Pancreatoduodenectomy is a basic technique of radical surgery for middle bile duct cancer, but some patients who underwent bile duct resection can be also long term survivors. In the present study, the authors examined curability of bile duct resection for middle bile duct cancer. Noncurative factor of bile duct resection was hw factor in 61.5%, dw factor in 76.9%, ew factor in 69.2%, and n factor in 30.8%.
The most frequent was dw factor and n factor was also frequent. Significant difference in cumulative survival rate was noted between curative resection and non-curative resection. Longterm more than 3 years survivors were 7 and macroscopically made up as follows: papillary type 1, papillary invasion type 2, nodular type 3 and special type 1. All of them were curative resection cases. Cumulative survival rate was not significantly different between bile duct resection and pancreatoduodenectomy.
Regarding indications for bile duct resection, it can be performed for cases of stage I, papillary or nodular type of the tumor gross type and no lymphnode metastasis. Particularly, it seems to be a useful operation for inelderly patients and those who are under unfavorable general condition.

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To clarify the relation between the macroscopic appearances and extent of the carcinoma of the papilla of Vater,26 cases were examined; 25 cases underwent pancreaticoduodenectomy and a case done papillectomy. Macroscopic classification of carcinomas were based on the General Rules for Surgical and Pathological Studies on Cancer of the Biliary Tract. In addition, the exposed tumor type in the General Rules is further subclassified into three categories, non-erosive, erosive and orifice-expansive subtypes. The invasion of carcinoma beyond Oddi's muscle layer was found in 20 of 26 tumors (76.9%); all cases in non-exposed tumor type, erosive subtype and ulcerforming type were invasive, but on invasion of carcinoma in non-erosive subtype and polyp type was found. Two of four in orifice-expansive subtype were invaded beyond Oddi's muscle layer. Lymphatic metastates were found is 7 of 26 cased (26.9%) in the only three groups; non-exposed type (1/3=33.3%), erosive subtype (4/10=40%) and ulcer-forming type (2/5=40%). Intraepithelial extension in the pancreatic duct and/or biliary duct was detected in all groups (12/26=46.2%). Macroscopic characterisitics of tumors seemed to make it possible to evaluate the depth of carcinoma of the papilla of Vater.

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From February 1993 to September 1997, we performed expandable metallic biliary endoprosthesis (EMBE) in 19 patients with biliary stricture, aged 80 or over. The cause of biliary stricture in these patients included common bile duct cancer (n=13), pancreatic cancer (n=4), gallbladder cancer (n=1) and benign biliary stricture (n=1). All patients underwent percutaneous transhepatic cholangiodrainage (PTCD), followed by placement of expandable metallic stent (EMS) through the PTCD route. EMS included three Z stents, four Wallstents, seven Accuflex stents and five Memotherm stents. The stents were successfully implanted in 18 patients (94.7%) without any serious complication, and then 15 patients (78.9%) were discharged without external drainage tube. But any adjuvant therapy was not carried out after stenting because of their advanced age. The stent patency rate of the discharged 15 patients was 50.9% for 6 months and 10.9% for 12months, respectively. Stent obstruction occured in 6 of 15 (40%) patients, and didn't occur till death in 5 (33.3%) patients. The survival rate of the all patients was 56.7% for 6 months and 26.4% for 12 months, respectively. On the correlation between the survival time and Performance status (PS), there were 4 early dead cases in PS-3 group until 60 days after stenting. In conclusion we suggested that expandable metallic endoprosthesis without any adjuvant therapy was effective in the palliation of biliary stricture in patients of advanced age because of improved quality of their life. But careful consideration was necessary in EMBE for patients of advanced age, especially in poor PS group.

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We evaluated appropriate lymph node dissection according to local extension based on the state of lymph node metastasis in patients with the papilla of Vater who underwent resection.
The subjects consisted of 29 patients in whom adequate postoperative histopathological examination was performed. They were divided into three groups 8 patients with early cancer (extension limited to the sphincter of Oddi),6 with semi-early cancer (extension beyond the sphincter of Odii without infiltration to pancreatic parenchyma), and 15 with advanced cancer (infiltration to pancreatic parenchyma).
Lymph node metastasis was observed in 11 patients (37.9%): 1 (12.5%) with early cancer,2(33.3%) with semi-early cancer, and 8 (53.3%) with advanced cancer. The patients with early or semi-early cancer showed only metastasis to the first lymph node group. However, in those with advanced cancer, the first group was involved in 2 patients, the 2nd group in 2, and the 3rd group in 4.
Paraaortic lymph node metastasis (No.16b₁) was frequently observed in patients showing a high proliferating cell nuclear antigen labelling index (PCNAL. I. ). Concerning to lymph node dissection according to cancer extension, we perform D₁for early, D₂for semi-early cancer and D₃for advanced cancer, particularly paraaortic lymph node dissection for patients with a high PCNAL. I..

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A new combination treatment of endoscopic papillary balloon dilation with infusion of isosorbide dinitrate (EPBD + ISDN) was attempted to remove stones from the common bile duct (CBD) in 20patients with CBD stones, and its effectiveness and related complications were compared between the patients and 14 patients who were treated with endoscopic sphincterotomy (EST). Characteristics of patients, numbers, size and clearance rate of CBD stones were not statistically significant in either group. but transient hypotension, no irreversible reaction, as a side effect of isosorbide dinitrate not only vasodilating actions but also relaxing effects in the sphincter of Oddi was observed in one patient receiving EPBD+ISDN. Another patient in the EPBD+ ISDN group required additional EST. Increase in mean serum amylase after 24 hours later the treatment in the EPBD + ISDN group was significantly lowered rather than that in the EST group. Acute cholecystitis did not occur in all of 11 patients with gallbladder stones in the EPBD +ISDN group. EPBD+ISDN is as safe and effective as EST for choledocholithiasis (about 10mm diameter), and sphincter preserving technique.

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During the period of Feb.1994 to Dec.1997, we inserted 18 biliary endoprostheses (Wallstent and Accuflex) PTBE in 14 patient (7 men 7 women; 47-89 years (mean 66.6 years) of age) with unresectable malignant biliary stenosis. These patients were treated with Wallstent (n=8) and Accuflex (n=10), respectively. Successful placement of expandable metallic stent (EMS) were achieved in 11(79%) patients. Nine patients were discharged, but two patients remained in the hospital due to recurrent jaundice without stent occlusion. The median survival time was 198.1days. Early acute obstruction was seen only in one patient (7%) and treated by tube stenting. EMS was easy to place percutaneously. Occlusion rate was lower than that by other stents.
EMS is advantageous in the palliative treatment of malignant biliary obstruction.

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This is a report on a case of woman to whom 11-year surveillance through Percutaneous Transhepatic Cholangiodrainage (PTCD) was performed. A 43-year old woman manifesting brown urine and systemic pruritis was introduced in 1985. Diagnosis was obstructive jaundice leading to performing PTCD. Cholangiography revealed a stenotic area extended to the second branch of the hepatic ducts confluence. We applied a catheter toward the peripheral hepatic duct by U-turn. Suspecting primary sclerosing cholangitis, we improved and maintained general conditions of the case through reinforcing and improving catheter resiliency, which eased distention of the duct.
When she left hospital, the total bilirubin value was 1.9 mg/dl that was 24 mg/dlbefore PTCD. For 10 years, no serious hepatic malfunction like jaundice occurred and catheter trouble was experienced. In April 1997, she got fever and jaundice then died of suppurative cholangitis and liver abscess in June. Autopsy revealed a severe stenosis around the hepatic ducts confluence and histopathology demonstrated amputation neuroma. This is interesting out of 54 cases reported, from the standpoint of lesion development modality and limit of drainage application to a nonoperable cases.

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A case of primary sclerosing cholangitis (PSC) that nature progress was able to be observed cholangiographically during 39 months and that cholangial stricture was improved by conservative treatment with percutaneous transhepatic cholangio drainage (PTCD) is reported. The patient, a 67-year-old male, was admitted to our hospital with jaundice. The examination of ultrasound revealed thickening and layered stricture of the common hepatic duct, and cholaniographical evaluation revealed marked stricture of that portion. Cytological examination via the PTCD route showed no malignancy, and the stricture of the bile duct was improved as jaundice was improved, thus diagnosed as PSC. PTCD tube was pulled out 6 months later followed by administration of steroid agent or ursodeoxycholic acid. The patient has been in good health for 39 months after the first hospitalization, and cholangiographical evaluation revealed no irregular stricture of the bile duct.

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We experienced a case of adenomyomatosis (ADM) of gallbladder associated with anomalous arrangement pancreaticobiliary duct (APBD). The patient was a 33-year-old woman, who had a chief compliment of right hypochondralgia. After ADM with APBD was diagnosed by several imaging technology, choledocho-and cholecystectomy was performed. Pathological examination of the resected specimen revealed Rokitansky-Aschoff-sinus (RAS) with a proliferation bundle composed of smooth muscle cells. Moreover we performed histological examination and cellproliferative activity using Ki-67 immunostain to clarify relation ADM and APBD. Although chronic inflamation, fibrosis and RAS were shown in body and fundus of gallbladder, these findings were not shown in neck. In addition, Ki-67 labeling index in epithelium and smooth muscle around RAS was shown at low incidence. Therefore in this case, there was no evidence of relation ADM and APBD.

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