EUS plays an important role in the diagnosis of biliary cancer. Especially, EUS is positioned as a modality for in-depth examination diagnosing T factor (TNM classification).

In 2013, general rules for clinical and pathological studies on cancer of the biliary tract (The 6th edition: edited by Japanese Society of Hepato-Biliary-Pancreatic Surgery) was modified and proposed as it was consistent with TNM classification (The 7th edition).

I discussed here how EUS served in the diagnosis of biliary cancers (bile duct cancer, gallbladder cancer and cancer of ampulla of Vater.) in this situation. Moreover, I had to raise the alarm over taking easy or too easy way of diagnosing biliary cancer by EUS-FNA.

We examined the effect of differences between surgeons on the Diagnosis Procedure Combination (DPC) for laparoscopic cholecystectomy (LC). The surgeons were divided into certified JBA supervisors (gS), advanced skills JSHBPS supervisors, and residents (gR). The postoperative courses did not show any differences that would affect DPC between groups. Hospital expenses were 53,395 p, which was 1,600 p lower than the 54,983 p using conventional calculation of volume instead of DPC. The medical expenses incurred by the gR increased to 54,033 p. The DPC calculation for the gS showed a decrease of 10 p compared with that for the gR, but the volume showed a decrease of 628 p as the primary reason. It was thought that the increase in the anesthetic fee depended on the longer operative time associated with the gR. The DPC for LC reimburses differently according to the category of the surgeon.

Objective: We aimed to investigate the difference in complications between native papilla and bilioenteric anastomosis cases in bile duct treatment by double-balloon enteroscopy-assisted ERCP (DB-ERCP) for a postoperative reconstructed intestinal tract. Methods: In the 4 years from January 2012 to December 2015, Roux-en-Y reconstruction cases and bilioenteric anastomosis cases were investigated retrospectively, which attempted to treat biliary tract with double balloon small intestine endoscope. Results: No complications were observed in 15 patients who did not arrive at the target site or failed to undergo bile duct treatment. Cases successfully treated with bile duct were divided into two groups for assessing complications: one group comprised 34 cases of native papilla and the other group comprised 21 cases of bilioenteric anastomosis. The complication rates were 20.6%, including 11.8% of pancreatitis and 8.8% of cholangitis in the native papilla group, and 19.0%, including 4.8% of pancreatitis and 14.3% of cholangitis in the bilioenteric anastomosis group. Conclusion: There was no significant difference in the incidence of complications between the two groups. However, it should be noted that in the bilioenteric anastomosis group, pancreatitis can occur without transpapillary treatment and cholangitis can occur without stenosis of the bile duct.

Surgical resection remains to be the most effective treatment for biliary tract cancer and offers the only chance for the long-term survival. However, most cases are discovered at an advanced stage and curative resection is impossible in such cases. For patients with advanced unresectable disease, chemotherapy or chemoradiotherapy is usually indicated due to the recent improvement of effective chemotherapeutic agents. As a result, reports describing cases with initially unresectable biliary tract cancer underwent resection as a conversion surgery are increasing. In particular, in cases with intrahepatic cholangiocarcinoma or gallbladder carcinoma, a significant favorable outcome has been shown after conversion surgery, which could become one of the most important new therapeutic strategies. To establish this strategy, however, there are several problems to be solved, such as the definition of "unresectable", the determination of the best timing for the conversion, the development of more effective chemotherapeutic agents including molecular-targeted drugs, the discovery of the most suitable chemotherapeutic regimen, and the development of the method for assessment of susceptibility to drugs for each cancer.

107 cases of bile duct cancer after extrahepatic bile duct resection with congenital biliary dilatation were reported. In these patients, cancer was detected at a mean of 12.0 years after surgery and the incidence of bile duct cancer after surgery was 2.0%. Inadequate bile duct excision is likely to relate to this serious complication, because 74.5% of bile duct cancer occurred from the intrapancreatic remnant bile duct and the hepatic hilum after extrahepatic bile duct resection. Therefore, complete excision of the intrapancreatic bile duct and removal of stenoses of the hepatic ducts are necessary to prevent serious complications after surgery. On the other hand, diagnostic criteria for pancreaticobiliary maljunction without biliary dilatation in adult remains unclear and it is controversial whether preventive resection of the extrahepatic bile duct should be performed or not. To solve these problems, author will make a suggestion that pancreaticobiliary maljunction considering with stenosis of the hepatic duct can be classified into cystic type, spindle type, forme fruste and no dilatation type. In addition, this classification is connected with appropriate treatment.

Mirizzi syndrome with biliobiliary fistula is a rare complication of cholecystolithiasis. It is difficult to distinguish their types or rule out malignant tumors using conventional preoperative imaging diagnosis. Herein, we report a case of a woman in her seventies who had cholecystolithiasis for the prior 30 years. She was referred to our hospital for suspicion of gallbladder tumor on abdominal CT. Abdominal CT revealed a gallstone strangulating the gallbladder neck. ERCP showed unilateral stenosis. Stenosis could not be rejected because of carcinoma, although Mirizzi syndrome was suspected. Direct viewing of stenosis using the SpyGlass system revealed it as Mirizzi syndrome accompanied by biliobiliary fistula (Corlette type I) and a defect of the semicircle of the common hepatic duct (Csendes type III).

A 75-year-old woman underwent upper endoscopy and was revealed tumorous lesions at the duodenal papilla. Preoperative biopsy showed well-differentiated tubular adenocarcinoma histopathologically, she then underwent surgical operation. Histological examination of the surgical specimens revealed coexistence of neuroendocrine carcinoma (NEC), small cell type, and adenocarcinoma components of the duodenal ampullary resion.

The NEC component formed a polypoid lesion in the distal bile duct, while the adenocarcinoma component exhibited intramucosal spreding in the pancreatic duct. Therefore, the tumorous lesion was histologically diagnosed as primary mixed adenoneuroendocrine carcinoma (MANEC) of the papilla. Multiple hepatic metastases were detected 2 months after surgery, and the patient died 8 months after surgery. The prognosis of MANEC is poor, and the standard surgical procedure and chemotherapy regimen for MANEC have not been determined. Herein, we report a case of MANEC, along with a review of the literature.

A 58-year-old woman with a body weight loss was referred to our hospital and had cholelithiasis and gallbladder wall thickness pointed out by CT. She became the follow-up. After 1year 1month. CT and ultrasonography showed a gallbladder tumor with irregular wall thickness and duodenum compression. Gallbladder cancer with duodenum invasion was diagnosed by a close inspection and we performed subtotal stomach preserving pancreaticoduodenectomy with liver resection of lower part of S4 and S5. Histopathological examination revealed the coexistence of adenosquamous cell carcinoma (T3aN1M1 Stage IVB) and spindle cell tumor with transformations between squamous cell carcinoma and adenocarcinoma. Adenosquamous cell carcinoma of the gallbladder was rare gallbladder neoplasms and poor prognosis. This case had dissemination and positive cytodiagnosis, which had never seen by the naked eye. We report a case of adenosquamous cell carcinoma of the gallbladder with so-called carcinosarcoma.

It is challenging to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. We retrospectively investigated the clinical outcomes of three patients with cholangitis, who had surgically altered anatomies and who underwent percutaneous transhepatic antegrade intrahepatic and common bile duct stone removal at Showa University Hospital between April 2014 and December 2015. All patients received percutaneous transhepatic biliary drainage (PTBD) and antibiotic therapy for cholangitis. After cholangitis was successfully treated, we performed percutaneous transhepatic antegrade treatment for removing stones from the bile duct. We succeeded in removing the stones completely without any adverse events. Percutaneous transhepatic antegrade bile duct stone removal may be feasible in patients with cholangitis, who have surgically altered anatomy.

A 86-year-old woman was admitted to our hospital with right upper quadrant pain. Ultrasonography and Computed tomography showed a 40mm tumor in the gallbladder. We diagnosed advanced gallbladder carcinoma, performed extended cholecystectomy and regional lymphadenectomy (D1). The histopathological diagnosis was squamous cell carcinoma of the gallbladder, T3N0M0 pStage IIIA (UICC), curative resection. She died seven years eight months after operation. Pathological autopsy was performed, there were not recurrence findings.

Squamous cell carcinoma (SCC) is a rare histopathologic subtype of gallbladder malignancy. SCC was reported often invade adjacent organs, tend to have poor resectability rates and prognosis even after resection.

Granular cell tumor of the cystic duct is a rare disease. A 58-year-old Japanese woman underwent abdominal ultrasonography at an annual general health examination and gallbladder swelling was detected. Furthermore, abdominal computed tomography (CT) indicated wall thickness of the cystic duct. She was admitted to the University of Yamanashi Hospital for evaluation of gallbladder lesion. In the physical findings at the time of admission, an egg-shaped mass (3cm diameter) was palpable at the right hypochondrium. The lesion was showed the same attenuation as the pancreatic parenchyma on unenhanced CT and a well delineated mass which enhanced progressively on dynamic contrast-enhanced CT. Cholecystectomy was performed. Histopathological examination confirmed the diagnosis of granular cell tumor without malignant features. The occurrence of granular cell tumor in the biliary tree is extremely rare, and this case is the sixth case reported in Japan.

A 74-year-old woman presented to a neighborhood hospital with complains of upper abdominal pain. Since US examination revealed a strong echo sign in the common bile duct and dilatation of the common and intrahepatic bile duct, she was referred to our hospital for further evaluation and treatment. Contrast-enhanced CT showed two tumors in the lower bile duct. Endoscopic transpapillary biopsy was performed, and histpathological evaluation of the specimen revealed adenocarcinoma. Subtotal stomach-preserving pancreatoduodenectomy was performed under a diagnosis of lower bile duct cancer. Histopathologically both lesions were papillary adenocarcinomas with the invasion depth of fm and diagnosed with intraductal papillary neoplasms of the bile duct (IPNB) with an associated invasive carcinoma. Since there was no histological continuity between the two lesions, a diagnosis in this case was synchronous double cancer of IPNB with an associated invasive carcinoma in the extrahepatic bile duct.

An update edition of General Rule for Clinical and Pathological Studies on Cancer of the Biliary Tract was published in 2013. Unlike the previous edition, TNM classification and stage grouping of this version are identical to those of Union for International Cancer Control (UICC) system, 7^th edition. Extrahepatic cholangiocarcinomas are divided into perihilar and distal tumors; the former is defined as cholangiocarcinoma involving the hilar bile duct despite presence or absence of significant hepatic tumor mass. The new Japanese system was described here. However, the UICC has published 8th version in 2017, where TNM classification and stage grouping has considerably changed. Because the UICC system is a global standard in the oncologic field, all physicians in the world have to use the new UICC system since 2017. In this context, the Japanese general rule is already out of date; its early revision is needed.