The short and long-term outcomes after the initial treatment with EST and EPBD for bile duct stones were examined. Of 206 patients initially treated for bile duct stones from 1990 to 2010, 39 post-cholecystectomy and 11 uncertain prognosis patients were excluded and 156 patients (EST: n=108, EPBD: n=48) were the subjects of this study. Treatment related pancreatitis in the EPBD group tends to be higher in the EST group (12.5% vs. 4.6%), but all these patients recovered by the conservative therapy. The recurrence rates of the bile duct stones were 10.2% (11/108) in the EST group and 6.3% (3/48) in the EPBD group without a statistical significance. The significant factors related to the recurrence of bile duct stones were the primary bile duct stones and acalculous gallbladder. The bile duct stones recurred more frequently in the patients who had not undergone simultaneous cholecystectomy than those received cholecystectomy, but the difference was not significant. These results suggest that the patients with primary bile duct stones and in those without simultaneous cholecystectomy for acalculous gallbladder should be careful follow-up after the treatment of bile duct stones.

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We investigated the usefulness of both the Tokyo guidelines (TG) and JPN guidelines for acute cholangitis (AC). We prospectively reviewed 48 cases of AC and divided them into an emergency-ERCP group (Group A, n=18) and an elective-ERCP group (Group B, n=30). According to the TG, the AC was severe in 10 cases and moderate in 8 cases in Group A, and moderate in 8 cases and mild 22 cases in Group B, whereas based on the JPN guidelines the AC was severe in 13 cases, and moderate in 5 cases in Group A, and severe in 2 cases, moderate in 24 cases, and mild in 4 cases in Group B. The severity of AC tended to be overestimated based on the JPN guidelines in comparison with the TG. When the five predictors of moderate AC in the JPN guidelines were used to devise a scoring system, the ROC curve of the scores showed good test performance for predicting emergency ERCP and predicting severe AC in TG with an AUC of 0.87 and 0.97. We therefore concluded that the scoring system would contribute to identifying indications for emergency ERCP and predicting of severe AC.

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The aim of this study is to clarify the benefit of single incisional laparoscopic cholecystectomy (SILC) for postoperative pain reduction. We investigated 63 patients who underwent SILC or laparoscopic cholecystectomy (LC). Among them, 33 patients were able to evaluate by visual analogue score (VAS) for pain. In the patients using epidural anesthesia, the VAS of SILC patients were significantly lower than those of LC patients at 24 hours after operation. SILC is beneficial for reduction of postoperative pain concomitant use of epidural anesthesia.

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Erich Mühe performed the first laparoscopic cholecystectomy using his unique device, "Gallscope" in 1985. Dr. Mühe happened to perform single port surgery as sell. The first report of single port laparoscopic cholecystectomy, reducing the number of incision and size intentionally, was performed by Dr. Navarra in 1997. This brand new concept of laparoscopic surgery has not spread immediately, because of its technical difficulty. However, improving of surgeons' skill and innovation of new devices have made easier and become feasible. Some Japanese endoscopic surgeons set up the society for single incision endoscopic surgery in order to penetrate this operation method safely and securely. The technique of single port cholecystectomy has been standardized. The surgeons can choose variety of devices to perform the operation confirming the critical view of safety. Benefit of the single port surgery is only cosmetic in the present circumstances. The single port surgery is expected to have further benefits.

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The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is also different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy. The limits of ductal resection could be changed in patients with anomaly of the intrahepatic bile duct system. In patients with invasive type of cholangiocarcinoma, operative procedure should be determined by evaluating whether the ductal portion of the beginning of tapering extends the estimated ductal resection limit on the precise cholangiography. Meanwhile in patients with intraepithelial cancer spread, the margin of the cancer is sometimes difficult to be diagnosed preoperatively. In such cases multimodal assessment and mapping biopsy should be performed taking into account the ductal resection limits so as to diagnose the spread of the cancer and to select an appropriate operative procedure.

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The patient who was a man in his late 50s had a history of bladder cancer with no sign of recurrence. Blood tests showed severe inflammatory reaction. On CT, a tumorous lesion 80 mm in diameter with irregular borders was depicted extending continuously from the gall bladder fundus to the liver. FDG-PET showed markedly high uptake by the tumor, with diffuse uptake present in the spine. Cytological testing of the gallbladder by ERCP detected squamous cell carcinoma. As the elevated white blood cell count did not improve even after placement of ENBD, and FDG-PET findings, G-CSF-producing carcinoma was diagnosed (G-CSF 119 pg/ml). The patient underwent chemotherapy, but died after 6 months. Autopsy showed adenosquamous cell carcinoma, mainly in the gallbladder and liver, with tumor cells positive for G-CSF. No tumor invasion of the spine was evident, with only hyperplastic changes.

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A 61-years-old man went to a clinic with high fever. Laboratory data showed liver dysfunction. At the first time symptoms and data recovered naturally, but same symptoms occurred four months later and pancreatic head swelling was pointed out. For the further examination and treatment, he was admitted to our hospital. Endoscopic retrograde cholangiopancreatography revealed a mass at the low bile duct. Abdominal enhanced computed tomography scan showed the enhanced tumor. Preoperative diagnosis was lower bile duct cancer and pylorus preserving pancreatoduodenectomy was performed. Pathological diagnosis was polyp type cancer of the papilla of Vater. It was difficult to differential diagnose between lower bile duct cancer and cancer of the papilla of Vater. We herein report an extremely rare case of polyp type cancer of the papilla of Vater that spread to lower bile duct.

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An 80-year-old female had undergone cholecystectomy in 1982. She was admitted because several images revealed a tumor of the bile duct. Biliary enzymes and tumor markers on blood sample were within normal limits. CT showed the enhanced nodule, which size was 13 mm in diameter, with clear boundary in the middle part of the common bile duct. This tumor described as a well defined high intensity nodule on T2-weighted and Diffusion weighted MR images. It was described as a low intensity tumor with hyper-echoic foci by Endoscopic ultrasonography. FDG-PET CT detected a minute abnormal uptake at the tumor. There were no signs of lymph node swelling, invasion to adjacent tissues and vessels.
Malignant disease could not be excluded, although brushing cytology during ERCP proved no malignant cells. Therefore, extra-hepatic bile duct resection with D2 lymph node dissection was performed. Resected specimen showed submucosal tumor with smooth mucosa. Histopathological examination of the tumor showed hyperplastic and disorganized nerve fibers, surrounded by fibrous connective tissue containing fibroblasts. There were no evidence of malignant cells. Pathological diagnosis was the amputation neuroma of the bile duct.
The amputation neuroma of the bile duct is difficult to differentiate from cancer of the bile duct. It should be considered as a differential diagnosis of middle bile duct tumor if cholecystectomy was performed.

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A 85-year-old female underwent endoscopic sphincterotomy 6 years ago for removal of common bile duct stones. Gallstones had been followed up without cholecystectomy. She complained of fever and anorexia for one month, and laboratory data revealed abnormal liver function test. US, CT, MRI and EUS revealed no recurrent bile duct stones, but marked dilatation of biliary tree and flat elevated lesions were seen in body and fundus of gallbladder. Although ERCP and peroral cholangioscopy revealed massive amount of mucin in bile duct, mucin-producing tumor was not detected in bile duct. Extended cholecystectomy performed under diagnosis of mucin-producing gallbladder carcinoma. Post-operative pathological findings revealed papillary adenocarcinoma localized in fundus to neck of gallbladder. The tumor invaded proper muscle layer, but lymph node metastasis or tumor extension to bile duct was not seen. We reviewed reported cases of mucin-producing gallbladder carcinoma and discussed about it.

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A 62-year-old man with non-alcoholic steatohepatitis was followed-up at the department of internal medicine of our hospital. Thickening of the gallbladder wall was detected on US, CT and EUS. Positron emission tomography-CT (PET-CT) scan also and ultrasonography (US). Positron emission tomography PET-CT scan also showed positive findings in the gallbladder wall and gallbladder bed, and surgery was performed in the suspected gallbladder cancer. Intraoperative pathologic diagnosis did not reveal any malignant findings, at the thickening of the wall and stump of the gallbladder, so we resected of the gallbladder bed. Pathological findings showed many lymphocytes, neutrophil cells, plasma cells and multinucleated cells, and granuloma was diagnosed. We report this case because we feel it can contribute to the understanding of this unusual disease entity.

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We experienced two cases, namely hyperplastic polyp of bile duct and intrahepatic cholangiocarcinoma, long term after side-to-side choledochoduodenostomy. Case 1; 46-years-old woman underwent bile duct resection by the diagnosis of common bile duct stones 21 years after side-to-side choledochoduodenostomy. The resected specimen revealed a polypoid lesion and widely filtrated inflammatory cells in the common bile duct, which was diagnosed as hyperplastic polyp pathologically. Case 2; 69-years-old man underwent hepatectomy and bile duct resection by the diagnosis of intrahepatic cholangiocarcinoma 31 years after side-to-side choledochoduodenostomy. The resected specimen revealed a moderately differentiated adenocarcinoma, and that revealed widely filtrated inflammatory cells in the bile duct and portal area of normal liver. The growth of bile duct tissue without dysplasia was also recognized near the main tumor. Side-to-side choledochoduodenostomy was more affected by inflammation than end-to side choledochoduodenostomy due to the stasis of digestive juice and meal in the construction, so this procedure should be carefully underwent because of possibility for carcinogenesis.

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We describe a case of delayed bile leakage after laparoscopic cholecystectomy. A 48-year-old woman suffering from cholelithiasis was admitted to our hospital. We performed laparoscopic cholecystectomy with careful manipulation due to the low junction of the cystic duct. The patient was discharged uneventfully. She was readmitted because of abdominal pain after the operation. She did not recover with conservative therapy. Abdominal computed tomography (CT) showed fluid collection around the dorsal area of the cystic duct as delayed bile leakage. Emergent endoscopic retrograde cholangiopancreatography (ERCP) was performed and showed bile leakage from the cystic duct. We performed endoscopic nasobiliary drainage (ENBD), and ENBD radiography showed bile leakage from the posterior branch of the bile duct. After recovery of the leakage, the ENBD tube was removed. The patient still had abdominal pain after ENBD tube removal, so we conducted ENBD again. We exchanged the ENBD tube for an endoscopic retrograde biliary drainage tube one week later, and she was able to leave the hospital.

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The definition of pancreaticobiliary maljunction (PBM) of Japanese Study Group of Pancreaticobiliary Maljunction (JSPBM) is following; PBM is a congenital anomaly defined as a union of the pancreatic and biliary ducts located outside of the duodenum wall, and beyond the influence of the sphincter of Oddi. The patient of PBM were classified into two types according to the shape of the extrahepatic bile duct: 1) dilated type, 2) non-dilated type. Standard surgical procedure for PBM with dilatation of the bile duct is bile duct resection and biloenteric reconstruction (flow-division surgery). Postoperative problem are complications such as cholangitis and intrahepatic stone. It is generally accepted that the gallbladder in PBM should be resected. However, controversy is PBM without dilation of the bile duct. Complex communication with accessory pancreatic duct or dilation of pancreatic doctor common duct often caused pancreatic stone (protein plug) leading to pancreatitis. Treatment for these conditions is reported.
By this report, we gave an outline about treatment for congenital biliary dilatation/PBM.

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