Combined hepatocellular and cholangiocarcinoma (CHC) is rare and its clinicopathological features have not been fully elucidated. The features of surgically treated CHC patients (n=6) were retrospectively investigated and compared to those of patients with hepatocellular carcinoma (HCC) (n=377) and cholangiocellular carcinoma (CCC) (n=36).
All patients with CHC were male and 83% of them showed viral hepatitis marker positive, chronic hepatitis or liver cirrhosis in the background liver, and tumors having vascular invasion. All CHC patients had greater than stage III disease and their 1-year and 2-year postoperative survival rates were 66% and 16%, respectively. CHC patients were younger and male dominant, and more frequently related to chronic hepatitis/liver cirrhosis than CCC patients, but these factors were similarly distributed compared to HCC patients. CHC patients had higher rate of CEA positivity than HCC and higher PIVKA-II positivity than CCC. CHC patients showed more lymph nodes or peritoneal recurrence than HCC. Postoperative survival was significantly poorer in CHC patients than HCC patients, and poor but statistically similar to that of CCC patients.
In CHC patients, their clinical backgrounds were similar to those of HCC, but postoperative survival rate and type of recurrence were similar to those of CCC patients.

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In recent years, SPC has been attracted attention but is not widespread at present, because surgical technique is often difficult. From June 2009 to December 2010, 65 patients were accomplished and were divided into 3 groups. Group A patients (n=14) were performed SPC before the surgical technique was established, Group B (n=41) were done by the same operator after the surgical technique was established and Group C (n=10) were done by 3 different operator after the surgical technique was established. Operative time was compared among 3groups because the operative time was regarded as the degree of stylized surgical technique. The mean operative time in Group C (90±17min) was similar to Group B (94±32min) and was significantly shorter than Group A (116±23min). The postoperative complications and intraoperative bile duct injury were not occurred. Our results suggest that SPC become the standard operation of benign gallbladder disease by doing the stylized surgical technique.

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Initial endoscopic treatment was attempted in 128 patients who were over 80 years old with common bile duct stones.
Complete stone removal was performed in 90 patients (70%). Long-term biliary stenting was selected in 28 patients (22%) for incomplete stone removal. Biliary cannulation could not be obtained in ten patients (8%), and either observation or operation was selected. Out of 28 patients with long-term biliary stenting, eight developed cholangitis. All these cases resolved by exchange of biliary stents. The mean duration from biliary stent placement until cholangitis onset was 367 days (33-1294 days). There was no death from cholangitis. Major complications included cerebral infarction in 2 patients who had anticoagulation or antiplatelet therapy stopped for complete stone removal.
In elderly patients with common bile duct stones, long-term biliary stenting for incomplete stone removal may be an acceptable alternative.

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Therapeutic strategies for cholecystocholedocholithiasis without acute cholangitis are indicated in both Guidelines for the surgical treatment using endoscopic surgery and Guidelines for the management of cholecystocholedocholithiasis. A combination therapy of laparoscopic cholecystectomy and choledocholithotomy is recommended in the former GLs, and a combination therapy of endoscopic transpapillary endoscopic choledocholithotomy and laparoscopic cholecystectomy is recommended in the latter GLs. Both combination therapies are performed by an expert doctor, and are supported by the evidences. Results of biennially questionnaires from 1990 by Japan Society for endoscopic surgery indicate that a combination therapy of endoscopic transpapillary endoscopic choledocholithotomy and laparoscopic cholecystectomy become majority year by year. On the other hand, Forty-two percentage of hospitals which answered to a questionnaire in 2009 performed open surgery for patients with cholecystocholedocholithiasis. This open surgery is still important therapy clinically. Therefore, those two combination therapies recommended in each of GLs and open surgery are standard therapy for patients with cholecystocholedocholithiasis without acute cholangitis in the present.

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Bile acids play an important role on bile formation as well as the solubilization of cholesterol in the bile. Bile acids are biosynthesized from cholesterol, excreted into bile. Bile acids play enterohepatic circulation, in which the effective transport systems in the terminal ileum and liver play important roles. The excretion of cholesterol and phospholipids from the bile canaliculus to the liver is mediated by ABCG5/G7 and MDR2, respectively. These molecules make unilamellar vesicles, which in turn change to micelles by the participation of bile acids excreted by BSEP. FXR, a nuclear receptor with bile acids as ligands, decreases intrahepatic bile acids by the down-regulation of CYP7A1 and NTCP and the up-regulation of BSEP. TGR5, a membrane receptor of bile acids, is considered to regulate the excretion of ductular bile flow.

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A 67-year old male who have been detected hepatic enzyme disorder was referred to our center for examination and treatment. Abdominal CT, Duodenoscopy and EUS revealed intra-amupullary type ampulla of Vatar tumor. Brushing cytology and forceps biopsies under ERC from the papilla lesion showed mild atypical epithelium; hence it is difficult to distinguish papillitis as being different from adenocarcinoma. Accordingly we performed EUS-FNA for papilla of Vatar lesion, and could obtain diagnosis of adenocarcinoma. Therefore pancreatoduodenectomy was performed and pathological examination for resected specimen showed well differentiated adenocarcinoma involving the duodenal muscularis but not exposed to duodenal mucosa (JSBS classification; 8×8 mm, panc0, du1, T2N0M0, stage II). EUS-FNA for papilla of Vatar lesion is useful when impossibility of diagnosis by biopsy under ERC.

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We report a case of curative resection of advanced hilar cholangiocarcinoma that responsed well to neoadjuvant chemotherapy; combined S-1/gemcitabine (GEM) therapy. A 67-year-old man was admitted to the local hospital because of upper abdominal discomfort and dark urine. PTBD was performed, and he was referred to our hospital with diagnosis as Bismuth type IV hilar cholangiocarcinoma. The hepatic hilar tumor extended around the left portal vein and metastatic No.8 lymph node was detected by abdominal CT. Serum DUPAN-2 level was elevated to more than 1600 U/ml. He was started on combined chemotherapy with S-1 80 mg/day on day 1-21 and GEM 1000 mg on day 8, 22. After completion of two course, serum DUPAN-2 level decreased to 450 U/ml, the abnormal accumulation on FDG-PET disappeared. A left hepatectomy with combined resection of caudate lobe was performed to obtain a possible safety margin. These treatment resulted in complete normalization of the serum DUPAN-2 level.

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A gastrointestinal bleeding is a relatively common symptom. In some cases, bleeding origins do not be detected. We herein report a patient with a gastrointestinal bleeding due to ruptured hepatic artery aneurysm into biliary tract.
A 78-years-old woman, who underwent pylorus preserving pancreaticoduodenectomy for intraductal papillary mucinous neoplasm 7 years ago, was admitted an emergency hospital because of hematemesis and melena. Gastrointestinal fiber findings showed no any active bleeding points in stomach. The patient was transferred to our hospital because of continuous a gastrointestinal bleeding. In our hospital, gastrointestinal fiber findings showed active bleeding from intrahepatic bile duct at choledocojejunostomy. Enhanced computed tomography revealed a hepatic artery aneurysm at A4. We diagnosed the case as hepatic artery aneurysm which ruptured and caused hemobilia. The aneurysm was successfully embolized. Gastrointestinal bleeding should be considered possibly due to rupture of the hepatic artery aneurysm into biliary tract.

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A 72-year-old woman was admitted with the complaint of abdominal pain and general fatigue. Percutaneous transhepatic gallbladder drainage was conducted with the diagnosis of acute cholecystitis, and cytodiagnosis of bile juice offered a strong suspicion of gallbladder carcinoma. Abdominal ultrasonography and computed tomography revealed a papillary tumor and diffuse thickness of the wall in the gallbladder. We performed an extended cholecystectomy with lymph node dissection. Histologically, the tumor was consisted of adenocarcinoma and sarcomatous tumor cells with a spindle shape and partial chondroid differentiation. Immunohistochemically, the sarcomatous elements was negative for an epithelial marker and positive for an interstitial marker. This histological evidence led to a definitive diagnosis of pure carcinosarcoma of the gallbladder. She is alive with no signs of recurrence 3 years after surgery. Carcinosarcoma of the gallbladder is very rare, so we report this case with a review of the literature.

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In various malignancies, photodynamic therapy (PDT) is a useful laser treatment option that achieves a strong necrotic effect on tumor cells by the cytocidal effects of singlet super-oxidization following the specific accumulation of a photosensitizer in cancer cells. Based on our previous trial using Photofrin-PDT in bile duct carcinoma (BDC), drug retention of the photosensitizer for a prolonged period and the associated sun-burn like dermatitis were serious and persistent side effects of PDT. To overcome this side effect, we performed PDT in 3 case of BDC using the next generation photosensitizer, talaporfin sodium (Npe6: Laserphyrin), which is rapidly metabolized at an earlier stage in comparison with that of Photofrin. These 3 cases of BDC included 2 cases of non-resectable BDC and one case of residual cancer infiltration at the cut-end of the hepatic duct after surgery. There were no severe toxic complications, but mild photosensitivity was diagnosed in one patient. Although the safety of new PDT using Laserphyrin was confirmed in the present cases, further examination of skin photosensitivity or other side effects in a larger number of patients remains necessary. Furthermore, careful management and follow-up of treatment effects on BDC are also necessary.

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Interventional procedures such as balloon dilation and/or stent application are employed firstly for benign biliary strictures. If interventional approach cannot achieve patency of constricted bile duct, it seems that you may consider magnetic compression anastomosis as one of therapies. In case biliary strictures cannot be treated with conservative therapy, surgical approach has to be considered for treatment. In 2 cases of postoperative benign biliary strictures, choledochojejunostomy with partial hepatectomy of segment IV was successfully performed with no recurrence.

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A colonic perforation due to a migrated biliary stent is a rare complication of endoscopic stent placement for biliary tract disease. We describe a case of 85-year-old man with an abdominal surgery in which a migrated biliary stent result in a colonic perforation. The biliary stent was seen to be present in the lower abdomen on Computed tomography. Laparotomy revealed a perforated stent through a sigmoid diverticulum. Local resection was performed. His postoperative recovery was unremarkable, and the patient was discharged 8 days after surgery. Patients with comorbid abdominal pathologies, including colonic diverticula, parastomal hernia, adhesion, and abdominal hernia, may be at incleased risk of perforation from migrated stent. We should try to remove them to prevent risk of perforation if migration has been diagnosed.

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The embryogenesis of pancreaticobiliary maljunction is inferred from the embryogenesis of bile duct, ventral pancreas and duodenum. Recanalization of the common duct frequently appears with two lumina and openings into the duodenum with two orifices. These two major canals create a narrow segment of the duodenum and this narrow zone is the area in the duodenum that is most prone to faulty recanalization and atresia formation. During the development of the bile duct, abnormal fusion may occur between the bile duct and branches of the ventral pancreatic duct. The site in the bile duct where a branch of the pancreatic duct joins is likely to develop atresia due to disturbance of the recanalization process, as seen in duodenal atresia. Severe impairment of vacuolation causes divided atretic bile duct at the site where the pancreatic duct inserts in a Y-fashion into the upper and lower bile duct. Moderate impairment of vacuolization causes a stenosis at the site where the pancreatic duct inserts in a T-shape.

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