In this retrospective study we aimed to clarify the incidence of disseminated intravascular coagulation (DIC) in acute cholangitis (AC) and to evaluate the usefulness of the Tokyo Guidelines 2013 (TG13) severity assessment of AC and problems with the Guidelines. We reviewed the cases of 127 consecutive patients diagnosed with AC according to the TG13 between 2008 and 2015, and investigated the incidence of DIC severally in each severity of AC based on the TG13. We made the diagnoses of DIC according to the Japanese Association for Acute Medicine (JAAM) criteria.

Based on the TG13, the AC cases were classified into three groups, 55 mild cases, 51 moderate cases, and 21 severe cases, and the respective incidences of DIC were 1/55, 2/51, and 17/21. DIC was found to occur as a complication even in AC cases assessed as mild or moderate according to the TG13. Multivariate analysis identified only factor as being association with long hospitalization: severe cases. It was concluded that using the DIC diagnostic criteria (JAAM criteria) in addition to the severity criteria in the TG13 will allow identification of high risk AC patients and will improve the management of AC based on the TG13.

Aim: We investigate Endoscopic Hemostasis (EH) procedures for the beleeding related with Endoscopic Papillectomy (EP), and evaluate effective hemostasis for EP bleedings.

Methods: We investigated 13 bleedings among 24 patients underwent EP.

Results: Bleedings occurred in perioperative periods of EP with 9 pts, the next day with 3, and the day after next day with one. First EH procedures were performed with Clip retractions in 3 pts, Argon plasma coagulation (APC) in 2, Hypersaline-epinephrine-injection (HSE) in 2, and combination of two methods out of these three methods in 6. First EHs were succeeded in 9 pts, and re-bleedings after first EHs were occurred in 4. Acute pancreatitis after hemostasis were occurred in 5 pts, and 3 pts of 5 were performed HSE.

Conclusion: It is considerable that HSE and Clip had high hemostatic effect, on the other hand, APC was poor. HSE may have risk to cause pancreatitis.

In the management of gallbladder cancer, the assessment of the depth of tumor invasion remains one of the most important issues to solve. We hypothesized that assessment of irregular vessels on the gallbladder wall might be useful for detection of subserosal infiltration. This study aimed to evaluate the feasibility of laparoscopic narrow band imaging (NBI) for the intra-operative diagnosis in 10 patients with gallbladder carcinoma. Laparoscopic NBI detected at least one abnormal finding, such as vessel dilatation, tortuousness, interruption or heterogeneity in 7 patients, and these findings associated with the pathological diagnosis of subserosal infiltration and lymphatic invasion. On the contrary, 3 patients with no abnormal NBI finding showed mild or no subserosal infiltration and no lymphovascular invasion. Our study showed that laparoscopic NBI may be useful for the diagnosis of subserosal infiltration and lymphovascular invasion.

Endoscopic approach using conventional endoscopes for pancreatobiliary disease in patients with surgically altered gastrointestinal anatomy had been considered difficult. The percutaneous or surgical treatments were the first line policy. However, application of balloon assisted endoscopes (BAE) radically made it possible. Today numbers of studies have been reported. The recent multicenter prospective study reported; the success rate of reaching the blind end was 97.7%, the success rate of cholangiography imaging was 96.4%, the success rate of ERCP-related interventions was 97.9%, and the occurrence of adverse event was 10.6%, which proved the efficacy and the safety of the procedure.

Furthermore, ERCP for pancreatobiliary disease in patients with surgically altered gastrointestinal anatomy (except for Billroth I method) using BAE was granted additional points for the health insurance coverage by the revision of medical payment system in 2016. This therapeutic modality with BAE is widely accepted as the standard treatment policy for such patients, and an increasing demand is expected.

Pancreatobiliary endoscopy is often performed with fluoroscopy, which means it is like IVR that employs an endoscopy as a sheath. Peroral cholangioscopy (POCS) is one of the modalities which enable us to observe biliary tract lumen. Three techniques have ever been reported, which are single operator cholangioscopy (SOC), dual operator cholangioscopy (DOC), and direct cholangioscopy (DC). SOC and DOC employ a mother-baby style. DOC needs two operators and the scope has excellent view, but it is fragile and has unfavorable maneuverability. SOC can be performed with a disposable cholangioscopy under a single operator. The scope has a good maneuverability, but image quality is inferior to that of DOC. DC is usually performed with an ultraslim gastroscope. The scope has a larger CCD and channels than those of baby scopes. However, DC is an unstable technique and has a rare but severe complication such as air embolism. Technical innovation is necessary to advance development of POCS.

A woman in her 70s presented with epigastralgia, and preoperative studies pointed towards gallbladder cancer derived from pancreaticobiliary maljunction. We resected the primary tumor, and pathological examination revealed that it was a carcinosarcoma. A hepatic metastasis was detected 6 months after resection, and she was administered chemotherapy using tegafur-gimeracil-oteracil potassium and consequent gemcitabine. Though a singular hepatic metastasis had been observed, any other metastatic lesions did not appear for 10 months. Therefore, we resected the metastatic lesion. After resection, she was administered adjuvant chemotherapy using gemcitabine, and currently lives without recurrence. Carcinosarcoma of the gallbladder is associated with frequent recurrence and poor prognosis. A standard therapeutic strategy has not been established for cases with recurrence. The present case suggests that resection is an effective strategy for treating recurrence of carcinosarcoma of the gallbladder.

A 41-year-old man was hospitalized for abdominal pain and obstructive jaundice in 2002. He had undergone laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis in 1997. Endoscopic retrograde cholangiopancreatography showed a common bile duct stone (CBDS), and endoscopic sphincterotomy (EST) was attempted, with incomplete extraction of the stone. He refused further treatment and was discharged. The patient was hospitalized again for CBDS in 2004, which was confirmed on magnetic resonance cholangiopancreatography. As he intended to avoid EST, laparoscopic common bile duct exploration was performed. However, the remnant cystic duct was found to be dilated intra-operatively, so laparoscopic transcystic duct remnant and common bile duct exploration was selected. A cholangioscope was inserted into the common bile duct from the cystic duct remnant after intraoperative cholangiography, and the CBDS was extracted using a basket catheter. The postoperative course was uneventful and the patient was discharged on day 3 post-operatively. Laparoscopic transcystic duct remnant and common bile duct exploration is a viable treatment option for patients in whom endoscopic treatment of CBDS has been unsuccessful, particularly when its advantage of preserving papillary function is taken into account.

A 67-year old woman with a complaint of epigastric distress was referred to our hospital under the diagnosis of gall bladder cancer. Enhanced computed tomography revealed the marked swelling of gall bladder, a high density mass which extended from the neck of gall bladder to the liver, and mass lesion in middle bile duct which was suspected the skip lesion. ERCP was not revealed the stenosis or occlusion of bile duct and showed a pancreaticobiliary maljunction. The exfoliative cytodiagnosis diagnosed the squamous cell carcinoma. The patient was diagnosed as gall bladder cancer with a pancreaticobiliary maljunction. Therefore, gallbladder bed resection, extrahepatic bile duct resection and biliary reconstruction were performed. The histopathological examination revealed adenosquamous cell carcinoma of gall bladder (Stage IIA) and high grade adenocarcinoma of common bile duct (Stage I). Adenosquamous cell carcinoma of the gallbladder is believed to have a poor prognosis. It is thought that strict follow-up was required.

The case was a 79-year-old male who was examined at our hospital for the chief complaint of right hypochondrial pain. He was diagnosed with choledocholithiasis and gangrenous cholecystitis based on contrast CT findings. Treatment with PTGBD was selected as three days had passed since the onset and the patient had taken aspirin. Although the patient had a favorable hospital course, hemorrhagic drainage was observed in PTGBD on the 11th day. Based on contrast CT findings, the patient was diagnosed with gallbladder hemorrhage and cystic artery pseudoaneurysm. We performed emergency open cholecystectomy. Choledocholithotomy that was performed at the same time revealed numerous blood clots in the gallbladder and the formation of a hematoma and calculus in the common bile duct. A pathological diagnosis of pseudoaneurysm was made. The patient had a favorable postoperative course and was discharged on postoperative day 15. Gallbladder bleeding due to a cystic artery pseudoaneurysm is extremely rare and treatment strategies have not yet been established. Evaluation of the timing of surgery and the effectiveness of different procedures and treatments (embolization, biliary drainage, etc.) is required. This is a case of cholecystectomy we performed on a patient with gallbladder hemorrhage caused by the rupture of a pseudoaneurysm. Here, we report this case with a review of the relevant medical literature.

A 47-year-old woman underwent further examination of her dilated common bile duct, which was detected during medical checkup. Contrast-enhanced CT detected a weakly enhanced 10-mm gallbladder polyp. The apparent diffusion coefficient value on diffusion-weighted MRI for the polyp was 2.41×10^-3 mm²/sec. EUS revealed pancreaticobiliary maljunction and an 18-mm isoechogenic gallbladder polyp. On contrast-enhanced EUS, the polyp was heterogeneous at peak-time enhancement, and washout of the contrast agent was observed at about 130 seconds after administration. These findings are mostly consistent with a benign gallbladder polyp. The patient underwent a cholecystectomy combined with the extrahepatic bile duct resection. Histopathological examination revealed that the lesion was confirmed as a pyloric-type hyperplastic lesion.

71 year-old male admitted to hospital due to stomach pain, diarrhea and vomiting, and diagnosed as acalculous cholecystitis by image and blood examinations. Contrast CT revealed wall thickness of gallbladder (GB) with contrast-enhanced cystic duct, which was suspected as carcinoma of cystic duct. On 13^th hospital day, we performed cholecystectomy because GB was damaged during ERCP. Pathological diagnosis was eosinophilic cholecystitis without any malignant cell in GB wall and with eosinophilic infiltration in submucosa and muscularis propria. The patient suffered liver dysfunction with peripheral eosinophilia and perivascular dermatitis after surgery, which was cured with steroid administration.

Eosinophilic cholecystitis is a rare entity that presents with symptoms of normal acute cholecystitis. Its incidence is reported 0.84% of all acute cholecystitis. Although there have been some reported etiologies such as hypersensitivity to bile acid, local inflammation from gallstones, drug-induced reaction (e.g. herbal medicine) and parasite, definite causes are not elucidated. Here we reported a case of esosinophilic cholecystitis. Clinical course involved hepatobiliary dysfunction, marked peripheral eosinophilia and perivascular dermatitis with exclusive eosinophilic infiltration after cholecystectomy.

A 78-year-old man presented with right upper quadrant pain as a chief complaint and was found to have peritoneal irritation and an elevated blood amylase level. Abdominal contrast-enhanced computed tomography (CT) showed high-density adipose tissue around the head of the pancreas, edematous thickening of the gallbladder wall, and ascites localized to the surface of the liver. Acute gallstone pancreatitis with acute generalized peritonitis and perforation of the gallbladder were diagnosed, and an emergency laparotomy was performed. During surgery, a perforation was identified in the fundus of the gallbladder. Intraoperative cholangiography after cholecystectomy resulted in a diagnosis of class IIb pancreaticobiliary maljunction according to Komi's new classification. A translucency believed to represent a protein plug was also present in the common channel, and after this had been discharged to duodenum by a biliary-tube. C-tube drainage was also performed. Histopathological examination showed multiple Rokitanski-Aschoff sinuses (RASs) and perforation, but there were no signs of malignancy. The substance assumed to constitute a protein plug had become incarcerated in the common channel, causing acute pancreatitis and further resulting in increased internal pressures of the pancreatic duct and the bile duct. The increased internal pressure of the bile duct resulted in the perforation of the RASs in the fundus of the gallbladder, leading to gallbladder perforation.

The Japanese classification of the biliary tract cancers was revised as the 6th edition in November 2013. Since the necessity of having a commonality to the international cancer-staging, approximate definition of T factors and N factors were adopted. However, several parts of traditional uniqueness of Japanese classification were remained such as hepatoduodenal ligament invasion, ie, 'Binf' in gallbladder cancer, and depth of pancreatic invasion '5mm in length' in the category of T factor in ampullary cancer.

Lately, UICC classification has been revised as 8th edition in January 2017. In UICC 8th edition, T2 gallbladder cancer divided into two categories according to the tumor location, ie, tumor on the peritoneal side and on the hepatic side. Furthermore, UICC 8th edition adopted the depth of pancreatic invasion in ampullary cancer similar to Japanese classification. Concerning the classification of regional lymph node metastasis, the number of lymph node metastasis up to three was classified as N1, whereas 4 or more was classified as N2. As seen above, both classification have been revised influencing each other whereas containing some differences. Further revision of Japanese classification for appropriate clarification of cancer-staging will be required due to remarkable development of diagnostic and therapeutic modalities.