It has been well documented that immunosuppression in patients with obstructive jaundice increases the complications after surgical operations. Although, the mechanism of its immunosuppression is controvertial. In our experimental models, lymphoproliferative response to concanavalin A (Con A) in rats with obstructive jaundice was significantly decreased and improved after external biliary drainage. To discover the cause of this decrease, we paied attention to serum bilirubin and bile acids that increased in rats with obstructive jaundice and returned to normal after drainage. In vitro, the lymphoproliferative response of rats was inhibited by adding bilirubin or bile acids in culture medium. Moreover, interleukin 2 (IL-2) production of mice T lymphocyte stimulated by Con A was inhibited by adding chenodeoxycholin acid. These results suggest that increase of bilirubin and bile acids in serum of patients with obstructive jaundice may be the cause of impaired cell mediated immunity. Especially the increase of bile acids may suppress lymphoproliferation by reducing IL-2 production of T lymphocyte.

View full abstract

23 autopsied cases of fulminant hepatitis were examined to evaluate the roles of Ito cells (fatstoring cells) in the periductular fibrosis, histologically. Bile ductular proliferation was observed on about 9 days from onset, and spindle shaped mesenchymal cells were revealed around the ductules, showing pericyte-like appearances. Immunohistologically, the cytoplasm of these mesenchymal cells showed positive for anti-α smooth muscle actin antibody(marker of activated Ito cells). Electronmicroscopically, the mesenchymal cells contained some small lipodroplets, and surrounded the ductules. From these findings, the pericyte like mesenchymal cells around the ductules were understood to be Ito cells.
On the course of fulminant hepatitis, regeneration of hepatocytes and bile ductules were progressed, and the stroma got fibrotic appearances. The presence of Ito cells still maintained around the ductules, and positive finding for anti-PCNA antibody (marker of proliferating cells) was still obtained in the nucleus of Ito cells. Furthermore, basement, membranes were revealed around the Ito cells, electron microscopically, which showed continuation to the basement membrane of bile ductules. PAM positive collagen fibers, which surrounded the bile ductules, got obvious according to the process.
From these findings, Ito cells are recognized to play great roles in periductular fibrosis in fulminant hepatitis, continuously.

View full abstract

We studied the mode of spreading and the biological grade of malignancy in 13 extra-hepatic bile duct carcinoma cases. Parameters were the gross (papillary (P), nodular (N) and diffuse (D)) and histological (pap, tub1, tub2) types, the expression of cell-cell adhesional molecule (E cadherin and α-catenin), the nuclear area of cancef cell, and the expression of Ki-67 and p53 proteirt.
The histology demonstrated that P and pap types infiltrated further toward the liver in the mucosal layer than in the subserosal layer, while other types developed further in the subserosal layer. The stronger expressions of both cadherin and catenin were found in pap and tub1 than tub2, The nuclear area of cancer cell, correlated with both labeling index of Ki-67 and aberrant accumulation of p53, was significantly larger in the subserosal layer than in the mucosal layer.
These findings suggest that there are two kinds of modes in spreading of bile duct carcinoma. P type developed the mucosal layer with low grade malignancy. N and D types developed toward deeper layer with high malignancy.

View full abstract

Transcystic ductal choledocoscopic choledocholithotomy during laparoscopic surgery was performed in 17 patients. In all cases, a choledocoscope was passed into the common bile duct via the cystic duct and an instrument to remove gallstone through the working channel of the scope. In 3cases, a choledocoscope with a small diameter (O. D.4.4 or 3.3 mm) was introduced through the cystic duct without dilating procedure. In 2 of these cases, calcium bilirubinate or black stones were fractured with either an electrohydraulic or pulsed dye laser lithotriptor and fragmented pieces were flushed through the ampulla and into the duodenum. In the remaining 1 case, the single stone was pushed into the duodenum with the tip of the choledochoscope. In other 14 cases, a choledochoscope with an ordinary diameter (O. D.4.9 mm) was introduced after dilating the cystic duct with a balloon dilation catheter. The stones were removed by repeated maneuver employing a stone basket. There were absolutely no serious intra- or postoperative complications in any but one case, where a fragmented piece was missed in the common bile duct. Laparoscopic transcystic ductal choledochoscopic approach appears to be one of the safest and minimally invasive methods for cure of common bile duct stone.

View full abstract

One hundred and twelve polypoid lesions of the gallbladder with diameters of less than 20 mm were surgically resected. A comparative study was performed on the shape, pathohistology, computer tomography (CT), angiography, and surgical treatment of these lesions. The cases were histologically clarified to be 8 carcinomas (7.1%),87 cholesterol polypi (77.7%),9 adenomas (8.0%),5 hyperplastic polypi, and 3 inflammatory polypi. One case (1.8%) with lesions of less than 5mm in diameter was carcinoma. Two cases (5.4%) with 6-10 mm diameter lesions, two cases (14.3%) with 11-15 mm diameter lesions, and three cases (75%) with 16-20 mm diameter lesions were carcinoma. All carcinomatous lesions with diameters of 10 mm or under were pedunculated, and limited to the mucosal layer. Only one among 5 carcinomas with a diameter of 11 mm or larger was pedunculated, and this was also limited to the mucosal layer. The other 4 were non-pedunculated with one invading into the proper muscle and the other three into the subserosal layer. Lesions showing positive contrast enhancement of CT and tumor stain at angiography were found to be carcinoma or adenoma. In conclusion, if a small pedunculated polypoid lesion of the gallbladder is found to be cancer, it is most likely limited to the mucosal layer, and laparoscopic cholecystectomy (LC) is indicated for its treatment. A non-pedunculated lesion with a diameter of 11 mm or larger which shows positive contrast enhancement of CT or angiographic tumor stain, is very likely to invade beyond the proper muscle layer, and laparotomy is indicated for this type.

View full abstract

A gallstone in the cystic duct called Mirizzi's syndrome was treated by extracorporeal shockwave lithotripsy (ESWL) without any other method. A 33-year-old female was admitted because of pain in the right quadrant and back. Abdominal ultrasonography and endoscopic retr ograde cholangiography (ERC) revealed that a part of the gallstone was obstructive in the cystic duct and the other was protruded into the common bile duct causing its dilatation. Simultaneously, blood chemistry revealed obstructive pattern of the biliary tract.
4 sessions of ESWL were performed under ultrasonograp hy focusing using Richard Wolf Piezolith 2500 (9,850 discharges in total). The stone was crushed into smaller fragments than 2 mm in diameter. Any complications were found during this treatment.
In conclusion, ESWL may have advantages in the lithotrips y of Mirizzi's syndrome because of its non-invasive and safe peculiarity.

View full abstract

A 24-year-old woman was referred to our hospital for relapsing pancreatitis after extrahepatic bile duct excision and Roux-Y hepatico-jejunostomy for anomalous arrangement of the pancreaticobiliary ductal system. Ultrasonography and Endoscopic ultrasonography revealed remnant choledocal cyst and a stone (7 mm in diameter) in the cyst. Endoscopic retrograde cholangiopancreatography revealed anomalous arrangement of the pancreaticobiliary ductal system associated with complicated anomaly of the pancreatic duct. Pylorus-preserving pancreatoduodenectomy was performed and the postoperative course of 3 years was uneventful.
We studied reasons for making choice of each operation for anomalous arrangement of the pancreaticobiliary ductal system which performed resection of pancreas head in 18 patients. The result suggest that the reasons classified into 3 groups as follows,1) pancreatic stones difficult to remove other methods,2) complicated anomaly of the pancreatic duct,3) choledocal cyst difficult to excise completely or remnant choledocal cyst after extrahepatic bile duct excision.

View full abstract