Ampullary Carcinomas (AC) are relatively rare tumors, comparing to other carcinoma of periampullary region and the literature about AC is limited. We retrospectively analyzed prognostic factors and risk factors of recurrence on 43 cases of resected AC from April 1998 to December 2014 in our department. The results indicated that mod/por on histological grade was independent poor prognostic factor and mod/por on histological grade, lymph node metastasis counts and preoperative biliary drainage were independent risk factors of recurrence. Their results might suggest that we need to perform adjuvant therapy for the cases which have risk factors of recurrence.

The aim is in this study to evaluate the clinicopathological characteristics, surgical procedures, and the long-term outcome of patients with incidental gallbladder carcinoma (IGBC). We performed a retrospective cohort study of 11 IGBC and 26 non-IGBC (NIGBC) patients who underwent curative resection from 2004 to 2014. Most IGBC was located at the neck of the gallbladder and was a flat invasive tumor type. The proportion of IGBC patients who underwent bile duct resection was significantly higher than that of NIGBC patients. All 4 IGBC patients with flat invasive type tumors located at the neck received bile duct resection due to involvement of the cystic duct. The 5-year recurrence-free survival rates of patients in the NIGBC and IGBC groups were 45.8 and 81.8%, respectively (p=0.045). Most importantly, the IGBC patients receiving radical cholecystectomy with bile duct resection had a good prognosis. Because IGBC was more likely to be flat invasive type located at the neck of the gallbladder, surgeons should perform the best surgical management, including bile duct resection, considering the possibility of involvement of the cystic duct margins.

As patients with biliary cancer often present obstructive jaundice, preoperative biliary drainage is essential in patients who are to undergo hepatectomy. After biliary drainage, surveillance bile culture is mandatory for selecting appropriate antibiotics. Bile replacement and use of synbiotics are important to maintain intestinal integrity, and pre-rehabilitation are also recommended to prevent sarcopenia, leading to reduce postoperative infectious complications.

Hepatectomy with extrahepatic bile duct resection is complicated and highly invasive. In addition, this procedure is categorized as contaminated surgery, due to intraoperative bile (colonized / infected in many cases) spillage. Based on the results of preoperative bile culture, therefore, antimicrobial prophylaxis should be selected. Recently, one randomized controlled trial clearly demonstrated that two-day administration of antibiotics is enough even in complicated major hepatectomy for biliary cancer. After hepatectomy, early enteral feeding with synbiotics and rehabilitation are also imoportant under the concept of enhanced recovery after surgery (ERAS).

Recently, three randomized controlled trials of adjuvant chemotherapy in patients with biliary tract cancer were presented (PRODIGE12-ACCORD18, BCAT, BILCAP). Unfortunately, these studies failed to show the survival benefit in intent-to-treat analysis. Although the BILAP trial demonstrated a longer survival time in the capecitabine group compared with the observation group in per-protocol analysis, this result could not change the statements of the NCCN guidelines. The benefit of adjuvant (chemo-) radiotherapy for biliary tract cancer remains controversial, too. Due to the lack of randomized trials, available data comes from single center experiences or data-based population studies with inconclusive result. Therefore, to assess the impact of adjuvant (chemo-) radiotherapy, further clinical trials should instead focus on patients with high-risk features.

A 60s male was referred for the further examination of a gallbladder tumor. He underwent left nephrectomy for renal cell carcinoma a year before. Contrast-enhanced computed tomography and endoscopic ultrasonography revealed an enhanced elevated lesion in the fundus of the gallbladder. Laparoscopic cholecystectomy was performed, and the pathological diagnosis was metastatic renal cell carcinoma of the gallbladder.

Metastatic carcinomas of the gallbladder are rare. The most common primary tumor metastasized to the gallbladder was renal cell carcinoma, followed by malignant melanoma, and gastric cancer/breast cancer. Metastatic lesions of renal cell carcinoma and malignant melanoma in the gallbladder often present elevated lesion, whereas those of the gastric and breast cancer often present wall thickening. The morphology of metastatic gallbladder tumors might depend on the primary site of the tumor.

Patients with an early gallbladder carcinoma, confined to mucosa or muscle layer, are candidates for a laparoscopic cholecystectomy because they seldom have lymph node involvements. Hence, a differential diagnosis of gallbladder tumors is essential with invasion depth of carcinoma. A symptomless 64-year-old man was referred to the hospital with a growing gallbladder tumor, showing no elevation of serum carcinoembryonic antigen or carbohydrate antigen 19-9. Ultrasound showed a heterogeneous hyperechoic gallbladder tumor, 3cm in diameter, with microcysts plus comet-like echoes and thickened outermost hyperechoic layer beneath the lesion without a deep hypoechoic area. Precontrast abdominal CT depicted the lesion, diffusion weighted imaging of MR revealed its decreased diffusion and endoscopic ultrasound showed an anomalous arrangement of the pancreatobiliary ducts. An early gallbladder carcinoma was suspected from the ultrasound findings. Laparoscopic cholecystectomy with liver bed fatty tissue extirpation was then performed. Macroscopically, an elevated lesion, 32×29mm in size, was evident in the resected gallbladder. Histologically, a tubular adenocarcinoma (tub1-tub2) confined to muscle layer was demonstrated. The subserosal adipose layer beneath the lesion was thickened and free from carcinoma consistent with the ultrasound image. A T1b gallbladder carcinoma could show a thickened outermost hyperechoic layer.

An 70-year-old man was admitted to our hospital with acute pancreatitis. At that time, the CT showed a mass lesion from the gallbladder to the liver and enlarged lymph nodes from the para-aortic to hepatoduodenal ligament. He underwent EUS-FNA for those lesions. The pathological diagnosis was signet ring cell carcinoma and metastasis to lymph nodes. As the gemcitabine+cisplatin chemotherapy were not worked, the S-1 monotherapy were added but they were not succeed. He died for 8 months from the first contact. The case of gallbladder signet ring cell carcinoma is rare and EUS-FNA was useful for diagnosis in this case.

Endoscopic ultrasound-guided gastrointestinal drainage is commonly performed for a reservoir of infection in the body cavity caused by pancreatitis, while percutaneous drainage and drainage by laparotomy are still common for causes other than pancreatitis. However, in recent years, endoscopic ultrasound-guided drainage has been performed for various reservoirs of infection. We present a case of successful endoscopic ultrasound-guided drainage for intra-abdominal abscess that developed following cholecystectomy. The patient was a 65-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis. He developed abdominal pain and fever following the procedure, and a computed tomography scan revealed the presence of an abscess in the location corresponding to the location of cholecystectomy. The route for percutaneous drainage was inaccessible; thus, endoscopic ultrasound-guided drainage was performed. Access was achieved from the duodenal bulb, and a tube stent was inserted into the abscess for internal drainage. Inflammation resolved rapidly, and the abscess was reduced in size and eventually disappeared. There has not been any recurrence of the abscess since the procedure was performed. Thus, endoscopic ultrasound-guided drainage of an abscess is a minimally-invasive procedure, and can be performed effectively and safely in patients.

A 59-year-old man was admitted for jaundice. Right hepatectomy was performed for perihilar cholangiocarcinoma. His serum CA 19-9 levels had gradually risen over the 2 years after the hepatectomy. PET-CT scan showed abnormal accumulation of fluorodeoxyglucose in the papilla of Vater, and endoscopy revealed enlargement and ulceration at this site. This lesion was diagnosed as adenocarcinoma on biopsy. The imaging findings indicated no recurrence of perihilar cholangiocarcinoma. We performed subtotal stomach-preserving pancreatoduodenectomy for the diagnosis of metachronous ampullary cancer. The patient is doing well at 5 years and 3 months after his first surgery, with no recurrence. Although it is rare to perform surgery for metachronous biliary cancer that develops after hepatectomy for perihilar cholangiocarcinoma, it is important to examine surgical indications to determine whether a curative operation may be possible.

A 38-year-old man who has family histories of stomach cancers and esophageal cancer was referred to our hospital because of suspicion of cholangiocarcinoma. We performed biopsies of bile duct many times, but no malignant neoplasms was seen. On the other hand, ulcerative colitis (UC) was revealed in colonoscopy and adenocarcinoma was detected by biopsy from 0-Is polyp in rectum. We performed laparoscopy-assisted proctocolectomy taking priority over performing pancreaticoduodenectomy. One month later, adenocarcinoma was detected by biopsy from bile duct, and we performed pancreaticoduodenectomy.

We report a very rare case in Japan of juvenile UC accompanied by rectal cancer and distal cholangiocarcinoma without PSC.

So-called carcinosarcoma is rare as a carcinoma of extrahepatic bile duct. Herein, we reported a case of sarcomatoid carcinoma with a specific appearance of peroral cholangioscopy (POCS). 66-year-old man was admitted to our hospital with obstructive jaundice. Laboratory findings demonstrated mild hyperbilirubinemia and liver dysfunction. CT imaging showed that the tumor was slightly enhanced in the distal common bile duct just above a major papilla. POCS disclosed that the tumor had a subpedunculated shape and elevated steeply on the villous mucosa just at the site on the CT imaging. Biopsy confirmed that histology of the tumor was a poorly differented cholanagioadenocarcinoma. Pancreatoduodenectomy was performed successfully. On microscopic examination after surgery, the tumor was poorly differented adenocarcinoma containing a component of sarcoma-like differentiation. Both of carcinoma component and sarcomatoid component were positive for Vimentin and CAM5.2. Final diagnosis was a sarcomatoid carcinoma.