An evaluation was made of the efficacy of a biliary endoprosthesis for the stricture of hepaticojejunostomy using self-expanadable metallic stents (EMS). From February 1991 to December 1995, EMS were placed in 6 patients, including one patient had gastric cancer, intrahepatic caliculi and congenital bile duct dilatation, and 3 had bile duct cancer. The site of the stricture were hepaticojejunostomy of pancreatoduodenectomy in 2, extrahepatic bile duct resection in 4, including three cases with partial hepatectomy. The cause of a stricture was recurrence of the tumor in 3, inflammation in 3. In all patients, the EMS was placed successfully without complications and led them to be tube-free. As patients with the recurrence of the tumor have a disturbance of motility of the limb, repeat cholangitis soon after EMS placement was observed. In the patients with inflammatory stricture, long-term placement of the EMS, over a year, caused repeat cholangitis. EMS placement for the stricture of hepaticojejunostomy have an advantage in that patients is in tube-free, while there is a problem that repeat cholangitis is observed before too long. We conclude that for the stricuture of hepaticojejunostomy, an external biliary drainage should be used in tumor recurrence, and re-anastomosis should be used in inflammatory stricture.

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Increasing detection of gallstones (GS) after curative resection for gastric cancer presses both surgeons and patients to make a difficult decision whether GS should be managed surgically or not. In this study, we assessed the incidence, incubation periods, and clinical presentations of symptomatic GS after gastrectomy in a total of 116 patients whose GS had been detected by ultrasonograexamination (US). GS, which required cholecystectomy for its related symptoms, occurred in 21.6% (25/116) of all the patients. There was no correlation of sex, extent of gastrectomy, reconstructive methods, with the occurrence of symptomatic GS. The onset of symptoms were relatively constant after gastrectomy; 32.0% in the first 3 years,36.0% in the 3rd to 6th year, and 32.0% after 6 years. In 56.0% (14/25) of the patients, GS was diagnosed first at the initial symptom. Cholecystectomy was performed within 6 years after gastrectomy in a half cases, whereas in the other after 6 years or later. Intervals to cholecystectomy were within 2 months from the detection of GS in 48.0% (12/25) and from the onset in 68.0% (17/25), respectively. Stones were frequently located both in the gallbladder and the common bile duct, and were more than two in number, less than 5 mm in diameter, calcium bilirubinate in type, and positive culture of the bile. These results made us to think it difficult to anticipate when GS after gastrectomy would be symptomatic. Because cholecystectomy was performed 6 years after gastrectomy or later in half of the patients, long-term follow up by US is mandatory to disclose this problem.

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One hundred and twenty-one cases undergoing laparoscopic cholecystectomy were subjected to a clinical study on intra-and postoperative courses and complications of the procedure. The times required for pneumoperitoneum and operation were prolonged in patients with negative cholecystogram, acute cholecystitis and/or presence of common bile duct stone. Six patients (5%) were converted into an open surgery, and 3 (2.5%) of them were caused by intraoperative accidents. Only one of patients with negative cholecystogram as well as acute cholecystitis or common bile duct stone required open conversion. Postoperative complications occurred in 13 patients (11%), but most of them (12/13) were minor troubles. Liver dysfunction appeared in 56 patients (49%)postoperatively, which had a significant correlation with the time required for pneumoperitoneum.
Experts on laparoscopic cholecystectomy can apply the procedure for most patiens with negative cholecystogram, acute cholecystitis and/or common bile duct stone. As the time for pneumoperitoneum is prolonged, liver dysfunction may increasingly occur. We think that laparoscopic cholecystectomy should be carried out within 120 minutes that appear the safety margin for pneumoperitoneum.

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We experienced a series of 106 cases of gallbladder cancer operated on with a preoperative diagnosis of benign gallbladder disease which came to be first diagnosed as the cancer during or after the operation. We investigated especially 14 cases of those with a preoperative diagnosis of acute cholecystitis. Ten cases were confirmed to have cholecystolithiasis. All acalculous cases had a lesion in neck of gallbladder, obstruction of the cystic duct due to a tumor might cause acute cholecystitis. We should entertain a possibility of gallbladder cancer in the treatment of acalculous acute cholecystitis. It is difficult to differentiate between invasive tumor and atrophy of the wall due to acute cholecystitis based on preoperative imagings and intraoperative frozen section diagnosis. There was a case diagnosed as acute cholecystitis even though irregular wall was observed which was considered as a change due to cholecystitis. More careful attitude not to be deceived by any findings suggesting that the lesion is likely cholecystitis is needed. In cancers with an invasion depth more than subserosal layer, cholecystectomy with resection of liver bed and lymph node dissection showed a better prognosis than cholecystectomy alone. Cancers with an invasion depth of muscular layer can have vascular invasion. So aggressive reoperation should be employed for cancers with the depth of more than muscular layer.

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The purpose of this study is to determine three components, cholesterol, calcium bilirubinate and black pigment in gallstone by means of infrared spectroscopy.
At a same time, chemical analysis was carried out, analytical data which were obtained by two different methods were examined on the relativity. The 1056 cm^-1 band was determined to be most suitable for the key band of cholesterol,1247 cm^-1 band for calcium bilirubinate, the two 1624 cm^-1,1247 cm^-1 bands for black pigment. Although there are a few situations limiting the usefullness of infrared spectroscopic analysis, it was expected that this method is widely applicable for clinical purpose.

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A 51-year-old man was repeatedly admitted to a nearby hospital because of fever of undetermined origin since January 1993. On July 12,1994, he was admitted to our hospital for close examination. Various examinations revealed that the duodenal papilla got impacted into the common bile duct repeatedly along with the peristaltic movement of the duodenum. There were no calculus and no carcinoma in the common bile duct, which suggested that the bile duct dilatation and cholangitis were caused by the specific movement of the papilla. Similar cases were not reported, and the cause of the papilla impaction in the common bile duct was unknown. The patient was not considered to be able to recover only by conservative treatment; therefor resection of the extrahepatic bile duct and Roux-Y hepaticojejunostomy were performed on October 27. After that, he has been doing well, and now,2 years and 9 months after the surgery, no bile duct dilatation and no cholangitis are observed.

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A 54-year-old male patient with no past history of surgery. Suffered from sudden epigastralgia. Ultrasonography, CT and ERCP revealed cholecystitis, cholelithiasis, cystic duct's obstruction and a semicircular smooth-surface tumor in the common bile duct (CBD). A peroral cholangioscopy (POSC) revealed that the tumor was an elevated lesion with a reddish, smooth surface sloping relatively gently. This suggested a submucosal tumor. A biopsy showed no malignant finding. When extripation of the gallbladder and bile duct and hepaticojejunostomy were performed, tumors of the cystic duct and the CBD,10 mm and 5 mm in each diameter, were observed. Histopathologically, these tumors were neuromas. This case of traumatic neuroma preoperatively observed by POCS is the first to be reported. POCS facilitated the differential diagnosis of neuroma from cholangioma and helped avoid excessive surgical invation.

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A case of bile peritonitis after t-tube removal, showing a sign of incomplete formation of t-tube fistula is reported. An 81-year-old woman with diabetes mellitus underwent laparotomical cholecystectomy and choledocholithotomy for cholecysto-choledocholithiasis, and a latex rubber ttube was inserted. A large amount of non-biliary exudate flowed outside from the periphery of the tube. Because of this exudate flow, everyday dressing around the tube was necessary until the 14th postoperative day. Except for this phenomenon the patient was well. After a common t-tube cholangiography was performed, the tube was removed 22 days after the operation. But she developed bile peritonitis and re-laparatomy was performed. After that she made an uneventful recovery. The cause of bile peritonitis of this case is delayed fistula formation. Phenomena of exudate flow from the periphery of the tube is considered an indirect sign of t-tube fistula immaturation.

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A 64 year-old male was found by endoscopy to have a gastric cancer on the anterior wall of the middle stomach. Preoperative ultrasonography revealed a dilated common bile duct and absence of the gallbladder. On Iaparotomy, the dilated common bile duct was observed, and absence of the gallbladder and only the thin fibrous band at the gallbladder fossa of the liver were identified. These findings suggested congenital absence of the gallbladder.
It is reported that congenital absence of the gallbladder is often accompanied by a dilated common bile duct, choledocholithiasis and malignant diseases. In patients with absence of the gallbladder, careful attention should be given to detecting these accompanying diseases.

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The authors experienced two cases of successful end-to-end anastomosis to treat the bile duct injury caused by laparoscopic cholecystectomy. Case 1 was a 51-year-old woman. The bile duct injury could not be found intraoperatively. Jaundice occurred postoperatively and the bile duct occlusion was found. End-to-end anastomosis was performed, but the anastomosis was occluded in the 4th postoperative month. As the occluded bile duct was less than 1 cm in length, the second endtoend anastomosis was performed. A splint tube was left for 9 momths. Case 2 was a 28-year-old woman. Hemorrhage occurred during the rough procedure of the Calot′s triangle. As clipping for the hemorrhage was done in a blind manner, not only the right hepatic artery but also her bile duct were clipped. The occluded bile duct was 2 cm in length, but end-to-end anastomosis was performed, considering the patient′s young age the patient. A splint tube was left for 7 months. In the bile duct injury, end-to-end anastomosis which can reservepapillary sphincter muscle function should be a treatment of the first choice and a splint tube should be left for at least 6 months.

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The case presented was a 53-year-old female suffering from breast cancer. Before mastectomy, an abnormal mass in the lower part of the common bile duct and dilatation of common bile duct were noted on ultrasonography. After mastectomy, Computed tomography revealed a dilatation of the common bile duct and an abnormal mass in the common bile duct. Endoscopic retrograde cholangiopancreatography demonstrated a dilatation of the intrahepatic and extrahepatic bile duct and an anomalous junction of the pancreaticobiliary duct. At laparotomy, the tumor was detected in the dilated common bile duct. Pancreato-duodenectomy was performed and the resected specirevealed the existence of poor-moderately diff. adenocarcinoma,20×25 mm in size, invading the pancreas. The patient has been well for 63 months after surgery.
A long term survival case of advanced bile duct cancer associated with congenital choledochal dilatation in relatively rare. This paper describes the rare case with a review of the literatures.

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