Objectives: Factors that contribute to difficult laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) were identified to maintain the safety of operation.

Methods: Seventy-five patients who underwent LC for AC in our hospital were retrospectively analyzed. The operation time, bleeding, and cases of difficult laparoscopic surgery (CDLS)/conversion rate were analyzed as an index of difficulty.

Results: Older age, ASA classification, CT diagnosis of necrotizing cholecystitis, WBC count, CRP level, cholecystitis severity, PTGBD were associated with surgical difficulty. Moreover, older age, ASA classification, CRP level and CT diagnosis of necrotizing cholecystitis were associated with the CDLS/conversion rate among these items.

Conclusion: We identified factors associated with surgical difficulty in delayed surgery. When these risk factors are identified beforehand, surgeons should keep in mind for conversion according to circumstances to maintain the safety of operation.

Recently, endoscopic radiofrequency ablation (RFA) for biliary stricture has been reported. In 2017, an endoscopic RFA catheter, Habib™ EndoHPD (Habib) (EMcision Ltd, London, UK) became commercially available in Japan. The aim of this study was to evaluate short-term outcome of endoscopic RFA using Habib on unresectable cholangiocarcinoma. Six patients who had unresectable cholangiocarcinoma underwent endoscopic RFA between August 2017 and July 2018 in Sendai City Medical Center. Endoscopic RFA was successful in all patients. Although post-ERCP pancreatitis occurred after procedure in one patient, it rapidly improved with conservative treatment. During follow-up (mean duration, 125 days), recurrent biliary obstruction (RBO) occurred in 2 patients. Mean time to RBO was 224 days. Mean survival time was 225 days. In conclusion, endoscopic RFA using Habib on unresectable cholangiocarcinoma could be easily and safely performed. However, long-term studies are needed to assess the time to RBO and survival time after endoscopic RFA.

We investigated the problems and issues associated with the treatment guidelines for pancreaticobiliary maljunction and congenital biliary dilatation. Discriminating congenital biliary dilatation from non-dilated maljunctions can be challenging. Therefore, rather than discriminating between such cases, we should consider classifying them as "pancreaticobiliary maljunction disease.". Classifying the condition as "localized dilatation of the extrahepatic bile duct including the common bile duct or origin of the cystic duct" might reduce confusion. While "performing resection up to close to the junction leaving as little of the intrapancreatic bile duct as possible" is recommended for treatment, "as little of the intrapancreatic bile duct as possible" could be misinterpreted as "a small amount may be left; " therefore, we suggest deleting this phrase. Moreover, in terms of the surgical technique, we would like the resection range to be clearly stated as follows: "complete resection of the intrapancreatic and extrahepatic bile duct, including resection of the bile duct stenosis in the hepatic portal region combined with biliary tract reconstruction."

EUS-guided biliary drainage has been developed as an alternative method for failed ERCP. EUS-BD can be divided into two main approach routes, such as transgastric or transduodenal approach. Also, EUS-guidedhepaticogastrostomy, choledochoduodenostomy, and gallbladder drainage have been reported. In this review, we described technical tips for each basic technique, including literature review. As advanced technique of EUS-BD, antegrade stone removal has been reported. More recently, electrohydraulic lithotripsy for bile duct stones under transluminal cholangioscopy guidance, hepaticojejunostomy stricture dilation through EUS-HGS route, or EUS-guided gastrojejunostomy have been reported. Although EUS-BD has various potential as treatment technique, treatment method should be selected for each patient's conditions.

An 81-year-old man with primary sclerosing cholangitis underwent PTBD because of intractable biliary stenosis. After PTBD, he developed a fever and his blood culture was positive. CT showed a pulmonary artery embolus and nodules with cavities in the peripheral lung area (feeding vessel sign). He was diagnosed with septic pulmonary embolism (SPE). CT also showed the PTBD tube contacted with the hepatic vein and there was a septic thrombus extending from that area. Venous bleeding was found on exchange of the PTBD tube, which was stopped with compression by the tube.

From these findings, we believe the SPE was an indirect result of an injury to the hepatic vein during PTBD which caused a biliary vascular fistula leading to a migration of a septic thrombus from the hepatic vein to the inferior vena cava.

SPE should be suspected if CT shows a feeding vessel sign after PTBD. SPE can be produced even with peripheral hepatic vein trauma. SPE due to PTBD is a rare but important complication after PTBD.

We describe the case of a 71-year-old woman with neurofibromatosis type-1 (NF1) diagnosed with a neuroendocrine tumor (NET) of the ampulla of Vater and a gastrointestinal stromal tumor (GIST) of the duodenum. The patient was admitted to our hospital and presented with multiple cutaneous neurofibromas and café-au-lait spots on the face and body. Esophagogastroduodenoscopy revealed an exposed protruding tumor of the Vater and a submucosal tumor in the descending part of the duodenum. CT showed both tumors, but somatostatin receptor scintigraphy visualized no tumor in the duodenum. The patient was diagnosed with NET of the Vater and GIST of the duodenum based on histopathological examination of biopsy specimens, and subsequently underwent subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection. Histopathological examination after the procedure confirmed NET (G1) of the Vater with lymph node metastases and GIST of the duodenum.

A 71-year-old female was referred for further examination of a gallbladder tumor. Blood test revealed elevated levels of γ-GT, AFP and AFP-L3%. Contrast-enhanced computed tomography revealed an enhanced irregular wall thickening lesion in the fundus and body of the gallbladder. Although histological diagnosis was not obtained, we strongly suspected gallbladder cancer based on the imaging findings. Cholecystectomy and hepatic S4a+S5 resection, bile duct resection, regional lymphadenectomy were performed. A 70×50×45-mm massive type tumor was located at fundus and body of the gallbladder. Histologically, the tumor was composed of hepatoid cell and adenocarcinoma. Hepatoid cells were stained for AFP, hepatocyte parafine-1, Arginases. Pathological diagnosis was hepatoid adenocarcinoma (HAC) of the gallbladder. We have present a rare case of HAC of the gallbladder with review of literature.

A 67-year-old man underwent endoscopic papillectomy for ampullary adenoma. The histological findings revealed a tubular adenoma. Endoscopic re-resection and transduodenal resection were performed because the local recurrence of adenoma. Three years later, the patient developed acute pancreatitis, and recurrence in the pancreatic duct was suspected. EUS revealed a low echoic mass in the pancreatic duct, and the pathological findings revealed an adenoma of biopsies from the orifice and pancreatic duct. We diagnosed the recurrence of ampullary adenoma and intraductal extension, and the patient underwent subtotal stomach-preserving pancreaticoduodenectomy. The pathological findings of the resected specimen revealed growth of adenoma in the main pancreatic duct and adenocarcinoma with invasion into the pancreatic parenchyma and duodenal wall. For cases suspected of repeated recurrence after local resection for ampullary adenoma, early pancreaticoduodenectomy should be considered.

The patient was an 88-year-old male who had undergone EST and cholecystectomy for CBD and GB stones at the age of 84. He was admitted to our hospital with a diagnosis of cholangitis at the age of 87. CT and ERCP examination demonstrated a large stone in the CBD. Although we tried to remove the CBD stone endoscopically, it was impossible to eliminate the stone completely. He was discharged with biliary plastic stent (PS) in place. One year later, he was readmitted for the treatment of cholangitis. The PS was still in place, and multiple calculi were observed from the liver side to duodenal side of CBD by ERCP examination. It was impossible to remove the biliary PS endoscopically over three times. We had a policy of surgical removal of the PS because cholangitis was not improved. We changed the surgical procedure during the operation from choledochal lithotomy to transduodenal papilloplasty because of the intense adhesion around bile duct. A stent-stone complex was observed on the liver side of the removed biliary PS, making endoscopic stent removal difficult.

Case 1: A 66-years-old woman was hospitalized with melena during chemotherapy for pancreatic cancer. Although hemobilia was suspected with CT, it was not confirmed by ERCP. When she vomited blood on the 8th day, CT demonstrated pancreaticoduodenal artery aneurysm accompanied by biliary extravasation, which was considered as the cause of the hemobilia. Successful hemostasis was obtained with transarterial embolization (TAE). Case 2: A 67-years-old man was hospitalized with cholecystitis. He had been curatively treated with proton beam therapy for hepatocellular carcinoma with portal vein tumor thrombus. Although PTGBD was performed on the day of hospitalization, the bile turned bloody color the next day. A rupture of right hepatic artery aneurysm was confirmed with CT. Because TAE was difficult for the extensive portal vein thrombus, a coronary stent was placed and hemostasis was obtained.

Hemobilia is the complication that should be taken into consideration, along with progress and diversification of treatments for hepatobiliary pancreatic diseases.

There are two types of EUS: Radial and Convex scan type, and either one can be used to perform the screening of the biliary system. However, the method of drawing the biliary tract differs in each echoendoscope, and there are also differences in the structure of the obtained images. In Radial scanning, it is possible to observe the bile duct in the long axis direction from the vicinity of the ampulla to so-called the superior bile duct, but in many cases, the hilar region cannot be observed sufficiently. On the other hand, in Convex scan type, the long axis observation of the bile duct is inferior to Radial scan type, but detailed observation of the hilar region can be performed. In addition, EUS-guide fine-needle aspiration biopsy for biliary disease is also performed with high diagnostic ability. By firmly understanding the advantages/weaknesses of each EUS model and performing biliary observation in accordance with the basic scanning method, accuracy of EUS diagnosis will certainly improve.