We examined postoperative survival results of 87 cases of hepatohilar bile duct carcinoma that underwent surgical resection in terms of the macroscopic type, histological type, degree of microscopic tumor invasion to the vessels and nerves, degree of extension surrounding the bile duct (t-category), comprehensive stage and comprehensive curability (cur). For t-category in differ ent histological types, total cases of t₁ and t₂ were as high as 62 % and 67 % in cases of pap and tub,; cases of t₁ included pap (54 %) tub₁ (20 %), tub₂, (3 %) and tub₃(0 %). For the proportion of comprehensive stages in different histological types, cases of stage I were frequent in pap and tuba cases, and cases of stage IV were frequent in tub₂ and tub₃ cases. This may be attributed to the fact that cancerous infiltration to the bile duct wall was frequent in tub_2-3 cases and intraluminal -expansive growth was observed and symptoms developed earlier due to biliary obstruc tion in pap cases. In pap and tubs₁ cases, there were macroscopic cases of expanded papillary type in as many as five of 13 cases (38 %) and those of expanded nodular type in as many as five of 15 cases (33 %), respectively, while in tub₂ and tub₃ cases, there were as many as 84 % and 93 % of cases of macroscopic invasive type including the papillary invasive type, the nodular invasive type and the flat invasive type, respectively. Thus, 'histological types may be conjectured from macroscopic types. Non-resection multidisciplinary treatment should be provided for cases where the stromal invasion surrounding the bile duct is remarkable and the hepatoduodenal ligament is expected to have a stick-like shape as a result of cancer-invasion to the hepatoduodenal ligament through various pre-operative diagnostic irnagings; aggressive extended radical operation satisfying cur A should be provided for cases where intraluminal growth is significant to achieve long-term survival. Thus, it may be important in terms of medical economics also to adopt a rational treatment system.

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Recent advances in color Doppler technology have allowed us to evaluate hemodynamics of the digestive organ. With the use of power Doppler imaging (PDI), for example, cystic arteries can be delineated as linear signals, so that Fast Fourier Transformation (FFT) analysis data can be obtained easily. The aim of this study is to assess the usefulness of PDI and FFT analysis for diagnosing wall-thickened lesions of the gallbladder.
The subjects included 16 cases of gallbladder cancer,95 cases of acute cholecystitis,9 cases of granulomatous cholecystitis,20 cases of chronic cholecystitis, and 45 cases of GB adenomyomatosis.
The machine used in this study was Acuson Sequoia 512 system (California, USA).
Doppler signals were detected in all patients, and linear pattern signals were seen in most of the thickened wall. Maximal velocity values (Vmax) of the cystic artery were significantly higher in GB cancer, acute cholecystitis, and granulomatous cholecystitis. Pulsatile index calculated by FFT analysis were also higher in patients with GB cancer, acute cholecystitis, and adenomyomatosis. As for the differential diagnosis of gallbladder cancer from other wall thickening diseases, the Vmax value of 40 cm/sec or more and PT value of 1.29 or more seemed to be suggestive to the cancer.
In conclusion, the evaluation of cholecystic flow by PDI and FFT analysis seems to be useful for the differential diagnosis of the wall-thickening lesions of the gallbladder.

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A case of bile duct carcinoma associated with superficial spreading is reported. A-77-year old woman was admitted to our hospital because of jaundice and upper abdominal pain. Abdominal ultrasonography revealed swelling of the gallbladder and dilatation of the intrahepatic duct. The cholangiography via PTBD revealed the defect of about 3 cm indiameter at the middle bile duct. Irregularity of the bile duct was recognized at the hepatic side from defect. PTCS revealed granular mucosa at the hepatic side from papillary tumor. Under the diagnosis of bile duct carcinoma associated with superficial spreading, pylorus preserving pancreatoduodenectomy was performed. Microscopically papillary, adenocarcinoma invaded to fibromuscular layer at the middle bile duct. The extension of the superficial spread of cancer was almost same at the preoperative estimation.

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We reported a case of primary sclerosing cholangitis (PSC); global type, stage II, in which ursodeoxycholic acid (UDCA) was effectiv teo normaliz tehe serum alkaline phosphatase (ALP)level. The patient was a 66 year-old man whose liver dysfunction was evaluated as the elevated level of ALP and positive anti-nuclea arntibody (ANA). In the intra-and extra-hepati bcile ducts, the wall-thickness was revealed by ultrasonography, and multiple narrowings and dilatations were characterized by endoscopic retrograde cholangiography(ERCP). In histopathology of the liver, fibrosis and chronic inflammation infiltrated the priporta pl arenchym tao form ‘piecemea nlecrosis’, and thus, the patient was classified stage II. The serum ALP level was normalized by administration of UDCA (600 mg/day) for 7 months, and thereafter, it remained within a normal range. Although the efficacy of UDCA for PSC was reported to be limited at stage I, this study suggested that a relatively old subject could successfully be treated by UDCA even at late stages.

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A 61-year-old woman with jejunobiliary anastomoses presented with biliary obstruction and ileus. Percutaneous cholangiography revealed strictures in all four anastomosed intrahepatic biliary tree due to recurrent cancer of jejunobiliary anastomoses. The patient was relieved of ileus by enteric bypass and was unifit for bypass surgery for the strictures of anastomosed intrahepatic biliary tree. Successful palliation of the biliary obstruction was achieved by placing metallic stents across the anastomotic jejunum and biliary stricture via the percutaneous transjejunal route. There were no procedure-related complications. This patient died approximately 3 months later without jaundice or complications.

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A case of laparoscopic cholecystectomy in a patient with surgical drainage for acute pancreatitis was reported. A 63 years old man who was performed surgically drainage for alcoholic pancreatitis was admitted to our institution complaining with right subcostal pain due to the attack of cholecystolithiasis. A linear incisional scar at the middle, two tiny scars at the left and one at the right side caused by effecting of surgical drainage were showed on the upper abdomen. We performed laparoscopic cholecystectomy after setting up the first trocar on upper quadrant of the abdomen with open laparotomy method, the second for the scope on near the right side of navel under laparoscopic observation and the third for right hand at the epigastric region avoiding peritoneal adhesion. The cholecystectomy was achieved completely by laparoscopic procedure and the postoperative course was good.

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We experienced a case of surgical clip within a common bile duct stone after laparoscopic cholecystectomy (LC). The patient was an 81 year-old-woman with cholecystolithiasis, who underwent the LC in another hospital in 1995. The operation was converted to an open cholecys tectomy to stop bleeding In June 1998 the patient suffered high fever and vomiting. Computed tomography demonstrated one stone within surgical clip in the common bile duct. Surgery was performed in June 29,1998. The stone was a pigmented gallstone with a nidus comprised of metal clip used in the LC. We performed choledocholithotomy and T-tube drainage and the patient had an uneventful recovery. Surgical clips have previously been reported to form choledochal stone. In this case the clip were located at the end of the cystic duct near the juncture with the common bile duct. Surgeons must, exercise caution in the use of surgical clip and electric cauterization to avoid damage to common bile duct, which can result in local inflammation around the common bile duct.

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