bile duct biopsy, and the patient was diagnosed with mucin-producing bile duct tumor extending from the common bile duct to the left intrahepatic area. By a contrast study, we were not able to accurately diagnose the intramural extension of the tumor due to the large amount of mucous masses. Therefore, we performed intraductal ultrasonography (IDUS). Since the extension of the tumor was not observed in either the right hepatic duct or the right intrapancreatic bile duct, we performed an extended left hepatic lobectomy. The pathological diagnosis was adenocarcinoma, and the margins of the right hepatic bile duct and the common bile duct were negative.
The preoperative diagnosis of mucin-producing cholangiocarcinoma is difficult in many cases because of diverse appearances of bile ducts due to modification by mucous masses. IDUS was considered an effective examination for diagnosing the tumor extension.

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A 72-years-old woman was admitted to the hospital because of sudden onset of vomiting, epigastric pain, and back pain. Gastroduodenal endoscopy revealed the impacted giant gallstone in the duodenum and duodenal ulcer. We diagnosed it as a gallstone ileus.
We tried to crash the giant stone. But stone was not crashed. After the Gastroduodenal endoscopy, Laparotomy was performed. After cholecystectomy, the impacted gallstone was extracted from the fistula of the duodenal bulb. The duodenum was closed transversely and covered with omentum.
Duodenal obstraction by gallstone is rare cause of gallstone ileus. We report the case of gallstone ileus in the duodenum with review of 16 cases in the Japanease literature.

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We report an extremely rare case of metastatic tumor thrombi from colon cancer in the extrahepatic bile duct. A 59-year-old man was admitted to our hospital due to obstructive jaundice. He had undergone a right hepatectomy for liver metastasis from an ascending colon cancer and partial resection of the remnant liver and right nephrectomy with partial resection of the diaphragm for local recurrence 7 years and 19 months previously, respectively. Abdominal computed tomography demonstrated a solitary lesion, approximately 2 cm in diameter, in the porta hepatis and dilatation of the intrahepatic bile duct. ERCP revealed a filling defect in the extrahepatic bile duct. Thus, extrahepatic bile duct resection and partial resection of segment IV with reconstruction of the biliary tract were performed. The resected specimen revealed a whitish tumor occupying the extrahepatic bile duct. Histologically, the tumor was determined to be a metastasis from colon cancer.

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A 74-year-old male reffered to our clinic due to jaundice, body weight loss, and an upper abdominal mass. Laboratory data indicated obstructive liver damage and autoimmune disorder. Sonography disclosed dilatation of intra- and extra-hepatic bile ducts accompanied by a pancreatic head mass, measuring 4.3cm in diameter. The mass was well enhanced on contrast-enhanced dynamic CT images, and inflammatory tumor was suspected due to elevation of blood IgG4 level. Additionally uneven thickness of upper bile ducts and gallbladder wall was observed, suggesting sclerotic cholangitis.
Steroid hormone therapy in a primary dose of 30mg/day resulted in dramatic improvement of symptoms and blood chemistry data in addition to shrinkage of pancreatic mass and decreased thickness of bile ducts.

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A 73-year-old woman who complained of the right hipochodrium pain came to our hospital. There were peritoneal irritation on the right hipochodrium. Abdominal CT showed a debris like lesion in the swelled gallbladder. We made a diagnosis of acute cholecystitis, and we pricked gallbladder with needle for the purpose of PTGBD. We did aspiration biopsy, because the part like debris was a tumor. The result of aspiration biopsy was gallbladder cancer. After 19 days of the hospitalization, we performed partial hepatectomy with the gallbladder, resection of the bile duct, partial resection of the trasverse colon and lymphnode resection (D₂). Pathological diagnosis was undifferentiated carcinoma. The patient was early complicated by respiratary failure after the operation. We made a diagnosis of lung edema with pnuemonia and treated the patient, but the patient did not react for the treatment, and died after 34 days of the operation. Because tumor maker rose rapidly after the operation and aspiration biopsy of the lung after death was Class IIIb, we suspected the lung metastasis.

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Although surgical treatment for hilar cholangiocarcinoma had been a high risk procedure, safety and curability has been improved as preoperative biliary drainage and portal vein embolization has become widely used and as the mode of tumor spread has become clear. Extended hemihepatectomy, with or without pancreatoduodenectomy (PD), plus extrahepatic bile duct resection and regional lymphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. Strategy including preoperative biliary drainage (BD) followed by portal vein embolization (PVE) enables major hepatectomy, i. e. extended hemihepatectomy and right or left trisegmentectomy, without mortality in patients with hilar bile duct cancer. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Extended resection, such as hepatopancreatoduodenectomy or combined vascular resection and reconstruction has been applied to the selected patients with widespread tumors. As a result, extended hemihepatectomy offers a chance for cure of hilar bile duct cancer with resectability of 74.5%, curability rate of 64% without liver failure and mortality. A 5-year survival rate was 33.9%, and postoperative adjuvant chemotherapy should be considered for patients with lymph node metastasis and with poor prognosis.

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In hilar cholangiocarcinoma, surgical resection is the only way to offer a better chance of long-term survival. The surgical procedure is determined according to the tumor extension diagnosed by several imaging modalities and liver function. Right-sided (right hepatectomy and right trisectionectomy) or left-sided hepatectomy (left hepatectomy and left trisectionectomy) with caudate lobectomy is simpler compared to central hepatectomy, being more recommended as resectional procedure. When the patient is not so old and has good liver function, extended resection with enough surgical margins is better to indicate. The surgical approach to Bismuth type I and II hilar cholangiocarcinomas should be determined according to cholangiographic tumor type. For nodular and infiltrating tumors, right hepatectomy is essential; for papillary tumor, bile duct resection with or without limited hepatectomy is adequate. When the portal vein is involved, portal vein resection and reconstruction is of clinical value; however, further studies is required for hepatic artery resection and reconstruction for involved hepatic artery.

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Radical resection has been revealed to be a most important prognostic factor for the prognosis after surgical resection in patients with hilar cholangiocarcinoma. Therefore, it is very important that surgical resection with cancer-free surgical margin should be done without postoperative major complications in surgical treatment for hilar cholangiocarcinoma. For obtaining favorable surgical outcome, several modalities of meticulous preoperative diagnosis of cancer extension and of liver functional capacity, portal vein embolization, biliary drainage, combined vascular resection and parenchymal preserving hepatectomy etc. should be appropriately selected and utilized in each patient. Herein, the present criteria of respectability of hilar cholangiocarcinoma were described, and also which surgical procedures should be selected in each respectable patient was revealed. The clinician has to stick to surgical resection for hilar cholangiocarcinoma as much as possible because surgical resection can be only hope for cure. Aggressive surgical management for hilar cholangiocarcinoma was described in this paper.

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