Aberrant right posterior hepatic duct (ARPHD) draining into the extrahepatic bile duct, the gallbladder or the cystic duct directly are most common and critical anomalies. Therefore, the secure process to detect them preoperatively is very important. In 506 consecutive patients who underwent laparoscopic cholecystectomy (Lap-C) during 5 years, we investigated whether an ARPHD existed on MRCP images preoperatively. And, in ARPHD cases, we investigated retrospectively whether ARPHD is infraportal or supraportal. All 40 (7.9%) cases with ARPHD were judged as infraportal. Of 40 cases, in 3 (0.6%), the cystic duct drained into ARPHD; and in 1 (0.2%), ARPHD drained into the cystic duct. These 4 cases were diagnosed before surgery. It seems possible to find ARPHD by attention to the infraportal hepatic duct, because most of them are considered to be infraportal. Lap-C must be performed carefully by an appropriate standardized procedure.

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OCT is a novel technique to obtain a high-resolution cross-sectional image that is 10 times higher than that of high frequency intraductal ultrasonography, corresponding to the histopathological image. In this study, OCT images obtained from prototype system of FUJIFILM were compared with histopathological findings to evaluate the extension of intramucosal carcinoma in biliary tract. In the normal area, high backscattering layer of approximately 20 μm thickness at the surface was observed and it was identified as a single layer of columnar epithelia. In the magnified image, higher backscattering spots or lines were observed in the outer side of this layer. We could recognize these findings as the series of cell nuclei which locate in the bottom of columnar epithelial cells. In case of intramucosal carcinoma, the high backscattering intensity was observed in this whole layer that suggested loss of polarity and pseudostratification of nuclei. This study suggested the OCT has potential to diagnose the intramucosal extension. Furthermore, we observed that 3 dimensional OCT effectively recognized the extent of intramucosal carcinoma.

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Pancreaticobiliary maljunction (PBM) is a congenital anomaly in which pancreatic and bile ducts meet anatomically outside the duodenal wall. In PBM, the common channel is longer than normal, which debilitates the influence of the sphincter on the pancreaticobiliary junction, and allowing the reciprocal reflux of pancreatic juices and bile. The reflux of pancreatic juices into the biliary tract (pancreatobiliary reflux) provokes various pathology and higher rates of biliary tract cancer. The Japanese Study Group on Pancreaticobiliary Maljunction (JSPBM), with the support of the Japan Biliary Association (JBA), established clinical practice guidelines on how to deal with pancreaticobiliary maljunction (PBM: also known as anomalous arrangement of the pancreaticobiliary ducts; anomalous arrangement of pancreaticobiliary ductal system; anomalous pancreaticobiliary ductal union; anomalous union of biliopancreatic ducts; abnormal junction of the pancreaticobiliary ductal system; or common channel syndrome). These guidelines were consisted on a total of 46 clinical questions (CQs): I. Concepts and Pathophysiology (10 CQs); II. Diagnosis (10 CQs); III. Pancreatobiliary Complications (9 CQs); and IV. Treatments and Prognosis (17 CQs), and statements and comments regarding each CQ. These guidelines were created to provide assistance in the clinical practice of PBM, their contents focusing on clinical utility, and they include general information on PBM to make this disease more widely recognized. The full versions of the present guidelines have been published in Japanese (Igaku Tosho, 2012). The English version will be published in Journal of Gastroenterology.

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Endoscopic papillary balloon dilation (EPBD) has not been performed in Western countries due to a concern about the post-procedure pancreatitis. However, it is still widely performed in Japan. The advantages of EPBD are lower risk of hemorrhage and perforation as compared with endoscopic sphincterotmy (EST), and the procedure is also much easier than EST. Several studies have also proven that the sphincter of Oddi function is preserved well even after the treatment. However, its clinical significance has not been elucidated. Recently, the long-term outcomes of EPBD have been reported, and they suggested that the lower incidence of stone recurrence and cholangitis than those of EST.

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A 74-year-old female with a past history of right nephrectomy due to renal cell cancer at 67-year-old was admitted for evaluation of an oval polyp at the gallbladder neck with 15 mm diameter in size, which had been recognized as a 7 mm hemispheric lesion on ultrasonography 7 months before admission. Abdominal enhanced CT revealed a strongly-enhanced lesion and endoscopic ultrasonography showed a 20 mm-diameter low echoic polypoid mass with a high echoic layer on its surface. We considered it as a metastatic gallbladder tumor of renal cell cancer and performed cholecystectomy. Histopathologically, the tumor consisted of clear cells similar to the previously operated renal cell cancer and existed in the mucosal layer without invasion into the muscular layer. The gallbladder lesion was diagnosed as a metastasis of renal cell cancer.

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A 63-year-old male was performed endoscopy, and he was found to have an exposed type tumor of the papilla of Vater. The finding of tumor biopsy showed adenocarcinoma, and pancreaticoduodenectomy was conducted. Histopathological finding showed adenocarcinoma in lamina propria, and positivity for chromogranin A, synaptophsin, and CD56 were observed in submucosa by immunohistochemistry. These findings were consistent with adenoendocrine cell carcinoma in papilla of Vater. Adenoendocrine cell carcinoma in papilla of Vater is known to be high-grade carcinoma. Present case was observed without postoperative chemotherapy because of curative surgical resection. Non-recurred long-term survival was obtained until 17 months after surgical treatment when present case died from malignant lymphoma.

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A 60-year-old woman, who had been followed after breast cancer treatment by surgeon of our hospital, was pointed out enlarging gallbladder polyp at abdominal ultrasonography. Ultrasonography visualized low echoic polyp at the fundus of gallbladder with high echo spot in the rim and polyp size was 11 mm in maximum diameter. And maximal gallbladder wall blood flow was 13.4 cm/s. This polyp showed linear type contrast enhancement pattern using Sonazoid^®. An abdominal CT revealed a polyp with contrast enhancement, especially in the rim. Endoscopic ultrasonography showed the surface of the polyp was nodular, and high echo line like outlining the surface and internally heterogeneous low echo area were seen. Open cholecystectomy was performed because it was difficult to distinguish this lesion from early gallbladder cancer. In the resected specimen, a light yellowish mulberry-like polyp with stalk, measuring 12 mm, was noted at fundus. Histologically, it was covered with a simple cuboidal epithelium and was composed of loose connective stroma. Thus, it was diagnosed as fibrous polyp.

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We present 2 cases where choledocholithiasis was treated using yttrium-aluminum-garnet (YAG) laser lithotripsy combined with cholangioscopy performed using the SpyGlass system. Case 1: The patient was a 67-year-old woman who had a bile duct stone. She underwent endoscopy during which the bile duct stone was grasped using a basket catheter but was incarcerated in the bile duct. We performed YAG laser lithotripsy to release the incarcerated stone and could successfully separate and remove the stone. Case 2: The patient was a 79-year-old woman. ERCP showed a filling defect with poor mobility, and the results of cytological examination of the blushing sample were suggestive of malignancy. On performing cholangioscopy with the SpyGlass system, the lesion was found to be a bile duct stone. Subsequently, we successfully removed the stone by using YAG laser lithotripsy. Of the new features provided in the SpyGlass system, 4-way deflected steerability and continuous saline irrigation via the dedicated irrigation channel were found to be particularly useful during YAG laser lithotripsy.

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A 67-year-old male patient with von Recklinghausen's disease was reffered to our hospital. Abdominal CT showed dilatation of the biliary tract and the main pancreatic duct, but there was no evidence of any tumors in the pancreas head area. Gastroduodenoscopy revealed a tumor at the papilla of Vater and somatostatinoma was confirmed in the biopsy specimen. Abdominal CT also showed an enhanced tumor 3 cm in diameter, extending from the horizontal part of the duodenum. The patient had a pylorus-preserving pancreaticoduodenectomy and these tumors were diagnosed as somatostatinoma of the papilla of Vater with lymph nodes metastases and duodenal gastrointestinal stromal tumor with positive staining for c-kit and CD34 by immunohistochemistry. There have been several reports about von Recklinghausen's disease patients associated with ampullary somatostatinoma and gastrointestinal stromal tumor, therefore it is necessary to pay attention these tumors as gastrointestinal lesions in these patients.

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We report the case of an 80-year-old woman with concomitant gallbladder carcinoma and xanthogranulomatous cholecystitis (XGC) having characteristic CT findings. She was referred to our hospital with elevated hepatobiliary enzymes and abnormalities of the gallbladder wall. CT revealed thickening of the gallbladder wall suggesting gallbladder carcinoma. We performed laparotomy after diagnosis of the gallbladder carcinoma infiltrating to the transverse colon and duodenum. The fundal tumor was identified as XGC by intraoperative pathological examination. Therefore, we performed hepatectomy (S4a5), lymphadenectomy, and partial transverse colectomy while preserving the duodenum. The pathological findings revealed advanced carcinoma at the gallbladder neck and XGC at the fundus. CT revealed that the tumor at the gallbladder neck had developed inside, while the tumor at the fundus had expanded outside and the mucosal line at the fundus had been observed evidently. Intraoperative pathological examination is important for differentiating XGC from gallbladder carcinomas and selecting the appropriate surgical procedure.

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An 83-year-old woman was transferred to our hospital by ambulance complaining of worsening upper abdominal pain since the previous day. Abdominal CT revealed an enlarged gallbladder, thickened gallbladder wall, and multiple gallbladder stones. Fluid collection was observed in the subcapsular space on the visceral aspect of the lateral segment of the liver. Under the suspicion of acute cholecystitis and concomitant subcapsular liver abscess, percutaneous transhepatic gallbladder drainage (PTGBD) was performed. However, the fever persisted, and a repeat abdominal CT showed enlargement of the subcapsular liver abscess and perforation. Therefore, percutaneous transhepatic abscess drainage (PTAD) was performed. Culture of the PTGBD and PTAD fluid led to isolation of Streptococcus milleri. Therefore, after the patient's condition improved, cholecystectomy was performed. The postoperative course was uneventful, and the patient was discharged from the hospital on postoperative day 20. Although the subcapsular liver abscess had ruptured, it responded to percutaneous drainage, and elective surgery could be performed safely. Herein, we report a rare case of subcapsular liver abscess complicating acute cholecystitis.

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A 70-year-old man was hospitalized for right upper abdominal pain. Abdominal CT, MRCP, and ERCP revealed irregular-shaped stones in the common bile duct with no stones in the gallbladder. The stones were removed following endoscopic sphincterotomy. One year after the endoscopic treatment, he was re-hospitalized for right upper abdominal pain. Abdominal CT showed slight contrast enhancement suggesting bile duct cancer. ERCP revealed a papillary lesion in the upper bile duct, and a biopsy diagnosis of well-differentiated adenocarcinoma was obtained. He underwent extrahepatic bile duct resection, with the final pathological diagnosis of stage 1A cholangiocarcinoma. As bile duct cancer can be complicated by bile duct stones, further examination is needed after endoscopic lithotripsy, especially when irregular-shaped bile duct stones are present.

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Screening endoscopy of the upper gastrointestinal tract using a forward-viewing scope has recently been utilized to help with the diagnosis of tumors of the major duodenal papilla. The tumors of the duodenal papilla can include hyperplasia, regenerative change, submucosal tumor, hemangioma, adenomas, carcinoma in adenomas and carcinomas. In patients with carcinoma in adenoma, it is extremely difficult to make a definitive diagnosis from a biopsy specimen because the carcinoma cells are located deep within the tumor. By using CT, MRCP, ERCP, EUS and IDUS, it is possible to determine the depth of tumor invasion.
It is very important to understand the feature of the tumors of duodenal papilla.

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