In terms of endoscopic biliary drainage, several novel techniques have been reported by skilled endoscopists. Ultraslim forward-viewing endoscope is useful for transnasal endoscopic biliary drainage without conscious sedation for the treatment of acute cholangitis. Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in which percutaneous transhepatic approach is contraindicated or anatomically impossible. Recently, several endoscopists report on the EUS-guided bile duct drainage and gallbladder drainage.
Concerning endoscopic lithotripsy, endoscopic sphincterotomy combined with large balloon dilation is effective for removal of large bile duct stones without serious complication. EHL using a mother-baby peroral cholangioscope are used for the crushing the huge stone. However, it needs two skilled endoscopists and two light sources. Recently, EHL using a ultraslim endoscope is performed by a endoscopist. Balloon enteroscope enables to perform the removal of bile duct stones even in patients with Roux-en-Y anastomosis.

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Biliary tract examination and medical malpractice litigation are discussed.
Firstly, medical malpractice litigation has been on a slight downward trend for several years, following a sharp increase in cases. Average trial duration has also somewhat decreased. The decline in admissibility rates in the closing stages of the trial is remarkable, but settlements are still proportionately high.
In addition, actual examples are introduced. Cases where a medical malpractice litigation committee has been in operation and given expert opinion have progressed well. It is also presented that mutual understanding between the medical and legal professions is being positively addressed.
Next, an actual case is presented. It is important that opinions relating to medical practice are verified by scientific associations and other experts and that medical litigation proceeds scientifically through the contribution of scientific societies.
Finally, it is proposed to medical associations that judicial precedents should be considered during conferences and that collection of accurate data relating to complications is vital.

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Endoscopic ultrasonography (EUS) is a useful tool in the diagnosis of pancreatic diseases as well as biliary ones; however until now, EUS has not been regarded as a common diagnostic modality. The possible reasons for this situation about EUS are that the equipment of EUS is relatively expensive compared to usual gastro-intestinal endoscope, and mostly, another reason is thought to be the technical problem. Methodologically, EUS is one of the most difficult endoscopic examinations, and it takes a long time to master EUS procedure, leading to a burden of suffering on the patients. Nonetheless, EUS technique can be acquired in a short term for anyone who has adequate experience with ERCP providing that they learn a standard EUS procedure. We believe that experienced technique provides less harmful EUS examination and reliable diagnosis. The contents of this paper describing instruction about standard EUS procedure was presented at the 40^th congress of Japan Biliary Association in the section of "Learn from the Experts".

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To clarify the risk factors for pancreatitis after procedures related to endoscopic retrograde cholangiopancreatography (ERCP), we statistically analyzed the associations of risk factors with the development of pancreatitis. The study group was comprised of 526 patients who underwent ERCP-related procedures. The following risk factors were analyzed: sex, age, body-mass index, history of endoscopic sphincterotomy (EST), the presence or absence of treatment with protease inhibitors, examination time, the number of times cannulation was performed, pancreatography, intraductal ultrasonography, cholangioscopic biopsy, biliary cytology, pancreatic brush cytology, endoscopic sphincterotomy, pancreatic sphincter precutting, endoscopic biliary drainage (EBD), non-EST/EBD, pancreatic-stent placement, pancreatic guide-wire placement, and operators. Multiple regression analysis showed that examination time, non-EST/EBD and pancreatography were significant risk factors. The optimal cutoff value for the examination time was calculated; the incidence of pancreatitis was found to differ significantly between 15 minutes or longer and less than 15 minutes.

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The biliary complication remains the Achilles' heel of living donor liver transplantation and is the most common cause of postoperative morbidity. The complication significantly affects the quality of life of the liver transplant recipients and is occasionally the cause of graft or patient loss. There are two major procedures of bile duct reconstruction, duct-to-duct and Roux-en-Y hepaticojejunostomy. Several investigators suggested that the use of duct-to-duct biliary anastomosis tend to observe an increased risk of biliary stricture and a decrease risk of biliary leakage compared with patients who underwent Roux-en-Y hepaticojejunostomy. However, further studies are necessary.

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Adenomyomatosis arising in the distal bile duct is extremely rare and mimics frequently neoplasm of bile duct. We review the clinical features of adenomyomatosis of distal bile duct. In total, 60 cases of adenomyomatosis of the distal bile duct and ampullary lesions including our five cases are reported from 1980 to 2008. Thirty-three were men and 27 were women. The mean age was 64 years (range: 31-82 years). Right quadrant pain or epigastralgia was seen more than half of the patients. Jaundice was seen in 49% of the patients. Adenomyomatosis of distal bile duct is usually diagnosed by histopathologic examination after surgery. Abdominal computed tomography shows the lesion to be a low-attenuating mass with a dilatation of the proximal bile duct. Although radiographic findings are not typical of biliary tract carcinoma, the preoperative diagnosis is still very difficult to make. Of 58 patients who underwent surgical treatment, 37 (64%) patients underwent pancreaticoduodenectomy. Thirteen patients underwent transduodenal treatment. In recent years, endoscopic or transhepatic sphicterotomy is reported in some cases. It may be difficult to diagnose as adenomyomatosis by endoscopic biopsy findings. When the lesion had been definitely diagnosed as adenomyomatosis, endoscopic or transhepatic procedures might be best in addition to detailed follow-up plans.

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We performed biliary stenting for anastomotic stricture, obstruction or transection of hepaticojejunostomy which was possible to turn in a free axis using a double slide C arm and real-time CT. Case 1: A case of separation of hepaticojejunostomy after extended right hepatectomy. Because the supersonic wave was interrupted by bowel gas, ultrasound-guided PTCD was difficult. We punctured the bile duct directly under real-time CT guidance and performed stenting via adjacent abscess under visualization with X-rays. Case 2: Complete occlusion of the anastomosis after extended right hepatectomy. We punctured the lumen of the jejunum directly from the PTCD route and performed stenting under visualization with X-rays. Case 3: Anastomotic stricture after extended left hepatectomy. We used X-rays image to determine the release points for the magnets or Yamanouchi magnet anastomosis. In all three cases, biliary stenting was successful. Advances in transhepatic approach sing a double slide C arm and real-time CT have facilitated obtaining a good 3 dimensional information and allow an alternative low stress option for the stenting procedure.

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A 54-years-old man, who had underwent esophagectomy and reconstructed with esophagogastrostomy for esophageal carcinoma in 2002, was referred to our hospital for further evaluation and treatment for perihilar cholangiocarcinoma and hypopharyngeal cancer. CT demonstrated a low density area measuring 50mm with unclear margin in left lobe of the liver. The patient received chemoradiation therapy both for hypopharyngeal cancer and for perihilar cholangiocarcinoma in November, 2007. After chemoradiation therapy, CT showed that hypopharyngeal cancer had disappeared, therefore, left hepatectomy, total caudate lobectomy, resection of the extrahepatic bile duct and wedge resection of portal vein was performed in February 2008. As the tumor invaded the gastric tube extensively, we underwent distal gastrectomy with preserving right gastroepiploic artery and vein additionally, resulting in curative operation. Multidisciplinary treatment enabled us to curative therapy for cholangiocarcinoma accompanied with hypopharyngeal cancer.

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A 39-year-old man was admitted to our hospital with a hepatic abscess and adenomyomatosis of the gallbladder. A 7-Fr pig-tail catheter was inserted into the abscess through a right intercostal space. On 32 days after drainage, the abscess was improved, and the catheter was removed. Although, the catheter ruptured at the abdominal wall and remained in the liver. An emergency laparotomy was performed. The wreckage of the catheter was removed and cholecystectomy was performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 15. In percutaneous transhepatic drainage, catheter migration and bleeding are familiar complications. In our case, the catheter ruptured as a result of gradual bending over time. It is important to avoid leaving the same catheter in place for long periods of time by regularly replacing it. Careful examination is necessary to avoid the catheter twisting and bending.

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A 74-year-old man was referred to our hospital for additional treatment of obstructive jaundice. An expandable metallic stent (EMS) was inserted for palliation of the biliary stricture following diagnosis as carcinoma in the pancreatic head. Eight days after stenting, he suffered from high fever and appetite loss. Peripheral blood examination revealed slight anemia. Emergency endoscopy was performed because injury of the duodenal mucosa caused by EMS dislocation was suspected. Esophagogastroduodenoscopy revealed severe edema and small ulcers in the duodenum, mainly around the ampullae. Subsequent CT showed edematous change in the second portion of the duodenum and around the bile duct. We attributed the allergic change to the EMS: after its immediate removal, methyl prednisolone (125 mg/day) was administered. A biopsied specimen from edematous duodenal mucosa showed infiltration of many eosinophils. A skin patch test indicated cobalt allergy. The EMS includes cobalt-containing alloys. Our diagnosis, therefore, was a metal allergy to the indwelling EMS. Although metal allergy to the EMS in the bile duct is extremely rare, it must be considered as a possible complication when using indwelling EMS for obstructive jaundice.

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Xanthogranulomatous cholecystitis (XGC) is occasionally difficult to distinguish from gallbladder cancer because it involves infiltrative inflammation of the surrounding organs such as the duodenum, colon and liver. We recently experienced an XGC case. The patient was a 69-year-old male. He consulted a local clinic, complaining of weight loss. Diagnostic imaging revealed thickening of the gallbladder wall, and the patient was referred to us. At our department, a gallbladder mass contiguous with the duodenum was revealed by abdominal ultrasonography, CT and MRI. In addition, an incarcerated gallstone was identified at the gallbladder neck. Based on the diagnosis of gallbladder cancer, the patient underwent open surgery (full-thickness cholecystectomy). Intraoperative rapid pathological examination revealed no signs of malignancy. The final diagnosis was XGC. The patient suffered no complications and was discharged from the hospital on the 12th postoperative day. According to previous reports of cases with XGC in which distinguishing this disease from gallbladder cancer was difficult, incarceration of gallstones at the gallbladder neck is a common finding. We describe one case in which XGC was difficult to distinguish from gallbladder cancer preoperatively and discuss preoperative strategies for distinguishing between gallbladder cancer and XGC with reference to the literature.

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An asymptomatic 72-year-old female presented with a slight elevation of the γ-GTP level during a medical checkup. She was referred to the hospital due to the dilation of the left intra-hepatic bile duct and a hyperechoic tumor in the left hepatic duct were demonstrated by abdominal US. CT and ERC showed a tumor measuring 25mm in size which was mildly enhanced by a dynamic study at a site 8mm from the confluence of the bilateral hepatic ducts in the left hepatic duct. The tumor demonstrated a low intensity on T1-weighted images and high intensity on the T2-weighted and diffusion-weighted images of MRI. A left hepatic lobectomy including the left caudate lobe was performed under a diagnosis of hilar cholangiocarcinoma. The histopathological examination revealed a papillary adenocarcinoma infiltrating into the fibromuscular layer of the bile duct without regional lymph node metastasis and this case was classified as stage IA according to TNM classification (UICC). This case is herein reported because ultrasonography should be performed to detect cholangiocarcinoma for cases with a slight elevation of biliary enzymes, though non-icteric early hilar cholangiocarcinoma are not rare.

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An 88-year-old man with prior Billroth II gastrectomy was admitted to our hospital because of choledocholithiasis. We conducted ERCP successfully using PCF260AI. The common bile duct was dilated and several common bile duct stones about 20mm in diameter were observed. Endoscopic sphincterotomy was performed, but we could not crush the stones by mechanical lithotripsy. We decided to try electrohydraulic lithotripsy (EHL) by peroral direct cholangioscopy (PDCS) using an ultra-slim endoscope. The scope was advanced into the common bile duct over a 5 Fr. nasobiliary drainage tube. EHL and stone extraction with a basket could be accomplished easily and safely by direct visualization of a clear image. There was no complication. EHL of the common bile duct stone under PDCS by using an ultra-slim endoscope was useful in a patient who could not be treated by conventional methods with a Billroth II gastrectomy.

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Diagnostic procedures of choledocholithiasis including US, CT, MRCP, ERCP, EUS, and IDUS were reviewed. US is the most safe procedure, but detection rate of choledocholithiasis is reported with 25-75%. Diagnosis of DIC-CT for choledocholithiasis is appreciated with 65-100% of sensitivity, 84-100% of specificity. MRCP and EUS are superior to other diagnostic images. Diagnosis of MRCP for choledocholithiasis is sensitivity 85%, specificity 93%, positive predictive value 87%, and negative predictive value 92%, and whereas EUS sensitivity 93%, specificity 96%, positive predictive value 93%, and negative predictive value 96%, respectively. There is no statistical difference between EUS and MRCP. It is decreasing to perform ERCP alone because of complication such as post ERCP pancreatitis. Diagnosis of ERCP for choledocholithiasis is reported with 67-97% of sensitivity and 82-100% of specificity. Diagnosis of IDUS for choledocholithiasis was reported as 100% of accuracy and sensitivity of 100%, compared with ERCP as 86.7% of accuracy and sensitivity of 92.9%. IDUS is reported as a useful method for diagnosis of remaining stones after endoscopic treatment. Because acute cholangitis caused by choledocholithiasis may become life-threatening, we have to diagnose earlier by making full use of these diagnostic images.

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