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Biliary strictures caused by inflammation or fibrosis lead to jaundice and cholangitis which often make it difficult to distinguish malignant strictures. In cases when malignancy cannot be excluded, surgery is often performed. The concept of immunoglobulin G4 (IgG4)-related sclerosing cholangitis (SC) as a benign biliary stricture was recently proposed. The high prevalence of the disease in Asian countries has resulted in multiple diagnostic and treatment guidelines; however, there is need to formulate a standardized diagnostic strategy among various countries considering the utility, invasiveness, and cost-effectiveness. We evaluated accuracies of various diagnostic modalities for biliary strictures comparing pathology in the Delphi meetings which were held in Rochester, MN. The diagnostic utility for each modality was graded according to the experts, including gastroenterologists, endoscopists, radiologists, and pathologists from the United States and Japan. Diagnostic utility of 10 modalities, including serum IgG4 level, noninvasive imaging, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography-related diagnostic procedures were advocated and the reasons were specified. Serum IgG4 level, noninvasive imaging, diagnostic endoscopic ultrasound and intraductal ultrasonography under endoscopic retrograde cholangiopancreatography were recognized as useful modalities for the diagnosis. The information in this article will aid in the diagnosis of biliary strictures particularly for distinguishing IgG4-SC from cholangiocarcinoma and/or primary SC.

Highlights • Cystic duct cancer following cholecystectomy is a very rare entity. • It is difficult to detect an early stage cystic duct cancer and confirm its superficial extension. • Preoperative diagnosis is necessary to select a curative surgical procedure., Introduction Although primary cystic duct cancer is a rare entity, remnant cystic duct cancer is even more rare. We report a case of early cystic duct cancer following cholecystectomy. Presentation of the case A 81 year-old man complained temporary loss of appetite. He had underwent cholecystectomy for acute cholecystitis 5 years prior. Contrast enhanced computed tomography, magnetic resonance image and endoscopic ultrasonography showed remnant cystic duct tumor with protrusion to common bile duct. Endoscopic retrograde cholangiography revealed defect of contrast medium around confluence of the remnant cystic duct and common bile duct. We performed step biopsy by using forceps which revealed adenocarcinoma. Based on these findings, extrahepatic bile duct and remnant cystic duct resection were performed. The histopathology showed adenocarcinoma, pap > tub2, filling in remnant cystic duct, 30 mm in size but showed no lymphovascular or perineural invasion, no lymph node metastasis and negative surgical margin, and was classified as pT1bN0M0. Conclusion This is a rare case of primary carcinoma of remnant cystic duct cancer which is detected during computed tomography follow up for hepatic cell carcinoma recurrence. We confirmed remnant cystic duct cancer and its superficial extension to common bile duct with endoscopic ultrasonography and intraductal ultrasonography. Proper curative surgery was performed.

Highlights • Gallstone ileus is an uncommon complication of untreated cholelithiasis affecting an aged population. • Amyotrophic lateral sclerosis has documented dysautonomia causing significant delays in colonic transit times and gastric emptying. • Intestinal hypoperistalsis and adrenergic hyperfunctioning may be related to impaired gallbladder contractility resulting in sludge and stone accumulation. • We present a unique case of gallstone ileus in a patient with amyotrophic lateral sclerosis., Introduction and importance Gallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility. Case presentation In this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine. Clinical discussion Delays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities. Conclusion We present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.

Recurrent acute pancreatitis is characterized by frequent episodes of inflammation in the pancreas. The most common causes are alcohol abuse and gallstones but approximately 30% of cases are defined as idiopathic because initial evaluation fails to detect the etiology. In these patients, extensive laboratory and imaging evaluations usually lead to the uncovering of an occult biliary duct stone or sphincter of Oddi dysfunction as the main reason for frequent pancreatitis. We report a 42-year-old female with a longstanding history of acute recurrent pancreatitis in the setting of pancreas divisum due to its rarity. We focus on appropriate investigations by application of specialized laboratory and radiological modalities because determining the etiology is a crucial step in patient management.

Background and Aims There is a lack of consensus on which GI endoscopic procedures should be performed during the COVID-19 pandemic, and which procedures could be safely deferred without having a significant impact on outcomes. Methods We selected a panel of 14 expert endoscopists. We identified 41 common indications for advanced endoscopic procedures from the ASGE Appropriate Use of GI Endoscopy guidelines. Using a modified Delphi method, we first achieved consensus on the patient-important outcome for each procedural indication. Panelists prioritized consensus patient-important outcome when categorizing each indication into one of the following 3 procedural time periods: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), and (3) non-time sensitive (defer for >8 weeks and then reassess the timing). Three anonymous rounds of voting were allowed before attempts at consensus were abandoned. Results All 14 invited experts agreed to participate in the study. The prespecified consensus threshold of 51% was achieved for assigning patient-important outcome(s) to each advanced endoscopy indication. The prespecified consensus threshold of 66.7% was achieved for 40 of 41 advanced endoscopy indications in stratifying them into 1 of 3 procedural time periods. For 12 of 41 indications, 100% consensus was achieved; for 20 of 41 indications, 75% to 99% consensus was achieved. Conclusions By using a Modified Delphi method that prioritized patient-important outcomes, we developed consensus recommendations on procedural timing for common indications for advanced endoscopy. These recommendations and the structured decision framework provided by our study can inform decision making as endoscopy services are reopened.

Highlights • Gallbladder involvement by lymphoma is extremely rare, and only 68 cases have been reported in the English literature so far. • We experienced a case of diffuse large B-cell lymphoma (DLBCL) of the gallbladder arising 8 years after DLBCL of the right testis. • We compiled and analysed reported cases in terms of background, symptoms, imaging findings, and prognosis. • DLBCL was significantly more involved in other organs simultaneously or heterochronously in contrast of MALT lymphoma (p = 0.004). • Gallbladder lymphoma should be added to the differential diagnosis of gallbladder tumours., Introduction Gallbladder involvement in lymphoma is extremely rare, and only 68 cases have been reported in the English literature so far. We experienced a case of diffuse large B-cell lymphoma (DLBCL) of the gallbladder arising 8 years after DLBCL of the right testis. Presentation of case A 68-year-old man underwent orchiectomy for malignant lymphoma of the right testis pathologically diagnosed as DLBCL 8 years ago. Systemic surveillance incidentally revealed a gallbladder tumour, and elective resection of the gallbladder bed of the liver was performed under a preoperative diagnosis of gallbladder cancer. The histopathological examination revealed DLBCL. At re-evaluation 3 months after surgery, he was diagnosed as having DLBCL involving the stomach. There had been no recurrence for 39 months after chemotherapy and radiation, but he suffered from a poor general condition due to protein-losing enteropathy and died of infection. Discussion We compiled and analysed reported cases of malignant lymphomas involving the gallbladder in terms of background, symptoms, imaging findings, and prognosis. Compared to MALT lymphoma, DLBCL was significantly more involved in other organs simultaneously or heterochronously (p = 0.004). Conclusion Gallbladder lymphoma should be added to the differential diagnosis of gallbladder tumours, especially when clinical findings are not consistent with the typical course of gallbladder carcinoma and cholecystitis.

Highlights • Hydatid disease is a parasitic infestation by a tapeworm of the genus Echinococcosis of which 50%–75% of hydatid cysts occur in the liver. • In approximately one-fourth of the cases, hepatic hydatid cyst ruptures into the biliary tree producing obstructive jaundice. • Moreover, primary hydatid cysts of the biliary tract have been reported in English literature. • This is an interesting and intriguing case of obstructive jaundice caused by hydatid cyst in extrahepatic ducts 13 years after liver hydatid endocystectomy. • ERCP represent an important management strategy for patients with hydatid cysts in extra-hepatic ducts even primary or complications of liver hydatid cyst., Introduction Hydatid disease affects most commonly the liver, and complications with the rupture into the biliary tree develop in approximately one-fourth of the cases. Moreover, primary hydatid cysts of the biliary tract have been reported. Presentation of case We report an extremely rare case of obstructive jaundice caused by hydatid cyst in extrahepatic ducts 13 years after liver hydatid endocystectomy treated by Endoscopic retrograde cholangiopancreatography (ERCP). A 28-year-old male patient who had undergone surgical treatment – removal of liver hydatid cyst 13 years earlier, presented with signs of obstructed jaundice, confirmed with blood tests results and magnetic resonance cholangiopancreatography (MRCP). Actually, there were no pathological changes detected in the hepatic parenchyma, but the intrahepatic and extrahepatic bile ducts were dilated. ERCP was performed and the entire hydatid material was evacuated and washed out into the gastrointestinal tract. In addition, after laparoscopic cholecystectomy, hydatid cysts were also confirmed in the gallbladder. Discussion Generally, the obstructive jaundice caused by hydatid cyst in the extrahepatic ducts can also be caused by the rupture of the liver hydatid cyst in the biliary tract, or by primary hydatid cyst in the biliary tract. The ERCP plays a key role in the diagnosis and the treatment of this pathology. Conclusion The ERCP, has now become an important diagnostic and therapeutic procedure in management of primary extrahepatic hydatid cysts and of complicated liver hydatid cysts.

Introduction Many studies looked at outcomes and risk factors in laparoscopic cholecystectomies in general, including a few studies on risk factors and scoring systems in predicting conversion to open surgery. Little data has been produced on high-risk patients undergoing cholecystectomy. Identifying risk factors in this group could help stratify decision making regarding best management strategies. The aim of this study was to investigate outcomes of laparoscopic cholecystectomies in patients with ASA 3 and 4. Methods Data was collected and collated from a prospectively maintained database of all laparoscopic cholecystectomies performed by 13 general surgeons in a single unit. Case notes were reviewed for all patients with ASA 3 and 4 between 2013 and 2017. Data analysis was performed using R studio v 3.4. Results 244 cases were reviewed. Common bile duct was dilated in 52 cases (21.31%). Gall bladder wall was thick in 102 (41.8%) of the patients. Surgery was elective in 203 (83.2%) of the patients. ERCP was performed in 41 (16.9%) of the patients prior to surgery. 150 patients (62.2%) stayed for 1 day while 36 (14.9%) stayed for 2 days and the remaining 55 (22.9%) stayed for 3 days or more. Complications occurred in 37 (15.16%) of the patients while 23 (9.43%) of the patients were readmitted. 7 patients (2.87%) returned to theatre and 8 (3.28%) stayed in ITU post-op. Two patients died (0.82%). Conclusion Laparoscopic cholecystectomies in higher risk populations are safe. Alternative methods such as cholecystostomy and ERCP may be of benefit in these patients., Highlights • Gallstone disease represents a significant volume of elective and emergency work in the United Kingdom. • The primary aim of the study was to explore the factors that lead to complications in high risk patients (ASA 3-4). • Histological gallbladder thickness and emergency surgery were the factors most strongly associated with negative outcomes. • Age greater than 65 as an independent variable does not lead to an increase in negative outcomes. • Cholecystectomy is a relatively safe procedure in what is typically considered higher risk patients.

Highlights • Hemobilia from pseudoaneurysm rupture after laparoscopic cholecystectomy is rare. • Due to consequent rapid hemodynamic instability, it could be life threatening. • Non-contrast CT and ERCP examinations were performed to confirm hemobilia diagnosis. • Investigations revealed that there was no contrast agent leakage. • Thus, our patient was treated conservatively as opposed to surgically., Introduction Hemobilia due to pseudoaneurysm rupture is a rare, life-threatening complication of laparoscopic cholecystectomy (LC) that can cause rapid hemodynamic instability. Therefore, symptoms of hemobilia must be assessed carefully. Presentation of case An 88-year-old woman underwent LC in our hospital, and blood tests revealed elevation of hepatobiliary enzyme levels on postoperative day (POD) 12. Computed tomography (CT) showed a high absorption area in the common bile duct (CBD), and a diagnosis of hemobilia and a pseudoaneurysm without active bleeding into the abdominal cavity was made. There was no leakage of contrast medium outside the CBD during endoscopic retrograde cholangiography; thus, an endoscopic nasobiliary drainage (ENBD) tube was inserted on POD 12 and an endoscopic retrograde biliary drainage (ERBD) stent was placed in the CBD on POD 13. Thereafter, hepatobiliary enzyme levels gradually normalized and the ENBD tube and ERBD stent were removed on POD 27 and POD 54, respectively. The patient was discharged on POD 66. Discussion Hemostasis establishment using surgery or intervention radiology is often required for the treatment of hemobilia due to pseudoaneurysms; however, conservative treatment was effective in our case and we were able to pursue a minimally invasive approach. Erosion due to clip penetration or incomplete clipping of the cystic artery or its branches during surgery may have caused the cystic artery pseudoaneurysm. Conclusion Hemobilia could be life threatening and cause acute hemodynamic instability; therefore, prompt diagnosis is required. Although the frequency of complication is low, the possibility of hemobilia after LC should be considered.

Highlights • The diagnosis and management of cases with acute biliary pancreatitis. • Minimally invasive techniques gave encouraging results with minimal complications. • Cholecystectomy is recommended to prevent the recurrence of acute gallstone induced pancreatitis., Background Acute pancreatitis (AP) is considered one of the most common gastrointestinal disorders; the annual worldwide incidence for AP is 4.9–73.4 cases / 100,000 people and the total mortality rate is 4–8%, increasing to 33% in patients with infected necrosis. This study aims to assess the outcome of providing standardized evidence-based care to patients with acute biliary pancreatitis. Methods Thirty patients diagnosed with acute biliary pancreatitis, were enrolled in this study and managed according to the Japanese guidelines, 2015 with a complementary scope on other recent guidelines. Results Out of 30 patients in the study, 60% were females. Twenty-five cases were presented in the early phase of the disease while the rest presented in the late phase. Gallstones were the commonest cause (80%). The complications encountered were a systemic complication in one case, organ failure in three cases, and the local complications in the form of fluid collections in (43.3%) of cases.Out of 30 patients, 6 patients had an intervention. The main approach was minimally invasive techniques (4 cases), Open approach was performed in 2 cases. The total mortality rate was 10%. Most mild cases were discharged within one week from admission. Cases readmitted with recurrent attacks of acute pancreatitis were 3 cases, one male and 2 females. Conclusion By applying guidelines in the management of acute biliary pancreatitis, we can reduce disease-related morbidity and mortality. Besides, we can reduce the costs of medical services with the proper investment of healthcare resources.

Highlights • Diaphragmatic agenesis is a rare condition. • In adults with partial diaphragmatic agenesis, laparoscopic cholecystectomy can be performed successfully. • A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done., Introduction The importance of unilateral diaphragmatic agenesis (DA) in adults for performing a laparoscopic cholecystectomy has not been well described in literature. Presentation of case A 60-year-old female patient entered our ward in March 2019 for laparoscopic cholecystectomy after 6 months history of epigastric pain and multiple episodes of biliary colic treated conservatively. She never complained of pulmonary symptoms. Preoperative chest Computed tomography (CT) was negative for diaphragmatic or pulmonary pathologies. Laparoscopic cholecystectomy was performed in 60 min with intraoperative detection of a thoracoabdominal communication with partial right hemidiaphragm agenesis. A chest CT and x-ray were performed in the postoperative period with progressive reduction of an asymptomatic small pneumothorax. The patient was discharged at home without complications on the fifth postoperative day. Thoracopulmonary surgery examination was performed without indications for diaphragmatic repair. Discussion DA is a rare condition and usually occurs in early neonatal period. The congenital form occurs in 1 out of 2200–12500 live births and is traditionally divided into anterior (Morgagni’s: 10%) and posterolateral (Bochdalek’s: 90%) hernias. Chest and abdomen CT with coronal and sagittal reconstructions is the most effective and useful imaging technique for the diagnosis of diaphragmatic hernia. In literature there are former two case reports of asymptomatic DA in cholelithiasis in which laparoscopic cholecystectomy was performed effectively. Conclusion In adults with partial DA, laparoscopic cholecystectomy can be performed successfully. A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done. Further studies with a higher level of evidence are needed.

Highlights • Cholecystogastric fistula (CGF) is rarest form of cholecystoenteric fistula (CEF). • Our patient had a CGF close to the pylorus. • Laparoscopic and endoscopic cooperative surgery (LECS) was used to treat CGF. • Intraoperative endoscopy helped see the margin between fistula suture and pylorus. • LECS is a viable option to treat CGF, a rare CEF in biliary tract surgery., Introduction Cholecystoenteric fistula (CEF) is rare in biliary tract surgery, and cholecystogastric fistula (CGF) is the rarest form of CEF. Although open cholecystectomy with the closure of the fistula is the gold standard treatment for nonobstructing biliary-enteric fistulas, the optimal treatment for CGF has not been established. Laparoscopic and endoscopic cooperative surgery (LECS), a minimally invasive surgery for gastric submucosal tumors, reportedly helps achieve favorable postoperative outcomes. This report presents a case wherein CGF was treated with LECS. Case presentation An-84-year-old man with a history of chemotherapy for ileocecal diffuse large B cell lymphoma presented with fever and abdominal pain. He was diagnosed with cholangitis, and endoscopic lithotripsy was performed. Abdominal contrast-enhanced computed tomography revealed gastric wall thickening close to the gallbladder, indicating a malignant lymphoma. Esophagogastroduodenoscopy revealed a concavity on the anterior wall of the antrum of the stomach. Direct endoscopic cholangiography, which was performed by the injection of a contrast medium into the concavity, confirmed the concavity to be a CGF. Cholecystectomy with the closure of the fistula using the LECS was performed to check for suture line leakage and the positional relation of the suture line and the pylorus. The resected specimen showed acute and chronic cholecystitis without malignancy. The patient did not experience postoperative complications in the subsequent 3 months. Discussion Resection and closure of the fistula using LECS were performed successfully. Conclusion LECS can be performed for CGF. LECS enables intraoperative observation of the fistula and suture line, and thus reduces postoperative complications.

Introduction and importance Acute appendicitis is one of the most common surgical diagnoses in clinical practice. In case of uncomplicated course, diagnosis and treatment do not cause significant difficulties. On the other hand, unrecognized or complicated appendicitis can rarely bring unusual complications that threaten the patient with delayed treatment rather than the course itself. Portal vein thrombosis, also known as pylephlebitis, with an incidence of 1/1000 acute admissions, certainly meets this statement. Case presentation In this study, we present a successful treatment of advanced acute appendicitis complicating treatment of biliary obstruction. Due to the advanced inflammation with forced intestinal resection in the extent of right-sided hemicolectomy. And then successful conservative treatment of portal vein thrombosis in the surgical facility lasting a total of 6 weeks when the patient was discharged to home care without sequelae. Clinical discussion The epidemiology, presentation, diagnosis and strategy of treatments as well as their outcomes were discussed. Conclusion Portal vein thrombosis after acute appendicitis is rare. In case of unfavorable postoperative course with high inflammatory markers, temperatures, discomfort and abdominal pain, a CT scan is in order, which can easily establish the diagnosis and subsequently target the treatment in the right direction. Treatment of pylephlebitis is conservative and long term. It consists in the application of low molecular weight heparin and targeted antibiotic treatment. The mortality rate is 32%., Highlights • Appendicitis following cholangoitis • Right hemicolectomy • Pylephlebitis • Treatment

Laparoscopic cholecystectomy can be complicated by a post- operative biloma. Bile leak from the duct of Luschka is reported to be the second most frequent cause, reported in 0.15%-2% of the patients. This case report aims to underline the significance of this anatomic variation and how the management of the aforementioned complication can be facilitated by MRI- MRCP. A 78 year old male patient underwent an elective laparoscopic cholecystectomy and was found to have a post-operative biloma. An MRCP was carried out to visualize the bile tree and bile leak was identified to be originated from a duct of Luschka. The patient was referred for an ERCP, sphingterotomy and placement of biliary stent to release the pressure in the bile ducts. In the next few days the bile leak was controlled and eventually ceased. The patient was discharged free of symptoms and no sign of bile leak was to be found on his follow up imaging. In comparison with other imaging modalities picturing the bile tree, MRCP fits the ideal profile to be used as a first line choice for clinicians, as it offers detailed anatomical images with high contrast between bile and adjacent tissues, without using any contrast agent or radiation. Keywords: Postoperative biloma, Duct of Luschka, Bile tree variations, MRCP

Highlights • Obstructive jaundice due to tumor thrombus in the common bile duct with HCC is classified as icteric-type HCC. • Biliary drainage for patients with icteric-type HCC is sometimes difficult. • A staged approach with initial tumor thrombectomy followed by hepatectomy should be considered as one of the options for icteric-type HCC., Introduction Biliary drainage for patients with icteric-type hepatocellular carcinoma (HCC) is sometimes difficult, because the drainage tube makes contact with the tumor thrombus (TT) and effective drainage cannot be achieved due to hemobilia. Presentation of case We performed endoscopic naso-biliary drainage for an icteric-type HCC patient; however, the serum bilirubin level was not decreased due to bleeding from the TT. Therefore, we performed tumor thrombectomy in the bile duct and transection of the right hepatic bile duct prior to right hepatectomy. After the first operation, the bilirubin level was decreased, and liver function was recovered so that the patient could undergo right hepatectomy 4 months after the first operation. The postoperative course was uneventful after the second operation and the patient was discharged from the hospital on the 30th postoperative day. The patient is well without recurrence 10 years after surgery. Conclusion Biliary drainage is one of the key points for successful treatment of icteric-type HCC patients. A staged approach with initial tumor thrombectomy followed by hepatectomy should be considered as one of the options for icteric-type HCC.

Objective: To study the prevalence, etiology, and outcome of acute pancreatitis (AP) in kidney transplant and stage 5 chronic kidney disease (CKD) populations in comparison to a non-CKD cohort. Patients and Methods: Using the Nationwide Inpatient Sample database, we identified patients with acute pancreatitis as the primary discharge diagnosis, after which propensity scores were used to create 2 cohorts of patients: 1 with CKD (n=13,425) and 1 without CKD (n=13,425). The CKD group was subsequently subdivided into dialysis-independent stage 5 CKD (n=690), dialysis-dependent stage 5 CKD (n=11,415), and kidney transplant recipients (n=1320). Patients younger than 18 years old, those who received a kidney transplant during the incident admission, and pancreas transplant recipients were excluded. Results: The adjusted odds ratios (ORs) of AP were comparable between the no CKD, stage 5 CKD, and kidney transplant populations. Adjusted inpatient mortality was highest in patients with dialysis-dependent stage 5 CKD (OR, 2.72; 95% CI, 2.2-3.3; P

Objective: To describe first episodes of bacterial cholangitis complicating autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (ADPLD) and to identify risk factors for cholangitis episodes among patients with ADPKD-associated polycystic liver disease (PLD). Patients and Methods: We searched the electronic medical records at our tertiary referral center for episodes of cholangitis in patients with ADPKD or ADPLD from January 1, 1996, through June 30, 2017. Cases were categorized as suspected or definite cholangitis by expert review. Clinical, laboratory, and radiologic data were manually abstracted. A nested case-control study was conducted to investigate risk factors for cholangitis in patients with ADPKD. Results: We identified 29 cases of definite or suspected cholangitis complicating PLD (24 with ADPKD-associated PLD and 5 with ADPLD). Among patients with definite cholangitis in ADPKD-associated PLD (n=19) vs ADPLD (n=4), the mean ± SD age was 62.4±12.2 vs 55.1±8.6 years, and 9 (47.4%) vs 0 (0%), respectively, were male. The odds of gallstones (odds ratio [OR], 21.6; 95% CI, 3.17-927; P

Highlights • Required inhibitors of all coagulation factors. • After liver resection. • Severe bleeding. • Benefits of using steroid., Introduction Acquired inhibition of coagulation factors is a rare disease, and the diagnosis is often difficult and delayed. We experienced a deficiency in all coagulation factors after hepatobiliary surgery. Case Presentation Extended left liver resection was undertaken and hepaticojejunostomy was performed in a 70-year-old man. He had suffered from a high fever caused by cholangitis for 35 days. The major cause was a narrowing of the hepaticojejunostomy, and reconstruction was carried out. Twenty-four days later, there was a sudden massive bleed from his nose and the surgical site. Steroid pulse therapy was used as a treatment because cross mixing and some blood tests revealed the patient was experiencing an inhibition of all coagulation factors, and consequently the levels of coagulation factors dramatically recovered. Discussion We considered malignancy and surgical damages to be the underlying cause. The reported treatment and examination will help clinicians explore additional reasons for massive bleeding after a severe physical injury. Conclusion We have described the first case of acquired inhibition of all coagulation factors associated with extended left lobectomy.

Highlights • A lymphoepithelial cyst (LEC) of the pancreas is a benign and rare lesion. • A pancreatic LEC is difficult to be diagnosed and differentiate from the malignancy preoperatively. • We summarized the imaging features of pancreatic cysts to differentiate from the malignancy., Introduction A lymphoepithelial cyst (LEC) of the pancreas is a benign and rare lesion that is difficult to diagnose preoperatively based on imaging studies. Presentation of case We report a case of a 49-year-old man who presented with weight loss and diarrhea. The serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were slightly elevated to 6.7 ng/mL (reference value

Highlights • Double cystic ducts with a single gallbladder is exceedingly rare. • Diagnosis of this anatomic variant is most commonly made intraoperatively. • Knowledge of biliary aberancies is crucial to preventing bile duct injury. • IOC should be utilized to elucidate biliary anatomy when unclear., Introduction Anatomical variants of the extrahepatic biliary tree are numerous, adding significantly to the risk of bile duct injury during cholecystectomy, especially when laparoscopic approach is employed. Duplicated cystic ducts draining a single gallbladder are extremely rare. Presentation of case A 34-year-old female presented with signs and symptoms of acute cholecystitis which was confirmed on imaging. She was found to have an accessory cystic duct on laparoscopic cholecystectomy requiring conversion to open laparotomy with intraoperative cholangiogram to delineate the anatomy. Discussion In the English literature, there has been 20 reported cases of double cystic duct with a single gallbladder. Most of these cases were diagnosed intraoperatively despite the completion of a preoperative endoscopic retrograde cholangiopancreatography in a few of these patients. Conclusion The limited success of preoperative biliary tract imaging in demonstrating anatomic aberrancies prior to cholecystectomy clearly highlights the importance of maintaining constant vigilance for even the slightest anatomic abnormality at operation. Any uncertainty or concern for ductal injury mandates immediate operative cholangiogram with cannulation of all structures in question.

Background and Aims Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). Methods In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. Results Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. Conclusions Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Summary: Background: Detailed evaluation of bile duct (BD) is main focus during endoscopic ultrasound (EUS). The aim of this study was to develop a system for EUS BD scanning augmentation. Methods: The scanning was divided into 4 stations. We developed a station classification model and a BD segmentation model with 10681 images and 2529 images, respectively. 1704 images and 667 images were applied to classification and segmentation internal validation. For classification and segmentation video validation, 264 and 517 videos clips were used. For man-machine contest, an independent data set contained 120 images was applied. 799 images from other two hospitals were used for external validation. A crossover study was conducted to evaluate the system effect on reducing difficulty in ultrasound images interpretation. Findings: For classification, the model achieved an accuracy of 93.3% in image set and 90.1% in video set. For segmentation, the model had a dice of 0.77 in image set, sensitivity of 89.48% and specificity of 82.3% in video set. For external validation, the model achieved 82.6% accuracy in classification. In man-machine contest, the models achieved 88.3% accuracy in classification and 0.72 dice in BD segmentation, which is comparable to that of expert. In the crossover study, trainees’ accuracy improved from 60.8% to 76.3% (P

Background & Aims Low-phospholipid-associated cholelithiasis (LPAC) syndrome, a rare genetic form of intrahepatic cholelithiasis in adults, is still poorly understood. We report the results of the largest-ever case-control study of patients with LPAC syndrome aiming to assess the prevalence, clinical features, and comorbidities of the disease. Methods We included all LPAC cases diagnosed between 2001 and 2016 in 11 French centres. Controls consisted of all patients who underwent a cholecystectomy for common gallstone disease in a single non-academic centre over 1 year. A logistic regression analysis was used to identify the clinical features associated with LPAC syndrome across several patient strata with increasing levels of diagnostic confidence. The ratio between the incident cases of LPAC syndrome and the total number of cholecystectomies for gallstones was used to assess the relative prevalence of the disease. Results In this study, 308 cases and 206 controls were included. LPAC syndrome accounted for 0.5–1.9% of all patients admitted with symptomatic gallstone disease. Age at first symptoms, Graphical abstract, Highlights • Low-phospholipid-associated cholelithiasis (LPAC) syndrome affects approximately 1% of adults with symptomatic cholelithiasis. • Normal weight, common bile duct stones, and lack of cholecystitis are clinical features significantly associated with this syndrome. • ABCB4 variants in patients with LPAC may be associated with an increased personal or family risk of hepato-biliary cancer.

Background and Aims Although coronavirus disease 2019 (COVID-19) has affected endoscopy services globally, the impact on trainees has not been evaluated. We aimed to assess the impact of COVID-19 on procedural volumes and on the emotional well-being of endoscopy trainees worldwide. Methods An international survey was disseminated over a 3-week period in April 2020. The primary outcome was the percentage reduction in monthly procedure volume before and during COVID-19. Secondary outcomes included potential variation of COVID-19 impact between different continents and rates and predictors of anxiety and burnout among trainees. Results Across 770 trainees from 63 countries, 93.8% reported a reduction in endoscopy case volume. The median percentage reduction in total procedures was 99% (interquartile range, 85%-100%), which varied internationally (P Conclusions The COVID-19 pandemic has led to restrictions in endoscopic volumes and endoscopy training, with high rates of anxiety and burnout among endoscopy trainees worldwide. Targeted measures by training programs to address these key issues are warranted to improve trainee well-being and support trainee education.

The landscape of advanced endoscopy continues to evolve as new technologies and techniques become available. Although postgraduate advanced endoscopy fellowships have traditionally centered on ERCP and diagnostic EUS, the breadth of training has increased over the years in response to the ever-growing demand for therapeutic endoscopy. The increasing diversity and complexity of emerging endoscopic techniques accompanied by the shift in focus toward competency-based medical education requires innovative changes to the curriculum that will ensure adequate training yet without compromising best patient practices. The purpose of this review is to highlight the expansive array of advanced endoscopic procedures and the challenges of both defining and measuring competence during training. All authors are interventional endoscopists at their respective institutions performing these complex procedures, as well as training fellows in these techniques. We share our perspectives based on our experience navigating through these issues at our institutions and discuss strategies to standardize training and how to potentially incorporate these measures toward the process of credentialing and privileging in endoscopy.

Highlights • An extremely rare early cystic duct carcinoma. • The protruding part was the cause of jaundice. • There is a significant interesting macro findings in the removed sample. • The only small part of the invasive part which reach fibro-muscular layer is revealed by the pathological findings., Introduction Cystic duct carcinoma is a rare disease, and only 33 cases reported worldwide have completely fulfilled the criteria first established by Farrar in 1951. Here we describe an extremely rare case of early cystic duct carcinoma that fulfilled the Farrar criteria, the papillary tumour protruding into the common bile duct, leading to obstructive jaundice. Case presentation A 76-year-old man visited a clinic with icteric conjunctivae, and was referred to our hospital for investigation of suspected obstructive jaundice. He was initially diagnosed as having a distal bile duct carcinoma on the basis of ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiography (MRC), and underwent pancreatoduodenectomy with regional lymphadenectomy. Macroscopic examination showed that the stalk of the papillary tumour originated from the cystic duct, and that the protruding lesion was 50 mm in size. Histopathological examination revealed the tumour to be a papillary adenocarcinoma confined within the fibromuscular layer, with no evidence of lymph node metastasis. Therefore, the final diagnosis was early cystic duct carcinoma. Conclusion To our knowledge, this is the first case report of obstructive jaundice due to early carcinoma of the cystic duct protruding into the bile duct, with characteristics fulfilling the Farrar criteria.

Highlights • Double cancers of the bile duct are often associated with pancreaticobiliary maljunction. • Double cancers of the bile duct without pancreaticobiliary maljunction are very rare. • Double cancers of the bile duct may have a terribly poor prognosis., Background Double cancers of the biliary tract system are rare. Most of these cancers are synchronous double cancers of the gall bladder and bile duct, associated with pancreaticobiliary maljunction (PBM). Synchronous double cancers of the extrahepatic bile duct without PBM are especially rare, and only 4 cases have been reported. Case presentation A 78-year-old woman was admitted to our hospital for examination of hyperbilirubinemia and liver dysfunction. Contrast-enhanced abdominal computed tomography, Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography revealed 2 stenotic regions in the common bile duct: at its junction with the cystic duct and in the distal bile duct. No findings suggested PBM, such as a markedly long common channel. The diagnosis based on endoscopic brush cytology from both stricture portions was adenocarcinoma. The patient had a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection. Macroscopically, there were 2 stenotic regions at the cystic duct junction and in the distal bile duct. Microscopically, the tumor at the junction of the cystic duct was a well-to-moderately differentiated adenocarcinoma. On the other hand, the tumor of the distal bile duct was a poorly differentiated adenocarcinoma. There was no evidence of communication between these 2 cancers. Conclusion Double cancers of the extrahepatic bile duct without PBM are very rare. Therefore, an accurate diagnosis prior to surgery is necessary. Furthermore, this rare condition seems to be associated with a poor prognosis.

Highlights • Pancreatobiliary fistulas (PBF) associated with IPMNs are rare. • PBF associated with IPMNs often develop obstructive jaundice and cholangitis. • The causes of death in them without resection are cholangitis or hepatic insufficiency. • Surgery should be considered in patients with PBF associated with IPMNs., Introduction Intraductal papillary mucinous neoplasms (IPMNs) occasionally involve formation of fistulas with other adjacent organs. Pancreatobiliary fistulas associated with IPMNs are rare, but affected patients often develop obstructive jaundice and cholangitis. Presentation of case A 79-year-old man was referred to our hospital for evaluation of abnormal biliary enzymes. Contrast-enhanced computed tomography and endoscopic retrograde cholangiopancreatography demonstrated multiple cystic lesions with septa in the pancreatic head and fistulas between the cystic lesions and common bile duct. The clinical diagnosis was pancreatobiliary fistula associated with a mixed-type IPMN and accompanying obstructive jaundice. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. The resected specimen showed fistulas between the cystic lesions and common bile duct. Histopathological examination showed that the main and branch ducts of the pancreatic head were dilated and filled with mucus. The epithelia of the pancreatic ducts revealed papillary proliferation and an invasive adenocarcinoma arising from an intraductal neoplasm. Immunohistochemistry examination showed CDX2- and MUC2-positive reactions. The final diagnosis was an intraductal papillary mucinous carcinoma of the intestinal-type. The patient remained disease-free for 9 months postoperatively. Discussion The causes of death in patients who have pancreatobiliary fistulas associated with IPMNs without resection are cholangitis or hepatic insufficiency. Nonoperative treatment is limited for cases with obstructive jaundice. It is necessary to prevent obstructive jaundice and cholangitis due to a large quantity of mucinous material. Conclusions Surgical resection should be considered, if possible, in patients with pancreatobiliary fistulas associated with IPMNs. A better prognosis is expected with prevention of obstructive jaundice or cholangitis.

Introduction Horseshoe kidneys are the most common fusion defect of the kidneys, which amounts to about 0.25% of the population. They are usually asymptomatic and are often identified incidentally. The horseshoe kidney can push the second and third part of the duodenum anteriorly, leading to an altered CBD course. Choledocholithiasis is seen in approximately 10‐15% of patients with cholelithiasis. Presently, the most preferred approach for managing CBD stones is ERCP. However, in ERCP failure cases, Laparoscopic CBD exploration is the primary treatment modality, with or without T-tube use, with all the advantages of minimally invasive surgery. Case presentation and discussion A 65-year-old female presented with complaints of pain in the right hypochondriac region for three months associated with nausea, jaundice, and loss of appetite and weight. Her USG abdomen showed cholelithiasis with dilated CBD with horseshoe kidney with severe hydronephrosis of the left kidney. They are usually asymptomatic and are often identified incidentally. In this patient, it was believed that the horseshoe kidney had pushed the second and third part of the duodenum anteriorly, leading to an altered CBD course leading to ERCP failure. MRCP confirmed cholelithiasis with choledocholithiasis with dilated CBD of 11.3 mm with horseshoe kidney. ERCP was attempted but was unsuccessful due to non-visualization of the papilla due to overcrowding of duodenal folds. For patients with ERCP failure, laparoscopic CBD exploration is mandatory. For this patient, the CBD was cannulated with a guidewire, if needed, for repeat ERCP and was closed with T-tube in situ. Conclusion There are no particular preoperative indicators that can predict the failure of ERCP. However, in ERCP failure cases, laparoscopic CBD exploration (with or without T-tube use) is the primary treatment modality., Highlights • Horseshoe kidney causing altered CBD course leading to ERCP failure • Laparoscopic CBD exploration in patients with ERCP failure • Cannulation of CBD with guidewire for easier identification of papilla in case of repeat ERCP • One step laparoscopic cholecystectomy with laparoscopic CBD exploration vs. ERCP • Laparoscopic CBD exploration with T-tube insertion

Acute pancreatitis is currently the most common cause of hospital admission among all nonmalignant gastrointestinal diseases. To understand the pathophysiology of the disease and as a potential step toward developing targeted therapies, attempts to induce the disease experimentally began more than 100 years ago. Recent decades have seen progress in developing new experimental pancreatitis models as well as elucidating many underlying cell biological and pathophysiological disease mechanisms. Some models have been developed to reflect specific causes of acute pancreatitis in human beings. However, the paucity of data relating to the molecular mechanisms of human disease, the likelihood that multiple genetic and environmental factors affect the risk of disease development and its severity, and the limited information regarding the natural history of disease in human beings make it difficult to evaluate the value of disease models. Here, we provide an overview of key models and discuss our views on their strengths for characterizing cell biological disease mechanisms or for identifying potential therapeutic targets. We also acknowledge their limitations.

Highlights • Jejunogastric intussusception occurred after distal gastrectomy followed by Roux-en Y reconstruction. • Common bile duct stone occurred after prophylactic cholecystectomy and distal gastrectomy. • Intussusception and common bile duct stone both could occur simultaneously after gastrectomy., Introduction Intussusception after gastrectomy is a minor complication after gastrectomy, while common bile duct stone (CBD) is also a rare complication post cholecystectomy. We report a case that simultaneously caused both intussusception and CBD stone following gastrectomy with prophylactic cholecystectomy. Case presentation A 74-year-old woman underwent distal gastrectomy with Roux-en-Y reconstruction and prophylactic cholecystectomy for gastric cancer. After 14 months, the patient reported nausea and vomiting. Abdominal computed tomography scanning showed antegrade intussusception of the Roux limb of the gastrojejunostomy and calculi in the common bile duct, with a diagnosis of jejunogastric intussusception and common bile duct stones. The patient was hospitalized and endoscopic examination was performed on day 3. Endoscopic treatment did not resolve the intussusception, which also obstructed the bile duct stones. Elective surgery was performed on day 10, in which the invaginated Roux limb of the gastrojejunostomy was resected after manual reinstatement to its original position. This was followed by open exploration of the common bile duct and T-tube drainage. The patient was discharged 25 days post- surgery. Discussion Jejunogastric intussusception and CBD stone may require operative management, although the operation could be elective after sufficient examination and preparation. Conclusion Jejunogastric intussusception and bile duct stones are rare after distal gastrectomy, physicians should be alerted to the possibility of these complications.

Highlights • Mixed adenoneuroendocrine carcinomas (MANECs) of the distal bile duct are extremely rare. • The treatment of MANECs of the bile duct remains controversial and the prognosis is poor. • Larger studies are required to establish standard treatment regimens of MANECs of the bile duct., Introduction Mixed adenoneuroendocrine carcinomas (MANECs) of the distal bile duct are extremely rare, and only a few cases have been reported in the English literature. Presentation of case An 82-year-old man was referred to our hospital for increasing biliary enzymes. Abdominal computed tomography (CT) showed enlargement of the intrahepatic bile ducts and stenosis of the distal bile duct. Endoscopic retrograde cholangiopancreatography showed stenosis of the distal bile duct and a high-density signal at the same site on diffusion weighted imaging. PET-CT showed increased FDG accumulation (SUVmax: 4.5) at the distal bile duct stenosis. Biopsy specimens obtained by endoscopic ultrasonography-guided fine-needle aspiration revealed adenocarcinoma. The patient was diagnosed with adenocarcinoma of the distal bile duct and underwent subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection. The resected distal bile duct tumor was 18 × 14 × 12 mm in diameter. Hematoxylin and eosin staining revealed a composite carcinoma with adenocarcinoma and non-adenocarcinoma elements. The non-adenocarcinoma component stained positive for synaptophysin and chromogranin A. The Ki-67 labeling index was 37%. The non-adenocarcinoma component was therefore diagnosed as a neuroendocrine carcinoma. The two composite carcinoma was diagnosed as MANEC of the distal bile duct. The patient was treated with surgery alone and he remained disease-free for 7 months after the surgery. Discussion The treatment of MANECs of the bile duct remains controversial and the prognosis is poor. Conclusions There is no standard treatment for MANECs of the bile duct. Larger studies are required to establish standard treatment regimens.

Highlights • Ruptured pancreaticoduodenal artery aneursym is a very rare but potentially catastrophic occurence in an emergency department and its treatment is challenging. • Very few cases of emergency endovascular treatment of ruptured visceral aneursyms are reported in the literature. • This case report has the intention to elucidate in pancreaticodudoenal artery aneursym the importance of collateral vessels that could feed the aneurysm sac even after embolization of the inflow and outflow of the aneurysm., Introduction True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for

Highlights • Small SPN of the pancreas is sometimes difficult to diagnose preoperatively and mimicking pancreatic cancer. • The clinical presentation of SPNs is nonspecific, but acute pancreatitis is rare in the reported literature. • We should be aware that SPN of the pancreas can become a cause of acute pancreatitis., Introduction A solid pseudopapillary neoplasm (SPN) of the pancreas is rare neoplasm that occurs predominantly in young women. The clinical presentation of SPNs is nonspecific, but acute pancreatitis is rare in the reported literature. Presentation of case A 36-year-old man was referred to our hospital because of upper abdominal pain and elevation of serum amylase. A computed tomography (CT) scan showed swelling of the pancreas body and a poorly enhanced and indistinct mass in the pancreas body. He was diagnosed with acute pancreatitis. The symptom was improved with conservative treatment, but acute pancreatitis recurred twice during a period of 2 months. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis of the MPD adjacent to the mass. Distal pancreatectomy was performed because the mass in the pancreas body seemed to cause repeated acute pancreatitis and malignant pancreatic cancer could not be excluded. Immunohistochemically, a diagnosis of SPN of the pancreas was made from the resected specimen. Discussion To the best our knowledge, only 6 cases have been reported in the literature concerning the SPN presenting with acute pancreatitis. Conclusion We report a man with a small SPN of the pancreas presenting with acute pancreatitis and mimicking pancreatic cancer. We should be aware that this rare pancreatic tumor can become a cause of acute pancreatitis.

Background & Aims: There is a pressing need to develop effective preventative therapies for postâendoscopic retrograde cholangiopancreatography pancreatitis (PEP). We showed that early PEP events are induced through the calcium-activated phosphatase calcineurin and that global calcineurin deletion abolishes PEP in mice. A crucial question is whether acinar cell calcineurin controls the initiation of PEP in vivo. Methods: We used a mouse model of PEP and examined the effects of in vivo acinar cell-specific calcineurin deletion by either generating a conditional knockout line or infusing a novel adeno-associated virusâpancreatic elastase improved Cre (IâiCre) into the pancreatic duct of a calcineurin floxed line. Results: We found that PEP is dependent on acinar cell calcineurin in vivo, and this led us to determine that calcineurin inhibitors, infused within the radiocontrast, largely can prevent PEP. Conclusions: These results provide the impetus for launching clinical trials to test the efficacy of intraductal calcineurin inhibitors to prevent PEP. Keywords: Adeno-Associated Virus, Calcineurin B1, FK506, Cyclosporine A, Intraductal Delivery

Highlights • LAGB can rarely erode into the stomach and migrate into the small bowel. • Migration of the LAGB can result in bowel and biliary obstruction. • Band erosion should be managed by removal of the LAGB., Introduction Laparoscopic adjustable gastric band is a bariatric operation which has lost popularity due to its high rate of reoperation and complications such as band erosion. Erosion may be partial or complete with intragastric migration of the band. Once in the stomach lumen, the band has the potential to migrate into the small bowel. Presentation of case A 43-year-old male with history of morbid obesity and laparoscopic adjustable gastric band placement presented with abdominal pain secondary to biliary obstruction. Endoscopic retrograde cholangiopancreatography revealed eroded gastric band tubing into the lumen of the stomach and duodenum with resultant distortion of the ampulla. Upon surgical exploration, the band was found to have migrated into the jejunum and was removed through an enterotomy. The patient did well and was discharged home on postoperative day 8. Discussion Once completely eroded into the gastric lumen, a gastric band can migrate into the small bowel with the distance traveled being limited by the length of the connecting tube. The stretched tubing can result in distortion of the ampulla leading to biliary obstruction. Band erosion should be managed with band removal which can be completed using endoscopic, laparoscopic, or open approach. Conclusion Band migration should be suspected in patients with a history of gastric band placement presenting with bowel or biliary obstruction. Its management depends on the location of the band as well as the expertise of the surgical team.

Highlights • Laparoscopic subtotal cholecystectomy was successfully performed for a patient. • The rates of bile duct injuries is high after laparoscopic cholecystectomy. • Removal of the stone is the main purpose of treatment. • Laparoscopic subtotal cholecystectomy is useful for patients with Mirizzi syndrome., Introduction Mirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome. Presentation of case A 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful. Discussion After laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment. Conclusion Laparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.

Highlights • Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. • Prophylactic cholecystectomy is not recommended in bariatric surgery. • Laparoscopic assisted-ERCP is a safe and feasible intervention. • B-ERCP and EDGE are two valid alternatives B-ERCP and EDGE are two valid alternatives., Introduction Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. In fact, typical procedures, such as ERCP, can’t be performed due to the altered anatomy of the patient. Nowadays, procedures on this kind of patient are performed not only in specialized bariatric centers, but, due to the increasing number of patients undergoing bariatric surgery, are starting to become more common even in smaller and non-specialized centers that don’t possess the same expertise and technology. Case presentation We present the case of a 33-year-old patient, who had already undergone bariatric surgery, and presented to our department with a diagnosis of choledocholithiasis. Due to the altered anatomy the patient was treated through a laparoscopic assisted ERCP. Discussion A review of the need and proper timing for a cholecystectomy in this kind of patient, in order to prevent choledocholithiasis, is discussed. Moreover, a review of the literature regarding the possible treatments of this pathology in bariatric patients underlines the presence of other treatments, beyond the one performed in our department, that can be performed even in small non-specialized centers. Conclusions Prophylactic cholecystectomy is not recommended in bariatric surgery. Laparoscopic assisted-ERCP is a safe and feasible intervention which is to be preferred, even if B-ERCP and EDGE are two valid alternatives.

Highlights • Choledochal cyst is a rare malformation of the common bile duct causing jaundice in the pediatric group. • Diagnosis can easily be made using abdominal ultrasonography, hence a high degree of suspicion is needed among clinicians. • Surgery, open or laparoscopic, remains the core management depending upon the availability of the resources and expertise., Introduction Choledochal cyst is a rare common bile duct malformation that usually presents in the pediatric group with abdominal pain, distension, and jaundice. The pathophysiology remains unclear for the cause, and surgery aims to restore biliary enteric drainage. Case presentation We present a six-year-old female who presented with gradual abdominal distention associated with jaundice. Abdominal ultrasound was suggestive of choledochal cyst, and CT-scan confirmed the diagnosis. She was operated on successfully and fared well. Conclusion Choledochal cysts are a rare entity of common bile duct malformations and should be considered as a differential diagnosis in the pediatric age group. Diagnosis can be easily made by non-invasive and in-expensive radiologic modalities like ultrasonography in resource-limited settings.

Annular pancreas (AP) in adults is a rare embryologic abnormality detected after development of complications or as incidental finding. Diagnosis and treatment strategies for symptomatic adult AP remain controversial. We describe two different presentation of AP: a woman with a specific upper abdominal pain treated with medical therapy and a man with upper gastroenteric obstructive symptoms which underwent surgical duodeno-jejunal by-pass. English language literature about annular pancreas etiology, diagnosis and treatment was reviewed. No specific guidelines and protocols exist about management of AP, therefore, treatment and operative approaches must be individualized. In consideration of the possible post-operative complications, surgical treatment should be reserved in case of failure of conservative medical therapies.

Highlights • CT can distinguish between benign and premalignant or malignant pancreatic cysts. • Solid component and septation were the only CT features that could differentiate benign from malignant cysts. • Cyst wall enhancements on CT were more commonly observed in premalignant or malignant cysts than in benign cysts. • CT is a necessary diagnostic modality to preoperatively detect and characterize pancreatic lesions., Purpose It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management. Methods In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses. Results On univariate analysis, a solid component (p

Highlights • Intraductal tubulopapillary neoplasms (ITPNs) is a rare malignant lesion. • The patient was diagnosed as causing acute pancreatitis by ITPN. • There are only 5 cases reported about ITPNs presenting as acute pancreatitis. • It is important to diagnose that the cause of acute pancreatitis is ITPN., Introduction The 2010 World Health Organization classification of intraductal neoplasms of the pancreas includes intraductal tubulopapillary neoplasms (ITPNs) and intraductal papillary mucinous neoplasms, the latter being a rare and new concept. ITPN sometimes cause acute pancreatitis; therefore, distinguishing ITPN from idiopathic acute pancreatitis is important but challenging. Presentation of case We present the case of a 72-year-old male who had recurrent pancreatitis for the past 2 years, his diagnosis was idiopathic acute pancreatitis. He was admitted to our hospital with severe acute pancreatitis and cholangitis due to intrapancreatic bile duct stenosis. After the treatment of cholangitis, contrast-enhanced computed tomography revealed a tumor at the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis of the main pancreatic duct and distal bile duct, and adenocarcinoma was detected using brush cytology of the bile duct stricture and pancreatic juice. The patient was diagnosed with invasive ductal carcinoma and pancreaticoduodenectomy was performed. Histopathological findings revealed dilation of the pancreatic duct, and proliferation of columnar cells and cuboid epithelial cells in the main pancreatic duct of the pancreatic head. Mucus production was poor, and immunostaining results revealed ITPN. The patient is alive and do not exhibit signs of recurrence for 12 months. Discussion ITPNs can cause acute pancreatitis, which can be challenging to preoperatively diagnose. ITPNs presenting as acute pancreatitis are rare, with reported only 5 cases. Conclusion It is important to be keep in mind that there is a possibility of ITPN after diagnosis of idiopathic acute pancreatitis.

Highlights • This is the first case of mass-forming intrahepatic cholangiocarcinoma with portal vein tumor thrombus and bile duct tumor thrombus, where the extrahepatic bile duct was preserved with thrombectomy. • Thrombectomy can be a valid option for intrahepatic cholangiocarcinoma with tumor thrombus, as well as for hepatocellular carcinoma., Introduction We report the first case of mass-forming intrahepatic cholangiocarcinoma (ICC) with portal vein tumor thrombus (PVTT) and bile duct tumor thrombus (BDTT), where the extrahepatic bile duct was preserved with thrombectomy. Presentation of case A 70-year-old male. Magnetic resonance imaging (MRI) showed the tumor extending from the hepatic hilum to the left hepatic duct with complete obstruction of the left hepatic duct and a defect at the left portal vein. We planned to perform extended left lobectomy, lymph node dissection, extra hepatic bile duct resection and reconstruction based on the diagnosis of mass-forming ICC with left portal vein and left hepatic duct infiltration (cT3N0M0 Stage III). Intraoperative cholangiography revealed a crab claw-like filling defect at the left hepatic duct, which suggested tumor thrombus. Accordingly, we performed thrombectomy. The margin of the left hepatic duct was tumor negative, so we performed extended left lobectomy, lymph node dissection and thrombectomy. Pathologically, the tumor was diagnosed as ICC (pT4N0M0 Stage IVA, vp3, b3). Tumors in the left hepatic duct and left portal vein proved to be tumor thrombus. The postoperative course was uneventful. He is doing well without recurrence. Discussion Thrombectomy is performed for hepatocellular carcinoma (HCC) with tumor thrombus. Furthermore, extrahepatic bile duct resection and reconstruction are recommended for ICC. In this case, intraoperative cholangiography was effective for precisely diagnosing. Thrombectomy could reduce surgical stress and prevent complications. Conclusions Thrombectomy can be a valid option for ICC with tumor thrombus, as well as for HCC.

Highlights • A quantitative assessment of bowel viability is desired in gastrointestinal surgery. • In pancreatectomy post gastrectomy, assessment of stomach viability is essential. • Near-infrared spectroscopy helped the surgeons to evaluate intestinal viability., Introduction Objective and quantitative intraoperative methods of bowel viability assessment could decrease the risk of postoperative ischemic complications in gastrointestinal surgery. Because the remnant stomach and the pancreas share an arterial blood supply, it is often unclear whether the remnant stomach can be safely preserved when performing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) post gastrectomy. We herein report two cases in which the remnant stomach was safely preserved using near-infrared spectroscopy to assess the regional saturation of oxygen (rSO2) in the remnant stomach during operation. Presentation of case The first patient, a 68-year-old man, was diagnosed with cancer of the pancreatic head and underwent PD a year after proximal gastrectomy for gastric cancer. The remnant stomach was safely preserved by evaluation of the rSO2 before and after reconstruction of the arteries. The second patient, an 82-year-old woman with a history of distal gastrectomy for gastric cancer 40 years previously, was diagnosed with a main duct intraductal papillary mucinous neoplasm of the pancreatic body, requiring DP. As in the previous case, we could safely preserve the remnant stomach through assessing the intraoperative rSO2 of the remnant stomach. Discussion Through comparing changes in the rSO2 during surgery, near-infrared spectroscopy provides objective and quantitative assessments of intestinal viability to predict ischemic complications. Conclusion This method may be a viable option to evaluate the blood supply to the alimentary tract.

Highlights • Chronic abdominal pain after laparoscopic Roux en Y gastric bypass (LRYGP) is a challenging clinical problem. • An unusual case of a fish bone perforation at the biliary-digestive junction with resulting adhesions and obstruction is described. • The importance of exercising a low threshold for laparoscopic evaluation in patients presenting with chronic abdominal pain after LRYGP is stressed., Background The management of chronic abdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGP) is complex and challenging. Foreign body intestinal perforation including that caused by fish bones has previously been reported in the literature and if clinically unrecognized, can cause significant morbidity and mortality. Fish bone perforation as a cause of chronic abdominal pain after LRYGP has rarely been reported. Summary The unusual case of a 54 year old female presenting with recurrent episodes of postprandial pain 2 years after LRYGP is reported. Previous radiological and endoscopic investigations did not reveal any abnormality and after the most recent clinical presentation, a laparoscopic exploration was performed. A protruding fish bone at the biliary-digestive junction was discovered intra-operatively and successfully extracted. Dense adhesions between the involved intestinal loops were lysed in an attempt to improve intestinal transit and subsequently relieve post-prandial pain. Conclusion This case highlights the possibility of a missed fish bone perforation causing chronic postprandial abdominal pain and discomfort in a patient with a Roux-en-Y gastric bypass anatomy. Foreign body perforation is a rare cause of abdominal pain after gastric bypass that should be considered when evaluating chronic abdominal pain symptoms after LRYGP.