This study was performed to determine whether pancreatoduodenectomy (PD) is required to accomplish lymph node dissection in patients with advanced carcinoma of the gallbladder. Lymph nodes were extensively disseced from the tissue at the head of the pancreas in surgical materials obtained from 20 patients with gallbladder carcinoma who underwent PD. The persistence of lymph node Nos.13a,13b,17a, and 17b was studied histopathologically. Lymph nodes remained in the peripancreatic tissue in 16 of the 20 patients (80%). Among 55 lymph nodes less than 3 mm in diameter,39 (71%) remained in peripancreatic tissue even after extensive dissection. About 7% of node Nos.13,13b,17a, and 17b that were less than 3 mm in diameter were metastasis positive. Cancer remained in the peripancreatic tissue after extensive lymph node dissection in two patients, one with venous invasion and one with lymphatic invasion. PD was considered essential for the complete dissection of peripancreatic lymph nodes; this procedure is indispensable in patients with venous or lymphatic invasion.

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To investigate the pathogenesis of gallstones after gastrectomy, bile in gallbladder was obtained from 62 patients with cholecystolithiasis and 22 patients without gallstone. Out of 27 patients with gallstone after gastrectomy 24 underwent gastrectomy for gastric cancer and 3 for peptic ulcer. Patients with gallstone, after gastrectomy had the similar level of bile pH and ionized calc ium to both of control patients, however they had the lower level of total bilirubin, total bile acid and phospholipides and higher G/T ratio. Similar results were obtained from patient with liver cirrhosis and calcium bilirubinate stone. These results were content with the fact that black stone or calcium bilirubinate stone was, highly developed in patients with gallstone after gastrectomy. In conclusion, it is critical for clarification of mechanism of gallstone formation after gastrectomy to analyze the data based on kind of stones.

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The concept of gallstone formation after gastrectomy has been almost established. However, in the patient received an similar operative procedure of gastric cancer, there are two types of patients, with gallstone and without one, and the report regarding the mechanism for the occurrence of gallstone formation after gastrectomy has not been demonstrated. Therefore, in the patients, without gallstones preoperatively, underwent distal partial gastrectomy for gastric cancer with Billroth I anastomosis, whose kinetics of intrinsic cholecystic contractility by ultrasonograp hy and kinetics of CCK secretion from preoperation to postoperative six months, we distributed these patients for gallstone complication group (A group) and gallstone non-complication group (B group) by existence of postoperative gallstone formation, and comparatively examined two groups. As a result, on the rate of maximal cholecystic contraction and the peak value of CCK, bot h of A group were lower than its of B group significantly, and at transition of the peak value of CCK through postoperative 6 months, no changes had been demonstrated in A group, whereas the v alue of B group had been significantly rising sequentially. From the above-mentioned, it was proved that a fall of postoperative cholecystic contractility depending on a lack of an excessive CCK secretion is one of more important primary factors of gallstone formation after gastrectomy.

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In the operation of obstructive jaundice patients, operative mortality was extremely high compared with patients who were not obstructive jaundice. Evaluation of biliary decompression before operation has been controvertial. In this report, we evaluated the biliary decompression from the point of immunology. Changes in lymphocyte counts, T cell subsets, a mitogen stimulation test of T lymphocytes with Concanavalin A (Con-A) and activation of Kupffer cell activity for free radical production meas uring by the reduction of nitro blue tetrazolium (NBT) in the presence of phorbol myristate acetate (PM A)were examined in experimental bile duct ligation for 2 weeks and after external biliary drainage in rats. Although T cell subsets did not change significantly, a lymphocyte stimulation was significantly low in bile duct ligation and was recovered to the control level after external biliary drainage. The increase in free radical production reached a statistical significance in bile duct ligation and reduced after external biliary drainage. As a result, we conclude that there is a value of the biliary drainage on immunity.

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From January 1980 to December 1995, fifteen patients (one infant and 14 adults) with pancreaticobiliary maljunction without bile duct dilatation have been treated by surgery at our hospital.
The infant patient was a three-year-old female. The adult patients included 4 males and 10females with a mean age of 56.9 years ranging from 20 to 76 years. The main clinical indications for surgery were cholecystolithiasis in nine cases, choledocholithiasis in 3, acute pancreatitis accompanied by protein plug in the bile duct in 1 and carcinoma of the gallbladder i n 2. Biliary amylase level was higher than the maximum level of normal serum amylase level of 400 IU/ml in 10 out of 12 patients (83.3%)
.Manometory of the bi le duct was measured in 11 patients,10 of whom showed a normal linear pattern, indicating that there was no bile stasis. As for the surgical procedure, simple cholecystectomy was performed in eight patients, cholecystectomy with bile duct drainage in 4, cholecystectomy with choledochojejunostomy in 1, and cholecystectomy with lymphatic node dissection in 2. Biliary diversion followed by bilioenterostomy was not performed in any of the cases. Two patients died of other diseases. The remaining 13 patients are well for nine months to 15 years and three months after surgery without recurrence.
These results suggest that cholecys tectomy is necessary, however, if thre is no bile stasis such as choledocholithiasis, biliary diversion followed by bilioenterostomy is not necessary for the patients with pancreaticobiliary maljunction without bile duct dilatation.

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Purpose of this study was to determine the feasibility of using Wallstent in the palliative treatment of malignant biliary obstruction.
Palliative treatment of unrese ctable malignant biliary obstruction was performed 27 s essions in 26 patients. These patients were treated with plastic endoprosthesis (n=6), Gianturco Z-stents (n=9), Strecker stent (n=3) and Wallstent (n=9). Stents insertion was successful in 24 patients (92.3% ). Twenty-two patients discharged from the hospital, but 2 patients remained in the hospital due to critical general condition. Adequate biliary drainage for one month to 24 months in 8 patients or until death was achieved in 9 patients. Clogging of the stents and cholangitis occurred in 7patients. Stents occlusion was observed in 50% of plastic endoprosthesis, in 33.3% of Strecker stent and 11.1% of Wallstent.
Wallstent w as easy to place percutaneously and sit better than other stents. Occlusion rate of Wallstent was lower than that of other stents. Wallstent may have particular advantages in the palliative treatment of malignant biliary obstruction.

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A case of ampullary carcinoma composed of two different components was reported.
A 67-year-old male was admitted to our hospital complaining of jaundice. Duodenofiberscopy revealed swollen longitudinal fold and nodular protruding tumor at the papilla of Vater. Biopsied specimen was papillary adenocarcinoma and pancreatoduodenectomy was performed.
On the cut surface of the resected specimen, the tumor was composed of two components; a vinous polypoid tumor in the duodenum and whitish tumor located in the, submucosal layer of the duodenum. There was no continuity macroscopically between them. Histologically, the vinous tumor was papillary adenocarcinoma with PAS-positive mucus, scattered endocrine and Paneth cells, focal and weak positivity for CEA and CA19-9. The intramural tumor was moderately differentiated adenocarcinoma with Alcian-blue-positive mucus and diffuse and strong positivity for CEA and CA19-9, invading the pancreatic parenchyma and colliding the villous tumor.
It is quite rare in ampullary carcinoma that the composed two components were h istologically and immunohistologically different, though it is unclear whether different two ampullary carcinomas collided or an ampullary carcinoma differentiated to two components.

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