In 1994, we first reported an experimental model for the efficient induction of extrahepatic biliary carcinoma in hamsters, which consists ot cholecystoduodenostomy with dissection of the extrahepatic bile duct at the distal end of the common duct (CD) and following administration of Nnitrosobis (2-oxoproyl) amine (BOP). The 74 hamsters that tolerated the CD procedure were treated weekly by BOP injection for 9 weeks and then killed on the 12 th,16 th and 20 th week after the initiation of BOP treatment. Extrahepatic bile duct carcinoma developed in 16%,24% and 41%and gallbladder carcinoma occurred in 58%,81% and 82% of the hamsters, respectively, at the corresponding times of killing.
Cholecystoileostromy (CI) was employed instead of CD in hamsters to reveal the role of duodenal juice regurgitation into the biliary system. The incidences of extrahepatic carcinoma and gallbladder carcinoma were significantly higher in CD group than that in CI group. The pathophysiological entity in our CD model was considered to be caused by the mixing of pancreatic juice, bile and duodenal juice. To test spontaneous development of biliary carcinoma in the CD model,14 hamsters that underwent the CD procedure were followed for one year. An extrahepatic bile duct carcinoma developed in one of the animals.

View full abstract

We propose that diagnostic T Staging (dT Stage) based on the fifth edition of the carcinoma of the biliary tract handling rule (2003). The definition to the diagnosis standard is that, distinction of T 1 and T 2 are “Scanty invasion to perimuscular connective tissue” and “massive invasion to perimuscular connective tissue”, and of T 2 and T 3 are “infiltrated” and “not infiltrated” to the organs (Panc/Hinf), and of T 3 and T 4 are “infiltrated” and "not infiltrated" to the vascular factors (A/PV).
In 58 surgical excision examples, the results were 1) Even if the diagnosis of S invasion, Panc/Hinf 1, and A/PV 1 used IDUS and EUS that are high spatial resolution, the accuracy rate was low, and 2) The significant prognostic factor were arterial invasion, lymph node metastasis and hepatic infiltration. It is necessary for diagnostic algorithm that minimum diagnosis for surgical excision and consideration of prognosis are arterial invasion, lymph node metastasis and the horizontal cancer extension.

View full abstract

To investigate the role that ErbB 2 activation plays in the development of gallbladder carcinoma (GBC), we assessed the levels of ErbB 2 in gallbladder carcinomas developed from BK 5. ErbB 2transgenic mice (ErbB 2 mice) (Kiguchi, K. et al. Cancer Res.,61: 6971,2001). Gallbladders from 52 BK 5. ErbB 2 transgenic mice aged 3 months were analyzed for ErbB 2 and p-ErbB 2 levels. Histological analysis of the gallbladders from transgenic mice revealed the following: 4 were diagnosed as normal (8%),14 had hyperplasia of the epithelial lumen (27%), and 34 were diagnosed as adenocarcinoma (65%). Analysis of the transgenic mice diagnosed as adenocarcinoma of the gallbladder revealed that GBC evolved by two distinct etiological pathways, carcinoma arising from hyperplasia in focal lesion (Type HIF Ca,41%) or hyperplasia in whole epithelium (Type HIW Ca,59%). Type HIW Ca had a higher frequency of invasiveness (70%, p<0.01) compared with that of Type HIF Ca (14%). Immunohistochemical analysis revealed that in the gallbladders of ErbB 2 mice, p-ErbB 2 (phosphorylated ErbB 2 active form of ErbB 2) was detected in areas of hyperplasia of the gallbladder and in both Type HIF and HIW Ca gallbladders. Strong expression of p-ErbB 2 was also observed in areas of invasion. These results not only suggest that GBC may arise via two distinct pathways in the ErbB 2 mice, but these pathways are reminiscent of the adenoma-carcinoma sequence and dysplasia-carcinoma sequence observed in human GBC. In addition, in this mouse model our analyses of ErbB 2 expression and activation in normal, precancerous, and neoplastic lesions revealed that active levels of ErbB 2 (p-ErbB 2) correlate with tumor progression.

View full abstract

Unlike previous procedures, laparoscopic-cholecystectomy is performed without touching the internal organs, so the ability of the operator is directly reflected in the results. One of the keys to success with this procedure is to share the terminology related to basic surgical technique by which all staff can represent the methods involved, allowing directions from the operator to be precisely followed. This paper describes in detail the tips of laparoscopic cholecystectomy. A thorough grasp of biliary tract configuration is important in the success of this operation, and ways of avoiding bile duct injury are proposed. Lastly, we would like to emphasize that the operator is asked to visualize the operative procedure objectively with mental well-being, but without overestimating their own technique.

View full abstract

Laparoscopic cholecystectomy (LC) has been standard operation of cholecystectomy. However, complications caused by laparoscopic view, instruments, and procedure have occurred. Bile duct injury, bleeding and organ injuries are known. Incidences of bile duct injury, bleeding and organ injuries are 0.74%,0.45% and 0.31%, respectively. Therefore, Prevention against those complications is important for keeping safety of laparoscopic cholecystectomy. This article shows complications caused by LC and safety procedure to prevent from those complications.

View full abstract

A bile duct injury is one of the most common pitfalls of laparoscopic cholecystectomy. Although laparoscopic approach becomes golden standard for cholecystectomy, a surgical complication is inevitable in a few cases. Detailed radiological images before surgery are very important to understand an anatomical variation, which help surgeon to avoid a bile duct injury. A meticulous dissection is required for a severe adhesion around hepatoduodenal ligament. An intraoperative cholangiography should be performed whenever bile duct injury was suspected. An open laparotomy could be the best option for a severe inflammatory case. Once bile duct injury occurred after surgery, a careful strategy of reconstruction should be planned to avoid a further biliary stricture. Radiological examination would help to understand severity of the injury. A scar tissue resection with choledoco-jejunostomy could be the best surgical strategy for a case whose disease history was prolonged after initial surgery, because severe adhesion can be expected with high risk of a complication. All these surgical strategies would help to avoid the injury during surgery; however, some complications are still inevitable.

View full abstract

We encountered a case of gallbladder carcinoma with subserosal invasion that presented as gallstone ileus, and report it here with a literature review. The patient was a 79-year-old man. He consulted another hospital with chief complaints of vomiting and abdominal pain. After emergency admission, he failed to improve with conservative management, so he transferred to our hospital on October 21,2003. We inserted an ileus tube, and recognized a bird's beak sign in the small intestine. Therefore, an emergency operation was done under the diagnosis of intussusception. A hard mass that entered the ileocecal valve with 100 cm of small intestine was detected at operation, and this lesion was resected. A gallstome with a diameter of 4 × 2.8 cm was found in the resected specimen. We also performed cholecystectomy and placed an ()mental patching after trimming the wall of the duodenum to close a cholecystoduodenal fistula. Postoperative pathological examination of the resected material gave a diagnosis of carcinoma of the gallbladder. We have followed up this patient because of his old age and ischemic heart disease, although we suggested an additional operation.

View full abstract

We report two cases of hepaticolithiasis associated with benign biliary strictures after pancreatoduodenectorny (PD). Case 1: A 70-year-old woman was diagnosed as intrahepatic stones 31months after PD for cancer of the lower bile duct. Case 2: A 57-year-old man was found to have hepaticolithiasis 29 months after PD for duodenal cancer. In both cases, a percutaneous transhepatic cholangioscopic lithotomy (PTCSL) was performed and biliary stricture was dilated with a balloon catheter. No evidence of malignancy at the biliary-enteric anastomosis was present by biopsy specimen or by intraductal ultrasonography. Transhepatic stents (20-French) were employed during one month after dilatation. They remained asymptomatic at 6 months follow up. Recent reports have emphasized the effectiveness of non-surgical treatment as an alternative to surgical management of benign biliary strictures. Although the role of stenting after biliary dilatation remains controversial, our experience suggested that short-term stent might make it possible to maintain long-term patency.

View full abstract

A 69-year-old man was operated for the duodenal stenosis due to post-bulbar duodenal ulcer. At the operation a left-sided gallbladder and a small defect of the hepatic parenchyma on the left lateral segment were found. Three D-CT taken after the operation revealed abnormal intrahepatic portal venous branching. The first branch of the portal vein ran to the right posterior segment and then branched to the lateral and medial segments diverged at almost same portion. After this divergence, the portal vein ran transversely to the right and ramified to the right anterior segment. The umbilical sulcus in which contained the round ligament lay to the right of P 4. On these findings, this reported case was diagnosed as a right-sided round ligament associated with abnormal intrahepatic portal branching. The right-sided round ligament joined the first bifurcation of the anterior portal vein without umbilical portion. The defect of hepatic parenchyma on the left lateral segment was considered as a remnant of true umbilical sulcus.

View full abstract