Although the utility of endoscopic biliary drainage for benign and malignant biliary stricture has been established, it was often difficult for hepaticojejunostomy cases with gastrointestinal reconstruction. In recent years, with the advent of balloon endoscope and endoscopic ultrasound-guided biliary drainage, endoscopic biliary drainage has also become possible in cases after hepaticojejunostomy, but sometimes we encounter difficult cases where treatment cannot be accomplished unless both procedures are used. Improvement of the safety and reliability is essential for the generalization of the techniques of endoscopic biliary drainage for patients after hepaticojejunostomy, and development of dedicated devices and further improvement of the endoscope are desired.

46 cholecystectomized cases assured as 'black' pigment gallstone by chemical analysis were studied for their determinants of stone formation. Adenomyomatosis (ADM) was accompanied in 32cases (69.9%). 30cases (94%) of them were segmental type of ADM. ADM is thought to be a major determinant for black stone formation. Some of another cases have a history of heart valve replacement, total gasterectomy, chronic hepatitis, duodenal stenosis, and IBS. Those factors have been already reported and discussed. In addition to them, this study showed that gallbladder polyp and a history of operation for appendicitis were identified as independent determinants. Appendectomy may be concerned through enterohepatic cycling. Black stones contained with calcium carbonate would have different factors from pure black stones and calcium phosphate-contained stones.

There are few available data on cholecystitis after Self-Expandable Metallic Stent (SEMS) placement in the patients with malignant distal biliary obstruction. This study evaluated the risk factors for cholecystitis. We analyzed 280 patients; 336 examinations who received endoscopic SEMS placement. Cholecystitis was found in 25 patients. Logistic regression analysis reevaled three independent risk factors for cholecystitis: covered type (p=0.014), tumor invasion to cystic duct (p=0.017), gallbladder stone (P-0.022). Three patients with severe cholecystitis were occurred after insertion of covered-SEMS in pancreatic cancer without tumor involvement of cystic duct. This study suggests that covered-SEMS was a risk factor of cholecystitis after SEMS placement, and that it is concern about the possibility of severe cholecystitis even if tumor does not involve cystic duct.

Endoscopic treatment for the patients with benign biliary stricture (BBS) has become an alternative to surgery or percutaneous transhepatic biliary drainage. Lots of papers reported the feasibility and the effectiveness of fully covered self-expandable metallic stents (FCSEMS). FCSEMS deployment is superior to multiple plastic stent deployment in the technical feasibility and the frequency of stent exchange. Treatment results such as resolution rate and re-stricture rate of BBS associated with chronic pancreatitis are not so good as postoperative BBS, and therefore, surgical approach is one of the therapeutic options. Patients with postoperative BBS have good prognoses once strictures are resolved. However, BBS after living donor liver transplantation is difficult to achieve technical success and stricture resolution. As a first endoscopic therapy, only balloon dilation without stent deployment should be employed for the patients with primary BBS associated with primary sclerosing cholangitis to avoid refractory cholangitis. The management for the patients which required long-term therapy and repeated procedures remains to be resolved.

Multidisciplinary therapy including biliary surgeon, gastroenterologists, interventional radiologists, endoscopists and other interprofessional team, is recommended for treatment of benign biliary stricture (BBS), especially surgical treatment have to be performed for intractable case of BBS that is not effective of repeat endoscopic or interventional radiological (IVR) treatment.

Exposure of healthy bile ducts without ischemia with a tension free repair is important for achieving optimal result in surgical treatment for BBS, therefore cases of hilar bile duct stricture such as Bismuth type III, IV and V might be performed hilar bile duct resection and cholangiojejunostomy with transhepatic approach. Even though some authors have reported good outcomes of endoscopic teqniques using with fully covered self-expandable metallic stent, surgical treatment is still necessary for refractory cases of BBS which resistant to endoscopic and IVR techniques.

The new macroscopic classification of gallstones was published by the gallstone classification committee of the Japanese society of gastroenterology on Nihon Shokakibyo Gakkai Zasshi in 1986. Since then the macroscopic classification have been widely spread in Japan, although it has actually several contradictory points. Now, recent paper reported the paper in which they verify the classification compared the stone kinds with the quantity of the components gallstones in JJBA 2017; 31: 205-213. The authors determined three components including cholesterol, calcium bilirubinate and black pigment in gallstone by infrared spectroscopy. They insisted that there is a lot of discrepancy between this classification and infrared analysis especially in black stones. Therefore, they had a negative view on this classification. However, we would like to point out two differences from our standpoint. First, they did not decide the kind of stones according to the rules of the committee. Second, they did not consider a few situations limiting the usefulness of infrared spectroscopic analysis. Particularly each component is unable to be measured quantitatively using infrared spectroscopic analysis. Therefore, the classification of gallstones in Japan (1986) should be re-conform and re-recognize even in 21 century.

A 66-year-old man was referred to our hospital following detection of a gallbladder tumor at another hospital. Contrast-enhanced computed tomography revealed a tumor in the gallbladder neck with a partially vague border at the right hepatic artery and hepatic parenchyma. The preoperative diagnosis was gallbladder neck cancer, and right hepatic lobectomy and caudate lobectomy were planned. However, there was serious concern of insufficient future remnant liver function. Left hepatic lobectomy including the gallbladder bed, caudate lobectomy, and resection and reconstruction of the right hepatic artery were performed. The operative duration was 1011 min and the amount of bleeding was 642mL. The patient recovered and was discharged 17 days after surgery. Pathological findings demonstrated well-differentiated adenocarcinoma of the gallbladder, pT3aN1M0 Stage IIIB. Follow-up visits up to two years and six months after surgery indicate no recurrence. This operative procedure has rarely been reported for gallbladder cancer, and may be an option when there is concern of insufficient future remnant liver volume.

We experienced a case of cystic duct carcinoma manifesting as hemobilia. A 77-year-old man visited our hospital because of upper abdominal pain. His hepatobiliary enzymes were elevated and a high density object in the choledochus and cystic duct was observed on plain CT; therefore, we diagnosed him with choledochus and cystic duct calculi. As he was taking two antithrombotic drugs, we placed a biliary stent during the first ERC. Upon re-examination after 5 days, no obvious calculi were found in the choledochus. However, as the cystic duct was not visualized, stones may have existed there. He was scheduled for surgery and discharged. The patient visited again with abdominal pain two months later. Plain CT revealed a high density substance in the choledochus, and we diagnosed hemobilia. On ERC, we saw bleeding from the biliary orifice and clots in the choledochus. A stained area in the cystic duct was observed on contrast enhanced CT. A diagnosis of adenocarcinoma was made by brushing cytology, and bile duct resection was performed. When patients undergoing antithrombotic therapy have liver dysfunction, we should consider the possibility of hemorrhage from hepatobiliary tumors.

A 63-year-old man was treated with endoscopic stone removal and plastic stenting for bile duct gallstones. Laparoscopic cholecystectomy was performed 5 days later. Five days after the cholecystectomy, he experienced onset of sudden epigastric pain. Abdominal contrast-enhanced computed tomography scan (CE-CT) showed an 8-mm diameter aneurysm of the right hepatic artery that had penetrated into the common hepatic bile duct. On the non-contrasted phase, we observed a high-density substance, suggestive of hemobilia. After the CE-CT, the patient suffered a cardiopulmonary arrest because of hemorrhagic shock. He was resuscitated, and we performed abdominal angiography and a transarterial coil embolization. The patient was discharged on the 96th day after the aneurysm rupture. A hepatic pseudoaneurysm was found near the distal end of the double-pigtail plastic stent, and we considered the stent to be the cause of the hepatic arterial pseudoaneurysm.

This is a case of pT2 (SS) gallbladder carcinoma extending into the Rokitansky-Aschoff sinus and invasive in part. The tumor showed regional difference in proliferation pattern. Pathologically, the tumor had a region with irregular tubular structure tumor cell proliferation pattern and a region with solid structure and dense tumor cell proliferation pattern. Preoperative Contrast-enhanced harmonic EUS showed two regions. One was a region that showed irregular vessel from the early phase and then the whole tumor showing strong enhancement. Another region showed thick tortuous irregular vessels in delay and then the whole tumor was enhanced heterogeneously. This case showed an interesting contrast-enhanced harmonic EUS image that suggests the existence of a different histologic component.

69-year-old woman was hospitalized for fever and right hypochondralgia. An abdominal enhanced CT revealed infected liver cyst in the right liver. US-guided percutaneous catheter drainage (PTAD) was performed to regulate infection and DIC condition. Infected liver cyst was suspected to communicate with biliary tract of anterior branch, and ERCP was performed to confirm whether a communication with biliary tract exists. After confirmation, EBD tube was inserted to eliminate the communication. Both PTAD and EBD could regulate infection and DIC condition. She was discharged having insertion of both tubes. In outpatient, the tubes were exchanged to be placed in an appropriate position. Finally, both tubes were removed and she has been free from symptom for 6 months. An appropriate drainage of both external and endoscopic internal ways may be required to treat for an infected liver cyst communicated with biliary tract.

A 65-year-old male was treated for gallbladder cancer in September 2014 by gallbladder bed resection and duct-sparing lymphadenectomy, but was readmitted in December 2015 diagnosed with obstructive jaundice and cholangitis. CT imaging showed stenosis of the common bile duct at the cystic duct junction and intrahepatic biliary dilatation, as well as two enlarged lymph nodes approximately 1cm in diameter near the hepatectomy site. After ENBD placement, bile cytology revealed moderately differentiated adenocarcinoma. For radical resection of the recurrent lesions we scheduled right hepatectomy and extrahepatic bile duct resection. We increased residual liver volume to 49.8% preoperatively by portal vein embolization, and performed right hepatectomy, extrahepatic bile duct resection, and combined portal vein resection. Postoperative clinical histology showed localized cancer recurrence, and we suspected recurrence via the cystic plexus. Adjuvant combination chemotherapy with GS was performed for one year, and the patient has survived recurrence-free for two years since surgery. Although the significance of the resection of the localized lesions remains unclear, we believe that if the kind of radical resection in this case can be performed safely, duct stenosis will also resolve, and this is an effective therapeutic method.

A 69-year-old female was noted to have liver dysfunction. Imaging examinations showed tumor occupied in the gallbladder and the bile duct and suggested mobility of the tumor in the bile duct. Intraoperative findings were compatible with tumor thrombus in the distal bile duct. Longitudinal incision was put on the common bile duct due to remove a part of the tumor. She has anomalous insertion of cystic duct into the right hepatic duct. We confirmed that proper incisional line of right hepatic duct was located at the extrahepatic region. Final surgical procedure was cholecystectomy with partial liver resection and resection of the extrahepatic bile duct. Histopathologically, papillary adenocarcinoma of the gallbladder developed through an anomalous insertion of cystic duct to the right hepatic duct and grew expansively in the distal bile duct. Her pathological TNM stage was Stage I. She is alive with no recurrence after the surgery for 5 years.

In a resection of congenital biliary dilatation, total excision of the intrapancreatic bile duct is mandatory to eliminate the origin of cancer. However, it should be difficult under the conventional laparoscopic view from the ventral side because the intrapancreatic bile duct is located behind the pancreatic parenchyma and interference between the surgical instruments and the parenchyma is inevitable. For such hepatopancreatobiliary surgery with the high degree of difficulty, we have developed a novel strategy of the retroperitoneal-first laparoscopic approach (Retlap), and applied the case of the congenital biliary dilatation with Todani type Ic. Mobilization of the pancreatic head with Retlap facilitated dissection around the intrapancreatic bile duct in an excellent view from the dorsal side avoiding interference between the instruments and pancreatic parenchyma. Furthermore, CO2 insufflation pressure supported to obtain a good and stable operative field without special assistance. Although improved methods for precise intraoperative identification of the maljunction is required, Retlap should become the standard technique for congenital biliary dilatation.