In order to perform hepatic resection for carcinoma of the hepatic duet confluence precisely and safely, it is significant to evaluate anatomical correlation of the vascular structure of hepatic hilus preoperatively. So we devised the Simaltaneous Cholangio-Portal CT and studied the anatomical correlation between the intrahepatic bile duct and portal vein of the left lobe.
At first, in 52 patients with obstructive jaundice, the ramifications of portal systems and biliary systems of the left lobe were examined respectively by 4 modalities(Portal CT, Cholagio CT, SMA portography, and Cholagiography), and classified into 4 types. As a result, two duct systems had the same pattern of ramifications in only 27%, and it was suggested that portal branches and biliary branches were not always parallel in hepatic hilus of the left lobe.
Next, Simaltaneous Cholangio-Portal CT was performed in 13 patients. In all 7 cases of Type 1(left lateral superior subsegment biliary branch: B2 and left laterel inferior subsegment biliary branch: B3 joined together to form common duct, which joined the medial segment biliary branch: B4), B2 and B3 joined beyond the umbilical portion(; in the left side of umbilical portion). So, it is considered that the point where B2 and B3 joint, might be clitical point, when performing hepatic resection for carcinoma of the hepatic duct confluence in Type 1 patient.

View full abstract

The involvement of tyrosine phosphorylation-dependent pathway in gallbladder contraction was investigated using sodium orthovanadate, a tyrosine phosphatase inhibitor, and genistein, a tyrosine kinase inhibitor. Pretreatment with sodium orthovanadate at 50μM, which did not affect the basal tension, markedly augmented the contractile response to KCl in the gallbladder strips isolated from guinea pig. On the other hand, histamine-induced contraction was not affected by sodium orthovanadate. Ca²⁺-induced contraction of the gallbladder in the presence of BayK 8644 was also markedly augmented by sodium orthovanadate. Sodium orthovanadate at high concentrations (above 50μM)itself induced a tonic contraction of guinea pig gallbladder, which was abolished in the absence of extracellular Ca²⁺ or in the presence of verapamil(1μM). Ouabain-induced contraction was further augmented by sodium orthovanadate and this contraction was inhibited by pretreatment with genistein. Genistein(30μM)strongly inhibited contractile response to histamine, but not that to KCl. These results suggest that tyrosine phosphorylation-dependent pathway is involved in gallbladder contraction through activation of voltage-dependent Ca²⁺ entry mechanism.

View full abstract

To investigate the contribution of β-catenin to the development of gallbladder carcinoma, we searched for genetic alterations of the β-cetenin gene, ctnnb-1. Mutational analysis of exon 3 in ctnnb-1, which encodes the serine/threonine residues for GSK-3β phosphorylation sites was performed for 5 gallbladder cancers with pancreaticobiliary malunion, PMB and 8 noncancerous tissues with PBM. PCR-SSCP analysis showed super-shifted bands in the electrophoretic display, but no mutation was detected through nucleotide sequencing analysis near potential GSK-3βphosphorylation sites. We also performed immunohistochemical analysis of β-catenin protein in all cases, and confirmed accumulation in both the nucleus and cytoplasm in three of 5 cancer tissues, while neighboring noncancerous tissue and the biliary tissue with PBM alone displayed membrane staining. Our results indicated that abnormal Wnt-wingless signaling, resulting in β-catenin accumulations, might be involved in the malignant transformation rather than the development of gallbladder carcinomas.

View full abstract

We evaluated the usefulness and problem of biliary endoprosthesis utilized biliary stents, Expandable Metallic Stent (EMS) and Plastic Tube Stent (TS), for irresectable malignant biliary strictures. In lower part of biliary stricture group, there was significantly longer in the patency of EMS than that of TS, but in hilar biliary stricture group, there was no differences in the patency among them. Owing to perform biliary stenting, Performance Status (PS), was improved in 13 out of 14 patients (92.9%) to PS-0 or PS-1. Recurrent jaundice due to stent occlusion was major complication. Especially, in the hilar biliary stricture group, occlusion of EMS was observed in 3/3(100%)at the mean period,80.6±7.3 days. ln the future, newly treatment devices for irresectable malignant hilar biliary stricture should be required.

View full abstract

One hundred and eleven patients with advanced gallbladder carcinoma (Stage IV) were treated by four different regimens; group 1: trimodality treatment with local hyperthermia using Thermotron RF-8, chomotherapy and radiotherapy (23 patients), group 2: R0-resection (9 patients), group 3: R 1,2-resection (30 patients), group 4: chemo and/or radiotherapy (49 patients). In group 1, complete response and partial response of the tumor evaluated with follow-up CT were obtained in 4 and 10 cases respectively, and complete and partial resolution of biliary obstruction evaluated by cholangiography were detected in 4 and 7 cases of 16 cases with obstruction or stenosis of bile duct. Mean survival months of group 2 was the longest (25.6 months); however, the difference in the survival rates between group 1 and 3 was not significant, and there was a significant difference between group 1 and 4. Trimodality treatment for advanced gallbladder carcinoma is useful in the control of the tumorous invasion to the hepatoduodenal ligament, which resulted in elongation of survivals and improvement of QOL for the patients.

View full abstract

We experienced a case of hepatoduodenal ligamentectomy after transcatheter arterial embolization (TAE) of the proper hepatic artery (PHA) for middle bile duct carcinoma. A 55-year-old man was admitted with liver dysfunction. Preoperative diagnosis was middle bile duct carcinoma with invasion to hepatoduodenal ligament. Angiography revealed replaced left hepatic artery (RLHA)from left gastric artery. TAE of the PHA was performed in order to develop intrahepatic collateral circulation preoperatively. Three weeks after TAE, angiography revealed intrahepatic collaterals from RLHA developed. Liver function after TAE was normal. Hepatoduodenal ligamentectomy and pylorus preserving pancreatoduodenectomy was performed. Portal vein was reconstructed by end to end direct anastotnosis, without reconstruction of the hepatic artery. The postoperative courses were uneventful. Liver function returned to almost normal values within 5 days of the operation. Thirty-four days after the operation, the patient was discharged. Preoperative TAE of the PHA would be a procedure that might enable hepatoduodenal ligamentectomy safely without reconstruction of the hepatic artery.

View full abstract

The case is a woman of 57-year-old, and underwent the laparoscopic cholecystectomy with the diagnosis of the chronic cholecystitis 15 months ago. Though abdominal ultrasonography undergone at that-time showed slight wall thickning and swelling of the gallbladder, cholecystolithiasis could not be recognized. And in DIC, the gallbladder was not depicted.
This time she had an obstructive jaundice and PTCD was performed. Cholangiogram via PTCD showed the complete obstruction of the common hepatic duct, and it was diagnosed as a bile duct cancer. In the operative findings, the remnant cystic duct of the gallbladder adhered to the bulbus of the duodenum, and since there is an adenocarcinoma in the peeled lesion, the pancreatoduodenectomy was performed. It was pathohistologically primary well differentiated adenocarcinoma of the cystic duct of the gallbladder.
In the case that the gallbladder is not depicted with direct cholangiogram and that there is swelling of the gallbladder, it always wakes up in the mind in respect of the coexistence of the cancer of the cystic duct of the gallbladder, and the indication of the laparoscopic cholecystectomy should be prudently decided.

View full abstract

The patient was a 72-year-old female who had a chief complaint of palpable abdominal wall mass. According to her medical records, she had undergone laparocholecystectomy for cholelithiasis, and choledochotomy and EST for choledocholithiasis. We recognized the mucous secretion from the abdominal wall mass and performed a biopsy of the left intrahepatic bile duct tumor. On the basis of the results obstained from the biopsy, we made a diagnosis of mucinous adenocarcinoma. Percutaneous transhepatic cholangiography (FTC) revealed a fistulation between the left lateral descending branch of the intrahepatic bile duct (B₃) and the abdominal wall mass. Efflux of the contrast medium from the mass was observed. Percutaneous transhepatic cholangioscopy (PTCS) disclosed a mucin-producing papillary protuberant lesion mainly in the lateral segmental branch extending to the left hepatic duct. Accordingly we made a diagnosis of mucin-producing cholangiocarcinoma complicated by abdominal wall infiltration and carried out left lobectomy. Nine months after the operation she died of cancerous peritonitis. We reported a rare case of mucin-producing cholangiocarcinoma complicated by continuous abdominal wall infiltration which we treated, together with some bibliographical comments.

View full abstract

A 64-year-old man was admitted to the hospital with complaints of right upper quadrant pain and fever. On admission the laboratory tests revealed a l7,600/μl of white blood cell count and 18.7mg/dl of CRP. An abdominal CT showed multiple low density lesions in the gallbladder wall and in the liver of S4+S5 and the gallbladder bed. After administration of antibiotics, the CT findings of the multiple low density lesions were remarkably decreased. Under a diagnosis of xanthogranulomatous cholecystitis (XGC) with multiple liver abscesses, cholecystectomy and opening the remaining S4 liver abscess were performed. On the permanent sections, we made a diagnosis of a xanthogranulomatous cholecystitis from the findings of granulomatous lesions consisting of multinuclear histiocytes in the gallbladder wall.
XGC is usually detected as a focal lesion of gallbladder wall, so this case is rare because of the diffuse lesion spreading all of the gallbladder wall with multiple liver abscesses.

View full abstract