We described the basic techniques of biliary stenting and tips for challenging cases. For the master of biliary endoscopists, we should know the characteristics of many kinds of plastic and metal stents at first. Then, we have to be trained by supervisor. The ultimate aims for master of biliary endoscopists is to get the skilled techniques of the multiple stenting for hilar bile duct strictures, severe duodenal obstruction, and stent troubles including obstruction, migration and dislocation into the duodenum.

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Although the prognostic improvement of gallbladder carcinoma requires the selection of appropriate surgical strategy compatible with curability and safety, the evidences for establishment of standard operations according to with primary tumor invasion are still insufficient.
In pT1 gallbladder carcinoma, lymph node metastasis has almost never been found in Japan, and good prognosis was achieved even after cholecystectomy. In cases strongly suspected pT1 gallbladder carcinoma, Japanese guideline for the biliary tract carcinomas recommends cholecystectomy under laparotomy. Although the appropriate surgical strategy can achieve a prognostic improvement in pT2 gallbladder carcinoma, its surgical procedure remains a matter of controversy. We had proposed S4a+S5 hepatic resection and combined resection of extrahepatic bile duct with D2 lymph node dissection as a standard surgical procedure for pT2 gallbladder carcinoma. In pT3 and pT4 gallbladder carcinoma, only the curative resection provides a long-term survival. Extended right hepatectomy or hepato- pancreatoduodenctomy is indicated for achievement of a curative resection. A surgical resection provided no survival benefit for the patients with peritoneal dissemination and liver metastasis.

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Surgical outcome of distal cholangiocarcinoma has been gradually improved. Pancreaticoduodenectomy is widely recognized as the standard procedure. However, there are still several different options. Concerning prognostic factors, several authors agreed that both tumor-related factors like lymph node metastasis, histological type and therapeutic factors like R1 resection, intraoperative blood loss were the negative predictive factors. Among these factors, many authors reported that incidence of lymph node metastasis was around 50%. Dissection of lymph nodes around the superior mesenteric artery are controversial. According to several reports, the incidence of lymph node metastasis around the SMA could not be ignored. Thus, it is advisable to dissect these nodes. Recently, some authors advocated the clinical benefit of dissection of the SMA tributaries at the beginning of operation. When SMA tributaries ligated prior to pancreatic resection, intraoperative blood loss can be reduced due to avoidance of congestion. Clinical significance of ductal margin status is also controversial. Carcinoma in situ at the ductal margins may not be affect patients' survival, however, some authors reported late anastomotic recurrence even in the patients with positive ductal margin with CIS. These issues should be clarified by a large scale study either retrospectively or prospectively in near future.

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Bile leak after biliary reconstruction remains a major complication. Herein, we examined the perioperative factors associated with bile leak in 81 patients undergoing bilio-jejunal anastomosis. Especially, we focused our attention on the efficacy of indocyanine green (ICG) bile leak test, which was done by an infrared camera system observation after intrabiliary ICG injection. This test intraoperatively visualized 11 bile leaks. Bile leak postoperatively developed in 5 of 42 patients without intraoperative bile leak test and 1 of 39 undergoing leak test. The exceptional bile leak in ICG leak test group was due to jejunal congestion. Among the perioperative factors, the presence of hepatectomy was significantly associated with the postoperative bile leak.
In conclusion, hepatectomy is associated with the postoperative bile leak. ICG leak test is useful to prevent postoperative bile leak, if unexpected trouble around the bilio-jejunal anastomosis does not happen.

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A gallbladder (GB) lying on the left side of the round ligament is said to be rare. Of 2569 patients who underwent cholecystectomy, 12 patients (0.47%) having the left-sided GB underwent laparoscopic cholecystectomy (LC). The patients consisted of 9 men and 3 women, with a mean age of 42.2 years. All patients were successfully treated with laparoscopic surgery. In all of them, lifting the round ligament (RL) and inserting the sub-xyphoid port in the left side of RL were conducted. Dissection was started from Calot's triangle in earlier 5 patients, but it was too difficult to dissect. Therefore, initial dissection was conducted from the liver bed in later 7 patients. The cystic artery was usually found in the GB bed. Mean operating time was 152 minutes, with no postoperative morbidity. All patients had a right-sided umbilical portion in our series. LC can be done safely and successfully even for the left-sided GB, taking a few technical modifications as mentioned above.

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Intraductal papillary neoplasm of bile duct (IPNB) is characterized by an intraluminal, growing papillary tumor covered by neoplastic biliary epithelial cells with fine fibrovascular core. IPNB was introduced as a precancerous and early neoplastic lesion by WHO 2010 tumor classification of digestive system. IPNB eventually invade into the bile duct wall and progress to invasive cholangiocarcinoma. IPNB resembles intraductal papillary mucinous neoplasm of pancreas, particularly the main pancreatic duct type. Recently, IPNB cases, probably corresponding to branch type IPMN, have been reported, and these cases involved significantly the peribiliary glands and grossly showed cystic dilatation, particulary aneurismal or diverticular dilatation. Herein, we reviewed these cases and also our cases which correspond to branch type IPMN and can be called as branch type IPNB, and discussed their development and progression processes.

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Cholecystectomy results in greater duodenogastric reflux (DGR). DGR is an interesting phenomenon which has potential serious consequence. Reflux of duodenal content, especially bile acid, is considered to increase the severity of esophageal damage and to lead to a greater incidence of esophageal cancer in my rat model. We need to understand these issues to adequately advice patients of the implications of cholecystectomy.

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Here we report the case of a 61-year-old man who underwent resection of peribiliary cysts that were clinically indistinguishable from intrahepatic cholangiocarcinoma. The patient was admitted to a hospital because of massive ascites and jaundice due to alcohol consumption. His symptoms were relieved by conservative treatment; however, CT revealed dilation of the left intrahepatic bile duct. The patient was subsequently referred to our hospital for further treatment. Although no mass was identified on CT, MRCP and ERC revealed translucency in a bile duct (B2+3) and significant dilation in the peripheral branches of B2 and B3, suggesting cholangiocarcinoma or biliary stenosis due to peribiliary cysts. We performed laparotomy after considering the possibility of cholangiocarcinoma. However, the final diagnosis was that of peribiliary cysts with no concomitant cancer as per intraoperative ultrasonography findings and pathological examination, and a lateral segmentectomy was performed. Although peribiliary cysts can be diagnosed using various imaging techniques, the coexistence of cholangiocarcinoma cannot be ruled out. Recent developments in imaging techniques have promoted the clinical recognition of peribiliary cysts. Furthermore, intrahepatic peribiliary glands have been reviewed from the standpoint of cholangiocarcinoma or IPNB (intraductal papillary neoplasm of the bile duct) genesis. Ours is a rare and valuable case of resected peribiliary cysts that were clinically indistinguishable from cholangicarcinoma.

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Transpapillary gallbladder drainage is most frequently performed for short-term external gallbladder drainage. Endoscopic transpapillary gallbladder stenting (ETGBS) was performed in 3 patients with recurrent acute cholecystitis and high operative risk to prevent recurrence of acute cholecystitis. Acute cholecystitis had occurred 3 times in 2 patients and 2 times in one patient. Surgery was difficult due to severe dementia in 2 of the 3 patients and acute-phase cerebral bleeding in the remaining patient. There were no recurrences of acute cholecystitis after ETGBS in any of the 3 patients. Two patients died due to other diseases at 17 and 42 months after ETGBS. The remaining patient underwent cholecystectomy one month after ETGBS since his condition became stable. Although further studies with a larger number of patients are needed, ETGBS is thought to be a useful method for the treatment of patients with recurrent acute cholecystitis and high operative risk.

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We report a case of lower bile duct carcinoma with a large pancreatic pseudocyst, the first such case reported to our knowledge. A 65-year-old woman was admitted to the hospital presenting with appetite loss and vomiting of 2 weeks duration. Laboratory examinations showed an elevation of hepatobiliary enzyme activities with serum CA19-9 at 422 U/ml. A 15-cm-diameter cystic tumor adjacent to the duodenum was found from results of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP). CT and MRI also revealed the wall thickness and stenosis of lower bile duct. Pancreaticduodenectomy combined with resection of the superior mesenteric vein was performed. The carcinoma was well-differentiated based on histopathological findings. A psuedocyst due to lower bile duct carcinoma is a rare disease. We could not rule out the possibility of cystic dystrophy in heterotopic pancreas. However, heterotopic pancreatic tissue was not microscopically found around the cyst.

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A 52-year-old man was admitted to our hospital because of upper abdominal pain, and found to have dilatation of the common bile duct by US. Abdominal CT demonstrated significant dilatation of the extrahepatic bile duct and proptosis of the cystic lesion to the duodenal lumen. EUS revealed 15 millimeter common bile duct, and the terminal expanded to duodenal lumen after becoming thin. ERCP showed dilatation of the common bile duct and successive cystic lesion to the terminal. Also, after contrast enhancing, neighborhood of major papilla seemed to be a submucosal tumor and protruded into duodenum. After confirming debris in the common bile duct by IDUS, we performed EST. ERP and MRCP demonstrated absent pancreaticobiliary maljunction. From above-mentioned results, we made diagnoses of choledococele and type IV-B congenital biliary dilatation. The next day of ERCP, pancreatitis occurred because of hematoma in the choledococele caused by bleeding after EST, and we performed emergency ENBD and argon plasma coagulation therapy for the ulcer after EST. We reported a case of type IV-B congenital biliary dilatation which was a significantly rare disease with choledococele causing bleeding after EST.

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A 69-year-old man was referred to our hospital with biliary infection. He was found in further examination to have unresectable pancreatic carcinoma and biliary obstruction. Endoscopic biliary drainage was thought to be difficult due to his past history of total gastrectomy.
Because percutaneous transhepatic biliary drainage (PTBD) was unsuccessful, we performed percutaneous transhepatic gallbladder drainage (PTGBD). As the structure of cystic duct was not complicated, we decided to insert a metallic stent through the cystic duct. We successfully placed a metallic stent using PTGBD route. He left our hospital, free from external drainage tube. This procedure is thought to be one option for patients with biliary structure with difficulty in PTBD.

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It is often difficult to distinguish gallbladder carcinoma from benign gallbladder diseases with thickened walls including chronic cholecystitis, xanthogranulomatous cholecystitis, gallbladder adenomyomatosis, and hyperplasia with a pancreatobiliary maljunction. US, CT, EUS, and MRI play important roles in the differential diagnosis between these benign gallbladder diseases and gallbladder carcinoma. In thickened gallbladder wall cases with inflammation or elevated serum CA19-9, it is sometimes difficult to distinguish gallbladder carcinoma and benign diseases. In these cases, the method of bile cytology using endoscopic naso-gallbladder drainage (ENGBD), or the cytology using EUS guided fine needle aspiration (EUS-FNA) may be useful for differential diagnosis. In the future, further studies will be needed to establish standard methods of ENGBD and EUS-FNA in gallbladder diseases with thickened walls.

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