We report the significance of routine intraoperative fluoroscopic cholangiography (IOC) during laparoscopic cholecystectomy (LC) in 1,179 cases. In 1,159 out of them (98.3%) IOC was successfully carried out, and there were very few technical troubles during IOC. Out of 135 cases diagnosed of common bile duct (CBD) stones by IOC,133 (98.5%) had CBD stones seen by choledochoscopy. Endoscopic retrograde cholangiography (ERC) was performed in 229 cases (20%) of the same series. Among 86 cases with positive ERC,78 cases (91%) had CBD stones with positive IOC, while the other 8 (9%) had no stones with negative IOC. Among 143 cases with negative ERC,136 cases (95%) had negative IOC, however the other 7 (5%) had positive IOC with stones. Unsuspected CBD stones were firstly found in 24 cases (24/1,159,2.1%) during IOC and followed by laparoscopic CBD exploration. Only two cases with negative IOC had retained stones after LC. Aberrant bile duct was found in 28 cases (2.4%). In 4 cases (0.3%) bile duct injury was found by IOC, and in 3 out of them the CBD had been misidentified as cystic duct but complete transection of CBD was avoided.
Routine IOC is useful tool to detect CBD stones and less invasive than ERC. It can be performed in almost all cases with less complications, and avoid unnecessary CBD exploration. It is very helpful for LC to realize the current anatomy of biliary tract and to prevent severe bile duct injury. We conclude that routine IOC is necessary for safety and good prognosis of LC.

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To elucidate the effectiveness and problems of radiotherapy for the advanced biliary tract cancer,19 cases with the biliary tract cancer adding radiotherapy (7 cases with bile duct cancer and 12 cases with gallbladder cancer) were stratified into two groups: 3 cases with microscopically non-curative resection adding radiotherapy (group I) and 16 cases with macroscopically noncurative resection or non-resection adding radiotherapy (group II). In the group I, one case of bile duct cancer has been alive for 8 years and 9 months, and the other case had survived for 1 year and 8 months, and one case of gallbladder cancer has been alive for 2 years and 2 months. Survival periods in 12 of 16 cases of group II were within 1 year. But recanalization of bile duct was recognized in 2 of 4 cases of bile duct cancer with external radiotherapy and 7 of 8 cases of gallbladder cancer with external and/or intraoperative radiotherapy. Moreover, in 5 of 6 cases with biliary stent, patency of billary stent had been kept until death. From the above results, radiotherapy is suggested to be effective on the prognosis in group I, and recanalization of bile duct and patency of biliary stent in group II.

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Sixty-seven patients with lower bile duct carcinoma underwent surgical resection in our depart-Of these patients,10 survived for more than 5 years (long-term survivors), while 29 died of recurrent tumor within 5 postoperative years (non-long-term survivors). We compared histological prognostic factors of these patients between the two groups. In the long-term survivors, the depth of wall invasion was mostly ss or less, and the macroscopic type was frequently the localized type. No significant difference was observed in the histological type. Lymph node metastasis was n1 or less in all long-term survivors but was n₂ or n₃ in many non-long-term survivors. Vascular or nerve invasion was not observed or, if present, was mild in long-term survivors, but it was advanced in many non-long-term survivors. Histological pancreatic invasion was panc_1a or less in more than half the long-term survivors but panc_1b or above in most ofthe non-long-term survivors. As for histological invasion, em factor was em₀ in all long-term survivors and was significantly different compared with the non-long-term survivors, but no significant difference was observed in hm factor. The comprehensive stage was I or II in many long-term survivors but was III or above in most of the non-long-term survivors. The comprehensive curability was curA or B in the long-term survivors but was often curC in the non-long-term survivors. To obtain a good long-term postoperative survival rate, surgical treatment should be indicated for tumors below stage II without vascular or nerve invasion. Even when vascular and nerve invasion is observed, they should be mild. However, the most important issue for obtaining a good long-term survival rate is to achieve above curB level of curability by radical resection of tumor.

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We studied histopathologically 6 autopsied patients with biliary carcinoma (3 gallbladder carcinoma and 3 bile duct carcinoma) treated with self-expandable metallic stent after combined therapy of local hyperthermia, chemotherapy and radiotherapy. The stent encroached into the membranous and submembranous layer and expanded the muscular layer of the bile duct. The lumen of the stent was nonpatent in 3 cases, and neoplastic proliferation across the mesh of stent (ingrowth) was detected in 3 cases. Stent was partly obstructed with debris or necrotic mass, however, no complete obstruction with carcinoma was detected. Extensive fibrosis, necrosis or granulation tissue were detected in the wall of the bile duct, which might be induced by the effect of combined treatment.
Placement of self-expandable metallic stent into the patency-restored bile duct of the biliary carcinoma after combined therapy is useful for keeping the longer patent period of the duct.

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We evaluated 56 cases underwent cholecystectomy for 62 polypoid lesions of gallbladder histopathologically. Forty of cases were diagnosed with cholesterol polyp. When ultrasonography was evaluated for the diagnosis for cholesterol polyp, the sensitivity, the specificity and the accuracy were 94%,70%, and 81% respectively.
Ninety-five % of them were smaller than 10 mm in size and 83% had multiple lesions. In 6 cases cholesterol polyp and adenoma were co-existed in each gallbladder. Two of these polyps, both of which were larger than 11 mm in size, consisted of foamy and adenoma cells. Large-sized cholespolyp should be carefully treated because cholesterol polyp larger than 11 mm in size often shows epithelial proliferation, i. e. hyperplasia, adenoma and carcinoma.

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A case provided a full of suggesting of a problem to metallic stent placement for benign biliary stricture. A 55-year-old man, in previous hospital, was placed the plastic stent for the common bile duct given a wrong diagnosis as an unresectable bile duct cancer, following external irradiation and chemotherapy was performed. Half a year after, he admitted in our hospital because of the stent obstruction. According to cholangioscopic biopsy of bile duct mucosa, no malignant lesion was observed. He refused our advice that should be undergone a operation, and wished to be tube-free, so metallic stents were placed across its stricture.2 years after, as the stents obstruction was observed according to the stent ingrowth, additional stents was placed at the bifurcation of hepatic duct and lower bile duct by stent-in-stent fashion.4 years after, a cholangioduodenal fistula was appeared.7 years after, acute obstructive supprative cholangitis was developed. In exploratory finding, granulomatous change was observed in common bile duct without as itself, and the metallic stents was buried in the hepatoduodenal ligament, partially exposed externally. Malignant finding was not seen in the resected specimens. These finding lead us that the long-term placement of metallic stents for the benign biliary stricture induced local severe inflammation which irradiation worsen.

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We described a hepatobiliary cystadenoma with estrogen receptor-positive and progesterone receptor-positive ovarian-like stroma occurring in a middle-aged woman. The multilocular cystic tumor, measuring 33×18cm, had a dense fibrous capsule and extended beyond the hepatic exterior. Nodular lesions on the cyst wall and an ovarian-like stroma consisting of densely increased spindle cells were identified. The lining epithelium of the cyst wall consisted of tall columnar neoplastic cells with mucin production and mild cytologic atypia. This was adenoma and showed papillary projections in places. The ovarian stroma-like tissue was diffusely positive for vimentin and focally positive for desmin, and may have been primitive mesenchymal cells showing differentiation to fibroblasts and/or smooth muscle. As the ovarian stroma-like tissue was positive for estrogen and progesterone receptor, hepatobiliary cystic tumors might be influenced by these hormones. Moreover, overexpression of p 53 was identified not only in the tumor cells but also in the spindle cells of ovarian-like stroma.

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We present a case of biliary dilatation combined with divism of pancreatic duct and biliary tract. The patient was a 22-year-old male. At the age of 2 years and 3 months, cystojejunostomy had been performed based on a diagnosis of congenital biliary dilatation. The patient consulted the hospital with a chief complaint of abdominal pain. A preoperative computed tomography revealed dilatation of the bile ducts from the hepatic portal region to the right and left hepatic ducts. Intraoperative cholangiography demonstrated divism of respective orifices in the biliary duct and pancreatic duct. Resection of the extrahepatic bile duct and biliary reconstruction by the Roux-en-Y method were performed. This case is interesting in terms of the pathogenesis of biliary dilatation.

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A case of localized inflammatory biliary stenosis is reported. The present case is clinically similar to bile duct cancer and histologically identical to localized primary sclerotic cholangitis. A 75 year-old man was admitted to our hospital with asymptomatic dilatation of the intrahepatic bile duct. US and CT revealed a tumor at the hepatic hilus. ERC showed smooth narrowing and obstruction of the right hepatic duct. With a diagnosis of bile duct cancer at the hepatic hilus, right hepatic lobectomy with the resection of the caudate lobe was performed. On cut surface of the resected specimen, a clear-margined round tumor,1.5cm in diameter, existed in the hepatic hilus. Histopathologically, no malignancy was confirmed, and infiltration of inflammatory cells mainly composed of lymphocytes and plasmacytes and proliferation of fibrosis were demonstrated in the wall and the neighboring area of the bile duct. We are considering that the etiology of this case was inflammatory pseudotumor of the liver caused by non-specific cholangitis due to chronic cholecystitis.

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The patient was a 43-year-old man. As abnormality of the gallbladder was pointed out at a nearby hospital, the patient visited our hospital. On abdominal CT and EUS multiseptate structure was shown at the core of the gallbladder body, which was divided into various sizes of vaculoles. Since ERCP presented the same findings, it was diagnosed as multiseptate gallbladder, a congenital anomaly, and laparoscopic cholecystectomy was performed. Histopathologically, it was adenomyomatosis, which was characterized by the highly enlarged cystic RAS, and presented unique appearance on imaging.

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