In patients with pancreaticobiliary maljunction (PBM), the amylase level in bile is usually extremely high. Here we report six patients with PBM who showed low bile amylase levels in the gallbladder and discuss their clinical features and pathological findings. Bile amylase levels were examined in 65 patients with PBM during surgery, and the median value was 63,000IU/L. Among these patients, six had low amylase levels (below 1,000IU/L). One patient had a massive common bile duct stone and another had carcinoma of the head of the pancreas. In these patients, reflux of pancreatic juice into the biliary tract was blocked by the stone or tumor. In three other patients, pathological examination revealed gallbladder carcinoma. Although continuous reflux of pancreatic juice into the biliary tract may cause bile duct carcinoma in PBM patients, it is interesting that some of these patients with gallbladder carcinoma showed low bile amylase levels. Regarding the cause of this phenomenon, we can suggest three possibilities. First, the bile may have been diluted by mucous which the carcinoma produced. Second, reflux of pancreatic juice occurs periodically, so the bile amylase level may have been incidentally low at the time of measurement. Third, the levels of other pancreatic enzymes (trypsin, lipase, elastase, etc. ) might have been increased instead of amylase. Further investigation is necessary, but continuous reflux of pancreatic juice into the biliary tract should beregarded as only one step in the multistage process of carcinogenesis.

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The prognosis of inoperable or postoperative recurrent cases of intrahepatic cholangiocarcinoma (ICC) is still poor. We reviewed an effect and complications of transcatheter arterial chemoembolization using epirubicin and mitomycin with degradable starch microspheres (DSM) which was a transient embolic material for these cases. The rate of CR + PR was 52.9%, the median survival time was 463 days (15.4 months), and the one year survival rate was 77.0%. Grade 1 and 2 toxic effects included mainly nausea and flank pain. Grade 3 to 4 toxic effects were hyperbilirubinemia and increase of aminotransferase value. But these toxic effects were moderate and readily reversible. We experienced liver injuries, liver abscess in one case, bile duct necrosis in one case and biloma in one case. But there was no liver injury related death. We have to be careful about a treatment of the patient who underwent repeated transcatheter arterial treatment choledochojejunostomv or biliary endoprosthesis, which are risk factors of liver injury associated with DSM-TACE. DSM-TACE is a relatively safe and effective treatment for inoperable or postoperative recurrent ICC.

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Akita Hepatobiliary Cancer Study Group has continued to survey the cases of biliary tract cancers in Akita prefecture between 1985 and 2001. Cases of bile duct cancers of 946 and gallbladder cancers of 731 were accumulated. The rate of non-curative resections was more frequent than a nation-wide survey, and 5-year survival rate after resections for bile duct cancers was lower than that of a nation-wide survey by about 10%. Five-year survival rates after resections for gallbladder cancers extending to mucosa and proper muscle layer were as low as 75% and 56%, respectively, and were also lower than those reported by a nation-wide survey. It was suggested that there could be a gap in the background between the actual treatment in local community and the conditions of treatment reported in a nation-wide survey that were conducted among high volume centers mainly consisting of university hospitals. Understanding the actual achievement of treatment in the own community by regional gastroenterologists and surgeons would be a key for improving the treatment in the concerned community.

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We retrospectively studied the efficacy and problems of endoscopic naso-gallbladder drainage (ENGBD) for acute cholecystitis in 56 patients. The technique was chosen because the patients were receiving anticoagulant or antiplatelet, with bleeding tendency, or with suspected complication with gallbladder cancer, etc. Technical success was obtained in 44 of 56 (78.5%), and drainage was effectively achieved in 43 of the 44 where drain was successfully placed (97.7%). The average tube placement period before the successful drainage was 3.4 days. The complications were injury to the cystic duct, seemingly typical of ENGBD, in 2 (3.6%), besides acute pancreatitis in 1 (1.8%).
ENGBD is highly effective drainage, and can be the first-choice drainage method for those where PTGBD and PTGBA are difficult. However, the goal yet to attain is to improve the success rate of the tube placement; and further improvement of the tools and advancement of the skills are required.

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Gallstone disease is a major health problem worldwide, and its prevalence to be 10-15% in industrialized countries according to the ultrasound study. In numerous epidemiological studies, a great variety of potential risk factors for this common disease has been identified; age, family history, obesity, physical inactivity, drastic body weight loss and fasting, certain hypolipidemic drugs, total parenteral nutrition, hemolytic diseases, diabetes mellitus, inflammatory bowel diseases, alcohol abstaining. Obviously, the contribution of such factors to gallstone formation varies according to stone types, classified by major constituents such as cholesterol and/or biriubin, into cholesterol stones or pigment stones. Cholesterol gallstones are associated with obesity, hyperlipidemias, middle-aged female gender, whereas such determinants are less associated with pigment gallstones. Gallstone pathogenesis is highly multi-factorial, resulting from complex interactions that involve environmental factors, dietary factors, metabolic disturbances, and genetic susceptibility. Because of the etiological difference, clinical differentiation of stone types is crucial in clarifying the reliable determinants of causal association between risk factors and gallstone diseases.

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Endoscopic mechanical lithotripsy has become a popular form of treatment in managing large bile duct stones and its success rate is just over or below 90%. Biliary stones which cannot be crushed by using mechanical lithotripsy are called as“difficult-to-treat-stone”; many of these are huge stones or impacted stones. Extracorporeal shock-wave lithotripsy is an alternative to difficult-to-treat-stones, and its success rate is comparable to intracorooreal lithotripsy. However, it needs many number of lithotripsy-sessions and endoscopic assistance. On the other hand. intracorooreal lithotripsy containing electrohydraulic lithotripsy and laser lithotripsy could be performed under x-ray fluoroscopic or cholangioscopic guidance. Although intracorporeal lithotripsy under strict cholangioscopic guidance is considered as a safe and efficient method, it has technical difficulties to manipulate cholangioscope. Furthermore, it is expected that a new peroral cholangioscope will have longer durability of optical images and better manipulation than previous scopes.

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Confluence stone is a rare disorder and remain a surgical challenge. It is generally considered as a contraindication to laparoscopic surgery. Marked inflammation of Calot's triangle may make dissection in this area extreamely hazardous. From 1991 to 2006. we experienced 11 patients, who underwent laparoscopic surgery. We have classified confluence stone into two types (A, B) on the basis of cholangiography. Type A lesion is characterized atrophy of the gallbladder and typeB lesion dilatation of the cystic duct. Procedure were completed laparoscopically in all cases. Mean operating time was 230 minutes and mean hospital stay was 19.1 days. There were no postoperative morbidity or mortality, and no biliary stricture in the follow-up period. Laparoscopic treatment of confluence stone is technically feasible and safe, and not a contraindication in specialized centers.

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Recently, endoscopic management for common bile duct stone is recognized as a standard therapy. But several treatments are needed for each patient, because pathology of each patient is not same and sometimes, plan of treatments between internal medicine and surgery is different. So, standard therapy for common bile duct stone is not only one in current state. There are two methods of laparoscopic choledocholithotomy, i. e. transcystic common bile duct exploration (TCCBDE) and supraduodenal common bile duct exploration (SDCBDE) or choledochotomy. TCCBDE is the best option for CBD stone fell from gallbladder, because transcystic route can be closed only by clips as laparoscopic cholecystectomy, but it's indication is limited. We began laparoscopic treatment for common bile duct stone from 1992, as SDCBDE is always appreciable whenever stones are larger than the diameter of cystic duct, number of stones are many and stones are in the common hepatic duct. We think that SDCBDE is very useful option for CBD stone, but it dose not become popular as there are many difficult procedures i. e. choledochotomy, how to remove stones completely, closure of CBD, drainage of biliary tract. Here, we report our methods of laparoscopic choledochotomy with primary closure of CBD and C tube drainage.

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We report a case of emphysematous cholecystitis related to rhabdomyolysis.
In summer,2005, a 76-year old man was transferred to our hospital by an ambulance because of the appearance of lassitude of extremities and dysbasia after farm labor under severe hot weather. He was diagnosed as acute renal failure associated with rhabdomyolysis and received intensive medical treatment including dialysis On the fith hospital day, he was referred to our department because of right upper quadrant pain. Abdominal CT scan, MRI examination showed gas and fluid in the ruptured enlarged gallbladder and abscess formation at the right paracolic gutter. The patient was diagnosed as emphysematous cholecystitis with perforation and underwent cholecystectomy and abdominal drainage. There have been no case reports on emphysematous cholecystitis that followed rhabdomyolysis in the Japanese literature and we reported the case with a review of the literature.

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Hypoplastic gallbladder is an extremely rare congenital anomaly. We report a case of hypoplastic gallbladder that was diagnosed preoperatively. A 36-year-old man was admitted to our affiliate hospital for right hypochondralgia. Although cholecystitis was suspected, US and CT failed to detect the gallbladder. He was referred to our hospital for further examination and treatment US and CT showed a small structure on the liver bed. EUS clearly revealed a consecutive small cystic structure to the cystic duct ERC demonstrated the structure continued with cystic duct. Since clinical symptom was not improved, open cholecystectomy was performed. Pathological examination revealed that the resected specimen has normal wall structure which is consistent with gallbladder. Preoperative symptoms disappeared after surgery.

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We reported a case of cholecystolitiasis with a communicating accessory bile duct A 41-year-old man was admitted to our hospital with diagnosis of cholecystolithiasis. ERCP and DIG-CT revealed a low union hepatic ducts and an extra bile duct connected the right and left hepatic ducts, forming circuit at the hepatic hilum. The cystic duct joined the right hepatic duct Laparoscopic cholecystectomy was performed and the bilialy anomaly was confirmed with intraoperative cholangiography. It is important to demonstrate the anatomy by preoperative biliary examinations to prevent intraoperative bile duct injury.

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A case of signet ring cell carcinoma of the gallbladder is reported. A 76-year-old woman complaining of appetite loss and body weight loss was admitted to our hospital. She had emaciation with edema in the both legs and the left arm. Blood chemistry examination showed the findings of anemia and malnutrition. CT, US and ERC demonstrated a tumor in the gallbladder associated with the invasion directly into the liver. Under a diagnosis of carcinoma of the gallbladder, she underwent an extensive cholecystectomy with regional lymph node dissection (D1). Resected specimen revealed a hydrops like form gallbladder within an irregular tumor filled in it. Histopathologically, signet ring cell carcinoma and various differentiate adenocarcinoma slightly invaded the gallbladder bed of the liver, and metastasized to the regional lymph node (ss, pHinfla, pBinfO, pT2, pN1-No.12b2stage III, fCurB). So she was discharged from our hospital with uneventful postoperative course and still lives with disease free one year after the operation.

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Multidetector row CT provides more thinner CT imaging slices in a short period of time. Thin slice axial im-. Thin slice axial images, multiplanar reconstruction (MPR) and 3D images offer detailed diagnosis of the extension of the tumor and the vascular anatomy of the hepatic hilum. MDCT may be exceptionally useful diagnostic method for hepatic hilar carcinoma.

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[in Japanese]

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