In this study, we clinically evaluated the usefulness of the FlowerBasket for endoscopic extraction of common bile duct stones with a diameter less than 1 cm after EST. The subjects were 105patients with choledocholithiasis. As many stones as possible were extracted using FlowerBasket or a conventional 4-wire basket, and a further extraction was performed using a balloon catheter. To examine whether stones can be further extracted using the FlowerBasket, additional extraction was performed in some patients after extraction using the conventional 4-wire basket. Further extraction of stones was impossible using the 4-wire basket in 36% of the 61 patients, using the FlowerBasket in 63% of the 27 patients. The difference is significantly better in the FlowerBasket. Additional extraction of stones using the FlowerBasket was possible in 71% of the 17 patients. The FlowerBasket was a useful device for the accurate and rapid endoscopic extraction of common bile duct stones with a diameter of less than 1 cm after EST.

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Liver cirrhosis is an established risk factor for cholecystolithiasis. This study aimed to clarify whether chronic hepatitis, a condition preceding cirrhosis, also increases the risk of cholecystolithiasis. A total of 222 patients underwent a hepatectomy with cholecystectomy for various disorders. They were divided into 3 groups: 64 patients with cirrhosis,70 patients with chronic hepatitis; and 88 patients without chronic liver disease. In resected gallbladders, gallstones were found in 15patients with cirrhosis,13 with chronic hepatitis, and 7 without chronic liver disease, respectively. The prevalence of cholecystolithiasis was significantly higher in patients with cirrhosis (p =0.008)and those with chronic hepatitis (p0.042) than in patients without chronic liver disease, while it was comparable between cirrhosis and chronic hepatitis (p = 0.489). Univariate analysis revealed that chronic liver disease and thrombocytopenia enhanced gallstone formation (p =0.026 and p=0.011, respectively). Multivariate analysis revealed that only chronic liver disease was the independent risk factor for cholecystolithiasis (Odds ratio =3.056, p= 0.013). In conclusion, chronic hepatitis is a high-risk condition of cholecystolithiasis.

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The present work is aimed to study the role of p 53 gene mutation and K-ras gene mutation in pancreaticobiliary maljunction (PBM).
Tissue samples were obtained from 33 patients with PBM (hyperplasia: 18, adenoma: 1, carcinoma: 14), and 36 patients with gallbladder carcinoma (GC) without PBM. Five hyperplasias (27.8%) of the gallbladder with PBM showed K-ras mutation, and three hyperplasias (33.3%)showed p 53 point mutation. One adenoma (100%) showed K-ras and p 53 point mutation.
In the cases of GC with PBM. p 53 mutation were detected in 3 cases (33%) and K-ras mutation were detected in 4 cases (28.6%). In the cases of GC without PBM, p 53 mutation were detected in 10 cases (36%) and K-ras mutation were detected in 3 cases (8.3%). No significant difference in K-ras and p 53 gene mutations were found between patients with hyperplasia and GC cases. Kras mutations suppose to relate the change of hyperplasia of the gallbladder mucosa with PBM.

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We reported here the therapeutic outcomes for common bile duct stones by endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) in our center. We performed EST or EPBD in 449 cases between April 1997 and December 2003. According to the eligibility criteria for treatment in our center, EST was performed as an initial treatment in 241 cases (53.7%), or EPBD in 208 cases (46.3%). Complete removal of stones was achieved in 237 of 241 cases (98.3%)in the EST group and in 198 of 208 cases (95.2%) in the EPBD group, respectively. We had to add EST to achieve complete removal of stones in 9 of 208 cases (4.3%) which we performed EPBD as an initial treatment. Complications occurred in 17 of 246 cases (6.9%) in the EST group and 10of 198 cases, (5.1%) in the EPBD group. While bleeding and perforation were frequent in the EST group, pancreatitis was rather frequent in the EPBD group. Although there was no significant difference in the therapeutic outcomes and complications between the EST group and the EPBD group, the stone recurrence after therapeutic procedure was more frequent in the EST group (10.4%(23/222) vs.2.1% (4/187)). These results suggested the possibility that the post-EST backward flow of gastrointestinal fluid into the bile duct might be involved in the stone recurrence. Further study would need to elucidate the precise mechanism.

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A 29-year-old woman had a few episodes of acute pancreatitis (upper abdominal pain and vomiting), following the birth of her first child. Abdominal CT and MRI at our hospital showed a cystic mass in the 2^nd portion of the duodenum (to the right of the aorta), but this mass was on the left side of the aorta in the abdominal CT at a previous hospital. Operation was performed with the diagnosis of choledochocele. Intraoperative cholangiography revealed a cystic dilatation of the common channel (30 mm diameter). Cholecystectomy and choledochocele resection were performed without reconstruction. Pathological findings showed that the lumen was lined with a duodenal mucosa and there was no evidence of malignancy. The patient recovered fully without any complicatioin.

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We encountered a patient with Churg-Strauss syndrome (CSS) under steroid therapy, in whom a pseudotumor of the gallbladder developed, and the morphology of the pseudotumor markedly changed within a short period. Here, we report the case.
The patient was a 60-year-old female who has been treated with oral steroids for CSS for 3 years. The symptoms began with right hypochondrial pain. Inflammatory findings were noted in blood testing, and abdominal echography detected multiple small stones in the gallbladder. Thus, the patient was diagnosed with cholecystitis, and admitted.
On thorough examination after admission, a protruding lesion with morphology changing with time was found in the gallbladder. Since the possibility of cancer of the gallbladder could not be excluded, laparotomic cholecystectomy was performed, and a protruding pediculated lesion measuring 4 cm×3 cm was found on the peritoneal side of the body of the gallbladder. The lesion mainly consisted of ischemic necrotic tissues, and was degenerated to a black color. The lesion almost entirely consisted of necrotic tissue. No atypia was noted in the partially remaining tissue. Severe inflammation accompanied by eosinophils was noted around blood vessels in the gallbladder wall, and epitheloid granuloma was formed in the lymph node.
Based on the above findings, the tumorous lesion was determined to be caused by ischemic changes in the gallbladder wall caused by angitis in the gallbladder wall. The process of formation of the tumorous lesion in this patient was retrospectively discussed based on the imaging findings and findings in the specimen.

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We report a case of bile duct cystadenocarcinoma of the liver. A 68-year old man, complaining of right hypochondralgia, was admitted to our University hospital. Abdominal ultrasonography and computed tomography (CT) revealed the presence of a cystic lesion,7 cm in diameter with an enhanced solid lesion in the lateral segment of the liver. The angiography showed an enhanced peripheral staining of the cystic leasion. These findings suggested bile duct cystadenocarcinoma. The CT also showed the another lesion,2 cm in diameter, in the segment 5 of the liver and carcinoma cannot be completely ruled out. After confirming that adenocarcinoma was present in the lateral segment by frozen section diagnosis of the needle biopsy specimen, left hepatic trisegmentectomy, caudate lobectomy, extrahepatic bile duct resection and lymph node dissection were performed. Histopathologically, the main cystic tumor was composed of mucin and proliferated well differentiated papillary adenocarcinoma invading the surrounding capsule and stroma. The final diagnosis was bile duct cystadenocarcinoma and lymph node metastasis was absent. However, the lesion in the segment 5 of the liver showed hyalinizing degenerative tissue without malignant cells. The postoperative course was uneventful and he is alive without recurrence for 15 months after surgery.

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An 85-year-old woman was admitted with epigastric pain, vomiting and anemia. EGD revealed duodenal ulcer and a giant stone packed in the duodenal bulb. Ultrasonography, CT and duodenography demonstrated a giant stone with cholecystoduodenal fistula. We diagnosed it as a gallstone ileus.
Bouveret's syndorome is gastric obstruction by a gallstone, which usually requires surgical operation. We tried to crash the giant stone, and then it was successfully removed by electrohydraulic lithotripsy. Endoscopic treatment of gallstone ileus is safe and effective as a less invasive alternative compared with surgery, although it requires condition that endoscope could reach the stone.

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Laparoscopic cholecystectomy (LC) is both a popular and a standard treatment for gallstones. In spite of its popularity, however, LC is not sufficiently utilized for gallbladder (GB) torsion because GB torsion is a rare entity and difficult to diagnose preoperatively. We present herein three cases of GB torsion treated by LC. Case 1 was a 96-year-old female with abdominal pain. Case 2was a 85-year-old female with right epigastric pain. Case 3 was a 81-year-old female with epigastric pain. All three cases were diagnosed as GB torsion preoperatively by abdominal ultrasonography (US). At laparoscopy, GB torsion with a 270-degree volvulus was found in case 1, and with a 180-degree volvulus in cases 2 and 3. A standard LC was performed with a three or four ports technique. LC for GB torsion is easier than that for acute cholecystitis, because a twisted GB does not usually adhere to the liver. Image diagnosis, especially US, is helpful in distinguishing GB torsion from acute cholecystitis. If this disease is suspected, LC should be the treatment of first choice.

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