We have recently demonstrated the simultaneous determination of biliary lipids by gasliquid chromatography. In present study, we prepared the micro-computerized program for calculating the cholesterol saturation index (CSI) in human bile from the critical table by Carey with using the above method. This program has been modified to automatically correct the effect of ursodeoxycholate on CSI and to be capable for the calculation of lithogenic indices by both of Admirand & Small, and Holzbach, Dam & Hegardt. This program is a great application for determining the biliary cholesterol solubility.

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Bile collections were attempted in 63 patients,40 males and 23 females, after endoscopic cannulation of the papilla of Vater at the time of endoscopic retrograde cholangiography (ERG)or/and endoscopic retrograde biliary drainage (ERBD) for the purpose of examining organisms in bile.82 collections were successful in 63 patients. The materials were injected into the CO₂ filled bottle and cultured by aerobic and anaerobic method. S. faecalis was the commonest isolate and account for 34.1%. But this was suspected to be one of contaminants. As Gram negative rods, P. aeruginosa, Klebsiella and E. coli were detected and respectively account for 29.4%,13.4% and 9.8%. P. aeruginosa was also possible to be a contaminant. As anaerobic species, Clostridium perfringens was isolated from two out of 82 cases and revealed mixed infection with Gram negative rods, as frequently encountered.

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Congenital choledochal cyst is often associated with biliary tract carcinoma. Reflux of pancreatic juice into the biliary tract due to anomalous choledocho-pancreatic ductal junction usually accompanied by congenital choledochal cyst may be responsible for malignant transformation of biliary epithelia. To elucidate the mechanism of the biliary tract carcinogenicity, investigation of mutagenicity of biliary tract contents and fluorocytometric analysis of DNA content of biliary epithelia were performed. Mutagenicity of biliary tract contents was confirmed in 6 among 12cases of congenital choledochal cyst with anomalous choledochopancreatic ductal junction.
The DNA histogram showed high incidence of DNA-aneuploidy in 2 among 4 cases examined: moreover, the 2 cases revealed marked biliary epithelial proliferative changes.
It is suggested that biliary tract contents mixed with pancreatic juice in the environment of anomalous choledocho-pancreatic ductal junction contain mutagenic substances, and that the biliary epithelia receive not only atypical changes but also DNA-aneuploidy in the environment.

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US, Cholangiography and CT were applied for the diagnosis of adenomyomatosis of the gallbladder (GB) in fourteen patients (G type 3, S type 8, F type 3).
1) G type: (US) Diffuse thickening of the GB wall and micro cystic areas can be demonstrated except mild dilatation of RAS. (Cholangiogram) The characteristic pearl beaded appearence (RA-sign) can be seen around the entire GB, especially in ERC or postcontraction on DIG. (CT) Diffuse thick-walled GB is seen, and sometimes also many micro cystic low density areas within the wall.
2) S type: (US) Compartmentalization of the GB (hour-glass deformity), segmental wall thickening, micro cystic areas are seen and sometimes comet like echo or triangle sign. (Cholangiogram)Cholangiogram shows stricture and distally narrowed lumen of the GB, but RA-sign appears only a few cases. (CT) Markedly contrast enhanced mass is seen in the GB.
3) F type: (US) Fundal thickening of the GB and micro cystic areas can be showed except very small lesion. (Cholangiogram) A filling defect of the fundus with small niche or RA-sign is visible.

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This paper describes central hepaticojejunostomy as a new by-pass operation for unresectable carcinoma of the hapatic hilus. The bile duct at the hepatic hilus runs along the ventral side of the portal vein. It is possible to expose the intrahepatic bile duct without damaging the portal vein. The right intrahepatic bile duct is exposed beyond the cancerous region at the hepatic hilus. This method requires only a small amount of liver to be resected. Hepaticojejunoanastomosis maintains the physiological bile flow, advantageous in that cholangitis dose not occur. The quality of life for the patient is maintained. Indication for this procedure are as follows: cancer infiltration involving mainly the left hepatic duct, infiltrating to the right limited to the secondary branch, infiltration extending to the main trunk of the portal vein and unable to perform portal vein reconstruction. In our experience of 4 cases, no complications related to surgery were encountered.

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We had 10 patients with stricture of the proximal bile duct caused by biliary malignancies. From their operative findings and histopathologic aspects of the specimens resected, it was considered to be reasonable that 2 of the 10 were diagnosed as primary bile duct cancer arisen from the superior portion of the bile duct,2 were arisen from the middle portion and the other six from the cystic duct. None of the 6 patients with primary cancer of the cystic duct conformed to Farrar's criteria. Distension of the gallbladder was demonstrated by CT and US in the 6 patients without exception but in the other 4 the gallbladder showed atrophic. At the time of appearance of jaundice, extension of the tumors in the 6 was extremely more progressive than that in the 4, and the route of the tumor extension in the former ones differed from that in the latters.

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A case of early carcinoma of the cystic duct protruding into the bile duct was reported.
A 81-year old man presented with common fever. A malignancy of the bile duct was strongly suspected by ultrasonography, endscopic retrograde cholangiography and percutaneous transhepatic cholangiography.
A papillomatous tumor of the cystic duct prolapsed into the bile duct was found in the resected specimen. Microscopically, the tumor was identified as papillary adenocarcinoma and limited in the mucosa of the cystic duct. There were no metastasis in the lymphnode.
Primary carcinoma of the cystic duct is a rare disease. To our knowledge, only 30 cases were reported in the world literature, but cystic duct carcinoma protruding into the common bile duct was not found in them. And this is the first case of the cystic duct carcinoma that limited in the mucosa in Japan.

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It has been noticed that congenital dilatation of the biliary tract is frequently associated not only with an anomalous arrangement of the pancreatobiliary ductal system (AAPD), but also with carcinoma of the biliary tract. Recently, some cases of AAPD without biliary tract dilatation have been reported, which have aroused renewed interest about the relationship between AAPD and carcinogenicity of the biliary tract. We have recently experienced a case of gallbladder carcinoma in early stage, associated with AAPD without biliary tract dilatation, who was treated at our department for acute cholecystitis. CEA activity and cytology of the bile in the gallbladder taken during the operation disclosed no signs suggestive of malignancy, but the amylase activity in the gallbladder indicated a significantly heigh level. Adenocarcinoma was found scattered about in the adenoma in the resected gallbladder, and intestinal metaplasia and dysplasia were found in the peripheral mucosa of the adenoma in the gallbladder.

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A 63 year-old man, complaining of abdominal pain and jaundice, visited our hospital. The first examination of ultrasound (US) revealed dilation of bile ducts and a hypoechoic mass in the pancreatic head. Percutaneous transhepatic cholangiography showed smooth stenosis of both intrapancreatic bile duct and bilateral hepatic ducts. From pancreatographic, angiographic and cholangioscopic findings, pancreatic or bile duct cancer was nearly ruled out. The examination of US disclosed that the bile duct wall was thickened to show three-layer structure, so sclerosing cholangitis was strongly suspected. Therefore, cholangioplasty was performed followed by administration of steroid agents. Serial US disclosed that pancreatic tumor decreased in size and then disappeared. The patient had been doing well, but he was admitted 6 months later due to exacerbation of liver function. Ultrasonography, performed on the second admission, revealed that bile duct wall was thickened to 5 mm in width. After re-administration of steroid, the duct wall became thinner to 3mm and jaundice was improved.

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The high risk of subsequent canceration on the congenital choledochal dilatation has made it a general rule to carry out the resection of choledochal cyst along with reconstruction by hepaticoentrostomy.
Our new method consists of total excision of the dilated bile duct including the biliopancreatic junction along with the positive and adequate opening of the pancreatic duct.
Case 1. a 22 year-old male had a choledochal dilatation associated with pancreatic calculus. The choledochocyst was totally resected and the dilated pancreatic duct was opened to remove the stone.
Case 2. a 47 year-old female had a choledochal dilatation with extremely short and narrow segment, thus making the wall of the cystic choledochus directly attach to the pancreatic duct. Subtotal excision of the extrahepatic bile duct was performed including the biliopancreatic junction and a shallow T-tube was inserted to the pancreatic duct.
Pancreatic fistula did not ensue from the cut end of the pancreatic duct on both cases.
Our original procedure indicates for such cases with the wall of the end of the choledochus directly adherent to the pancreatic duct, and for such cases having pancreatic stone as well as gallstone in the pancreatic duct. When the pancreatic duct is properly sutured and pancreatic juice is duly drained, leakage of pancreatic juice would not take place. In short, this operation is proven not only capable of lithotomy but also much safer than the blind ligation of the end of the bile duct.

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A case of cholesterol polyp with difficulty in differential diagnosis from the gallbladder carcinoma is reported.
The patient was a 59 year-old woman. Polypoid lesion about 15mm in diameter was found at the neck of the gallbladder by transabdominal ultrasonography. The diagnosis was polypoid gallbladder carcinoma before operation. The histopathological examination showed that it was cholesterol polyp.

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The patient was a 53 year-old female with chief complaint fo fever and jaundice. PTC revealed obstruction of the common hepatic duct and outflow of the contrast medium from inside the irregular gallbladder into the duodenum and colon. With the diagnosis of Mirizzi syndrome or confluence stones complicated by cholecystoduodenal and cholecystocolic fistulas, operation was performed. After division and closure of the cholecystocolic fistula and two cholecystoduodenal fistulas, the stones located at the body and neck of the gallbladder were both removed. The stone in the neck was impacted into the common hepatic duct through a fistula between the gallbladder and common hepatic duct. After cholecystectomy, the fistula was closed using the part of the wall of the neck followed by choledochostomy with T-tube drainage.
A case of complicated multiple internal biliary fistulas was reported with some review of the literatures.

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Two patients with the anomalous pancreato-biliary ductal system accompanied with cancer of biliary tract, which is very uncommon, are reported.
One patient, a 38 year-old woman was adomitted to the hospital complaining of epigastralgia and jaundice. ERCP (Fig 1) revealed the anomalous pancreato-biliary ductal system associated with choledochal cancer after decompression of biliary truct by ERBD procedure (Fig 2), choledocho-jejunostomy was performed successfully. Occasionaly, cancer at the fundus of the resected gallbladder was found. Other patient, a 50 year-old woman was adomitted to the hospital due to liver dysfunction. US (Fig 3) revealed tumor of the gallbladder. ERCP (Fig 4) showed the anomalous pancreato-biliary ductal system and filling defect in the fundus-body region of the gallbladder. Pathologically it was found that cancer cells were localized within mucosal layer of the gallbladder. The clinical entity seen in these two cases encounter very rarely. This sort of lesion have been described as duplicately-jointing type or ramifiedcommunication type.

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A rare case of cystic dilatation of the intrapancreatic bile duct, not a form of choledochocele, is presented. The case was 34 years old male complaining epigastralgie. ERCP revealed cystic dilatation of the intrapancreatic bile duct with no protrusion into the duodenal lumen. The existence of anomalous arrangement of the pancreaticobiliary duct system was also strongly suggested. Excision of the intrapancreatic bile duct along with the extrapancreatic common bile duct and the gall bladder was performed followed by the reconstruction with end-to-side choledocho-duodenostomy.
The histological examination of the resected specimen revealed that the existence of intestinal metaplasia in the choledochal cyst epithelium, which might be pre-malignant condition of choledochal carcinoma. The amylase value of the bile in the gall bladder was extremely high (67,100unit), which was considered to suggest the existence of the anomalous arrangement of the pancreaticobiliary duct system.
Post-operative course was uneventful, and sustained no reflux cholangitis.

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A 85-years old female complaining of jaundice was admitted to our hospital on February 3,1986.
Percutaneous transhepatic cholangiography revealed a stricture of hilar hepatic duct and angiography showed a neovascularity at the hilum. Because the cause of the stricture was hardly differentiated from carcinoma with these radiographic findings, percutaneous transhepatic cholangioscopy (PTCS) was performed.
Though PTCS and the cholangioscopic biopsy were repeated, there was no evidence of malignancy. We diagnosed the stricture was due to chronic atrophic cholecystitis and decided to follow up the patient conservatively. The drainage catheter inserted trough the stricture for internal drainage was drawn up to the left hepatic duct on march 14,1986.
As the cholangiography showed no stricture, we drew out the PTCD catheter on May 22,1986. After 16 months the patient has no symptom. PTCS and the cholangioscopic biopsy were useful for the diagnosis of benign bile duct stricture.

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