We have proposed the new liver anatomy that right liver should be divided into the ventral, middle and posterior segments as an alternative to Couinaud's anatomy. We recognized important new findings that posterior hepatic duct joins with middle hepatic duct in 28% of cases. Among of them, posterior inferior hepatic duct joins middle hepatic duct while posterior superior hepatic duct joins with left hepatic duct. These new findings are very important to perform rational surgery for hilar bile duct cancer. We have performed ventral segmental resection combined with total caudate lobe resection in several cases with hilar bile duct cancer.
The hepatic hilum is overlapped by plate system. The variance of the running of bile duct and hepatic artery is occurred inside the plate system. The artery connecting with left and right hepatic artery (CA) runs inside the plate system. The CA is the very important vessels to supply the caudate lobe and bile duct. Furthermore investigating regarding plate system is required.
The understanding of caudate lobe anatomy including Spiegel lobe, paracaval portion and caudate processis is very important. The all portal vein to caudate lobe arises from bilateral portal vein and root of posterior portal vein. The right and left caudate lobes are supplied by common trunk of portal vein in 43% of cases, so that the caudate lobe should be considered one segment.

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We performed an endoscopic lithotomy for the bile duct stones after endoscopic sphincterotomy. When the size of stone is over 10 mm. we usually performed an endoscopic mechanical litotomy (EML). When EML is failed, we usually performed an extracorporeal shock-wave lithotripsy ((ESWL) and/or electronic hydraulic lithotripsy (EHL). After endoscopic procedures, we usually performed endoscopic billiary stenting because of preventions for the postoperative cholangitis. Endoscopic lothotomy is safe and useful technique for the bile duct stones.

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The communicating arcade between the right and left hepatic arteries is extrahepatically located on the hilar plate, and plays an important role not only in the interlobar arterial collateral system but also in the blood supplies to the hilar bile duct. Reclassification of the liver to divide the right liver into 3 segments facilitates an understanding of relationships between the hilar portal and biliary systems. We believe that recognition of this anatomy of the hilar plate is useful in surgical approach to hilar cholangiocarcinoma.

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This report describes percutaneous choledocholithiasis treatment performed in this department focusing primarily on instruments used and the actual procedure. The route was internally and externally drained and dilated following PTCD. After observing the inside of the bile duct with a narrow-diameter cholangioscope, the duodenal papilla was dilated percutaneously. Lithotripsy was carried out cholangioscopically using an EHL system as necessary. The stone was evacuated into the duodenum using a large-diameter balloon catheter. Lithotomy can also be performed from the PTGBD route using an extension of this technique. We have thus far performed PTCS-L on 58 cases and percutaneous transhepatic transcystic lithotomy on 17 cases. The amount of time until removal of the drainage tube was an average of 10.6 days (minimum of 4 days). Percutaneous choledocholithiasis treatment is considered to be one of the procedures of choice for treating choledocholithiasis along with a transpapillary approach.

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Purpose: To investigate an appropriate treatment strategy for patients with non-dilated bile duct of pancreaticobiliary maljunction (PBM) through an evaluation of pancreaticobiliary reflux using secretin-stimulated MRCP.
Patients: Six patients with non-dilated bile duct of PBM.
Methods: MPCP images were obtained every minute over a 15-minute period after secretin stimulation. The sequential morphological changes in the gallbladder, extrahepatic bile duct, and duodenum were assessed, and the total pixel values and intensity ratios of these organs were measured for each image.
Results: An increase in the intensity of the gallbladder was prominent and was maintained at a high level. Although an increase in the intensity of the bile duct was also observed, the total pixel value of the bile duct was less than that of the gallbladder. One year after cholecystectomy, reflux into the extra-hepatic bile duct was still observed, showing almost the same changes previously observed.
Conclusion: In cases of non-dilated bile duct of PBM, the gallbladder should be excised. It is, however, still controversial as to whether the extra-hepatic bile duct should be excised or not. Even if the bile duct is preserved, long-term observation is crucial.

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We analyzed the pathology of the biliary tract based on a novel standpoint of view. The biliary tract and pancreas are known to derive from the foregut at almost same time, and several genes are commonly involved in the development and maturation of the biliary tract and pancreas. Histological studies show that pancreatic exocrine acini are identifiable in the peribiliary glands which are physiologically distributed along the biliary tract. These findings suggest that the biliary tract and pancreas have plasticity to change to each other. Among many types of biliary tract and pancreatic diseases, several diseases present common pathophysiologies. For example, IgG4-related sclerosing diseases and intraductal papillary neoplasm are known to develop in the biliary tract and pancreas, and it is possible to understand these diseases based on mutual plasticity of the biliary tract and pancreas. There must be other diseases of the biliary tract and pancreas which are understandable by this mutual plasticity of the biliary tract and pancreas.

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Endoscopic sphincterotomy (EST) affects the function of the sphincter of Oddi and, eventually, the biliary tract. Manometry demonstrates the absence of the basal pressure of the sphincter of Oddi but partial recovery of sphincter contractions later, after EST. EST decreases the fasting volume of the gallbladder and increases the contraction ability for a long period. EST often causes duodenobiliary reflux and bacterial contamination of the bile ducts, but rarely induces biliary infection. Although EST causes transient pancreatobiliary reflux, the reflux is abolished within one year after EST. On the other hand, endoscopic papillary balloon dilation (EPBD) transiently improves papillary functions and gallbladder motility. EPBD does not appear to induce severe duodenobiliary reflux.
The incidence of bile duct stone recurrence of 5.8-24% after EST is comparable to the reported incidence of 7.1-13.5% after EPBD. The reported incidence of cholangitis after EST (5.8-9.7%) is lower than that after EPBD (0.9-2.2%). The incidence of acute cholecystitis after EST is reportedly 10-15% in patients with gallbladder stones but approaches 0% in those without gallbladder stones. The reported incidence of acute cholecystitis after EPBD is significantly lower than that after EPBD (2.2-3.4%). The reported incidence of carcinoma development in the biliary tree after EST or EPBD is extremely low (0-0.6% after ES and 0-0.6% after EPBD). EST or EPBD is unlikely to increase the risk of development of biliary tract carcinoma.

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Bilioenteric anastomosis is an essential procedure for biliary tract reconstruction in a variety of hepatobiliary and pancreatic disease. The procedure is inevitably associated with loss of duodenal papilla (papilla of Vater) function resulting in reflux cholangitis, which has been reported to increase the incidence of carcinoma in long-term follow-up studies. We seek to regenerate extrahepatic bile ducts using a biodegradable polymer to preserve papillary function. It appears necessary to develop in the 21st century a new operative procedure for biliary reconstruction following surgical treatment in hepatobiliary and pancreatic disease that can prevent reflux cholangitis and that can improve long-term QOL.

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A 84-year-old Japanese female was admitted to our hospital with the primary complaint of jaundice. Mirizzi syndrome due to xanthogranulomatous cholecystitis (XGC) was diagnosed after abdominal ultrasonography, CT scan, and MRCP. Conservative treatments improved the symptoms transiently, but she experienced aggravated hepatic dysfunction again. An endoscopic biliary drainage (EBD) tube was inserted to reduce obstructive jaundice. After EBD, liver function returned to normal, and she has a follow-up visit at this time. Consideraion of EBD is important as a conservative treatment for Mirizzi syndrome due to XGC for elderly patients.

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A 78-year-old man underwent ultrasonography as a follow-up study for a resected bladder carcinoma. Although he revealed neither symptoms nor abnormal laboratory data, US delineated the localized irregularly thickened internal hypoechoic layer of the bile duct. CT could not detect any abnormality. Cholangiography revealed a slight rigidity in the upper and middle bile duct. Intraductal ultrasonography showed an irregularly thickened hypoechoic layer of the bile duct almost corresponding to the rigid region on ERC. Cytologic examination of the bile juice revealed adenocarcinoma cells. Peroral cholangioscopy also showed a slightly protruded lesion with abnormal vessel near the confluence of the cystic duct and an irregularity of the middle to upper bile duct mucosa. Histological examination verified superficial bile duct carcinoma with extensive intraductal spread.
Our case suggests that the localized irregularly thickened internal hypoechoic layer of the bile duct is an important finding for detecting superficial bile duct carcinoma.

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We experienced a case of intrahepatic cholangiocarcinoma, successfully resected 33 months after first diagnosis. A 72-year-old man, who had been referred to our hospital for the operation of intrahepatic cholangiocarcinoma and declined the treatment 2 years before, was admitted to our hospital for the same diagnosis. CT scan revealed the enlargement of the low density mass at the posterior segment of the bile duct and the atrophy of right lobe due to right portal vein occlusion. Under the diagnosis of intrahepatic cholangiocarcinoma, extended right hepatic sectionectomy and excision of the extrahepatic bile duct were performed. The lesion in the posterior segment was histologically diagnosed as intraductal growth type of intrahepatic cholangiocarcinoma, which is compatible with intraductal papillary neoplasm of the bile duct. The patient is currently alive 3 years after the operation without any signs of recurrence.

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A 74-year-old man was referred to our hospital for further investigation of liver dysfunction. He had past history of diabetes mellitus, hyperlipidemia and post cholecystectomy for cholecystitis. In US and CT, the common bile duct was dilated to 12 mm, Wirsung duct was found 3 to 4 mm in diameter. There was a disconnection between the ventral and dorsal pancreatic ductal systems. An exposed protruding type tumor of papilla of Vater was also detected. Additionally, tumor biopsy indicated adenocarcinoma of papilla of Vater. In EUS examination, infiltrations to the common bile duct and main pancreatic duct were under suspicion. Based on the diagnosis of papilla of Vater adenocarcinoma with pancreatic divisum, we performed pylorus preserving pancreaticoduodenectomy. The pathological finding showed moderately differentiated adenocarcinoma, od, panc₀, du₁, t₁, pN₀. The whole course of hospitalization was smooth and the patient was survived 20 months post-operation without recurrence. According to our knowledge, there were few cases illustrated the papilla of Vater adenocarcinoma with pancreatic divisum in the Japanese literature.

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In May 2006, a 67-year-old male who had undergone subtotal esophagectomy for thoracic esophageal cancer with gastric-tube reconstruction 5 years earlier was referred to our center for treatment of a tumor of papilla of Vater. Common bile duct dilatation and an elevated value of serum transaminase had been noted in May 2005. After precise examinations, he was diagnosed as having papillary cancer with intracholedochal spread and invasion beyond the Oddi sphincter. Therefore, pylorus preserving pancreatoduodenectomy with gastric-tube preservation was performed in July 2006. Pathological examination for resected specimen showed poorly differentiated adenocarcinoma involving the pancreatic parenchyma and lymph node metastasis (JSBS classification; pT3, pN2, M0, fStage IVa). Because the left gastric artery and left gastroepiploic vein had been divided in the previous surgery, it was essential to preserve both the gastroduodenal artery -right gastroepiploic artery and right gastroepiploic vein- gastrocolic trunk, which were the feeding and draining vessels for the gastric tube.

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Gallstone disease is one of the most frequent biliary tract diseases that a biliary specialist often makes diagnosis and medical treatment. There are two national surveys in 1996 and 1997 by the Japan Biliary Association as epidermiology investigation of the gallstone disease. However, the recent trend is unknown without investigation being preformed for the past 10 years. In this article, we give an outline of the epidemiology of the choledocholithiasis and hepatolithiasis in Japan based on the national surveys. Moreover, we also review the pathogenesis of the cholesterol gallstone and calcium bilirubinate gallstone.

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