We analyzed a background factor and treatment outcome of biliary pancreatitis 28 cases to clarify utility and adaptation of endoscopic treatment for biliary pancreatitis. When endoscopic treatment was performed, 11 cases showed a stone impaction at the papilla of Vater. In 6 cases of them, precut was performed and stone impaction was removed. In one case of the non-impaction, precut was performed. 23 cases had common bile duct stone or debris. In 12 cases of them, stone was removed perfectly by once endoscopic treatment and 7 cases was twice. 5 cases finished the treatment in bile duct stenting because they were high age or bad condition. On the other hand, 5 cases did not have bile duct stone. It was thought that they were passed stones. 9 cases of a stone impaction were mild pancreatitis, but they had much intensity abdominal pain and endoscopic treatment was performed early in comparison with non-impaction cases. The pain and pancreatitis were improved immediately. Mild biliary pancreatitis with strong pain may have a stone impaction. Endoscopic treatment by precut is effective in these cases.

Detailed endoscopic findings of the bile duct mucosa have not been fully established. This is a fundamental ex vivo study to assess the association between magnifying endoscopic findings and histopathological findings of the bile duct mucosa. 41 common bile ducts, which were surgically resected, were enrolled in this study. Oval-shaped, depressed areas and a fine, regular network of microvessels were the characteristic features of normal bile duct mucosa, and inflammation obscured these findings. Especially in cases with severe inflammation, a wide variety of vessels and mucosal architectures were observed. Distinguishing neoplasm from non-neoplasm may be difficult in some cases with severe inflammation. With regard to delineating tumor margin, tumor margin was clearly seen only in papillary type tumors, owing to mucosal structure and the characteristic vessels which were observed only in papillary type tumor. On the other hand, it was very difficult to detect tumor margin of nodular type tumor, especially in case with severe inflammation.

We devised a bile cytology method using endoscopic suction for convenient sample collection of bile spillage occurring immediately after biliary stent placement, and investigated its usefulness. The subjects were 19 patients who underwent biliary stenting after having been diagnosed with malignant biliary strictures at our hospital between March and December 2015. Final cancer diagnosis was based on all sampling methods and clinical follow-up. After completing other tissue collection procedures, we collected bile spillage occurring immediately after biliary stent placement, using endoscopic suction with a tracheal suction kit. The amount of the samples collected by endoscopic suction was 11.9±9.5ml, and samples assessable as cytological diagnosis were obtained in 95% of the cases (18/19 patients). The cancer-positive rate (sensitivity) is 79% (15 out of 19 cases), 95% confidence interval (CI) was 0.54-0.94. No complications occurred due to the collection of bile with suction. Endoscopic suction cytology after biliary stent placement is a useful means of pathological diagnosis for convenient sampling offering high diagnostic sensitivity.

An update edition of General Rule for Clinical and Pathological Studies on Cancer of the Biliary Tract has proposed the new term, "perihilar cholangiocarcinoma", which has been defined more specifically, compared to the previous version. Based on this new definition, tumors developing from the large duct (extrahepatic type) and those developing from the intrahepatic bile duct are managed together in the same tumor staging scheme. However, the latter is characterized as higher incidences of left-sided predominance and vascular invasion. Therefore, the proportion of left hepatic trisectionectomy or vascular invasion may rise in the era of the new definition. Institutional indication of these procedures may affect the overall resectability. Meanwhile, according to the nationwide survey, the mortality rate after left hepatic trisectionectomy or hepatobiliary resection is higher (>5%) than anticipated. Thus, hepatectomy for perihilar cholangiocarcinoma remains challenging.

It is not uncommon for biliary cancer to have reached at an advanced stage at the time of diagnosis. Even in resectable cases, biliary cancer often recurs soon after surgery. Recently completed randomized studies have shown that the abilities of chemotherapies to prolong the survival period of patients with biliary cancer. These results have led to the rapid growth of interest in the development of new drugs for biliary cancer. Proactive clinical studies examining promising molecular drugs targeting specific mutations and immunocheckpoint inhibitors, which have been successful in patients with non-biliary solid cancers, are now underway for the treatment of this cancer.

A 79-year-old man presented with abdominal pain. It showed a rise of the tumor marker CA19-9 (182U/ml) in the blood test. The computed tomography (CT) scan revealed thickening of the bile duct wall. The endoscopic retrograde cholangiopancreatography (ERCP) showed narrowing of the lower common bile duct. An ill-defined lesion was confirmed in extrahepatic bile duct. As transpapillary bile duct biopsy showed moderately differentiated adenocarcinoma. The positron emission tomography (PET) showed integrated and MaxSUV 3.6. We diagnosed extrahepatic cholangiocellular carcinoma. Subtotal Stomach-Preserving Pancreaticoduodenectomy were performed. Pathological examinations showed the extrahepatic cholangiocellular carcinoma with Lymph node metastasis (UICC, pT2 N1, M0 Stage IIB). Microscopically, Immunohistochemistry was performed to identify IgG4-positive plasma cells and the storiform fibrosis. More than 10 IgG4-positive plasma cells/high power fields were detected in the CBD. The bile duct wall showed the typical features of IgG4-related sclerosing cholangitis. This case was cholangiocarcinoma accompanied by fibroinflammatory lesions with IgG4-positive plasma cells. Proactive pathological examination is needed to detect potential cholangiocarcinomas.

A 78-year-old male patient presented to our hospital with acute cholangitis. The patient had medical history of acute myocardial infarction, for which antithrombotic therapy, including warfarin and clopidogrel, were initiated. Image findings revealed hemorrhage at the intra-bile duct, and acute hemorrhagic cholangitis was diagnosed from ERCP. Furthermore, a neoplastic papillary lesion was detected in the gall bladder, and subsequent cholangiography revealed bile duct stenosis. At this point, further diagnoses middle part of bile duct cancer was made. Subtotal stomach-preserving pancreaticoduodenectomy and gall bladder bed resection (partial liver resection) were performed. Pathological findings revealed poorly differentiated bile duct cancer with areas of obvious tumor necrosis and hemorrhage, as well as a well differentiated gall bladder cancer. Based on these results, synchronous double biliary cancer, which included distal bile duct cancer and gall bladder cancer were diagnosed. Furthermore, hemobilia was identified originating from bile duct cancer. Antithrombotic therapy with more than two agents was considered a high risk factor for hemobilia in this patient. Therefore, immediate and precise diagnosis with appropriate treatment is mandatory for adequate management of hemobilia.

We recently encountered a patient who developed bile duct cancer of the porta hepatis, 43 years after cholangiojejunostomy for congenital biliary dilatation (CBD). This 59-year-old woman had undergone cholangiojejunostomy for CBD at 15 years old. She had remained asymptomatic and no long-term follow-up was performed. However, she developed epigastric pain, and was referred to our hospital after intrahepatic stones were diagnosed.

Imaging showed an irregular stricture of the left hepatic duct and mucosal erythema and irregularity of the opening of the left hepatic duct and cholangiojejunostomy site. Biopsy revealed moderately differentiated adenocarcinoma. Resection of the left hepatic and caudate lobes and site of cholangiojejunostomy was performed. Histopathological examination showed a nodular, well-differentiated adenocarcinoma (T1bN0M0, stage I) in the bile duct.The patient has remained recurrence-free as of 2 years postoperatively. Cholangiojejunostomy for CBD is associated with high risk of cancer, and the prognosis is poor if cancer develops. Patients who have undergone cholangiojejunostomy for CBD may develop complications involving cancer of the residual bile ducts when conditions such as intrahepatic stones develop, and this possibility needs to be addressed through detailed examinations. Some patients, such as the present patient, have not received periodic surveillance after undergoing surgery for CBD during childhood.

With the advent of balloon enteroscopy, we have come to be able to easily perform endoscopic biliary treatment (EBT) for patients with surgically altered anatomy (SAA).

On the other hand, a good level of effectiveness for EUS-guided biliary treatment (EUS-BT) in failed ERCP cases has been reported. And it has also been reported that EUS-BT enables EBT even in difficult cases of SAA.

We performed 13 EUS-BT's for patients with SAA, and these cases were all failed ERCP cases using double-balloon enteroscopy (DBE). This time, we retrospectively evaluated these cases. The technical success rate was 100% (13/13 cases). The complication rate was 7.7% (1/13 cases) and in that case plastic stent migration occured.

In conclusion, EUS-BT is useful in cases when ERCP failed using DBE. Although we are faced with many tasks, it is hoped that EUS-BT will be a standard procedure in the near future.

We report a rare case of bile duct carcinoma associated with pancreaticobiliary maljunction (PBM) without choledocal cyst. A 52-year-old woman was admitted to our hospital with abdominal pain and jaundice. CT and MRI showed an enhancing mass in the middle portion of the common bile duct. ERCP and MRCP showed PBM without choledocal cyst and stenosis in the middle portion of the common bile duct. As pathological findings, tubular carcinoma was seen at the distal bile duct but no cancerous lesion was found in the gallbladder.

A 63-year-old man was referred to our hospital for intensive examination of a bile duct stricture. Computed tomography (CT) with contrast medium showed the wall thickness of the middle bile duct with contrast enhancement. Endoscopic ultrasound (EUS) revealed malignant-like irregular wall thickness. With endoscopic retrograde cholangioscopy (ERC), stenosis of the middle bile duct was revealed, and intraductal ultrasonography (IDUS) showed cystic lesions of 1-2mm inside the wall. We also performed peroral cholangioscopy, which showed that the surface of the lesions had fine granular patterns with no vasodilation, suggesting inflammatory changes. Though there were no malignant cells detected by histological examination, cancer could not be ruled out, and surgical resection was necessary. Histologically, the lesion was diagnosed as adenomyomatosis of the common bile duct. Case reports of bile duct adenomyomatosis are rare. In most cases, adenomyomatosis of the bile duct is difficult to distinguish from a malignant tumor, but cholangioscopy may be useful to differentiate it from a malignant lesion. There are no reports describing adenomyomatosis of the bile duct that has become cancerous, but histologically, the mucosa of the bile duct showed gastric-type metaplasia, so malignancy could not be ruled out, and surgical resection was recommended. If we can diagnose adenomyomatosis preoperatively, limited surgery should be considered.

We report a case of cholecystocolic fistula diagnosed by endoscopic retrograde cholangiopancreatography. A 77-year-old woman was referred to our hospital because a fecal occult blood test was positive and a colonoscopy showed a fresh blood clot of hepatic flexure of colon. Our colonoscopy revealed a submucosal tumor-like lesion close to the hepatic flexure of colon, and an endoscopic clip was placed around the lesion for further tests. Contrast-enhanced CT indicated that the gallbladder stuck to the colon around the clip and air was seen in the gallbladder. We suspected cholecystocolic fistula. We performed barium enema, drip-infusion cholecystocholangiography, and endoscopic ultrasound, which ended up with few clues. Finally, we performed endoscopic retrograde cholangiopancreatography, inserted a catheter into the gallbladder, and injected contrast material, which proved a fistula between the gallbladder and the colon.

Sclerosing cholangitis (SC) is classified as follows; primary (PSC), IgG4 related (IgG4-SC), and secondary SC (SSC). Liver transplantation is the only therapy of late-stage PSC, but endoscopic therapy is effective for cases with jaundice and/or biliary infection, to retard the progression to liver failure. Ursodeoxycholic acid and bezafibrate are used, although the efficacy is controversial. In contrast, steroid is defined to be effective for treatment of IgG4-SC. Intractable cases are treated with immunosuppressive agents. Prognosis is mostly well, but a long-term assessment is still to be established. For SSC, underlying diseases are to be managed.