Postoperative benign bile duct stricture is a serious complication, and the choice of treatment is difficult. We investigated the treatment of 34 patients diagnosed as having postoperative bile duct injury in our department. Thirty-three patients (97.1%) sustained their injury at another hospital. Seventeen patients (50.0%) had undergone repair before referral. Thirty-one patients (91.2%) underwent surgical repair. Mean follow-up was 8 years 11 months. The outcome of repair was good in 28 patients (82.3%) and re-stenosis in 3 (8.8%).
Cholangitis, death occurred in 1 each (2.9%). Fifteen patients were managed by hepaticojejunostomy, 7 by end-to-end ductal anastomosis. Choledochoduodenostomy, jejunal interposition, and other procedures were performed in 3. Three were managed by non-surgical repair. In most patients who underwent hepaticojejunostomy and in re-operated cases, obstruction was more than Bismuth type III. Many end-to-end ductal cases were Bismuth type II and these patients all showed a good prognosis. Treatment is difficult in many cases showing postoperative bile duct stricture. Performing surgical repair positively facilitated a good prognosis. End-to-end ductal anastomosis is a useful procedure when appropriately indicated.

View full abstract

In the rapidly aging society of this country, we have increasing opportunity to treat the elderly patients with choledocholithiasis.
We made a comparative review of two groups comprising 122 cases of the aged group over 80 years old and 304 cases of the non-aged group under the age of 80. We added the review of hospitalization cost regarding the cases after the May 2003.
There were no significant differences in rate of complete stone removal, numbers of treatment sessions, periods of hospitalization in the patients, and complications. Although we found that the endoscopic treatments for elderly patients with choledocholithiasis were effective and satisfactory, great care must be taken to avoid the postoperative complications by meticulous postoperative management of the elderly patients who frequently have cardiopulmonary diseases. There were no significant difference in hospitalization cost in both groups. Because it becomes reduction of medical cost to decrease the numbers of treatment sessions and to shorten the periods of hospitalization, it is necessity to improve treatment tools.

View full abstract

We evaluated prognosis of our consecutive choledocholithiaisis patients who underwent laparoscopic treatment (57 cases) by comparing with those who had conventional laparotomic treatment (14 cases). Laporascopic treatment did not require extra time for its performance compared to laparotomic treatment. Furthermore, laparoscopic treatment had significantly less intraoperative blood loss and shorter average hospital stay. Successful laparoscopic stone clearance was achieved in 54 cases (94.7%). Retained common bile duct (CBD) stones were observed in three cases (5.3%) and recurrent CBD stones in two cases (3.5%). Overall, laparoscopic choledocholithotomy is a less invasive and feasible treatment if preoperative evaluation for patients is carried out appropriately.

View full abstract

In 141 very old patients over 85 years of age who were admitted to our hospital because of common bile duct stones, 135 patients who underwent endoscopic procedure were treated more effectively than 6 patients who underwent conservative treatment by fasting and antibiotics. Comparing 75 patients who underwent complete lithotripsy with 55 patients who underwent endoscopic biliary stenting, patients who had more stones tended to undergo biliary stenting, and there were no differences in rates of complications, successful treatment and recurrence. However, two patients had cerebrovascular accidents after endoscopic procedure. Regarding very old patients, endoscopic treatment for common bile duct stones should be performed positively under sufficient informed consent and strict management during and after procedures because it is effective and safe.

View full abstract

The aim of this study were to clalify the efficiency of endoscopic treatment (EST, EPBD and endoscopic biliary stenting) for common bile duct stones (CBDS) in elderly patients. 389 patients who underwent endoscopic treatment for CBDS were divided into 2 groups: 90 were over 80 years old (Group A) and 299 were less than 79 years old (Group B). Patients in Group A had serious concomitant diseases and received anticoagulants more frequently than those in Group B. The rate of complete removal of CBDS was 91.4% in Group A and 98.0% in Group B. 25 in Group A and 6 in Group B underwent endoscopic biliary stenting without stone removal because of various risks such as serious concomitant diseases. The difference in the rate of late complications between Group A and Group B was not significant. Late complications were manageable and not serious. Endoscopic treatment for CBDS was safe and effective in elderly patients.

View full abstract

We analyzed postoperative usage of fresh frozen plasma (FFP) in hepatobiliary resections for hilar bile duct carcinomas and evaluated the feasibility of the guideline for the use of FFP of Japan. Subjects were 120 cases treated in our institute from April 1989 to December 2007. Patients with high levels of postoperative total bilirubin, intraoperative blood transfusion, and the absence of autologous blood transfusion used significantly larger amount of postoperative FFP. Dividing these into three groups chronologically (1989-2001, 2002-2005, 2006-2007), postoperative FFP requirement was reduced, which correlated with postoperative hospital stay. In patients with mild coagulation abnormality, there were no difference in frequency of postoperative complication, length of postoperative hospital stay, and mortality rate, regardless of FFP use. This suggested the feasibility of the guideline for the use of FFP. Compliance with the guideline and the improvement of postoperative management will make it possible to reduce postoperative FFP use.

View full abstract

We described gallbladder drainages for acute cholecystitis. Gallbladder drainages are divided into six types; 1. PTGBD, 2. PTGBA, 3. ENGBD, 4. Endoscopic transpapillary gallbladder stenting, 5. EUS-guided transmural naso-gallbladder drainage, and 6. EUS-guided transmural gallbladder stenting. Of these, PTGBD, which has been developed more than three decades ago, is one of most established procedure. PTGBA become widely used as an alternative procedure although the efficacy is less than those of PTGBD. Recently, several endoscopists have reported the usefulness of ENGBD. However, the procedure success rate and post-ERCP pancreatitis should be considered. Furthermore, so far, whether EUS-guided gallbladder drainage is truly necessary, is controversial because the procedure and devices have not been established yet.

View full abstract

Abstract: Xanthgranulomatous cholecystitis (XGC) is an usual disease and considered as uncommon variant of chronic cholecystitis resulting in the development of a granulomatous inflammation, mainly consisting of xanthoma cells containing bile pigments. Laparoscopic cholecystectomy is frequently unsuccessful with a relatively high conversion rate to open cholecystectomy because of its pathologic feature. Pre and intra-operative diagnosis is difficult and it often mimics a gallbladder carcinoma. Therefore, detailed radiological and histological exploration is necessary to avoid over surgery with misdiagnosis, and intra-operative frozen section histology is helpful to differentiate XGC from gallbladder carcinoma.

View full abstract

Gallbladder hemorrhages controlled by transarterial embolization and treated by elective operation are rare. A 60-year-old man was admitted to our hospital because of epigastralgia at the end of April, 2008. Blood tests revealed liver dysfunction and inflammation. Enhanced CT scan showed the presence of gas inside the gallbladder and thickening of the wall of the gallbladder and bile duct. A diagnosis was made of acute cholangitis and cholecystitis. He underwent endoscopic nasobiliary drainage (ENBD), after which his physical status gradually improved. However, hemobilia from the ENBD tube and progressive anemia developed in the middle of May. Enhanced CT showed hemorrhage inside the gallbladder. Angiography showed extravasation from the cystic artery, and we successfully performed transcatheter arterial embolization (TAE) using a microcoil. Cholangiography showed a stenosis of the hilar bile duct and a diagnosis was made of Mirizzi syndrome. He underwent elective cholecystectomy. Atrophy of the gallbladder and strong adhesion of the tissues surrounding the gallbladder were seen. A hematoma approximately 1 cm in diameter was seen on the hepatic side of the neck of the gallbladder, but no communication to the bile duct or hemorrhage inside the gallbladder were found.

View full abstract

A woman in her seventies showed a mass formation in the hepatoduodenal ligament on abdominal CT. Dilatation of the intrahepatic bile ducts of both lobes was induced by the mass. Cholangiogram revealed severe stenosis from the bilateral hepatic ducts to the common hepatic duct and dilatation of the left and anterior branches of the intrahepatic bile duct, but the posterior branch was not affected. Abdominal angiography revealed stenosis from the main portal vein to the right and left bifurcation. Under the diagnosis of hilar cholangiocarcinoma with invasion to the portal vein, we performed resection of the left and caudate lobes with the portal vein and D2 lymph nodes and reconstruction. Continuous hyperthermic peritoneal perfusion (CHPP) was performed throughout, as the intraoperative cytology was class V. Histologically, this case was BsBpBmC, se, pHinf2, pGinf0, pPV2, pA (uncertain), pN1, pHM2, pDM2, pEM2, fStage IVa, and fCur C. This case was treated with adjuvant chemotherapy, internal S-1 and intravenous paclitaxel, and has now been followed postoperatively for 4 years and 10 months.

View full abstract

A 73-year-old woman was pointed out a gall bladder polyp by abdominal ultrasonography (US) enforced in a screening purpose, and was admitted to our hospital because of further examination. We diagnosed it as multiple early gallbladder cancers by endoscopic ultrasonography (EUS) and endoscopic double contrast cholecystography, and the cholecystectomy was carried out. The pathology organization diagnosis was, adenocarcinoma (pap-tub1, tub1, low grade, tub2), mp, ly0, v0, pn0, pHinf0, pBinf0, pBM0, pHM0, pEM0, 0-Is+0-Ib+0-Ip, pat Gbn. We experienced a case of the early gallbladder cancer that the Is-type and the IIb-type, the Ip-type without the adenoma were co-existed together. In the graft, it seemed with a rare case from the point where the possibility was thought about of multiple cancer, and the point that was Ip-type early gallbladder cancer without the adenoma.

View full abstract

A 64 year-old man came to our hospital for evaluation of left cystic tumor of the liver. Ultrasonography, CT and MRI showed an approximately 2 cm diameter of cystic lesion in the hepatic segment 2. ERC did not demonstrate the communication between the cystic tumor and the bile duct. However, MRCP exhibited the communication between them. Under the diagnosis of the mucin producing bile duct tumor with suspicious malignancy, left hepatic lobectomy was performed. There was papillary solid mass in cystic lesion of the resected liver. The tumor was histologically adenocarcinoma in situ with adenoma component. Ovarian-like stroma was not observe in the wall. Based on these findings, the tumor was diagnosed as intraductal papillary neoplasm of the bile duct (IPNB). We report a case of IPNB showing round shape.

View full abstract

We encountered a 50's male complaining of occasional colic attacks over 16 years with a desire for laparoscopic cholecystectomy. Several stones were observed in the wall-thickened gall bladder. Dissection around the cystic duct had been difficult but cholecystectomy was completed. The patient was discharged uneventfully on the 4th POD. However he returned with pain in the lower right abdomen. The CT showed a liquid collection in the pelvic cavity. The patient was readmitted on the 10th POD on grounds of peritonitis. On exploration of emergent laparotomy, bile peritonitis became apparent from a hole 1 mm in size where bile flow could be seen at the CBD. After peritoneal lavage, bile drainage was performed from this hole. On verification from laparoscopic video tapes, the rupture was caused by repeated contact with the shaft of forceps during dissection. He was discharged on the 16th POD uneventfully. Careful manipulation of forceps is crucial at and around the operation site.

View full abstract

A 32-year-old man consulted a local hospital for epigastric pain and was diagnosed as obstructive jaundice. He was referred and hospitalized in our hospital. One year ago, he had treatment of pulmonary tuberculosis. Contrast-enhanced abdominal multi-detector row CT (MD-CT) showed a low density mass with an enhanced rim at hepatic portal region. PTBD was done and revealed a smooth narrowing of the upper part of common biliary duct. Based on these results, we suspected that an enlarged lymph node at hepatic portal region caused obstructive jaundice. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the lymph node at hepatic portal region was done. The pathology of specimen showed caseating granulomas and polymerase chain reaction analysis for tuberculosis of the specimen was positive. Thus we diagnosed as tuberculous lymphadenitis at hepatic portal region which caused obstructive jaundice. Antituberculosis medications were started and the size of the lymph node reduced gradually. After 6 months, biliary drainage tube was removed, and the patient stayed well without development of jaundice.

View full abstract

Ultrasonography (US) is quite sensitive in detecting changes in the gallbladder. Endoscopic ultrasonography (EUS) makes it possible to visualize detailed morphological features of gallbladder lesions as well as the layer structure of the gallbladder wall itself, and, therefore, the depth of cancer invasion can be diagnosed based on the correlation of the tumor echo and the condition of the layer structure of the adjacent wall. Recently, several reports have been published on US diagnosis of the depth of cancer invasion based on the findings of hemodynamics in the tumor using Doppler assessment and/or such imaging with administration of contrast, which may be a promising imaging technique in EUS as well and may enable more precise diagnosis of the depth of invasion in gallbladder cancer.

View full abstract

Gallbladder cancer is the most common cancer of the biliary tract with a high mortality rate. To improve its prognosis, early diagnosis and adequate surgical treatment are absolutely required. The intraluminal polypoid lesions, which detected with unenhanced computed tomography and focal asymmetric wall thickening are important signs to the differential diagnosis of neoplastic lesions. The multi-planer reconstruction imagings improve the accuracy of staging. For the diagnosis of the local extent of cancer, MDCT has an advantage to distinguish T2 lesions from more advanced lesions. The combination the size criteria and pattern of enhancement is useful for the diagnosis of possible spread to lymph nodes.

View full abstract