It is well known that the biliary tract disease causes extrahepatic portal vein obstruction (EHO), and there are some reports that EHO complicates obstructive jaundice and/or common bile duct stones. To search for the cause of these phenomena, we examined ERCP and PTC in 11 cases of EHO unrelated to a biliary disease, and then we studied the appearance of these cholangiograms. In all cases, stenosis was observed on the middle and lower bile duct, and in 7 out of 11 cases, dilation of the upper bile duct was seen. In 6 cases, the intrahepatic bile duc t was dilated, and in 3 cases, a high degree of irregurality was observed on the intrahepatic bile duct wall. Judging from the appearance of the bile ducts, and the fact that a high degree of stenosis was observed in the cases with extensive portal vein occulusion, it is thought that stenosis of the extrahepatic bile ducts was caused by hepatopetal collaterals which developed into EHO, and we believe that this stenosis most likely results in complications of biliary duct diseases.

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We studied the effect of biliary decompression and operative risk in patients with obstructive jaundice. Subjects were a consecutive series of patients (n=42) in the past 10 years excluding those with calculi. Bile was drained by means of percutaneous transhepatic, endoscopic, or cholecystostomy method. We statistically analyzed predictive factors of postoperative complications such that developed in nine (21%) of our patients. Comparing factors before and after biliary drainage, the levels of total bilirubin, transaminases, alkaline phosphatase, lactic dehydrogenase, and rglutamic transpeptidase were significantly decreased. A multivariate analysis revealed that predrainage platelet count and post-drainage platelet count and creatinine level correlated positively with postoperative complications. Little was described in the literature on the platelet count as a poor risk factor. In conclusion, icteric patients having an increased number of platelet or renal dysfunction would dictate less invasive procedures or close postoperative management.

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The mode of cancer cell extension along the intrahepatic bile duct was studied histopathologically in serial sections of surgical specimens taken from 53 patients with hilar bile duct cancer. Two modes of extension were observed, a mucosal type (M: n=18) and an adventitial type (A: n=35). In the M type, cancer cells prominently infiltrated the mucosal layer rather than the adventitia. In contrast, A type cancer cells extend conspicuously along the adventitia. As to the macroscopic or histological characteristics of the lesions showing M type tumor extension,88% of them were grossly papillary type and papillary adenocarcinoma accounted for 12 out of 16 lesions (75%). On the other hand, A type tumor extension was more common in the cases with grossly infiltrating type and tubular adenocarcinoma including 5 cases with poorly differentiated type. In the cases with tumor with A type extension pattern, positive rate of residual cancer at the resection margin was significantly higher than that of M type.

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Black pigment is a polymer derived from bilirubin, and main component of black stone. It had not been measured by the usual method because it constitutes many polymers. Recently we could measure black pigment by infrared absorption spectroscopy. We measured the black pigment and 7 kinds of metal components (Mg, Mn, Fe, Cu, Zn, Cd, Pb) of 60 gallstones, and compared them. Black pigment was contained 63.3+20.1% in the black stone,43.5+21.6% in the calcium bilirubinate stone. Black stone contained large quantities of metals than calcium bilirubinate stone. Black pigment and metal content (Mg, Mn, Fe, Cu, Zn, Pb) especially Cu, were correlated. This report sustained the idea that the black pigment makes bilirubin-metal complex compounds like a bilirubin-Cu complex.

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We evaluated the form of the arrangement between the pancreatic duct and the common bile duct in the cases with pancreaticobiliary maljunction. On the cholangiograms obtained by endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography, the forms of the common bile duct at the pancreatico-biliary junction were classified into three types: (a) the terminal portion of the common bile duct at the pancreatico-biliary junction has a narrow segment, (b) the terminal portion of the common bile duct has relative stenosis at the junction and (c) the terminal portion of the common bile duct has no stenosis at the junction. This study revealed that the occurrence of gallbladder cancer or bile duct cancer was significantly lower in patients with the type (a) arrangement. We also evaluated the relation between biliary malignancies and the form of common channel. The occurrence of biliary malignancies was significantly higher in patients with a dilated common channel.

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A case of 65-year-old man admitted our Hospital complaining with fever and diagnosed as common bile duct stone. He had undergone cholecystoduodenostomy for cholecytolithiasis 30 years ago.
Cholecystectomy, partial resection of the duodenum, choledochotomy and T drainage were done. Histologically, mucosal dysplasia of the gallbladder was detected. Immunohistochemically, MIB-1 positive rate was 38%, and p53 protein over expression was also detected in this lesion.
In the case of cholecystoduodenostomy, chemical stimulation caused acceleration of cell cycle in gallbladder mucosa and contribute the development of dysplasia of the gallbladder. Tumor suppressor gene p53 is supposed to play an important role in pathogenesis of mucosal dysplasia of the gallbladder.

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A case of primary sclerosing cholangitis (PSC) following extirpation of chronic sclerosing sialadenitis of the submandibular gland (so-called Kuttner's tumor) was reported. To our knowledge no case of PSC has been reported in association with Kuttner's tumor. The pathogenesis of both disorder is still unknown, although vari ous hypotheses have been disathsed in the literature, e. g. autoimmunity. The patient, a 62-year-old male, was admitted to our hospital with liver dysfunction and jaundice. He was experienced extirpation of bi-lateral submandibular glands 1 year 8 months ago, and the pathological diagnosis of specimens was so-called Kuttner's tumor. The examination of ultrasound revealed thickening and layered structure of the common hepatic duct, and cholangiographical evaluation revealed marked stricture of that portion. Cytological examination showed no malignancy, thus diagnosed as PSC, cholecysto-choledochotomy and hepatico-jejunostomy were carried out. Histopathological examination of the resected bile duct showed inflammatory reaction with increased collagen fiber and chronic inflammatory cell-infiltration of lymphocytes. The patient has been in good health for 3 years and 6 months after resection.

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67 year-old-female was admitted to our hospital because of right subcostal pain. She was diagnosed as gallbladder cancer associated with the invasion directly into duodenal bulbus and liver by the examination of ultrasonography, CT, angiography, fiberscopy and so on. She underwent operation resected the tumor involved liver (S4+5), choledochus, duodenal bulbus and was performed lymphadenectomy. Pathological stage was stage IV (si; duodenum, hinf3, binf3, n2). Although almost all the part of tumor histologically consisted of well differentiated squamous carcinoma, there was signet cell carcinoma in the extremely little part of tumor. And the same findings were shown in the metastatic lymph node (No.12b). Pathological findings and the results of Keratin staining showed that signet cell carcinoma partly involved the characteristics of squamous carcinoma. In conclusion it was suggested that there was the possibility which might cause the rechange that squamous carcinoma would change to adenocarcinoma maintainning the feature of adenocarcinoma although adenocarcinoma in this case had changed to squamous carcinoma.

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In this paper, experience with laparoscopic cholecystectomy successfully carried out in a patients with chronic cholecystitis with severe adhesion was reported. The patient was a 65-year-old man presented with a severe epigastralgia. Pre-operative examinations (ultrasonography, abdominal CT) revealed a severe cholecystitis with thicked wall and gallstones. Moreover it was suggested an existence of dense adhesion around to the gallbladder. After dissection of the omentum adhesed to the gallbladder, laparoscopic cholecystectomy from fundus downward (LCFD) was indicated in this particular case because a dense adhesion between the gallbladder neck and duodenum was noted. For performance of cholecystectomy, the use of ultrasonically powered aspirator was extremely effective to dissect the gallbladder from the gallbladder fossa. Moreover endoscopic linear cutter was useful in the cases whose gallbladder had to be dissected at its neck because the cystic duct was not clearly identified. Finally the use of LCFD technique was strongly advocated in the cases with severe cholecystitis to prevent bile duct injury.

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