Recently, most of common bile duct (CBD) stones have been removed by using therapeutic endoscopic techniques. However, it is still controversial which technique that is EST or EPBD, is better procedure. We experienced three hundred and two cases with CBD stones treated by these endoscopic procedures, and, twenty eight cases with recurrence CBD stones (9.3%). Especially, in forty four cases, bacterial infection in bile was estimated. In CBD stone group (33 cases), this infection was observed in thirty cases (90.9%), on the other hand, in CBD stone free group, this infection was observed in one case (9.1%). The CBD width of these two groups were measured and compared. The average of this width in CBD stone group was 14.8mm, that in CBD stone free group was 8.9mm, that in the former was larger than in the latter significantly (p<0.01).
These results suggested that the important factors to prevent the CBD stone recurrence are the maintenance of bile flow rate and the protection of retrograde infection in bile. Thus, clinically, it is desirable to be maintained the function of gallbladder as well as the function of papilla Vater.

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Multiple deployment of metallic stents (MS) in hilar biliary strictures still remains controversial in the chemotherapy of unresectable cholangiocarcinoma. Between 1999 and 2006, 46 patients were allocated to the chemotherapy group (n=31; CHT-group) and to the best supportive care group (n=15; BSC-group). Survival time, patency time of MS, and complications were compared between them. Multivariate analysis disclosed that the chemotherapy contributed to the elongation of survival (HR0.36; 95%CI 0.14-0.91). The median survival time is 420days in CHT-group and 190days in BSC-group (P<0.05). Cholecystitis (n=3) and liver abscess (n=1) occurred as complications in CHT group, and hemobilia due to pseudoaneurysm in BSC-group. Multiple deployment of metallic stents in hilar biliary strictures is safe and effective in the treatment of unresectable cholangiocarcinoma.

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Background: Although early cholecystectomy is the standard treatment in case of acute cholecystitis, the morbidity in patients at high risk for surgery is high.
Patients and methods: Between Jan. 2002 and Dec. 2006, 134 consecutive patients with acute cholecystitis who underwent percutaneous cholecystostomy were enrolled in this study. The technical success rate, clinical response rate, and incidence of complications were evaluated.
Results: PC was technically successful in all patients. Good clinical response was obtained in 90%. Dislodgment of catheter was observed in 2.2%. Mortality rate was 2.2%. Cholecystectomy was performed in 99 patients. The incidence of conversion to open procedure was 16% in the laparoscopic group.
Conclusion: Percutaneous cholecystostomy is a safe, effective procedure for selected patients with acute cholecystitis who cannot immediately undergo cholecystectomy.

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The preoperative biliary drainage for hilar cholangiocarcinoma can be achieved via percutaneous or endoscopic access, however, there is no clear standard for the choice. Early establishment of the criteria for selection is necessary. In this study, we compared the periods from hospitalization to surgical operation and the complication rate of cholangitis according to the drainage method for hilar cholangiocarcinoma patients, who underwent a surgical resection at our hospital. In addition, we compared the diagnosis rate for cancer by the histopathological inspection according to the approach method. The complication rate of cholangitis in endoscdopic group were identical for those in percutaneous group, moreover, those in bilateral intrahepatic biliary drainage group and those in unilateral drainage group was also equivalent. The hospitalized period to operation in endoscopic access group was shorter than those in percutaneous access group. The comparison results of the histopathological inspection indicated that the correct diagnosis rates by the cytology, the brushing cytology and the organization biopsy in endoscopic access group were equivalent in percutaneous access group.
These results suggested that endoscopic unilateral drainage is the first-line therapy for the preoperative biliary drainage of hilar cholangiocarcinoma..

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Little reports is known about gene expression of thymidylate synthase (TS), thymidine phosphorylase (TP), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyl transferase (OPRT) in biliary tract carcinoma. We semiquantified the mRNA levels of these enzymes in 22 patients of biliary tract carcinoma using Danenberg tumor profile method, compared to 63 patients of colorectal carcinoma, and 29 of gastric carcinoma. We also studied the correlation between these enzymes and clinicopathological features. No difference in TSmRNA and OPRTmRNA expression levels was observed among other carcinoma. DPDmRNA and TPmRNA expression levels were significantly higher in biliary tract carcinoma than in other carcinoma. In clinicopathological features, no difference in histological typing, depth of tumor invasion, cancer-stroma relationship, INF, ly, v, and pn was observed. TSmRNA and OPRTmRNA expression levels were significantly lower in pT4 than in pT1, 2. We thought that DPD inhibitory drugs had enough effectiveness in biliary tract carcinoma. Because TPmRNA expression level were significantly higher than in other carcinoma, the effectiveness of DPD inhibitory drugs was possible to be reduced.

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‹Purpose›
We investigated appropriate lymph node (LN) dissection for ss (and/or pHinf_0-1a) gallbladder cancer (GbCa).
‹Method›
We retrospectively examined result of 371 cases of resected GbCa at our institution. We included 74 cases in which the depth was ss (and/or pHinf_0-1a), D₁ or more LN dissection was performed.
‹Result›
There was a difference in survival rate between curative (5 year survival rate (5ys) 71%) and no curative resection (5ys 38%, P=.0006). The rate of LN metastasis was 55% (41/74). PD was effective in pN (+) Binf (-) cases (5ys: without bile duct resection (BDR) 53%, with BDR 38%, with PD 76%, with or without BDR vs with PD: P=0.045 and 0.055, respectively). PD was not effective in pN (-) Binf (-) cases, and there was no difference in degree of LN dissection between D₁ and D₃. With or without BDR in pBinf (-) cases were also not significant.
‹Conclusion›
Obtaining curative resection is most important. We consider performing (PP) PD in pBinf (-) pN (+) cases. We could not find significance of BDR for LN dissection of ss GbCa.

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Clinical and pathological discriminations between primary sclerosing cholangitis (PSC) and IgG4-related sclerosing cholangitis (IgG4-SC) are important, because therapeutic strategies are different for these disease entities. PSC is pathologically characterized by lymphoplasmacytic infiltration, mucosal erosion, and frequent association with biliary intraepithelial neoplasia. In contrast, IgG4-SC shows diffuse lymphoplasmacytic infiltration containing abundant IgG4-positive plasma cells, diffuse thickening of bile duct wall, and obliterative phlebitis. These two disease entities are pathologically quite different, but discrimination only by non-invasive examination is sometimes difficult. We have to carefully diagnose sclerosing cholangitis based on clinical, radiological and pathological features. Different pathogenetic processes might be involved in PSC and IgG4-SC. Regulatory T cells are decreased around bile ducts in PSC, whereas these cells are increased in the affected bile ducts of IgG4-SC. Interestingly, expression of Th2 and regulatory cytokines, such as IL-4, IL-5, IL-13, IL-10, and TGF-beta1, was increased in IgG4-SC compared to PSC. Overexpression of IL-10 and TGF-beta1 might be involved in IgG4-production and fibroplasia, because IL-10 and TGF-beta1 induces IgG4 class-switch and activation of fibroblasts, respectively.

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The case is a 59-year old male. He was admitted to the Tokai University for treatment of diabetes mellitus, chronic renal failure and skin ulcer of the left foot in october, 2006. At that time, a liver tumor with a diameter of 30 mm was found in the left lobe of the liver by abdominal CT. Abdominal ultrasonographic examinations also revealed the presence of a round tumor with a size of 30 mm in the left lobe of the liver. The margin of the tumor was unclear and the echo pattern was heterogeneous and hypoechoic. The mass partly enhanced with contrasts. Abdominal CT revealed a low density mass of 30 mm in size in the left lobe of the liver. The mass was enhanced irregularly. The mass was shown as a defect of uptake of SPIO by abdominal MRI SPIO. The mass was diagnosed as cholanglocellular carcinoma by echo guided biopsy. We determined that resection of the tumor would be difficult. Therefore, we performed RFA with direct vision.

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A 84-year-old man had postprandial nausea, epigastralgia and fervescence, and he was admitted to our hospital with diagnosis of cholangitis. Abdominal ultrasonography revealed a polyp whose diameter was 12 millimeters in the gallbladder, and contrast ultrasonograhy demonstrated the polyp was well vascularised. Cholangitis promptly improved. Clinical progress was similar to the passing of gallstones, but ultrasonography didn't reveal gallstones. It was suggested cholangitis was caused by the spontaneous detachment of the polyp. Because of old age, we didn't practice a surgical therapy, but follow-up ultrasonography revealed the polyp which increased to 24 millimeters. We considered the polyp may be malignant, and open cholecystectomy was performed. Pathological examination revealed the pedunculated polyp was villotubular adenoma. The trace of bleeding suggested a possibility of the spontaneous detachment of the gallbladder polyp.

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We reported here a case of congenital biliary dilation which underwent pancreatoduodenectiomy for pancreatitis and hepatectomy for hepatolithiasis after excision of the extrahepatic bile duct and reconstruction.
The patient is a 72-year-old woman. She underwent excision of the extrahepatic bile duct and hepaticojejunostomy in 1973. She underwent pancreatoduodenectomy for pancreatitis caused by residual cyst in the pancreas head in 1980. CT and MRCP revealed stenosis of the left hepatic duct and intrahepatic calculi for abdominal pain in 2007. The cytology of the bile juice revealed classIV. She was given a diagnosis of the hepatolithiasis and suspected intrahepatic cholangiocarcinoma and underwent left hepatectomy. Macroscopic findings showed membranous stenosis of the left hepatic duct. Pathological findings revealed fibrous stroma at the site of stenosis and yielded a diagnosis of benign stricture of the hepatic duct.

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A 56-year-old female complaining of general fatigue, appetite loss and jaundice was referred to our hospital for further examination and to undergo treatment for a hilar liver tumor and dilation of the intrahepatic bile ducts. Abdominal CT demonstrated a hilar liver tumor measuring 60mm in size and multiple lymph node metastases. ERCP revealed that the tumor invaded the superior bile duct. After performing biliary drainage with a plastic stent, she was treated by combination therapy consisting of Real-time tumor-tracking radiation therapy and chemotherapy with gemcitabine. We changed the plastic stent to a metallic stent after the radiation therapy. Thereafter, the patient has been receiving gemcitabine infiltration once every two weeks. Sometimes the metallic stent became obstructed by debris and at such times stent cleaning using a balloon catheter was carried out. The tumor and lymph nodes both decreased in size and the tumor markers also decreased to the normal range. The patient is still alive at more than three years since the above therapeutic regimen was started.

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A 71-year-old man, resident in China, visited a local hospital there with chief complaints of jaundice and brown urine, and was diagnosed with obstructive jaundice. After returning to Japan, he was admitted to our hospital for further evaluation and treatment. PTBD performed after admission, demonstrated a massive number of Clonorchis sinensis eggs in the drained bile, resulting in the diagnosis of clonorchiasis. In addition, CT scan and MRCP findings led to the diagnosis of cancer of the head of the pancreas. Praziquantel administration resulted in the elimination of numerous flukes via the drainage tube, but there was no subsequent improvement in jaundice. His general condition deteriorated, and he died of liver failure on the 61st hospital day. In the absence of demonstrable liver flukes in the pancreatic ducts at the time of autopsy. There have been very few reports of a combination of these two conditions, and so this case is of interest.

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An 85-year-old woman was presented to our center with a right lower abdominal pain and a mass. Abdominal computed tomography showed multiple cystic lesions adjacent to the gallbladder. The patient underwent cholecystectomy with ascending colectomy and the intraoperative findings were suggestive of a gallbladder carcinoma invaded to the ascending colon. The pathological findings after surgical resection revealed a moderately differentiated tubular adenocarcinoma at cystic regions and xanthogranulomatous cholecystitis (XGC) at the fundus of the gallbladder. Although invasion to the colon was suspected intraoperatively, only inflammation of XGC was affected to the colon. This case was an unusual case is described in which a gallbladder carcinoma was complicated with XGC and formed a lower abdominal mass.

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A 78-year-old woman was admitted to our hospital because of an abdominal pain. It was pointed out the focal wall thickening of gall bladder by ultrasonography (US). In the US, endoscopic ultrasonography (EUS) and abdomen CT, the qualitative diagnosis was difficult, but, by endoscopic double contrast cholecystography, we defected the irregular membrane of the gallbladder that normal reticular pattern disappeared, granular pattern fused and it was drawn to the center. We diagnosed it as IIb-type early stage gallbladder cancer and cholecystectomy was carried out. The pathology diagnosis was IIb-liked advanced gallbladder cancer, ss, well-differenciated tubular adenocarcinoma, ly0, v0, pn0, n0. The range was defected by endoscopic double contrast cholecystography approximately precisely agreed with the change of IIb menbrane. It was thought that gallbladder cancer had difficulty with a preoperative diagnosis conventionally for the non-elevated type, but it was thought that the cancer was able to be detected by doing the endoscopic double contrast cholecystography, even if it was non-elevated-type gallbladder cancer.

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Purpose : We conducted this study to evaluate the optimal surgical procedure for ss (pT2) advanced carcinoma of the gallbladder without hepatoduodenal ligament invasion.
Methods : Patients included 115 pT2 advanced carcinoma of the gallbladder, and the cumulative survival rates and mode of postoperative recurrence were retrospectively analyzed about preventative extra-hepatic bile duct resection, method of lymph node dissection and preventative hepatic resection.
Result : The most valuable clinico-pathological factor which influenced survival rate was R0 curative resection and the second factor was lymph node metastasis. On surgical procedure, there were no significant differences in survival rate or recurrence form between the groups that underwent preventative extra hepatic bile duct resection and the group preserved extra hepatic bile duct for lymph node dissection. In R0 curative resection, D0-1 dissection of lymph node metastasis was preferable for the patients with negative lymph node and PD was recommended for the patients with positive lymph node metastasis. There were also no significant differences in survival rate or recurrence the form of liver metastasis between the groups that underwent resection of all layer resection, the gallbladder bed, and the group that underwent segmentectomy4a+5.
Conclusion : For pT2 (ss) advanced carcinoma of the gallbladder without hepatoduodenal ligament invasion, R0 curative resection is most preferable for optimal surgical procedures. Neither preventative extra hepatic bile duct resection nor hepatic resection has any evidence for long term survival. PD was recommended for the patients with positive lymph node metastasis.

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Although the outcome after resection for gallbladder carcinoma is generally considered unfavorable, radical resection provides chance for cure for patients with pathologic T2 (pT2) tumor. The incidence of lymph node metastasis is high (around 50%) in pT2 gallbladder carcinoma. Thus, lymph node dissection is essential in the surgical management of pT2 gallbladder carcinoma. Since 1982, in the author's department, extended radical cholecystectomy (modified Glenn operation), which consists of a cholecystectomy, wedge resection of the gallbladder bed, bile duct resection, and en bloc regional lymph node dissection, has been adopted as a standard resectional procedure for pT2 gallbladder carcinoma. We have also performed pancreaticoduodenectomy in selected patients with marked nodal involvement around the head of the pancreas. In this article, the author reviews the current status of radical surgery for pT2 gallbladder carcinoma, in order to define surgical strategy for this disease.

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