Twelve cases which underwent pancreato-duodenectomy (6 cases were lower common duct carcinoma and the remaining cases were another disorder) were examined to look over the rule of invasion of the surgical margin (e. w. ) in lower common duct carcinoma. The portion about 3 cm upper from the papilla of Vater was observed histologically with hematoxylin eosin stain. To judge the e. w. factor accurately,4 cases of lower common duct carcinoma were examined without opening of the common duct and 2 cases of that were examined after opening it. The former cases revealed a reliable information to judge the e. w. factor compared with the latter cases. Furthermore, the posterior dissected tissue of the bile duct which was less than 5 mm thick in all other disorder cases. These results suggest that the lower common duct should not be opened in case of lower common duct carcinoma for accurate judgment of the e. w. factor. We propose that relative noncurative resection in the General Rules should be called relative curative resection or curability B.

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We analyzed the inflow vessels of the cholecysic vein using angio-CT.
Subjects were 14 patients of pancreatobiliary disease. Using the angio-CT of the cystic artery, we confirmed the cystic veins in all patients. And about them, we analyzed the inflow vessels and the inflow point of the cystic veins.
We confirmed 37 cystic veins. All of them flowed into the intrahepatic portal branch or sinusoid of the liver. There were two types of veins. The veins from the hepatic hilus (n=10) flowed into the sinusoids in 3 and P4a in 3 but 4 of them flowed into the umbilical portion or the right branch of the portal vein. The veins from the liver bed (n=27) mainly flowed into the portal branches of S4a or S5, or sinusoids. The inflow point into the P4a was mainly distal side, on the other hand the inflow point into the P5 was mainly proximal side.
Angio-CT is useful to analyze the blood flow of the cystic veins. By this analysis the appropriate operation method was suggested.

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One hundred ten patients (gallbladder cancer,19 cases; bile duct cancer,34 cases; pancreas head cancer,33 cases; carcinoma of the papilla Vater,10 cases; recurrent gastric cancer,9 cases and others,5 cases) who underwent percutaneous transhepatic cholangeal drainage (PTCD) for malignant biliary obstruction during past 10 years were evaluated in this study. Insertion of PTCD catheter was successfully performed in all patients, and no complication was encountered except 2cases of hemobilia by many safety devices. As for reduction of jaundice, PTCD was effective on 33of 38 patients (87%) for upper bile duct obstruction and on 67 of 72 patients (93%) for middle or lower common duct obstruction. The decreasing speed of total bilirubin levels in 4 patients that were not successful in reduction of jaundice was accelerated after drinking discharged self-bile juice. All of the 110 patients were released from itching within 3 days after PTCD. Cyto-pathological examinations of bile juice or bile duct wall via the PTCD route in 89 patients revealed the 97%accuracy. Only reconstruction of the biliary tract was carried out on 25 unresectable patients after PTCD. Interventional radiotherapy combining expandable metallic stents was effective on 8 of 9patients who did not undergo any surgery, and they were persistently released from jaundice with good quality of life after discharge.

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Collagen type IV·7S as marker of liver fibrosis and serum metals (zinc and copper) were studied in comparison with the bilirubin decreasing rate in patients with obstructive jaundice. Collagen type IV·7S levels and “b value” are correlated every day after PTBD. “b value” and Zn/Cu are correlated before PTBD, on the first, third, seventh day after PTBD. Zn/Cu and collagen type IV·7S levels correlated before on the first day. In poor bilirubin decreasing rates group, collagen type IV·7S levels were significantly higher every day after PTBD in comparison with those of good bilirubin decreasing rates group. Serum copper levels of good bilirubin decreasing rates group were consistently lower than those of poor bilirubin decreasing rates group. Seurum zinc levels of good bilirubin decreasing rates group were higher than those of poor bilirubin decreasing rates group on the first day after PTBD. From these results it is concluded that metabolism of serum metals has connection with liver fibrosis in patients with obstructive jaundice the zinc, copper and collagen type IV·7S concentration in the blood are very useful barometers to diagnosis the hepatic function.

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A 45-year-old male consulted our department with complaints of anorexia, nausea and jaundice. Twenty months previously he had undergone endoscopic retrograde cholangiography (ERC) at another hospital. ERC showed a smooth stenosis extending from the upper bile duct toward to the hepatic hilum. Despite the finding of common bile duct stenosis on ERC, the patient was placed under observation under a diagnosis of the influence after cholecystectomy and he failed to continue the follow up. A second ERC performed twenty months later demonstrated severe stenosis extending from the lower bile duct to the intrahepatic bile duct. Peroral cholangioscopy (POCS) following endoscopic sphincterotomy (EST) was performed to establish a diagnosis.
POCS revealed a papillary tumor in the lower bile duct. Histological study demonstrated papillary adenocarcinoma. We suspected retrospectively it is possible that a smooth stenosis on ERC twenty months previously was due to common bile duct cancer of the hepatic hilum. And we suspected that the disease had slowly progressed over about two years in this case because of the expansion of bile duct cancer in the longitudinal direction. This case demonstrating the growth of bile duct cancer of the hepatic hilum on cholangiogram is considered a valuable addition to the literature.

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The expandable metallic stent (EMS) is useful for treatment of malignant biliary stricture.
However, its use has not been established for treatment of benign biliary stricture. We report our use of the Wallstent for leakage of bile after surgery for gastric cancer. A 70-year-old man was admitted Kawasakiichouh Hospital because of advanced gastric cancer.
A retrograde transhepatic biliary drainage (RTBD) tube was inserted at the site of iatrogenic biliary trauma after gastrectomy.
However,3 months after, continuous bile leakage was found, and position of RTBD tube was not satisfactory. The patient underwent percutaneous transhepatic biliary drainage (PTBD). After 1week, a Wallstent was inserted at the common bile duct through the PTBD tract. The patient was died after 5 month, but in the interim recurrent leakage and obstruction were not seen.

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A 53-year-old-woman admitted to our hospital because of intrahepatic cystic lesion but she had no complains. Physical examination was unremarkable other than for hypertension. Laboratory results were normal apart from slightly elevated triglyceride value. A cystic lesion was located in the right hepatic hilus and possessed calcificated contents surrounding a low density capsule. A percutaneous transhepatic cystography revealed solitary cystic dilatation of anterior biliary branch. Cholecystectomy and cystectomy with distal anterior bile duct ligation were done. A cystic dilation,3 cm in diameter, contained a lump of numerous pigment stones. Microscopic findings showed slightly inflammation and periductal mucous glands within the walls of the dilated bile duct and gallbladder was normal. Post operative course was uneventful except for elevated transaminase, alkaline phosphatase and gamma glutamyltranspeptidase values.4.5 years later, she was well and no complain. Solitary cystic dilatation of the intrahepatic bile duct was very rare but it is important to take care of intrahepatic cystic lesion like our case.

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A 79 year-old man was admitted to our hospital because of epigastralgia of acute cholecystitis. We performed him percutaneous transhepatic gallbladder drainage. After we diagnosed gallbladder cancer, gallbladder resection and partial hepatectomy with lymphnode dissection were performed. The pathological diagnosis was gallbladder cancer (Gfb) ss, hinf₀, binf₀, vs₀, hw₀, ew₀, n₀. The cause of cholecystitis was neither gallbladder stone nor cancer invasion to the cystic duct. We report this case with a review of the literature because the cause of the cholecystitis is thought to be rare and suggestive.

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A 72-year-old male with acute cholecystitis, complicated by liver abscess due to penetration of gallbladder, was reported. Several days prior to admission the patient complained of right upper quadrant pain and high fever. Ultrasonography and CT-scan showed an enlarged gallbladder and an abscess in the right lobe of the liver. He was diagnosed to acute cholecystitis complicated by liver abscess. Percutaneous transhepatic cholecyst drainage was performed, and cholecystography showed a communication between the gallbladder and the cavity of liver abscess. Liver abscess accompanied with biliary infection is usually caused by retrograde infection through the biliary tract. Pyogenic liver abscess caused by penetration of the gallbladder is relatively uncommon. In Japan, there were only 8 reported cases of liver abscess due to by penetration of cholecystitis.

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