Vascular closure staples (VCS) has been introduced for vascular anastomosis and used widely in clinical vascular surgery. It was demonstrated that these clips do not penetrate into the vascular lumen. We have studied and proved that the VCS was effective for the bile duct closure in a short period of time. In this experiment, we tried to demonstrate the long term effectiveness of VCS in bile duct closure. The common bile ducts were harvested from six rabbits 3,8, and 15 months after direct closure of the common bile duct with VCS. Histological findings and blood chemistry were evaluated. All rabbits were alive and showed normal levels in blood chemistry. No major complications such as bile leakage or bile duct stenosis were experienced. The VCS clips stayed on the closure line of the common bile duct at 3 and 8 months, but came off into the abdominal cavity at 15 months. We suggest that the VCS is useful and effective in direct closure of the common bile duct in clinical settings.

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We have previously reported that catheter displacement occurred in 18% in percutaneous transhepatic biliary drainage (PTBD), and the incidence was significantly higher in the patients in whom PTBD tubes were inserted through the right chest wall or in the patients in whom the distance of the catheter in the bile duct was not enough long. From 1997 to 2002, we standardized our PTBD method to an approach from the anterior abdominal wall to the left peripheral intrahepatic bile duct. The displacement of the catheter significantly decreased to only 1.4% (3 out of 219catheters). However, readjustment of the location of the catheter tip during the early peri od following initial placement was very important to prevent its dislocation even in this method because intraductal distance of the catheter was easily shortened due to effective drainage and succeeding normalization of biliary tree. In the cases in which sufficient intraductal distance of the catheter was hardly obtained due to stricture site, an immediate internal catheter fistularization using balloon catheter with multiple pores was effective.

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Diagnostic ability of sphincter of Oddi manometry (SUM) for 63 patients with biliary diseases and 12 patients of normal was evaluated. Basal pressure>40 mmHg with the length of not less than one minute in either the biliary and pancreatic segment of the sphincter of oddi were defined as abnormal high pressure. The presence of abnormal high pressure was recognized in 62% of cholecystolithiasis,60% of cholecyst-choledocholithiasis, and 50% of sphincter of Oddi dysfunction (SOD), respectively. The presence of stones in biliary ducts was considered to have possibility of the complication of papillary stenosis.
The presence of abnormal high pressure was recognized in half patients with SOD. Therefore many patients with abdominal pain of unknown origin were considered to have possibility of the complication of papillary stenosis. It was thought that endoscopic sphincter of Oddi manometry was a useful method of confirming the presence of SOD.

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The patient was a 69 year-old male who underwent percutaneous transhepatic lithotomy for common bile duct stones ten years ago. Although he had no symptom, computed tomography and magnetic resonance cholangio-pancreatography suggested stones in the right posterior segmental bile duct and the common bile duct. Endoscopic retrograde cholangio-pancreatography revealed that the right posterior segmental bile duct (aberrant hepatic duct) joined the common hepatic duct in the distal side of the hepatic hilus and the cystic duct joined this aberrant bile duct (Hisatugu type I). There were two stones in the common bile duct and one stone in the right posterior segmental duct distally to the junction of the aberrant bile duct and cystic duct. Operation was done laparoscopically; at first, cholecystectomy was performed, then cholangioscope was inserted into the biliary system via cystic duct, and stones were removed from the common bile duct and the right posterior segmental duct. His postoperative course was uneventful and he discharged on the seventh day. There were few reports of stones in the aberrant hepatic duct, and there was no report about laparoscopic surgery for this disease. In the recent case, because the cystic duct joined the aberrant hepatic duct, the stones could be removed transcystically.

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Spontaneous cholecystocholedochal fistula is a rare but serious complication of cholelithiasis. The operative surgery of first choice for this complication has been the repair of the bile duct defect using gallbladder wall placing a stent there. If this seems unsuccessful, biliary reconstruction by choledochoenterostomy has been recommended. We report a case of cholecystocholedochal fistula successfully cured by covering the defective part of the bile duct with ligamentum teres hapatis and greater omentum. The postoperative condition of the patient has been satisfactory for one year after the operation. The method is easy and imposes less operative stress to patients than choledochoenterostomy. We consider this operation is a useful method for surgical treatment of cholecystocholedochal fistula.

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In Western countries, approximately 80% of patients with primary sclerosing cholangitis (PSC)have inflammatory bowel diseases. Although in Japan the incidence of this complication was low, higher incidence has been reported in recent studies. Concomitant colitis associated with PSC in Japan appears to have different clinical characteristics compared with Western countries. We report a case of PSC with concomitant colitis which was predominant in the right-sided colon and completely disappeared after living-related liver transplantation. The patient was a 33-year-old male who was diagnosed as having PSC when 21 years old. Colitis was found in the terminal ileum and ascending colon. The findings were erosion and insufficiency of haustral formation. The findings of follow-up colonoscopy between 1991 and 2001 were similar to the first ones. The patient underwent living-related liver transplantation in 2001 because of liver failure. Serum levels of transaminase and alkaline phosphatase have been normal and the general conditions of the patient have been stable after the liver transplantation. Fourteen months after the liver transplantation, follow-up colonoscopy was performed and the colonic lesions disappeared completely.

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We report the successful treatment of an intrahepatic bile duct ablation. A 41-year-old female underwent a laparoscopic cholecystectomy for the treatment of gallbladder stones. Eighteen months later, she visited a local clinic complaining of back pain and was diagnosed as having the liver dysfunction. She was referred to our hospital for further examination. Abdominal CT, US and MRCP studies revealed an intrahepatic biliary dilatation in the hepatic posterior segment. We diagnosed the patient as having a biliary occulusion resulting from a post-laparoscopic cholecystectomy bile duct injury. After admission to our hospital, a PTCD tube was inserted into the posterior biliary branch. The inner biliary fistula could not be reached, so the posterior biliary branch was injected with absolute ethanol. The PTCD tube was removed two weeks after the bile duct ablation. Two days later, the patient was discharged from our hospital. The post-biliary ablation course was uneventful. Two years after this treatment, the patient remains symptoms-free and the posterior biliary branch shows no signs of dilatation, as observed using diagnostic imaging. Intrahepatic bile duct ablation using absolute ethanol may be useful for the treatment of postlaparoscopic cholecystectomy bile duct injuries.

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We found a few reports of expandable metallic stent fractures. We report a rare case of SMART stent fracture.
A-76-year-old woman was referred to our hospital, department of radiology. Because the obstruction at the lower biliary tract due to pancreas head cancer was found. A 6-cm-long by 10mm and a 4-cm by 10-mm diameter expandable metallic stent were inserted like connecting the two ends of stents. Eight months later the patient returned to our hospital with obstructive jaundice. A fracture was found at the mid portion of the stent which was inserted lower biliary tract. This complication may be due to tumor ingrowth, and continuous stress. Other cause may be that SMART stent is more weak as bending because more stiffer than other bile duct stents such as Wallstent.

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A 14-year-old girl visited a nearby hospital because of right subcostal pain, and she was transfered our hospital because an abdominal mass was palpable. A retroperitoneal tumor was mostly suspected by US, CT and magnetic resonance image examination and laparotomy was performed. Resected mass had a thick fibrous capsule and was filled with blood clots inside. No neoplastic tissue was identified, and pathological examination confirmed chronic expanding hematoma. Chronic expanding hematoma is clinical concept of hematoma which is gradually enlarging. This concept was first proposed by Reid et al. in 1980. There is no reported case of intraabdominal chronic expanding hematoma in Japan. A complete resection is the best therapeutic procedure. Inflammation and enlargement of hematoma may persist for a long period of time, and it is not rare that a resection of adjacent organ may be required

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Intrahepatic choalngiocarcinomas (IHC) have various histological types. The authors present a case of IHC with three histological patterns, which consisted of (1) glandular component with fibrosis, (2) thick trabecular component, and (3) honeycomb component. These pathological characteristics were reflected in preoperative tomographic imageries. This histological variety made difficult to distinguish this tumor from combined hepatocellular-cholangiocarcinoma.. I mIm-munohistochemical staining with cytokeratin (CK) 19 and CK 7 were helpful to make differential diagnosis.
A 66-year-old Japanese man was referred to our institute with liver tumor of 12 cm in maximum diameter, which was located mainly in the right paramedian sector with partial invasion to the left paramedian sector. Computed tomography revealed three areas of the tumor: (1) with early enhancement, (2) with delayed and long-lasting enhancement, and (3) with scarce enhancement. These three characteristics corresponded to histological three components respectively, as mentioned above. The thick trabecular component with sinusoid was similar to hepatocellular carcinoma, and it was difficult to distinguish this tumor from combined heaptocellular-cholangiocarcinoma only with Hematoxylin-Eosin stain. The cytoplasm of all the three components were positive for CK 19 and CK 7, and negative for Hep Par 1. Following this immunohistological results, we finally diagnosed thiis tumor as IHC.

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A very rare case of choledochocele with perforation of the gallbladder is reported. A 76-year-old man complaining of right hypochondralgia admitted to our hospital. He had medical past histories of diabetes mellitus and cerebral bleeding. Operation was performed with diagnoses of choledochocele having chledocholithiasis and perforation of the gallbladder without pancreaticobiliary ducts anomalous arrangement. Intraoperative cholangioscopy revealed normal bile duct mucosa. Cholecystectomy and partial excision of the extrahepatic bile duct with a reconstruction of hepaticoduodenostomy was performed. Fifty calcium bilirubinate stones diameter 3 mm approximately were extracted from the lumen of the cele. Pathological diagnosis of resected gallbladder was chronic cholecystitis. It was suggested that,1) internal high pressure of thd bile duct caused by choledochocele and/or,2) advance of cholecystitis due to cholelithiasis associated with the bile duct dilatation and/or,3) fragility of gallbladder wall by general disease of diabetes or vascular lesion regarded as the cause of gallbladder perforation.

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