In this study we performed common bile duct repair using non-perforating vascular closure staple (VCS) clips made of titanium that were originally developed for vascular anastomosis, and evaluated the effectiveness and problems associated with their uses. VCS clips were used in 7laparotomy operations and 13 laparoscopic operations in patients with common bile duct stones. In the laparotomy operations, the VCS clips were effective and useful for primary closure of the common bile duct. In laparoscopic choledochotomy, to close common bile duct directly using VCS was possible by using stay sutures and forceps, however bile leakage and stenosis of bile duct were occurred after operation in one emergent case. In other cases, bile duct stenosis and recurrence of stones have not occurred after operation. We suggest that VCS clips may be useful for primary closure of the common bile duct.

View full abstract

Several procedures of lithotripsy for common bile duct (CBD) stones were certified and were reported. However, it is controversial which option is the best therapeutic strategy for CBD stone lithotripsy. Regarding the advantage of preserving sphincter contraction and the efficient combination of procedures, we compared each management and estimate whether extracorporeal shock wave lithotripsy (ESWL) is able to be a first choice for CBD stone's management. Without any additional procedure, the complete stone extraction rate was achieved in 83.3% of patients in the EST group, in 80.8% in the EPBD group, and in 67.6% in the ESWL group, however, to analyse the therapeutic effect of each procedure on the stone size, patients were divided into the two subgroups by stone size (group A; stone diameter <10 mm, group B; stone diameter≥10 mm). In group A, this rate was achieved in 100% in the EST, in 90.0% in the EPBD, and in 69.2% in the ESWL, in contrast, in group B,60.0% in the EST, in 42.9% in the EPBD, and in 62.5% in the ESWL. The analysis of components of stone residues that resist to ESWL showed that the rigidity of stone was soft in 92.9%.
These results suggest that for the management of CBD stones, ESWL will be recommended as a first choice, especially for large stone and reveal that ESWL is not proper procedure for the stone which rigidity is not so hard.

View full abstract

Although Endoscopic Papillary Balloon Dilation (EPBD) has been widely performed for patients with bile duct stones, there are still some issues such as indications for EPBD and prevention of pancreatitis after the procedure. The precut sphincterotomy was performed before the papillary balloon dilation (preEST+EPBD) to make the approach to bile duct orifice easier and to prevent pancreatitis after the procedure, when the patients had bile duct stones of 10 mm or larger. The final success rate, average number of sessions for a single patient, and occurrence of pancreatitis after the procedure were not so different from the outcomes of EPBD carried out on patients with bile duct stones smaller than 10 mm. These results suggest that preEST+EPBD may be useful and safe for the patients with large size of stones.

View full abstract

In 54 patients with gallbladder cancer resected in our department, their diseases were classified into 4 stages according to the general rules for surgical and pathological studies on cancer of the biliary tract (GRSPS) (the 4 th edition) and the pTNM classification (5 th edition) and their follow-up outcome were investigated.
The number of patients on each stage classified according to the GRSPS were as follows: stage I: 18, stage II: 20, stage III: 7, stage IV a: 6, and stage IV b: 3 and those according to the pTNM classification (the 5 th edition) were stage I: 20, stage II: 12, stage III: 16, stage IV A: 3, stage IV B: 3. Thirteen cases (24%) were inconsistent between the both stages, and these factor was progression in the perigallbladder region in four and lymph node metastasis in nine. The inconsistent cases due to progression in the perigallbladder region were classified into stage IV a in the GRSPS and stage III in pTNM classification and all patients died of recurrence within one year after surgery. Among the inconsistent cases due to lymph node metastasis, cases that were positive for metastasis only in the first group lymph nodes were classified into stage II in the GRSPS, while stage III in pTNM classification. All these patients are still alive. In conclusion, patients classified into stage III by pTNM classification should be carefully treated, because they could be subdivided into two different populations with either favorable or unfavorable prognosis following radical surgery.

View full abstract

Choledochocele is a rare abnormality of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct. We reviewed four our cases and 55 cases found in the literature, and proposed a classification of choledochocele, subdividing into three groups in view of flow of bile and pancreatic juice as follows; (A type: 21 cases) cystic dilatation of the common channel, (B type: 21 cases) cystic dilatation of the terminal portion of the common bile duct opened into the duodenum forming common channel with the pancreatic duct, and (C type: 17 cases) cystic dilatation of the terminal portion of the common bile duct opened into the duodenum separately from the pancreatic duct. Acute pancreatitis occurred in 9 cases of A type, and 6 cases of B type. Choledochocele forming the common channel with the pancreatic duct is frequently associated with acute pancreatitis, probably due to stasis of pancreatic juice or reflux of bile duct into the pancreatic duct. Especially in A type, we should noto the occurrence of the biliary carcinoma, due to reflux of pancreatic juice into the bile duct.

View full abstract

The patient was a 61-year-old man who had a chief complaint of abdominal pain and high fever. According to CT and US examination, he was diagnosed as choledocholithiasis. Endoscopic findings demonstrated two separated orifices. The orifice on the oral side was located inside the diverticulum. Endoscopic retrograde cholangiography (ERC) revealed three stones,13 to 15 mm in diameter, in the common bile duct (CBD) Endoscopic papillary balloon dilation (EPBD) was performed and CBD stones were removed after broken by mechanical lithotripsy (ML). Two days later, laparoscopic cholecystectomy (Lap-C) was performed for cholecystolithiasis. On the sixth postoperative day, two residual stones in CBD were completely removed endoscopically. No complications after the removal of stones by EPBD occurred. The separated orifice of the common bile duct from the pancreatic duct orifice was rarely encountered, and was reported to appear at lower than 4% in Japan. EPBD seemed useful and safe for the treatment of CBD stones even with the bile duct opening inside the diverticulum.

View full abstract

Jaundice developed and hilar bile duct cancer was diagnosed in a 51-year-old woman. A cholangiopancreatogram showed pancreaticobiliary maljunction without bile duct dilatation (Shin Komi type II a) and stenosis of the hilar bile duct and the right hepatic duct. Preoperative portal vein embolization was performed because of the large percent of hepatic parenchyma to be resected (67%). Three weeks later, right hepatic lobectomy, caudate lobectomy, bile duct resection and lymph node dissection were performed. Cancer cells consisted of moderately differentiated adenocarcinomas and spreaded from the hilar part to the lower part of the bile duct, and the right hepatic duct dividing the secondary branches. Surgical margins were negative for cancer cells. In the gallbladder, localized intestinal metaplasia was noted but hyperplasia and malignant lesions were not observed. Bcl-2 expression, K-ras point mutation, telomerase activity and p 53 overexpression were also negative for the gallbladder mucosa. We reported a rare case of pancreaticobiliary maljunction without bile duct dilatation associated with hilar bile duct cancer and discussed about the carcinogenesis.

View full abstract

The patient was a 45-year-old man with alcoholic liver cirrhosis, who had chief complaints of jaundice and epigastralgia. Endoscopical retrograde cholangiography disclosed common bile duct multiple stones. Since he had Child's class C liver cirrhosis, he was inoperable. Therefore, conservative therapies were continued, but hyperbilirubinemia was not ameliorated. We performed endoscopical sphincterotomy (EST), and then placed endoscopic naso-biliary drainage (ENBD) tube in the common bile duct. Cholangiography via ENBD tube 7 days after EST showed that more than half of common bile duct stones disappeared spontaneously. We remove remaining common bile duct stones using balloon catheter. Thereafter, jaundice was rapidly ameliorated without any complications. For high risk patients, removal of common bile duct stones using balloon catheter after EST and ENBD may be safe and effective procedure.

View full abstract

A case with high amylase concentration of bile regardless of reaching the effect of sphincter to the portion of conjugation of pancreatic duct and bile duct is reported. A-50-year old woman was admitted to our hospital because of the treatment for gallstones. Abdominal ultrasonography showed 2 gallstones of 6 mm in diameter and 5 mm in width of low echoic layer which revealed mucosal and muscular layer of gallbladder. ERCP revealed the portion of conjugation of pancreatic duct and bile duct was situated outside the duodenal wall, but the effect of sphincter reached to the upper portion of conjugation. The bile duct and main pancreatic duct were not dilated. Laparoscopic cholecystectomy were performed. The value of amylase in the bile of the gallbladder was 127,932 U/l Two cholesterol stones of 5 mm in diameter were found in the gallbladder. The mucosa of the gallbladder revealed remarkable hyperplasia but no dysplasia. This case revealed same pathomorphology as anomalous arrangement of pancreaticobiliary ductal system though the effect of sphincter reached to the portion of conjugation situated outside the duodenal wall.

View full abstract

This report was a case of so-called carcinosarcoma of the gallbladder associated with anomalous arrangement of the pancreaticobiliary ductal system. The patient was a 71-year-old woman who had followed for autoimmune hepatitis were examined abdominal ultrasonography. The ultrasonography showed nodule type tumor of gallbladder. Dynamic CT showed enhancement of tumor from surface mucosa to deep tissue. We also recognized anomalous arrangement of the pancreaticobiliary ductal system on ERCP. Operation was performed in 2000 april 17 and the gallbladder, liver metastasis were resected surgically. And also infurther port system was detained to the proper hepatic artery. The pathological findings were so-called carcinosarcoma composed of well differentiated adenocarcinoma and sarcomatous elements. We treated for liver metastasis using infurther port system, but she died in 2001 January 31 for multiple liver metastasis and peritonitis carcinomatosa.

View full abstract