We reported here our experience in cases of post-gastrectomy cholelithiasis relative to its clinical characteristics and etiologies along with reference to the relevant literature.
The post-gastrectomy formation of gallstones may result chiefly as the result of dissection of the vagal trunks, however, it should also be noted that the gastrectomy itself may also exert major influence upon the change of the bile constituents.
Most of the post-gastrectomy gallstones are formed within 5 years of the operation. When those stones formed within 10 years of the surgery were examined, there were several common features as follows: Calcium bilirubinate stones were the most common, and the incidence of black stones was inconspicuous.
Our tentative conclusions were as follows: Even though the etiologies of formation of calcium bilirubinate and black stones are different from each other, their formation is influenced by both gastrectomy and dissection of the vagal trunks in such a complex way that calcium bilirubinate stones are formed in one occasion and black stones in another.

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Clinicopathological features of 55 cases of choledochal cancer excluding intra-hepatic and Vater's papilla cancer were investigated with reference to the macroscopic figures (papillary: P, nodular: N, diffuse: D), histopathology and immunohistochemical expressions (p53 protein, PCNA, E-cadherin, MMP2, MMP9, MUC1, MUC2).
D type revealed most malignant natures, including poor histologic differentiation, high lymphatic invasion and high p53 immunoreactivities correlated with both well histologic differentiation and expansive growth, while positivities of MMP2 in the tumor interstitial cells correlated with irregularly invasion. MMP9 showed high positivities in deeply invasive, histologically poorly differentiated and lymphatic invasion groups. Prognosis of MUC1-negative cases was more favorable than of MUC1-positive ones.

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Metallic stents (MS) were widely used as a noninvasive biliary endoprosthesis. However, we sometimes experience a case without improving the quality of life (QOL), that is an essential aim, following the placement of metallic stents. In this study, the problems and its treatments for improving the QOL were evaluated from our experiences. The occurrences of restenosis and complication in 51 cases with malignant biliary stenosis were evaluated on each background such as the route of insertion, sorts of devices, causative disease, stenosis levels and adjuvant therapy. The restenosis occurred in 29% and 80% of the reasons were the tumor growth. The severe complications were present in 14%. Although the average rate of successful placement through each route alone such as transhepatic or transpapillary was 86%, the successful rate increased to 94%by using the other route if one route was failed. The significant differences of the number of restenosis were seen in the sort of device (Wallstent<the others) and causative disease (pancreatic cancer<bile duct cancer, lymphnode metastasis). On the other hand, the complications did not have a significant difference on every background.75% of the cases complicated with refractory cholangitis or liver abscess were without preserving the function of papilla. Therefore, the important points for improving the QOL on MS placement were as follows.1) The other route should be tried for the refractory to the insertions.2) The use of Wallstent is recommended.3) The longer MS should be indicated for the lymphnode metastasis that is easy to grow longitudinally.4)The function of papillia is to be preserved as much as possible.

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Endoscopic papillary balloon dilation (EPBD) was performed in the 21 patients with common bile duct stones, and its effectiveness and related complications were compared with the 21 patients who were treated with endoscopic sphincterotomy (EST). Characteristics of patients, numbers and size of stones were not statistically significant in either group. All stones were completely removed in both of the groups. As for the complications of EST, one patient experienced pancreatitis and two cholangitis. But these complications did not occur in the EPBD group. Increase in serum amylase on the next day of the treatment in the EPBD group was significantly lowered rather than that in the EST group. EPBD was useful for the extraction of common bile duct stones, because it was easier and safer technique than EST.

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One hundred and ninety four patients with gallbladder stones were treated by extracorporeal shock wave lithotripsy (ESWL). Clearance rate was 37.1% at 60 months (Kaplan-Meier analysis). Clearance rates in cases with fragments smaller than 3 mm in diameter and bigger than 4 mm were 66.4% and 15.4% at 5 years after ESWL, respectively. Solitary pure cholesterol stones small than 20 mm in diameter were disappeared in 78.8%. Stone recurred in 11.5% of cases at 60 months after complete clearance. Symptoms such as colic, cholecystitis and jaundice appeard in 7.5% of patients with fragments at 5 years after ESWL. Symptom-free rate after ESWL was not different from that in untreated patients. ESWL is useful in select patients with gallbladder stones.

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Hepatobiliary cystadenoma with mesenchymal stroma (CMS) was first identified by Wheeler in 1985 as a distinct clinicopathologic entity, and he called attention to the exclusive occurrence of CMS in women. A case of CMS with ovarian-like stroma causing obstructive jaundice is reported. A 34-year-old female was admitted to our hospital because of obstructive jaundice. Abdominal imagings (ultrasonography, computed tomography, cholangiography) revealed a cystic mass lesion, measuring 12 cm, in the liver (S4,5) and a stricture of the common hepatic duct. The total cystectomy with partial hepatectomy were done. Microscopic findings showed the lining epithelium composed of the columnar cells and the densely cellular stroma composed of spindle (ovarian-like)cells. Immunohistochemical studies showed the positive staining for CA19-9 and BerEP4 in the epithelium, and showed positive staining for α-smooth muscle actin and vimentin in the mesenchymal stroma.

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A case of carcinoid tumor arising in the duodenal papilla was reported. A 42 year-old female was admitted with a complaint of nausea. Endoscopy of the upper gastrointestinal tract revealed a tumor in the second portion of the duodenum. The tumor with constriction at the base was three centimeters in diameter and had smooth mucosal surface. A shallow depression believed to be the papilla was identified at center of the tumor, but cannulation was not succeeded. Hypotonic duodenography revealed a tumor with diameter of three centimeters with bridging fold at the second portion of the duodenum. These findings suggested the diagnosis of carcinoid tumor, but the histopathological diagnosis was not obtained. At operation, the duodenum was incised first, and the tumor and the adjacent normal mucosa including the muscle of Oddi was resected. Frozen section examination suggested a neuroendocrine tumor with severe invasion to the muscle of Oddi. Pancreaticoduodenectomy was performed. The final histological diagnosis was carcinoid tumor, and no remnant of the tumor was found in the specimen resected by pancreaticoduodenectomy. Uncertainty of the preoperative diagnosis and the histological finding of the frozen section suggesting invasion to the muscle of Oddi required pancreaticoduodenectomy although there is possibility that unnecessary PD was performed in this particular case.

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The patient is a 67-year-old man who visited our clinic with a chief complaint of jaundice. Endoscopic Retrograde Cholangiography revealed a narrowed lesion 3 cm in length t hat was localized in the upper portion of the bile duct. We suspected bile duct carcinoma and performed laparotomy. During the operation, rapid pathological diagnosis revealed no malignancy. We suspected primary sclerosing cholangitis (PSC); and then, excised the narrowed lesion in the upper portion of the bile duct and performed choledochojejunostomy (Roux-en-Y). Pathological examination of the resected specimen revealed PSC.
It is extremely difficult to differentiate localized PSC from bile duct carcinoma before surgery. The patient has been in good health for 48 months after the operation. A further investigation regarding post-excision, long term prognosis of localized PSC is necessary.

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A case of hilar bile duct carcinoma with residual cancer cells at the surgical margin effectively treated with radiotherapy that progress was uneventful over 8 years is reported. The patient, a 71year-old male, was admitted to our hospital with liver dysfunction. The examination of abdominal imagings revealed irregular stricture of hilar bile duct. Cytological examination via the percutaneous transhepatic cholangio drainage route showed aclenocarcinoma cells, thus diagnosed as hilar bile duct carcinoma, cholecysto-choledochectomy was carried out. Intraoperative histological examination of the surgical margin showed residual cancer cells in the fibro-elastic layer at two bile ducts. Intraoperative radiation therapy was given in a total dose of 20Gy to the stump of the bile ducts and dissected area of the liver hilus. Furthermore, postoperative external radiotherapy was given in a total dose 45Gy to the same portion. The patient has been in the good health over 8 years, and it suggested that radiotherapy is an efficacious selection in the treatment of hilar bile duct carcinoma with microscopical residual cancer cells at the surgical margin.

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