Extrahepatic cholangiocarcinomas (ECC) arise from the epithelial cells of the bile ducts and the most common symptom is jaundice. Because of biliary stricture in the early stages of the disease, the incidence of distant metastases and peritoneal dissemination in ECC are much lower than in other malignancies, such as pancreatic cancer and gallbladder cancer. Therefore, surgical resection is indicated for curative treatment. ECC often grows longitudinally along the bile duct rather than in a radial direction. Because surgical margin negative is an important prognostic factor, preoperative accurate assessment of cancer extension is desired. Multidetector computed tomography (MDCT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRC), intraductal ultrasonography (IDUS) with a miniature probe, and peroral transpapillary cholangioscopy (POCS) using a mother baby endoscope have been used to determine tumor extent along the bile duct system. These diagnostic imaging techniques are accompanied by some risk to the patient. Therefore, their usefulness and invasiveness should be considered in each case of this disease.

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We performed bacteriological analysis of bile in Acute cholecystitis (AC) patients graded in severity according to the guidelines, and also analyzed the risk factors for bactibilia according to whether bacteria were present or absent. One hundred sixty-three AC patients who underwent cholecystectomy plus bacteriological analysis of bile were enrolled. The AC severity was classified as Mild 28 cases (17.2%), Moderate 70 cases (42.9%), and Severe 65 cases (39.9%). In the analysis of high risk factor of bactibilia, more severity grade, elderly cases, elevated body temperature, high CRP, and severe local inflammation were significant risk factor for bactibilia. The prevalence of bactibilia differed significantly between three grades (Mild: 28.6%, Moderate: 55.7%, Severe: 75.4%, P=0.0003). Our local antibiogram showed a higher antimicrobial resistance rate of Enterococcus faecium, Klebsiella pneumoniae, Enterobacter cloacae, and Pseudomonas aeruginosa. In conclusion, adequate antimicrobial therapy perioperatively should be administered according to the bacteriological analyses in bile.

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We reported the experience with single-incision laparoscopic cholecystectomy using ICG fluorescence cholangiography. After injecting ICG, under general anesthesia, 11 patients with gallbladder stones underwent single-incision laparoscopic cholecystectomy (SILC) by 2.5-cm umbilical incision and glove method including three ports (10 mm×1, 5 mm×2). We observed biliary tract under the guidance of real-time fluorescence imaging, and confirmed the cystic duct. Furthermore, the cystic artery was observed by re-injection of ICG. The procedure was completed in all cases. There was no additional ports or conversion to open cholecystectomy. The manipulation by left hand is more effective during SILC without the fighting between laparoscope and instruments. The mean operation time was 92 min. We obtained the clear vision of biliary tract in all patients and the cystic artery was confirmed 10 seconds after re-injection of ICG. There were no particular perioperative complications related with an intravenous injection of ICG. The mean postoperative hospital stay was 3.2 days. The intraoperative exploration of biliary tract using ICG is a useful navigation, and the manipulation by left hand using ordinary laparoscopic instruments is a necessary technique to get a successful and safe SILC.

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Purpose: Laparoscopic cholecystectomy is performed using microinstruments, specific protocols, and so on; however, it is difficult for many surgeons because of technical problems. Single-incision laparoscopic cholecystectomy is increasingly used in Europe and the United States. We have retrospectively evaluated TANKO cholecystectomy with regard to its safety and technical aspects.
Methods: This retrospective study evaluated 55 patients undergoing TANKO and 55 patients undergoing conventional laparoscopic cholecystectomy (Lap-C). The surgical techniques used for both procedures were similar.
Results: There were no significant differences in the baseline characteristics of the 2 patient groups. The operating times for TANKO and Lap-C were 75.6 and 77.3 min, respectively, and the blood loss volumes were 3.9 and 3.2 mL, respectively. One patient undergoing TANKO developed paralytic ileus. All of the patients except a patient with ileus were discharged on day 3 after surgery.
Conclusions: Although the surgical techniques used in TANKO remain difficult because of the problems involved in inserting the laparoscope and 2 instruments through a single small incision, TANKO performed using methods similar to those used in Lap-C is feasible, and we believe that TANKO has utility.

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In recent years, institutions offering single-incision laparoscopic cholecystectomy have also been increasing in Japan. We introduced the procedure at our department in January 2010. Of the cases indicated for laparoscopic cholecystectomy at our department, conventional laparoscopic cholecystectomy was performed in those requiring cholangiotomy, etc., and single-incision laparoscopic cholecystectomy was performed in all the other cases. We had accumulated 24 cases of single-incision laparoscopic cholecystectomy until January 2011. While the mean operative time was 71.1 minutes, the procedure was completed in around 60 minutes in the 10th case and subsequent cases. No complications occurred. In comparison with the cases of conventional laparoscopic cholecystectomy performed in 2009, the operative time was slightly longer for single-incision laparoscopic cholecystectomy; however, there was no difference in the amount of bleeding and the length of postoperative hospital stay. Especially in 13 cases without complication of cholecystitis after we became accustomed to single-incision laparoscopic surgery in the 10th case and subsequent cases, the mean operative time was 49.7 minutes, which was almost the same as that of 45.1 minutes for conventional laparoscopic cholecystectomy performed in the previous year. Single-incision laparoscopic cholecystectomy could be one of the standard procedures of cholecystectomy.

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Lysophosphatidylcholine (LPC), recently recognized as a lipid mediator, has been reported to induce apoptosis in several different cells, and to be increased in the bile of patients with anomalous arrangement of the pancreaticobiliary duct and intrahepatic cholelithiasis, both of which are well-known risk factors for biliary tract cancers. Since biliary epithelial cells (BECs) are exposed to bile, an increase in biliary LPC concentration is suggested to be involved in BECs injury and carcinogenesis. This study aimed to examine the biological effects of LPC on BECs and its underlying mechanism using human bile duct carcinoma cell line HuCCT-1. LPC at 100 μM concentration induced significant cytotoxicity and apoptosis in HuCCT-1 in time-dependent manner as determined by MTT assay and Annexin V-FITC/PI staining flow cytometric analysis. Fluorescent microscopic analysis of LPC-treated cells stained with DAPI also depicted the typical morphological changes seen in apoptotic cells such as the condensed chromatin gathering. These changes were paralleled with the significant activation of caspase 3, 8, and 9, as well as up-regulation of Fas receptor mRNA. Interestingly, LPC induced the expression of LPC-related receptor G2A at mRNA and protein levels. These data suggests that LPC plays an important role in BECs injury and carcinogenesis.

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purpose: In the field of gastroenterological surgery, laparoscopic surgery has advanced remarkably, and now accounts for most gastrointestinal operations. This paper outlines the current status of and future perspectives on robot-assisted laparoscopic surgery for the biliary diseases.
Methods: A review of the literature and authors experience was undertaken.
Results: The da Vinci Surgical System is a robot for assisting laparoscopy and is safer than conventional endoscopes thanks to the 3-dimensional hi-vision images it yields, high articular function with the ability to perform 7 types of gripping, scaling function enabling 2:1, 3:1, and 5:1 adjustment of surgeon hand motion and forceps motions, a filtering function removing shaking of the surgeon's hand, and the magnification of vision possible with it. This system is expected to be particularly useful in patients requiring delicate operative manipulation.
Conclusion: Issues of importance remaining in robot-assisted laparoscopic pancreatectomy include its time of operation, which is longer than that of open surgery, and the extra time needed for application of the da Vinci, unlike ordinary laparoscopic surgery. These issues may be resolved through accumulation of experience and modifications of the procedure. Robot-assisted laparoscopic pancreatectomy appears likely to become a standard procedure in the near future.

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A 77-year-old man was admitted with the chief complaints of upper right abdominal pain and fever, and was diagnosed as having obstructive jaundice and cholangitis. Abdominal CT revealeda multilocularcystic lesion in the pancreatic head, and fistula formation between the common bile duct and this cystic lesion. Drainage of Mucous bile was noted via the PTBD tube. Therefore, we suspected penetration of the common bile duct by an IPMN, causing obstructive jaundice and cholangitis. We made an aggressive effort to ensure complete drainage of the mucous bile, which was followed by resolution of the cholangitis. Then, we performed pancreaticoduodenectomy for the IPMN. Histopathologicalexamination revealed findings suggestive of intraductal papillary mucinous carcinoma in situ, with no evidence of invasion around the fistula between the IPMN and the common bile duct. No complications were encountered during the postoperative period, and the patient remains without evidence of relapse 28 months since.

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Undifferentiated carcinoma of gallbladder is rare and has a poor prognosis. We report a case of undifferentiated carcinoma of gallbladder suspected by EUS-guided FNA, and diagnosed by autopsy. 85-year-old woman presented with right hypochondralgia and palpable bulky tumor. Abdominal CT scan, MRI and US showed a tumor over 10 cm in diameter with necrosis within. There was no indication for surgery because of age and extent of the tumor. We performed EUS-guided FNA. Histopathological findings were suspicious of undifferentiated carcinoma of gallbladder. We performed endoscopic stent placement for duodenal stenosis caused by rapid growth of the tumor. The patient developed perforation of stomach 24 days after the stent placement, and died 31 days after the procedure. EUS-FNA may be able to make the diagnosis gallbladder carcinoma. However, it is extremely difficult to make the diagnosis of undifferentiated carcinoma, due to the necessity of several samples for the confirmation of the diagnosis. Most undifferentiated carcinoma of gallbladder is unresectable. Moreover, resected cases have a low survival rate. It is necessary to establish multidisciplinary treatment by accumulation of cases.

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A 66-year-old man was admitted to our hospital for the treatment of common bile stones. He underwent endoscopic paillary balloon dilation (EPBD), because he could not stop taking anti platlet drugs (aspirin and clopidogrel sulfate) for coronary drug eluting stent and we could not perform endoscopic biliary sphincterotomy (EST). Three days after EPBD, he complained of upper abdominal pain. He was diagnosed as hemobilia,because abdominal CT revealed the high density lesion in common bile duct, and gastroendoscopy showed hemorrhagic bile discharged from duodenal palilla. Insertion of ENBD tube was performed and clopidogrel sulfate was stopped. Ten days after the diagnosis, hemobilia was stopped. Twenty days after the admission, he was discharged.

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Although major hepatobiliary resection for hilar cholangiocarcinoma has been a widespread curative treatment, combined hepatic arterial resection and reconstruction still remains a challenging surgical procedure. A 70-year-old woman was diagnosed with an advanced hilar cholangiocarcinoma involving both the left portal vein and the right hepatic artery. After left trisectional portal vein embolization, the tumor was curatively resected by left trisectionectomy with caudate lobectomy and combined hepatic arterial resection and reconstruction with negative surgical margins. The hepatic arterial reconstruction between the posterior branch of the right hepatic artery and left hepatic artery was performed under the microscopic technique in end-to-end fashion. Histologically, a well-differentiated adenocarcinoma invaded the media of the left portal vein and the adventitia of the right hepatic artery. Postoperative recovery was uneventful, and the patient is alive 15 months after surgery with no evidence of tumor recurrence. The left hepatic artery can be available for hepatic arterial reconstruction even in case of a left-sided hepatectomy in terms of a tumor extension.

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A 65-year-old woman was performed cholecystectomy with regional lymph node dissection for gallbladder cancer (JSBS classification; well-differentiated tubular adenocarcinoma, pSS, pN0, M0, fStage II). One year after surgery, follow-up PET scan detected increased FDG uptake in the right liver. She was diagnosed as having superficially-spreading distal cholangiocarcinoma with hepatic metastasis by imaging examinations. Right hemihepatectomy with extrahepatic bile duct resection and reginal lymph node dissection was performed. Pathologically, the tumor spread superficially into the intrahepatic bile duct and formed a mass in the right liver. According to JSBS classification, the tumor was identified as papillaryadenocarcinoma, pT4 (Hinf3), pN0, M0, fStage IVa. This is a rare case of metachronous biliary double cancer associated with superficially-spreading distal cholangiocarcinoma with intrahepatic mass-formation and gallbladder carcinoma, but not associated with anomalous arrangement of the pancreaticobiliary ductal system.

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A 67-year-old woman was found to have dilatation of the extrahepatic bile duct by ultrasonography, during ambulant treatment of hyperlipidemia. Enhanced computed tomography demonstrated mild thickness of the lower bile duct wall. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiography revealed dilatation of the extrahepatic bile duct with a non-enhanced area of the ampulla of Vater. A low-echoic lesion was observed in the bile duct portion of the ampulla of Vater by endoscopic ultrasonography, and the lesion also extended to the inferior bile duct. It was suspected that there was focal invasion to the pancreatic portion of the ampulla of Vater. No apparent malignancy was detected in the biopsy specimen. However, the possibility of a malignant tumor could not be completely excluded. Therefore, we performed pylorus-preserving pancreatoduodenectomy. Static and infected bile juice spouted from the dilated bile duct at resection. Macroscopically, the lumen of a portion of the bile duct of the ampulla of Vater was partially occluded by a papillary lesion. Microscopic examination showed that the epithelium of the papilla was lined by a single layer of columnar epithelial cells, accompanied by chronic inflammatory infiltrate in the lamina propria. Based on these findings, we diagnosed Papillary hyperplasia of the ampulla of Vater.

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Diagnostic procedures of congenital dilatation of the bile duct (CDBD) and pancreatobiliary maljunction (PBM) were reviewed. CDBD is classified into 5 types, from type I to V. US, CT, and MRCP can easily delineate the dilation of the bile duct except in patients with CDBD of type II and type III. MRCP, EUS, ERCP, and contrast-enhanced MDCT are useful to diagnose PBM observed in patients with CDBD of type Ia, type Ic, and type IV-A. Although MRCP is non-invasive and useful, it is necessary to perform EUS and/or ERCP to detect biliary tract cancer highly complicated with PBM. It is important to detect patients with PBM without dilatation of the common bile duct, because such patients have high incidence of biliary tract cancers. In such patients, diffuse thickening wall of the gallbladder and/or slight dilatation of the common bile duct are observed frequently. From the viewpoint of early detection or prevention of biliary tract cancer, we should diagnose carefully in patients with such findings.

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