Laparoscopic cholecystectomy is the procedure of choice for patients with cholecystolithiasis, but the risk factors and consequences of a failed attempt in patients with an impacted gallstone (IG) remain unknown. We analyzed technical aspects, efficacy, and complications of the laparoscopic approach in patients with IG versus non-impacted gallstone (NIG). Subjects were 167 patients who underwent a laparoscopic cholecystectomy at the hospital between 1996 and 2001. Twenty (12%)of these patients were diagnosed with having IG. Mean operation time for IG was longer than that for NIG (148.8±49.8 min, vs96.5±36.5min, p<0.05). Mean blood loss was significantly greater for IG than for NIG(144.5±151.4g vs31.5±120.6g, p<0.05). Five IG patients(25%) required conversion to open Surgery, while one NIG patient (0.7%) required it. Mean time for the conversion was 59±47.4min in the IG patients. In most of these cases, inflammatory changes or unclear anatomical findings during the operation led to technical difficulties that required conversion to open surgery, Complications of remnant gallstones were found in two patients (10%). In conclusion, laparoscopic cholecystectomy is possible in patients with IG. Inflammation around the cystic duct, however, is the prime determinant of conversion to open surgery. Early assessment of Calot's triangle will quickly determine the feasibility of laparoscopic cholecysytectomy without wasting the time and endangering the bile duct. Physicians should maintain a low threshold for conversion to the open procedure.

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This study aimed to evaluate the usefulness of 3 D-RDSC in delineating the anatomical confirmation of the right intrahepatic bile duct (rtIHBD). Of the 49 patients,45 (91.8%) were assessable for analysis. One large branch of B 5, a subsegmental branch of B 5, downstream from the subsegmental branch of B 8 was recognized in 26.7%. The incidence of various ramified subsubsegmental branches of B 5, downstream from B 8 but without the distinguishable subsegmental branch of B 5was 33.3%. The incidence of a subsegmental branch of B 5 from the subsubsegmental branches of B 8 was 40.0%. The case in which the anterior segmental bile duct was absent was recognized at 33.3%. As to the posterior branches, the incidences of a subsegmental branch of B 6 from the subsegmental branch of B 7, subsubsegmental branches of B 6 from the subsegmental branch of B 7and subsegmental branch of B 6 from the subsubsegmental branches of B 7 were 31.7%,56.1% and 12.2%, respectively.3 D -RDSC is feasible and is a promising technique for accurate assessment of the rtIHBD ramification.

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To determine the clinical differences of the relationship between gallstones and gallbladder cancer between genders, we studied 183 cases of gallbladder carcinoma which were not associated with pancreaticobiliary maljunction among 197 cases ascertained by surgery or autopsy. These consisted of 117 gallbladder carcinomas with stones, and 66 carcinomas without stones. We also investigated 2,330 patients with gallstones but without gallbladder cancer during the same period. Women with gallbladder cancer had a higher percentage of coexistent stones than men (p<0.001). The mean age of the patients with both gallbladder cancer and gallstones was older compared to that of the patients with gallstones only, by 16 years in men and by 12 years in women. Among men with gallbladder cancer, the incidence of cholecystolithiasis increased with age, up to 80% in those in their eighties, whereas there was no such tendency among women. On the other hand, the proportion of cancer patients among cholecystolithiasis patients increased with age, and the frequencies in women were consistently higher than those in men in every 10-year group. The se facts indicate that gallstones can influence more significantly the occurrence of gallbladder carcinoma in women.

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A 43-year-old man had asymptomatic gallbladder stones and was admitted to our hospital for operation. US and CT showed two bladders, one of which had stones in. Drip infusion cholangiography revealed double gallbladder and each lumen had their own cystic duct which joined common bile duct, individually. Therefore, he was diagnosed as having double gallbladder with cholelithiasis in the one. Laparoscopic cholecystectomy was performed for both. Intraoperative cholangiography revealed that each cystic duct was opening to the common bile duct and there wasn't any sign of damage of bile duct. According to the pathological findings, the gallbladders had their own proper muscle layers, while they had continuous serosa. Preoperative and intraoperative identification of the cystic duct is important to avoid the biliary injury.

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We describe a case of porcelain gallbladder here, together with a literally review on the cases reported so far. The case was a 67-year-old woman with no symptom, who had been diagnosed accidentally 2 years previously. Porcelain gallbladder has been reported to be associated sometimes with gallbladder cancer, so open cholecystectomy was performed. There was no evidence of malignancy. When a patient is diagnosed porcelain gallbladder, operation has been recommended. But recent investigations in USA show that incidence of cancer in porcelain gallbladder is 0% or 5%, and it depends on the pattern of calcification; selective mucosal calcification poses a significant cant risk of cancer whereas diffuse intramural calcification does not. Our case was later one with no malignancy. Hereafter we should reconsider the management of patients who are diagnosed porcelain gallbladder with diffuse intramural calcification.

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Biliobiliary fistula is a rare complication in Mirizzi syndrome and its diagnosis prior to operative exploration has been extremely difficult.
A 58-year-old man was admitted for obstructive jaundice and ascites. Computed tomography on admission revealed a low density area at the hepatic hilum, dilatation of intrahepatic bile duct and severe atrophy of the right hepatic lobe. Endoscopic retrograde cholangiography showed a stone there and a smoothly stenotic common hepatic duct. From these findings, we diagnosed the illness as Mirizzi syndrome with biliobiliary fistula preoperatively, but biliary carcinoma could not be ruled out, until intraoperative pathological diagnosis proved it. In operation, we found a biliobiliary fistula between the gallbladder and the right hepatic duct. Intraoperative pathological diagnosis proved no malignancy, but the hepatic right lobe was severely atrophied, so we performed right hepatic lobectomy and common hepatic duct plasty with a T-tube. Although we could not find hepatectomy for biliobiliary fistula in the literature, hepatectomy may be a better method than hepaticoenterostomy in some cases like ours.

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A 60-year-old woman was found to have a polypoid lesion of the gallbladder by abdominal ultrasonography taken during the annual check-up in 1998. Because the polypoid lesion enlarged in December 2001, she was recommended further precise examination and consulted our department. Abdominal ultrasonography showed a broad-based elevated lesion,12 mm in size, in the fundus of the gallbladder. Abdominal CT showed enhanced wall thickening in the fundus of the gallbladder. Endoscopic retrograde cholangiopancreatography showed unclearly demarcated image defect,20mm in size, and suspected pancreaticobiliary maljunction. With the tentative diagnosis of gallbladder carcinoma, the operation was performed. At surgery a soft mass was observed in the fundus of the gallbladder. Amylase level in bile juice elevated, so we diagnosed a gallbladder cancer with pancreaticobiliary maljunction. S 4 a, S 5 segmentectomy of the liver was performed. The pathol ogical diagnosis of the tumor was adenomyomatosis with mucosal hyperplasia.

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A 96-year-old man, who had been admitted to another hospital for obstructive cholangitis as a result of common bile duct stone, was referred to our hospital for further treatment. The patient received conservative treatment for about three and a half months. Removal of the common bile duct stone by transpapillary approach was complicated by the presence of a giant juxtapapillary duodenal diverticulum. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed for biliary decompression, and papillary balloon dilatation was performed using transcystic approach. The common bile duct stone was removed successfully.
Percutaneous transhepatic transcystic papillary ballo on dilatation is minimally invasive, and the procedure is easy to perform. The results of the present case suggest that this procedure may be useful for the treatment of 1) cases in which a transpapillary or conventional percutaneous transhepatic approach is difficult to perform,2) cases in which PTGBD has already been performed for biliary decompression, or 3) elderly patients or patients with a concurrent disease.

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A 60-year-old man who had been followed up for cholesterosis of the gallbladder, was admitted to our hospital because of right upper abdominal distention and pain. Ultrasonography depicted an enlarged gallbladder with multiple tiny hyperechoic polypoid lesions. No gallstones were found. These findings were considered to represent a diffuse type of cholesterosis associated with acute cholecystitis. This patient underwent laparoscopic cholecystectomy after conservative treatment had improved acute cholecystitis. Pathologic examination of the surgical specimen demonstrated that cholesterosis involved the cystic duct as well as the entire gallbladder. The wall of the gallbladder neck and the cystic duct was thickened with inflammatory cell infiltration, which was compatible with cholecystitis. Cholesterosis in the gallbladder neck and the cystic duct seemed to obstruct bile outflow. The present case indicates that cholesterosis can cause acute cholecystitis.

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The amputation neuroma of biliary tract is a rare disease, which generally occurs in the stump of the cystic duct after cholecystectomy. The patient was a 51-year-old woman with a chief complaint of jaundice. Previously, the bile duct was injured during laparoscopic cholecystectomy and reconstruction of the bile duct anastomosis promptly enforced. As a result of radiological diagnosis we recognized the bile duct stricture near the anastomosis. Therefore, we enforced the bile duct resection and choledochojejunostomy. We recognized the amputation neuroma in the bile duct stricture by the histological inspection. Especially, as in our case of the bile duct stricture after the biliary injury, we always take into account this point and make diagnosis and medical treatment.

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The authors report a rare case of cancer of the papilla of Vater occurring 7 years after the surgical papilloplasty for benign papillary stenosis.
The patient, a 70-year-old woman, underwent laparoscopic cholecystectomy for cholelithiasis at another hospital in August 1994. About 1 year later, the repeated upper abdominal pain was revealed and she was diagnosed as benign papillary stenosis by ERCP and EUS. Surgical papilloplasty was performed in September 1995, intraoperative biopsy of the papilla of Vater showed the benign fibrosis with mild inflammatory change. The postoperative course was uneventful, but she noticed that her stool became white 7 years after second operation. Duodenal endoscopy showed the elevated lesion with superficial ulcer at the papilla being diagnosed as cancer of the papilla of Vater. In September 2002, pancreaticoduodenectomy with D2 lymph node dissection was performed. Postoperative pathological classification was stage II as t₂, n₁, H₀, P₀, M(-).
Although the diagnosis of benign papillary stenosis is obtained, the long-term observation is required with attention of new malignancy occurring at the papilla of Vater and biliary tract.

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An 80-year-old female who had a chief complaint of upper abdominal discomfort, was admitted to our hospital with a diagnosis of acute pancreatitis and gallbladder tumor. ERCP was revealed small tumor-like defects in the lower bile duct without pancreaticobiliary maljunction (PBM). Several other imagings showed double polypoid-typed and advanced gallbladder carcinomas. Although the patient had high risk factors for operation because of age and heart disease, simple cholecystectomy was performed since we thought that acute pancreatitis was caused by exfoliated cancer cells derived from gallbladder carcinomas.
Macroscopically, two polypoid lesio ns and many exfoliated cancer cells in bile, were seen in gallbladder. Histological examination showed papillary-infiltrated and nodular-infiltrated advanced gallbladder carcinomas. Interestingly, almost gallbladder mucosa showed atypical epithelium to carcinomain situlike PBM. Moreover those of lesion showed K-rascodon 12 mutations. Therefore, although amylase in bile was not examined, these results suggested it might be impossible that somewhat pathological findings similar to PBM were existed in the present case.

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