Endoscopic ultrasound/ultrasonography-guided biliary drainage (EUS-BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS-BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS-BD as well as safe introduction of the procedure to non-expert centers. The guidelines comprised patient-intervention-comparison-outcome-formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS-BD and its introduction to non-expert institutions.

Factors related to the smell level of the bile drained were analyzed in 72 patients with acute cholecystitis who underwent percutaneous transhepatic gallbladder aspiration or drainage from February 2016 to October 2018. Doctors evaluated the smell level of the bile drained based on a score of 0 to 10 (0, without smell and 10, worst smell), and the average was defined as the Smell score. The cases with a Smell score of ≥5 were classified as the bad smell group and those with <5 as the non-bad smell group. Gallbladder wall thickness of ≥8mm (p=0.02), peak C-reactive protein of ≥20mg/dl (p<0.01), and the amount of isolated E. coli (p<0.01) were found to be significant factors related to bad smelling bile in acute cholecystitis patients.

E. coli was isolated more commonly and the gallbladder wall was thicker in cases with bad smelling bile. The smell of the bile is suggested to be proportional to the grade of inflammation.

Of 1,222 patients who underwent laparoscopic cholecystectomy (LC), 13 patients with postoperative bile leakage were included in this study. Leakage occurred in 5 (0.4%) LC and 8 (11.1%) patients with conversion to laparotomy. Leakage was observed <24 hours and ≥24 hours after surgery in 10 and 3 patients, respectively. The site of bile leakage was detected; with LC completion, the cystic duct stump (n=1); with conversion to laparotomy, the stump of the gallbladder neck (n=5) and the fistula of PTGBD (n=1). The site was not detected in 6 patients. Treatment included a drain placed during surgery (DS) (n=7), exchange of DS (n=1), endoscopic nasobiliary drainage (ENBD) +right subphrenic drainage (n=1), DS+right subphrenic drainage (n=1), DS+liver bed drainage (n=1), and ENBD (n=2). The mean time for bile leakage resolution was 10.6 days. Bile leakage commonly occurred in subtotal cholecystectomy patients who underwent conversion to laparotomy due to difficulty in managing the gallbladder neck.

An updated edition of clinical practice guidelines for the management of biliary tract cancers was be released on June 2019, after 5 years since the previous version. This new guideline involves 45 clinically important questions including 3 new ones, commentaries against which have been updated/generated on the basis of the articles published between 2012 and 2017. However, related clinical researches during this period were exclusively categorized as retrospective observational study, rather than prospective randomized control trial. Therefore, evidence grade for each commentary was classified as low in most questions (A in 1, B in 2, and C in 42), resulting in minor revision on the whole. In this edition, the guideline functions as textbook for learner in addition to practical guide for clinician. Some emerging problems throughout the bureau work are shared here for the upcoming revision.

Ampullary tumors arise in anatomically complex major duodenal papilla (papilla of Vater) so that show various pathological features. Ampullary adenomas or adenocarcinomas are mixed with various cell lineages (intestinal, pancreatobiliary or gastric type) even in a single tumor, but including those resembling colorectal adenoma or adenocarcinoma, those resembling pancreatobiliary intraductal papillary neoplasm, and those resembling ordinary pancreatic ductal carcinoma or bile duct carcinoma, showing each specific biological behavior. It is necessary to consider these differences and characteristics for the diagnosis and treatment of ampullary tumors.

A 70-year-old woman was diagnosed as having GAD antibody-positive cerebellar ataxia. One year later, her symptoms had not improved despite treatment with steroid administration. Plane computed tomography (CT) for suspected paraneoplastic syndrome revealed a gallbladder polyp with calcification. Abdominal ultrasonography (US) depicted a low-echo tumor of 12mm at the inferior portion of the gallbladder. Enodoscopic US showed a high-echo margin, low-echo center, and disruption of the outer layer of the gallbladder. Contrast CT revealed the polyp as gradually stained, with the gallbladder wall protruding into the liver floor. A diagnosis of gallbladder cancer with liver floor infiltration was made. However, subsequent cholecystectomy and partial resection of the liver floor disclosed histological findings of fibrous tissue covered by simple epithelium for a final diagnosis of a fibrous polyp of the gallbladder. This is a rare case in which fibrous tissue from the gallbladder invaded the liver floor.

Pseudolithiasis after administration of ceftriaxone (CTRX) is widely known, and mainly reported in children. While, in recent years, reports in elderly are increasing. We report two elderly cases of gallstone pancreatitis associated with administration of the CTRX. Before the onset of gallstone pancreatitis, the first case 80-year-old female was given CTRX for 3 days because of bronchialitis. The second case 70-year-old male was given CTRX for 5 days because of colitis. Both cases were admitted to the hospital and started receiving conservative treatment. However, elevation of inflammation and hepatobiliary enzymes were exacerbated, then they required endoscopic treatment. Most of CTRX-associated pseudolithiasis are asymptomatic, and disapear early due to discontinuation of administration. Therefore, even if symptoms such as abdominal pain appear, conservative treatment is the first choice. However, we are necessary to be fully aware of the possibility that endoscopic procedures required as in our cases and CTRX-associated pseudolithiasis is easily formed not only in children but also in elderly.

A 30-year-old woman was seen at another hospital because of jaundice. She was suspected distal bile duct cancer, and was referred to our hospital for close inspection and treatment. CT showed an enhanced tumor 10mm in diameter at the distal bile duct. MRCP revealed a stricture at the distal bile duct. A biopsy from the distal bile duct stenosis suggested hyperplasia or adenoma. The cytology from the bile juice suggested adenocarcinoma suspected. A preoperative diagnosis of distal bile duct cancer was made, and the patient underwent pylorus-preserving pancreaticoduodenectomy. The resected specimen showed a circumferential tumor with distinct border in the lower bile duct. Histopathological examination revealed a benign granular cell tumor. The postoperative course was uneventful, and she is alive without recurrence for 8 years after surgery. The occurrence of granular cell tumor in the biliary tract is rare. To the best of our knowledge, this case is the ninth case reported in Japan.

A 63-year-old man was pointed out the pancreatic head tumor at another hospital. He was referred to our hospital for close inspection and treatment. CT showed an early stage enhanced tumor 8mm in diameter at the pancreatic head. ERCP showed a tumor with smooth surface which had protruded into the distal bile duct. A preoperative diagnosis of pancreatic head neuroendocrine tumor was made, and the patient underwent pylorus-preserving pancreaticoduodenectomy. Histological examination revealed growth of atypical cells with funicular and ribbon-like arrangement under the bile duct epithelium. And atypical cells were positive for chromogranin A by immunohistochemical staining. A final diagnosis of neuroendocrine tumor of the distal bile duct was made. The postoperative course was uneventful, and he is alive without recurrence for 8 years after surgery. Since neuroendocrine tumor of the extra bile duct is rare, we report on this case with some bibliographical comments.

A 90-year-old man with acute cholecystitis underwent emergent laparotomy cholecystectomy. However, liver dysfunction prolonged after surgery, and contrast-enhanced CT was performed.

According to the CT findings, common bile duct injury was suspected, and the patient was transferred to our hospital for treatment.

Cholangiography with PTBD revealed complete dissection of the biliary injury, and a PTBD tube was indwelled from the left hepatic duct to the right hepatic duct.

After improvement in ADL, the patient was scheduled to undergo biliary reconstruction but no improvement was noted in the level that could be tolerated.

Moreover, because internalization was required, EUS-BD was performed via the PTBD route, and an internal and external catheters were placed in the stomach from the intrahepatic bile duct, and replaced with metal stents later.

In conclusion, EUS-BD via the PTBD route after PTBD is useful as a drainage method.

The patient was a 72 year-old male, who was transported to the ER complaining of fever and vomiting. He was admitted to our hospital with a diagnosis of acute cholecystitis with gallstone impaction. Although his symptoms improved after antibiotics therapy and PTGBD, hemorrhagic shock due to gallbladder bleeding occurred. Contrast CT revealed cystic artery pseudoaneurysm accompanying hemoperitoneum. Transcatheter arterial embolization (TAE) and subsequent laparoscopic cholecystectomy (LC) were performed. His postoperative course was uneventful and he was discharged at postoperative day 6. Cystic artery pseudoaneurysm is mostly recognized as gastrointestinal bleeding and rarely accompanies hemoperitoneum. Treatment should be decided according to the extent of hemorrhage, pseudoaneurysm, and cholecystitis. Preoperative TAE and subsequent LC is a feasible therapeutic option for ruptured cystic artery pseudoaneurysm especially for technically-difficult cases or cases with shock vital.

ERCP and associated procedures are widely used for the management of biliary disorders. Deep biliary cannulation is a prerequisite for successful ERCP. Achieving deep biliary cannulation can be challenging. We should not repeat the same approach and try to use alternative techniques which are tailored to the individual papillary and ductal anatomy of each patient. It is necessary to be aware of the fundamental knowledge and techniques of these procedures in order to avoid unexpected results. The indication of diagnostic ERCP should be considered carefully because there is a potential risk of post ERCP pancreatitis.