Any consensus has not been established in Japan regarding risk factors for post-ERCP pancreatitis. Therefore, to evaluate factors that stimulate the papilla, total operation time, was studied along with other factors previously reported. Among patients who underwent ERCP between August,2003 and May,2006,629 patients (average age of 65.5 years old and male: female ratio of 1.4: 1.0) were studied. The total incidence rate of post-ERCP pancreatitis was 4.1%. The patients were divided into two groups and compared: 1) those that“developed”and 2) those that“did not develop”pancreatitis. No differences were detected in the two groups for age, male: female ratio, common bile duct diameter, and main pancreatic duct diameter. The following parameters were significantly greater in the“developed”group: operation time: 47.5 vs.29.4 minutes; and imaging rate of pancreatic duct: 85.2% vs.63.5%. The time until deep insertion showed a longer tendency in the“developed”group: 17.4vs.8.7 minutes. These data suggest that operation time and imaging rate of the pancreatic duct are risk factors for post-ERCP pancreatitis.

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Backgrounds: Tumors of the duodenal major papilla are difficult to diagnose histologically, endoscopic papillectomy is performed as a method of complete biopsy. Due to a few of clinical evidence, this technique has not yet become established. We evaluated the safety of endoscopic papillectomy in 20 patients treated at our hospital.
Methods: Endoscopic papillectomy was performed on 20 patients at our hospital from October 2002 to April 2007. The patients consisted of 11 men and 9 women with a median age of 68.9 years (range: 34 to 89 years). The bile duct and the pancreatic duct drainage were performed after resection as possible.
Results: A local bleeding was occurred in 6 patients, which was controlled endoscopically and needed no blood transfusion.3 patients occured pancreatitis, but it was recovered after 3 days. The presence (n=15) or absence (n=5) of a pancreatic duct drainage did not correlate with subsequent pancreatitis (p=NS). One patient occurred cholangitis, but it was recovered by conservative therapy. There was neither perforation nor any fatal complications.
Conclusions: We could perform endoscopic papillectomy of the tumor with duodenal major papilla safely.

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We investigated clinicopathological factors and prognosis for appropriate operation for 44 patients who received resections for gallbladder carcinoma with subserosal invasion. Their 5-year survival rate was 50.2%. There was a significant difference in the survival rate between the patients with and without hepatectomy, whereas there was no survival advantage for the anatomical liver resection or partial hepatectomy group cornpared with the extended cholecystectomy group. However, the 3-year survival rate of patients who underwent pancreaticoduodenectomy was 83.3%; the outcome after pancreaticoduodenectomy was comparable to that after resection of the bile duct. A significant difference in the survival rate was observed between lympahadectomy with D2 and D0/1. In particular, the tendency was remarkable in the gallbladder neck and cystic duct carcinoma. The significance of anatomical liver resection, pancreaticoduodenectomy, and resection of the bile duct was indistinct. The presence of lymph node metastasis was an independent prognostic factor by multivariate analyses. These results suggest that radical resection with hepatectomy and lympahadectomy with D2 is the appropriate procedure for gallbladder carcinoma with subserosal invasion.

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The long-term prognosis of cases treated for bile duct stones by endoscopic papillary balloon dilation (EPBD)5 years earlier was evaluated. The duration of the ebservation of 101 subjects was 87.3±26.5 months and early complication was limited to pancreatitis (2 cases,2.0 %). For late complications, the recurrence of bile duct stones was noted in 5 cases (5.0%). In 4 of these 5 cases, these stones were believed to have escaped from the gallbladder. No incidence of cholecystitis was recognized nor were there pneumobilia detected in the imaging diagnoses. Four patients succumbed, their causes of death being pancreatic cancer, intrahepatic cholangiocarcinoma, hepatic failure and myocardial infarction. Their survival ranged from 25 to 34 months. When a gallbladder that contains stones is preserved, the possibility of their repeated escape presents a problem. Therefore cholecystectomy should be performed if possible following EPBD. On the other hand, the incidence of cholecystitis is low after EPBD and this approach should be considered as the first choice for the treatment of bile duct stones in cases indicating a high risk for cholecystectomy.

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Primary sclerosing cholangitis (PSC) is a chronic progressive inflammatory disease with fibrous obliteration of intra- and extrahepatic bile ducts. Although immunological abnormalities are considered to cause PSC, precise pathogenesis of PSC is unknown. According to national surveys, PSC patients in Japan have revealed to have two peaks in the age distribution; Typical PSC patients complicated with inflammatory bowel disease (IBD) are included in the younger peak, whereas the elder peak includes patients with sclerosing cholangitis with autoimmune pancreatitis (AIP), which are nowadays considered to be different from typical PSC. Recently, the presence of patients with sclerosing cholangitis similar to AIP without apparent pancreatic lesions has been identified. The actual situation of such patients, which is also called as IgG4-related sclerosing cholangitis, should be clarified in near future.

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Double balloon endoscopy (DBE) is a novel technique for the diagnosis and treatment of the small bowel. We endoscopically treated a case with ileus from an impacted gallstone in the duodenum. A 70-year-old woman was referred to our hospital because of vomiting. Abdominal CT and duodenoscopy showed an impacted calcified gallstone 4cm in diameter in the second portion of the duodenum. We attempted to remove the stone endoscopically using electrohydraulic lithotripsy (EHL). Then we performed EHL with duodenoscopy; however, the gallstone, which had gotten smaller from the first session of EHL, passed into the small bowel. Therefore, we performed further EHL treatment using DBE. After two sessions of EHL using DBE, the stone could be fragmented. Abdominal CT performed 7 days after the last session of EHL therapy showed complete disappearance of the stone. We recommend that endoscopic treatment including the combination of EHL and DBE is considered before the decision for surgery is made.

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We report a relatively rare case of small intrahapatic cholangiocarcinoma. A 84-year-old woman was referred for further examination due to the focally dilated intrahepatic bile duct detected by ultrasonography. Laboratory data including tumor markers and liver function test were within normal limits except for γ-GTP. Computed tomography showed a dilated intrahepatic bile duct (B2), but the tumor could not be detected. ERCP revealed severe stricture at the origin of B2. Angiography suggested an encasement of the intrahepatic arterial branch for segment 2. Although the presence of cancer was not evident, left hepatic lobectomy was performed with the suspicion of cholangiocarcinoma. Histological examination of the resected specimen revealed a small (9mm in size) cholangiocarcinoma confined to the periductal portion without invasion to the hepatic parenchyma.

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It is known that biliary system branching shows various morphological abnormalities including accessory communicating bile duct. In this study, we report 2 patients with an accessory bile duct communicating between the right hepatic duct and the cystic duct. Patient 1 was a 68-year-old female. Patient 2 was a 63-year-old male. The two patients were referred and admitted to our hospital for obstructive jaundice. Detailed cholangiography prior to PTBD revealed the presence of an accessory bile duct communicating between the right hepatic duct and the cystic duct.
Pancreatoduodenectomy was performed under diagnoses of advanced cholangiocarcinoma and pancreatic head cancer in Patients 1 and 2, respectively. In these patients, the accessory communicating bile ducts did not have any single dominant region in the liver, and there was no stenosis affecting bile outflow in the right hepatic duct. Therefore, ligation was performed to treat the accessory communicating bile ducts. These abnormalities in the present cases were detected on direct cholangiography. However, such abnormalities have been increasingly detected on MRCP or DIC-CT. In the future, the widespread use and development of these procedures may facilitate the noninvasive evaluation of abnormalities in the biliary course without direct cholangiography.

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We report choledochocele accompanied by severe acute pancreatitis. A 70-year-old male was admitted to our hospital for upper abdominal pain. The patient was diagnosed as having severe acute pancreatitis, with a severity score of 6 according to the Japan scoring system. Intra-arterial injection of a protease inhibitor and antibiotic was carried out for partial necrosis of pancreas. He recovered gradually without complications. The patient had experienced acute pancreatitis several times in the past without cholelithiasis, hyperlipemia, or alcohol drinking. Endoscopic retrograde cholangiopancreatography was carried out to investigate the cause of the pancreatitis. Choledochocele was found, and endoscopic sphincterotomy (EST) was performed. The patient has experienced no pancreatitic symptoms, and no malignant change has been detected in the 4 years since EST.

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A 69-year-old man was admitted to our hospital for further examination of his acute pancreatitis. Abdominal CT and MRCP showed a dilatation of the main pancreatic duct (MPD). ERCP revealed a cystic dilatation of the common channel to a diameter of 7mm. The physiologic stenosis by the sphincter of Oddi intervened between this cystic dilatation and common bile duct (CBD) or MPD, so a diagnosis of choledochocele was made. Although deep CBD cannulation was difficult, precutting using a needle knife made it possible. After endoscopic sphincterotomy (EST), the stone in the CBD was removed with a retrieval balloon Thereafter, a laparoscopic cholecystectomy was performed. In addition, the initial ERCP revealed an elevated amylase level in the bile juice to 13930IU/l, which fell to 604IU/lone month after the EST. Therefore, it was assumed that pancreatic juice had been refluxing into the CBD. This suggested that the presence of a choledochocele with biliopancreatic and pancreatobiliary refluxes was the cause of both the acute pancreatitis and cholelithiasis.

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A 52 year-old woman complaining of jaundice was received close examination. Two cystic lesions around the porta hepatis, which oppressed the extrahepatic bile duct, were found. One of those was unilocular and existed in the median segment of the liver. Another was multilocular and existed on the hepatoduodenal ligament The latter lesion had a papillary tumor on its wall. Extended left lobectomy of the liver and extra-hepatic bile duct resection was performed. By the pathological examination, the histologic continuity of the two cystic tumors was proved and the tumor was diagnosed as a biliary cystadenocarcinoma originated from the bile duct of the porta hepatis. It showed luminal communication to the bile duct and lacked ovarian stroma, and was thought to be categorized as IPNB.

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Biliary drainage and anti-tumor treatment are important for the treatment of non-resection cases of hilar cholangiocarcinoma. The considerable standard way of biliary drainage was unilateral metallic stenting from recent reports. However, there was no high rebel evidence, and need a more studies. There was no standard antitumor treatment either for locally or metastatic cases. For the locally advanced cancer, photo dynamic therapy reported its efficacy by randomized controlled trial, but radiation therapy had not confirmed. There are no standard systematic chemotherapy, however, recent developed new agent, such as gemcitabine and S-1 showed good results in response rate and median survival. Combination therapy using these 2 drugs also showed good results. In the near future, the standard chemotherapy will be these drugs or these drugs based regimen.

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At present, although imaging diagnosis has been developed, most hilar bile duct cancer is still diagnosed at an advanced stage and its prognosis is generally poor. In hilar bile duct cancer, radiotherapy and other several therapies, for example-chemotherapy, arterial-infusion chemotherapy, photodynamic therapy, etc-are being performed for non-operative cases. But standard therapies for this cancer has not been established yet.
On the other hand, metallic stents (MS) have been widely used to relieve biliary obstructions as an alternative to plastic prostheses and conventional drainage. The use of MS offers good palliation in hilar bile duct cancer, but patients selection is a key to obtain good results.
In this article we reviewed previous studies and clinical trials regarding the anti-cancer therapy and biliary stenting for unresectable hilar bile duct cancer. And optimal therapeutic strategy for hilar bile duct cancer is proposed, primarily based on present views.

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Local anatomy of the hepatic hilus and surgical anatomy of the hepatic segments and subsegments have been studied by Western surgeons, however clinical and surgical anatomy was further studied by Japanese clinician.
Recent development of MDCT changed a diagnostic work-up system and provides much useful information about the stage of the disease and suggested surgical procedures. However, there have been several unresolved questions: endoscopic or percutaneous biliary drainage? timing of cholestatic liver resection after portal vein embolization? which should be clarified in the near future. Indication of surgical resection has not been standardized and each institution has its own criteria which should be standardized and established in the near future as surgical resection is the only treatment of choice to cure the patients. Therefore indication of nonsurgical treatment should be reevaluated after careful investigation of the stage of the disease not to lose a change of cure.
Further clinical studies are required to establish adjuvant treatments to provide high level of evidences.

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