Poor prognosis after treatment in advanced gallbladder carcinomas remains, despite the development of the modern diagnostic modalities. Early detection of the carcinoma and subsequent cure seem to be essential for resolution of such problems. When gallbladder cancer is suspected based on clinical symptoms and risk factors, ultrasonography should be performed through not only the skin but also the duodenum (EUS) and enhanced CT should be carried out. If the carcinoma is limited around the gallbladder without distant metastasis, standard radical surgery might be a curative procedure. The favorable procedure can be, however, selected and confirmed after the correct pathological examination of the specimen is removed. It is recommended to do the strategies of second radical surgery, because unfavorable and over surgery would be especially refused.

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The introduction of portal vein embolization and improvement of surgical management for bile duct cancer have made it possible to safely perform the standard curative resection such as right or left hepatectomy with caudate lobe. Accordingly, preoperative biliary drainage strategy has been changed. And imaging diagnostic method has also advanced; especially progress in the less invasive apparatuses such as MDCT is remarkable.
In the bile duct cancer, diagnosis of distant metastasis and local extension of cancer is preoperatively important; the latter includes not only invasion of the vessels but also longitudinal extension of the bile duct. The longitudinal tumor extension varies depending on the gross type and the location of cancer, of which appropriate diagnosis is required. Namely intraluminal tumor extension is highly frequent in hilar or upper bile duct cancer; the diagnostic point is to correctly read the images of tapering stenosis of the bile duct, using the surgical limits that separate the hepatic ducts from the vasculature and ductal division as an index. On the other hand, the superficial tumor extension is frequent in the middle or lower bile duct cancer, for which a cholagioscopy and biopsy are used often.
For bile duct cancer, close examination must proceed with biliary drainage as a way to improve liver function before surgery. Endoscopic biliary drainage, especially ENBD, is currently a first choice of preoperative drainage method for operable patients with cholangiocarcinoma.

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The incidence of intrahepatic cholangiocarcinoma (ICC) has been increasing in the world. Recently, hepatitis C virus infection and non-specific liver cirrhosis are recognized as causes of ICC. ICC is classified into three macroscopic types; mass-forming, periductal infiltrating and intraductal growth type. This classification is useful to determine the clinical status of patients and to predict surgical outcomes. Mass-forming type ICC is significantly related with hepatitis C virus infection and the clinicopathological findings of mass-forming type ICC are similar to those of hepatocellular carcinoma. Mass-forming plus periductal infiltrating type ICC is considered to be a more advanced tumor of periductal infiltrating ICC because of the clinical features and the histopathological findings. Multivariate analysis shows that lymph node metastasis, intrahepatic metastasis and curative resection are significant independent factors. Recurrence rates are high even if curative surgery is performed and therefore adjuvant therapy (immunotherapy and chemotherapy) should be performed for better survival.

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We reviewed 29 cases with advanced gallbladder cancer of invasion depth ss or more for the purpose of clarifying significance and problems of dissection for lymph node metastasis and invasion to hepatoduodenal ligament. The pBinf is 0 for the cases with invasion depth ss and development locus to Gf/Gb, therefore lymphadenectomy becomes main purpose of dissection. On the other hand, we require both lymphadenectomy and dissection of hepatoduodenal ligament, because lymph node metastasis is extremely high for cases with invasion depth se or more, and pBinf positive rate is 75% for cases with development locus to Gn/C/B. About lymph node metastatic site and frequency, 12b was 36%, and 13a was 28%, and both frequency was high. Long-term survival more than five years was obtained in the cases that pancreatoduodenectomy was performed for cases more than pN2. On the other hand, for pBinf positive cases, an operation to remove main blood vessels surgically together is necessary for carcinoma loss of dissected tissue margin in hepatoduodenal ligament. However, it is necessary to try for improvement of operative procedure and to consider operative indication to show operation-related death to an extended operation.

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Palliation of unresectable malignant hilar biliary stricture is controversial with respect to optimal types of stents and extent of drainage. A consecutive series of 92 patients from 13 institutions with unresectable malignant hilar biliary strictures undergoing palliative stent placements were prospectively reviewed. Extent of biliary drainage and type of stents used are: unilateral metallic stent placement in 19, unilateral plastic stent in 22, bilateral metallic stents in 21 and bilateral plastic stents in 30. Relatively small caliber stents were inserted in most patients undergoing bilateral drainage with plastic stents. Major cause of stent occlusion was: tumor ingrowth for metallic stents, and bile encrustation for plastic stents. Early and late cholangitis associated with stent occlusion was significantly frequent in patients undergoing bilateral plastic stent placement. Cholangitis was not observed in patients undergoing metallic stent placement. According to Kaplan-Meier method, bilateral metallic stents offered significantly longer patency, compared with the other three groups. There was no significant difference in the median length of survival between groups. Bilateral metallic stent placement may provide effective palliation in patients with hilar biliary strictures. Palliation with bilateral small plastic stents, due to their propensity to be easily occluded, may become less feasible.

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We report our experience of laparoscopic cholecystectomy using needlescopic instruments for acute or chronic cholecystitis after resolution of acute inflammation. During recent five years, eleven needlescopic cholecystectomies were performed in eight males and three females. Their mean age was 57 years. Percutaneous gallbladder drainage was preoperatively performed in two patients. The mean duration from onset to operation was 25 days. Under general anesthesia, 12-mm port was placed at the subumbilicus, and three 2-mm or 3-mm needlescopic ports were inserted at right upper quadrant under the guidance of laparoscope. There were no conversions to open surgery. Needlescopic instruments were converted to conventional ones due to the difficulty of manipulation of gallbladder in two patients. The mean operation time was 154 min. There were no severe intra-and postoperative complications, however, we experienced an postoperative intra-abdominal abscess requiring percutaneous drainage in one patient. The mean postoperative hospital stay was 10 days. Although laparoscopic cholecystectomy using needlescopic instruments for acute or chronic cholecystitis is feasible with the strict evaluation of the patients and the adequate control of associated diseases preoperatively, we require a careful surgical technique with the consideration of morbidity.

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Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a union of the pancreatic and biliary ducts that is located outside the duodenal wall. The PBM results in free reflux of pancreatic juice into the bile duct and inflammatory changes in the epithelium of the bile duct, and may be a key factor in the pathogenesis of malignant changes in bile duct. The incidence of bile duct carcinoma with PBM is approximately 1,000 times greater than the incidence of bile duct carcinoma in the general population. Excision of extrahepatic biliary tract and hepaticojejunostomy is the standard operation for choledochal cysts. However, reports of bile duct carcinoma after cyst excision are gradually increasing. Careful long-term follow-up is very important, even after complete excision.

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This review deals with the relationship between adenomyomatosis of the gallbladder and gallbladder carcinoma (GBC), mainly based on our previously published data that included a total of 7,757 consecutive patients who underwent cholecystectomy for various conditions. Adenomyomatosis of the gallbladder was classified into segmental, fundal, and diffuse types. The prevalence of GBC was higher in patients with segmental adenomyomatosis (34/522, 6.5%) than in those without (274/7235, 3.8%; P=0.002). This difference was more marked among patients equal to or older than 60 years of age (P<0.001). The other types of adenomyomatosis showed no increased prevalences of GBC. In all 34 patients with both segmental adenomyomatosis and GBC, the tumors developed only in the fundal mucosa and showed a gastric mucous phenotype. Segmental adenomyomatosis is a high-risk condition for GBC, especially in elderly patients. Gastric type of epithelial metaplasia appears related to carcinogenesis in gallbladders with segmental adenomyomatosis.

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A 35-year-old woman presented with upper abdominal pain. Dilatation of the common bile duct was detected on abdominal ultasonogaphy. Endoscopic retrograde cholangiopancreatography revealed that the vental duct was short and had no connection with the dorsal pancreatic duct.
On the basis of these findings, the patient was given a diagnosis of pancreas divisum accompanied with pancreaticobiliary maljunction.
Resection of the gall bladder and the extra-hepatic bile duct was performed We did not treat panceas divisum because she had no pancreatitis and dilatation of the main pancreatic duct. The post-operative course was uneventful.
There have been only six reports of these anomalies occurring together, Surgery for pancreaticobiliary maljunction or congenital bile duct dilatation were performed in these reported cases and their post-operative course was fair.
Further accumulation of the cases and long observation must be necessary.

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A 75-year-old man was admitted to our hospital for further examination of an intraductal lesion of the bile duct. Peroral cholangiography (POCS) revealed 2 yellowish protruding lesions in the lower bile duct. These lesions were diagnosed as cholesterol polyps and were surrounded by rough mucosa. Cytology indicated adenocarcinoma, so pancreatoduodenectomy was performed. Pathological diagnosis was dysplasia and carcinoma in situ (CIS) localized to the lower bile duct, and CIS was detected at the same region as cholesterosis of the bile duct with no metastasis. POCS was useful, allowing direct observation of the cholesterosis and rough mucosa and cytological diagnosis of early-stage bile duct cancer under direct observation of the rough mucosa.

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A 68-year-old woman was admitted to our hospital because of confluence stone with abdominal pain. For lithotripsy, we found it difficult to use mechanical lithotriptors; therefore, we used extracorporeal and electrohydraulic shock wave lithotripsy. Following lithotripsy, peroral cholangioscopy was performed, which revealed a single polyp, discolored and hemispherical with a smooth surface, in the common bile duct. A biopsy specimen obtained from the polyp showed inflammatory granulomatous tissue, which confirmed the histological diagnosis of inflammatory polyp of the bile duct. One year post surgery, the patient is healthy and has shown no clinical symptoms of fever, jaundice, or any abdominal pain.

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A patient was a 66-year-old female. Abdominal multi-detector row CT (MD-CT) showed 31×25 mm of a low-density mass in the pancreatic head, and 10×10 mm of slightly enhanced tumor in the gallbladder was indicated by computed tomography multi planar reconstruction (CT-MPR). Abdominal angiography revealed the tumor invaded the trunk of the right hepatic artery. She underwent the pancreatoduodenectomy with the right hepatic artery resection dispensed with reconstruction. Since lymph node tissue was seen in the pancreatic head mass by pathological examination, we diagnosed that isolated lymph node metastasis from the gallbladder cancer directly invaded to the pancreas and bile duct. This case was a rare advanced gallbladder cancer, in which isolated lymph node metastasis showed direct invasion of the pancreas and bile duct, presenting a pancreatic tumor-like appearance.

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Our paper describes morphological characteristics of surgically resected cases of gallbladder cancer. Gallbladder cancer showed unique wall invasion pattern, based on the thin gallbladder wall structures. The majority of gallbladder cancers were adenocarcinoma; well differentiated type in the mucosal components and moderately to poorly differentiated type in the invasive components. Gross types of advanced cancers were classified into three groups: papillary infiltrating type (mass-forming tumor mainly in mucosa), nodular infiltrating type (mass-forming tumor mainly in bile duct wall) and flat infiltrating type (infiltrating tumor without distinct mass). The majority (80%) of advanced cancer cases were nodular infiltrating type or flat infiltrating type. The advanced cancers (subserosa-invasive cancers) revealed frequent lymphatic permeation (80%), venous permeation (60%), neural invasion (50%, and lymph nodal metastasis (60%). Wall invasion patterns are categorized in to two group: infiltrative growth type (53%) and destructive growth type (47%). The destructive growth type were thought to be more aggressive, characterized by more frequent vascular invasion and higher cell proliferation.

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There are several important characteristics of the gallbladder from the view of surgical pathology and anatomy. These are the facts of no existence of the muscularis mucosa, the thin and rough proper muscle, existence of the Rokitansky-Aschoff sinus, the attachment of the liver, existence of the neck of the gallbladder and cystic duct in the same area as hepatic hilar tissues such as the bile duct, hepatic artery and portal vein surrounded by the same serosa, existence of direct lymphatic vessels from gallbladder to paraaoritc region. These facts may sometimes make complete resection of the advanced gallbladder carcinoma difficult. To investigate the spread and nature of pT2 gallbladder carcinoma with subserosal invasion is important for adequate operation. Generally, partial resection of the liver, dissection of the lymph nodes of the hepatoduodenal ligament, common hepatic artery and posterior aspects of the pancreas is considered to be necessary. However, there are several controversy about the area of resection of the liver as liver bed resection versus S4a and S5 subsegmentectomy, and about necessity of the prophylactic bile duct resection. When the tumor is small and the depth and mass of the invasion in the subserosal portion is short and small, and style of invasion is IINFα or INFβ, there are no invasion of the hepatoduodenal ligament and no lymphatic metastasis by investigation of autopsy cases. Carcinoma of the gallbladder has the nature of easily invading the subserosal region since the gallbladder has no muscularis mucosa, but it is suggested that the invasion of the subserosal region does not necessarily result in the invasion outside of the gallbladder. There are still may problems in the diagnosis and therapeutic strategies for the pT2 gallbladder carcinoma with subserosal invasion. Analysis should be performed from various aspects such as the sites of origin and degree of mass of invasion.

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