Prof. Satoshi Kondo passed away due to lung cancer on January 17, 2011. He underwent R0 resection: left extrapleural pneumonectomy for locally advanced cancer on September 17, 2010. However, early recurrence was found unexpectedly and multidisciplinary treatment did not prolong his life.
He has been a real leader since he was a captain of his high school rugby football team. He has built an internationally recognized surgical team in the Hokkaido Univesity and developed an unique surgical strategy for hilar cholangiocarcinoma and locally advanced pancreatic body cancer.
He was elected as the President of Japan Biliary Assosciation (JBA) in September 2008. His leadaership was remarkable to establish the postgraduate education system in JBA. He advised young JBA members to be specialized biliary doctors without any clinical borders, and the JBA made a contract with Japanese Society of Hepatobiliary Pancreatic Surgery (JSHBPS) to publish a "secondary publication article" selected from the "Tando": offical Japanese journal of JBA in Journal of Hepatobiliary Pnacratic Science: official journal of JSHBPS. We learned much from his thoughtful message shown in his final stage of his life. We hope that JBA will be internationally recongnized association to realize the soul of our Past President, Satoshi Kondo.

View full abstract

Endoscopic procedures are currently used as the first line of treatment for bile duct stones. Endoscopic sphincterotomy (EST) is usually performed in Western countries; however, in Japan, endoscopic papillary balloon dilation (EPBD) as well as EST is performed at many institutions. Endoscopic procedures have several advantages over open surgery: they are much less invasive and involve much less manpower, preparation, and procedure time. Therefore, they can be performed even for emergency cases. In addition, the endoscopic procedures are more cost-effective. However, procedure-related complications occur occasionally; representative complications include bleeding and perforation for EST and pancreatitis for EPBD. These complications are associated with several contraindications and pose several difficulties. Therefore, we must understand the merits and demerits of these procedures, and we should choose the appropriate procedure on the basis of the indications and perform the procedure accordingly. We should also be aware of several guidelines for performing safe and effective procedures and several measures for managing complications.

View full abstract

Endoscopic ultrasonography (EUS) is now a widely accepted modality for the diagnosis of gastrointestinal and pancreatobiliary diseases. EUS-guided fine needle aspiration (EUS-FNA) using a curved linear array echoendoscope has been made possible and since then, many researchers expanded the indication of EUS-FNA to various kinds of lesions and also for a variety of therapeutic purposes. Here, we introduce endosonographic anatomy of hepato-biliary system and staging of extrahepatic or intrahepatic biliary cancer using a curved linear array echoendoscope, EUS-FNA for the definite diagnosis of biliary cancer, and endoscopic ultrasound-guided biliary drainage (EUS-BD) as one of the choice for obstructive jaundice.

View full abstract

In the bile duct cancer, preoperative clinical diagnosis of distant metastases and local extension including invasion of the vessels and longitudinal extension is important. The longitudinal tumor extension varies depending on the gross type and location of tumor, and the appropriate diagnosis is required. Recently, preoperative diagnosis for the longitudinal tumor extension has become simple because bile duct resection with hepatectomy has been established as standard surgery for hilar bile duct cancer. According to frequent intraluminal tumor extension in hilar or upper bile duct cancer; the findings of wall thickness by MDCT and tapering stenosis of the bile duct by detail cholangiography are interpreted with care about the limits of ductal resection of the residual liver lobe as an index. Close examination must proceed with biliary drainage to improve liver function before surgery. ENBD is currently the first choice of preoperative drainage method for hilar bile duct cancer.
On the other hand, the superficial tumor extension is frequent in the middle or lower bile duct cancer; therefore, peroral cholagioscopy and biopsy are often necessary.

View full abstract

Clinical features of multiple cancers detected in case of cancer of the ampulla of Vater were investigated. Of the 35 patients with cancer of the ampilla of Vater who underwent surgery at our hospital between 1995 April and 2010 March, 7 patients (20%) were found to have multiple cancers. Triple cancers were found in 1 of those patients. The mean age of the 7 patients was 67 years, and male-to-female ratio was 6 : 1. Multiple cancers was synchronous in 1 case and metachronous in 6 cases. The sites of other organ cancers were the stomach in 2 cases, colon in 2 cases, lower bile duct in 1 case, pancreas in 1 case, and bladder and lung (triple cancers) in 1 case. In metachronous multiple cancers, cancer of the ampulla of Vater often develops after resection of preceding cancer, and we therefore need to consider the occurrence of other organ cancers after resection of cancer of the ampulla of Vater.

View full abstract

Since September 2004, percutaneous transhepatic gallbladder aspiration (PTGBA) has been performed as the first choice of gallbladder drainage for the twenty-five patients with acute cholecystitis in order to evaluate the efficacy and safety of this method. Improvement of clinical symptoms was obtained in 15 patients (60%) by one-time PTGBA procedure and in 22 patients (88%) by the second PTGBA procedure. All cases, in whom clinical improvement did not recognized by PTGBA, showed impacted gallstone. In one patient who had taken antithrombotic-drug, hematoma of under liver capsule was observed. No serious complication was noted in the other patients. Good clinical response was also obtaind in 16 patients who were observed without cholecystectomy due to severe concurrent disease or poor performance status. The only one of 16 patients showed recurrence of acute cholecystitis after 27 months. This case could be treated by PTGBA again.
PTGBA, which can avoid drainage tube troubles, is a convenient, safe and effective treatment of acute cholecystitis. It is considerd that this procedure is paticularly useful for the patients without application of cholecystectomy due to severe concurrent disease or poor performance status, and can be the first choice treatment of acute cholecystitis.

View full abstract

Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with surgically altered anatomy because of the extremely long length of afferent limbs that must be traversed to reach the major papilla or bilio-enteric anastomosis. Use of an anterior oblique-viewing endoscope enables good success rates of reaching the major papilla in patient with Billroth II gastrectomy, and a new insertion method using a double balloon endoscope or a single balloon endoscope enables easier access to the afferent duodenal loop in a patient with Roux-en-Y anastomosis. However, no standard procedure has yet been established, so it is desirable to accumulate more cases in the future in order to overcome various problems with such endoscopes and other treatment devices, and it is hoped this will lead to further improvements in these endoscopes and devices.

View full abstract

Gallbladder cancer is a relatively rare neoplasm that differs from other cancers of the digestive tract. Therefore, the epidemiology has not well progressed and the risk factors have not been fully elucidated. With respect to the association between gallbladder cancer and gallstones, this review article introduced the data on the meta-analysis of the published findings that were conducted abroad, and those on the results of the Japan Public Health Center-Based Prospective Study, an epidemiological study based on the prospective follow-up of a large number of the Japanese population that has recently been reported from the Ministry of Health, Welfare, and Labor. This review also refers to the natural history of gallstone disease. There has been a consensus that a prophylactic cholecystectomy for subjects with asymptomatic gallstones does not improve their survival outcome throughout a decreased number of mortality, because of gallbladder cancer. It may not be true that all subjects with asymptomatic gallstones carry a high risk of gallbladder cancer. In the future, in order to focus attention on the high risk subjects, exploration and development of useful biomarkers is desired for the detection of gallstone-associated chronic inflammation and persistent biliary epithelial injury, which in turn are closely related to gallbladder carcinogenesis.

View full abstract

A-70-year-old man was referred to our hospital for the treatment of gall bladder stones and common bile duct (CBD) stones. Endoscopic biliary drainage (EBD) using plastic stent was performed following sphincterotomy. After laparoscopic cholecystectomy, we noticed the migration of the plastic stent into CBD and tried to remove it endoscopically through the duodenal papilla. However, the plastic stent was incarcerated just behind the duodenal papilla, thereafter it would not move despite the application of any endoscopic devices. Next day acute obstructive cholangitis occurred and PTBD was performed. To release the plastic stent from the biliary wall, we employed the AMPLATZ GOOSE NECK^TM Microsnare Kit through the PTBD route. After the successful release, we retrieved the plastic stent endoscopically from the duodenal papilla. Specific devices for removing foreign bodies of CBD are not available because such a case is rarely encountered. The AMPLATZ GOOSE NECK^TM Microsnare Kit is a very useful device. Due to a thin caliber, it can be safely applied to even bleeding tendency patient through the small number of PTBD catheter exchange.

View full abstract

A 71-year-old woman with chronic hepatitis B underwent chemotherapy, followed by operation being diagnosed with cancer of the gallbladder. She was admitted to our hospital because of general fatigue. CT showed a liver abscess with air density. Redness appeared on the right lateral abdominal wall. The redness on the abdominal wall gradually enlarged. We performed percutaneous transhepatic abscess drainage for liver abscess and treated with antibiotics. However, she died of sepsis seven hours after admission. Aeromonas hydrophila was detected in the blood and abscess afterward. A. hydrophila infection is known to become very serious in immuno-compromised hosts. We here report a fatal case of A. hydrophila sepsis with liver abscess.

View full abstract

Benign recurrent intrahepatic cholestasis (BRIC) is an autosomal recessive disorder characterized by episodic cholestasis without elevation of serum gamma-glutamyltransferase (GGT) levels, and usually lacks progressive liver damage. Recent studies have demonstrated that BRIC, or BRIC type 1, is caused by mutations in ATP8B1 gene encoding FIC1 (familial intrahepatic cholestasis) protein, P-type ATPase. We herein report a female case with BRIC, who developed prolonged jaundice at 22 years old. While medical treatments including ursodeoxycholic acid administration were not effective, we performed ENBD (endoscopic nasobiliary drainage) to interrupt the enterohepatic circulation of bile salts. Her subjective symptoms rapidly subsided, and serum levels of total bile acids and bilirubin was reduced to the normal levels in a week. She has remained asymptomatic for two years after the removal of ENBD. It is assumed that the reduction of bile acids pool in the enterohepatic circulation contributed to resolving her symptoms and prolonged cholestasis. We propose that temporary ENBD is a successful therapeutic option for prolonged jaundice due to BRIC.

View full abstract

A 30-year-old woman with intermittently persisting high fever from 2007 was referred to our hospital. On admission Oct 2008, she complained of high fever and back pain. CT revealed a large cystic liver tumor with papillary projections locating mainly in the left lobe. Distinct mucin secretion from papilla of Vater were observed during ERC. Under the diagnosis of IPNB with metastases to the ovary and lymph nodes, she underwent extended left lobectomy of the liver, bile duct resection, biliary reconstruction and ovariectomy because reductive surgery may appear to be beneficial. Mucinous tumor was founded on the left lobe of the liver, and metastatic lymph nodes around pancreas and paraaortic region were found. After the operation she was received chemotherapy with gemcitabine and S-1. Although metastatic lymph nodes and local recurrence were developing gradually, she is still doing well in 2 and half years after operation.

View full abstract

We described the treatment for the difficult cases of differential diagnosis in patients with middle to lower biliary strictures. The main reasons of difficult diagnoses are atypical clinical and imaging findings compared to expected histopathological diagnoses. In case of difficult diagnoses, we have to comprehensively diagnose by the case conference among physicians, surgeons, radiologists, and pathologists. In addition, short term follow-up is mandatory to avoid the misdiagnosis.

View full abstract