The idea whether "I should think about the outbreak of a tumor, the disease in an epithelium of the whole organ" from the report of the autopsy example that a cancer coincided to the experience of the case that lower part cholangiocarcinoma generated 11 years after a hepatic portal region cholangiocarcinoma operation and gallbladder, lower part bile duct is realistic enough. In other words, you should think about "biliary tract running through the liver and gall pancreas" about the patient of the biliary tract disease. I remove only main tumor of the central part cholangiocarcinoma surgically, and there may be the operation adaptation to anastomose bile duct and jejunum. I wrote down frequency of gallbladder IPNB, Nomenclature (taxonomic glossology) of IPNB. In addition, I wrote down relations of importance of the dissection of the hepatoduodenal ligament, gallbladder cancer and cholelithiasis, an art of the surgery excision for the benign tumor of the papilla of Vater, the main point of the pancreaticooduodenectomy art.

Current image diagnosis and surgical treatment for gallbladder cancer was reviewed, especially as to early-stage cancer, the mode of hepatic spread, and the extent of lymphadenectomy. It is necessary to understand the concept and the morphological features of early gallbladder cancer in the management of this disease entity. Simple cholecystectomy is appropriate treatment for early gallbladder cancer only if tumor is absent at the margin of the cystic duct. In the preoperative diagnosis and staging of gallbladder cancer, it is important to understand the usefulness and limitations of various imaging modalities. Direct liver invasion and portal tract invasion are the main modes of hepatic spread from resectable gallbladder cancer and portal tract invasion mainly results from lymphatic spread within the portal tracts. Hepatectomy margin should be decided to remove the main tumor and its adjacent microscopic portal tract invasion when performing radical resection for gallbladder cancer. Rational extent of lymphadenectomy for gallbladder cancer should include regional lymph nodes including No. 13a nodes defined by the 6th edition of the Japanese TNM classification.

Evidence-based clinical practice guidelines for cholelithiasis 2016 was published by the Japanese Society of Gastroenterology, and TG13: Updated Tokyo guidelines for Management of Acute Cholangitis and Acute Cholecystitis was published in Journal of Hepato-Biliary-Pancreatic Sciences, are very useful for treatment of cholelithiasis. Based on their guidelines, we will explain some important points in surgical treatment of cholelithiasis.

When the patient with cholecystolithiasis undergo laparoscopic cholecystectomy, 1) check the biliary anatomy before the surgery, 2) to confirm the critical view of safety, 3) to consider the timing of convert to open surgery or subtotal cholecystectomy in severe inflammation, are important. To learn well the skill of laparoscopic or open choledocholithotomy are necessary for biliary surgeon. Take care of the occurrence of biliary malignancy and the recurrence of gallstone over the long term for follow-up of the patients with hepatolithiasis.

Because cholelithiasis causes acute cholecystitis or cholangitis, it is important to develop a strategy considering concomitant inflammation status.

The causes of benign biliary stricture (BBS) include chronic pancreatitis, surgical injury, Mirizzi syndrome, IgG4-related sclerosing cholangitis, and primary sclerosing cholangitis. Endoscopic treatment, medication such as steroid, or surgical treatment is performed according to the etiology of BBS. As for endoscopic treatment, dilation of a biliary stricture using a balloon/bougie catheter followed by biliary stenting is a standard technique. Placement of multiple plastic stents, 10Fr in diameter, side by side for up to 12 months has become the current standard care for the majority of BBS. Recent studies have demonstrated that placement of a fully covered metal stent has similar success rate to multiple plastic stent therapy, with fewer procedures. The developments of balloon enteroscopy and interventional EUS contribute to widespread of endoscopic treatment for BBS. Surgical treatment should be considered for difficult or refractory cases of endoscopic therapy.

Recently, ERCP and EUS associated procedures are widely used for the management of biliary disorders. ERCP is useful for detection of lesions and ERCP-guided brush cytology and/or transpapillary forceps biopsy are widely applied to provide cytohistologic diagnosis. High resolution endoscopic evaluation and cholangioscopic-guided target biopsy will improve the diagnostic capability for indeterminate intraductal lesions. Endoscopic management of common bile duct stones and biliary drainage are accepted as a first line treatment because of the increasing needs for minimal invasive procesures. Endoscopic snare papillectomy in selected patients is a useful technique as an alternative to surgery. Currently, EUS has important diagnostic and therapeutic roles in the field of biliary disorders. EUS-FNA and EUS-BD is being used in cased of failed ERCP associated procedures. ERCP and EUS associated procedures are much less invasive. However, procedure-related complications occur occationary. It is necessary to be aware of the fundamental knowledge and techniques of these procedures in order to avoid unexpected results.

In recent years, in order to noninvasive treatment methods, endoscopic treatment for primary and recurrent choledocholithiasis are becoming popular. This study evaluated short and long term outcomes of end-to-side choledochoduodenostomy for primary and recurrent choledocholithiasis. Thirty patients (18 men) with primary and recurrent choledocholithiasis who underwent end-to-side choledochoduodenostomy between 2002 and 2013 were examined retrospectively at our center and associated hospitals. Short and long term outcomes were analysed for these patients. Average postoperative hospital days were 16.3 days and short term complications were 20% of wound infection, 3.3% of each liver disorder, depression, and delirium. Mortality was 0% of these patients and morbidity was 23.3%. After operation, average follow-up period was 54.9 months. Long term complications were 13.3% of cholangitis, 3.3% of each liver abscess and liver disorder, however we had been no recurrent lithiasis. The end-to-side choledochoduodenostomy for primary and recurrent choledocholithiasis was feasible.

We have studied 6 cases of gallbladder torsion to clarify the clinical features of this disease. The characteristic findings in ultrasound and CT images associated with gallbladder torsion, such as deviation of the gallbladder axis and constriction of the gallbladder neck, were found in all 6 of our cases. Gallbladder torsion is strongly doubted when these findings are observed. Moreover, if indirect findings, such as reduced blood flow in the gallbladder wall or a blocked cystic artery, are found, gallbladder torsion is verified. Therefore, we think that enhanced CT should be performed for diagnosis of gallbladder torsion when possible. On the other hand, abdominal physical findings did not necessarily accompanied with pathological findings. Importantly, the serum CRP levels were related with the presence of necrosis of the gallbladder wall, and this finding was thought to be significant to show the clinical condition of gallbladder torsion.

Surgical resection that leaves no residual tumor (R0 resection) offers the best chance for cure in patients with gallbladder cancer. The tumor may easily infiltrate various adjacent organs due to its anatomical location and malignant tumor biology and thus, the scope of the radical resection for gallbladder cancer should be tailored based on the extent of tumor spread in individual patients to achieve R0 resection. An aggressive surgical approach (major hepatectomy and/or pancreaticoduodenectomy) to gallbladder cancer has been advocated to improve treatment outcomes for this disease mainly in Japan and now indications and limitations for these procedures have been delineated. As for surgical procedures for pT2 gallbladder cancer, there is no evident consensus on the extent of resection such as hepatectomy, lymphadenectomy, and bile duct resection. Recent studies have reported new findings regarding the surgical treatment for incidental gallbladder cancer. Here, we clarify current surgical treatment for gallbladder cancer and consider the optimal extent of resection for this disease based on the tumor spread.

The indication for radiotherapy is unresectable non-metastatic locally advanced biliary tract cancer. Recently, stereotactic radiotherapy and intensity modulated radiotherapy is improving survival periods for this disease compared to conventional external beam radiotherapy with combination of intraluminal radiotherapy. Additionally, particle radiotherapy using proton or carbon-ion beam with precipitous dose distribution is expected to be favorable treatment option. The median survival time and 5-year overall survival rate of our study for 41 patients with unresectable non-metastatic hilar cholangiocarcinoma was 23 months and 29%, respectively. These treatment modalities may become increasingly common options as adjuvant for resection, and radical or palliative treatment to biliary duct cancer with some issues such as concurrent chemotherapy, biliary stent, radiation damages, and methods for response evaluation.

Obstructive jaundice caused by limy bile is a rare biliary disease. All three patients presented with epigastric pain, and were diagnosed easily based on abdominal CT findings showing the calcified material with niveau in common bile duct (CBD). Cholangiography revealed both cystic duct and gallbladder were contrasted in all cases. Two of them had a CBD stone. To remove limy bile and stone from the CBD, endoscopic papillary dilatation were performed in two cases and endoscopic sphincterotomy was done in another case. Laparoscopic cholecystectomy was performed after the endoscopic treatment successfully. The histopathological examination of gallbladder demonstrated chronic cholecystitis. Their clinical course have been uneventful. We reported three cases with obstructive jaundice caused by limy bile and reviewed the past reported 37 cases in Japan.

An 81-year-old woman, who was treated with nivolumab monotherapy, was referred to our department because of high levels of biliary tract enzymes, detected on performing a blood test. Computed tomography and endoscopic ultrasound showed diffuse wall thickening of the bile duct and gallbladder. Endoscopic retrograde cholangiography revealed extrahepatic bile duct dilation without obstruction. Nivolumab-induced cholangitis was diagnosed and she received steroid therapy. After steroid therapy, both the levels of biliary tract enzymes in blood and the diffuse wall thickening of the bile duct and gallbladder decreased.

A 52-year-old woman was admitted with a complaint of right hypochondralgia. Laboratory results showed increased white blood cell counts and biliary enzymes. CT and MRCP showed swollen gallbladder and dilated intrahepatic bile duct of hepatic segment 5. A diagnosis of acute cholecystitis was thus made, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. Cholecystocholangiography using the PTGBD tube revealed dilation of the aberrant bile duct with complete U-shape occlusion.

These findings led to a diagnosis of cholecysto-cholangitis due to the obstruction. The patient underwent cholecystectomy with resection of the aberrant bile duct, extrahepatic common bile duct resection and choledochojejunostomy.

Histopathologically, the obstructive bile duct remained into slit form, in the inflammatory granulation and no malignant findings were observed in that area.

These anomalies of the biliary tract which had arisen from the cystic duct to the right hepatic duct are rare.

It is important to perform the procedure with proper recognition of these bile duct anomalies to prevent intraoperative injury.

The patient was a 50-year-old female. Enhanced CT examination revealed an irregularity of the gallbladder wall. Abdominal US screening showed a thickening of the inner hypoechoic layer of about 3mm and low protuberances in some areas of the gallbladder. EUS confirmed the absence of any irregularity or disappearance of the outer strong echo band of the gallbladder, and findings of anomalies whereby the pancreatic duct joined the bile duct outside the proper muscular layer of the duodenum.

Based on the images, we diagnosed gallbladder hyperplasia complicated by pancreatobiliary maljunction. We performed laparoscopic cholecystectomy. Macroscopic images of the gallbladder showed granular mucosa and a lesion with papillary protrusion. The histopathological image showed hyperplasia dominating, and partial biliary intraepithelial neoplasia (BillN)-1. We were able to provide treatment in the early stage of gallbladder hyperplasia including BillN-1. This case proved important in the context of the carcinogenic process in the gallbladder complicated by pancreatobiliary maljunction.

A 70-year-old woman was referred to our hospital for evaluation of biliary stricture. The Magnetic Resonance cholangiopancreatography (MRCP) and the computed tomography (CT) showed extensive stricture from the perihiar to intrahepatic bile ducts. Transpapillary biliary forceps biopsy failed to confirm malignancy. Left hepatic trisectionectomy with bile duct resection were performed under diagnosis of Bismuth type IV perihilar cholangiocarcinoma. Pathologically, granulomas with caseous necrosis was found in the stenotic bile duct, leading the probable diagnosis of tuberculosis. Biliary tuberculoma, a rare disease, is difficult to diagnose accurately. Biliary tubeculosis should be recognized as a potential discriminatory disease for benign biliary stricture, because anti-tuberculosis therapy improves the associated stenosis,

Acute cholangitis (AC) is a disease in which acute inflammation of the biliary tract develops, and early diagnosis, appropriate severity assessment and adequate treatment of are necessary. The Tokyo Guidelines 2013 (TG13) provide a consistent basis for the management of AC. AC is diagnosed when cholestasis and inflammation based on clinical signs or blood tests together with biliary tract manifestations based on diagnostic imaging findings are present. According to TG13, when organ failure is present the severity of AC is classified as grade III. When any two of five predictors are present AC is will classify as Grade II. All others cases are classified as Grade I. Since even some mild case of AC progress to severe cases during their course, repeated severity grading is necessary. Procalcitonin has been reported to be a useful biomarker to predict grade III AC. Based on the Japanese Association for Acute Medicine criteria, disseminated intravascular coagulation (DIC) has been found to occur as a complication even in AC cases assessed as Grade I or Grade II.