Aragonite, one of calcium carbonate polymorphs, is crystallographically unstable but commonly found and proved to be stable thermally in calcium carbonate gallstones. In this paper some considerations were made about crystalline stability of the gallstones by thermal analysis compared with samples of coral, shell, calcareous sinter and rock.
Differential thermal analysis (DTA) proved that biochem i c al aragonite like coral and shell transformed to calcite at the lower temperature (310 - 325°C) than those of calcareous sinter (406°C) and rock (507°C). On the other hand, that of gallstones gave no clear peak of transformation.
X-ray diffraction analysis revealed that aragonite of calcareous sinter completed its conversion to calcite at 500°C, while in gallstones only 8 % transformed to calcite at 500°C,56% at 600°C and 69% even at 650°C respectively. Aragonite form of calcium carbonate gallstones proved to be stable thermally.
It is sugg e sted that some organic material in the gallstone affects thermal stability of the aragonite crystal.

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Changes in plasma bile acid and bilirubin concentrations, bile flow, biliary lipid levels and bile acid composition were examined for 14 days after intra-duodenal release of bile in rats in which the bile duct had been ligated for 1 and 2 weeks. Plasma bile acid concentration rapidly decreased to the normal range after release of the bile duct obstruction but the recovery of plasma bilirubin concentration, especially in the 2-week ligated rats, was delayed. Bile flow once decreased on day-1 of the release, but turned to increase in the 1-week ligated rats showing a value twice that of normal days 5-7 and gradually decreased to the normal range thereafter. The bile flow in the 2-week ligated rats gradually recovered to the normal level after the decrease on day-1 without any increase on days 5-7. Biliary bile acid levels once decreased on day-1 but showed a marked increase around day-7, and then returned to the normal level in the 1-week ligated ras, but the biliary bile acid levels in the 2-week ligated rats gradually recovered after the first decrease. These results suggest that the changes in bile flow and biliary bile acid levels in cholestatic rats are normalized after the release of obstruction when the obstruction period is short but actually not when the period is long, that is 2 weeks or more.

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Rat's liver in experimentally induced obstructive jaundice was examined with the histochemical techniques.
Microscopically ductular proliferation and fibrosis were observed at the portal area in the obstructive jaundice. Electron microscopically the reduction of microvilli and blebs formation were encountered in the bile canalicular membrane and the luminal membrane of the ductular cells. Horseradish peroxidase injected into the common bile duct penetrated through the tight junction into the intercellular spaces of the hepatocytes and the ductular cells in the obstructive jaundice.
These findings suggested that the plasma membrane of the hepatocytes and the ductular cells were injured in the obstructive jaundice and increased permeability of the tight junction permitted the regurgitation of the bile into the blood circulation.

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We made a detailed assessment about the influence of bile acids for the concentration of ionized calcium in human gallbladder bile.
In Ca-bile acid solution, calcium binding capacity of glycine-conjugated bile acids and dihydroxy bile acids were respectively dominant in comparison with that of taurine-conjugated ones and trihydroxy ones. Furthermore, the ionized calcium concentration decreased on adding lecitin. These facts show that the calcium binding capacity of bile acids may be affected according to the bile acid micelle size.
Addition of various bile a cids also reduced ionized calcium concentration in bile, and the agreement with the results of our experiments in Ca-bile acid solution. Ionized calcium concentrations in human bile with black stones or calcium bilirubinate stones were significantly hygher than that in the bile without gallstones.
It is suggested that ionized calcium, rich in reactivity, is quite requisite in the pathogenesis of pigment gallstones.

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Pathologic study of 106 resected specimens bile duct carcinoma was performed. In 87 specimens carcinoma invaded beyond the bile duct wall, while in 19 specimens carcinoma was limited within the bile duct wall. In those cases where carcinoma invasion was limited to the bile duct wall but extended to outer fibroelastic layer, incidence of lymph node metastases and neural invasion was higher than that of carcinoma limited to inner fibroelastic layer. Extended surgery should be considered in cases with cancer invasion to outer fibroelastic layer in order to improve postoperative survival.
The problem of surgical treatment of bile duct carcinoma is intraductal tumor seeding which causes recurrence. Microscopic study disclosed that resection should be performed more than 2 cm distant from the main tumor to be surgical stump free from cancer cell. In 24 cases (23%) longitudinal intraductal spread of carcinoma was verified in the duct epithelium, but in 88cases (77%) tumor extended beneath the duct epithelium through bile duct wall of periductal tissue. This result indicated that it would be difficult to determine intraductal tumor spread with intraoperative macroscopic findings.
The modes of the lateral spread of cancer cells were analyzed into three types; i.e.direct invasion, (37%), vascular invasion (32%) and neural invasion (31%).

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A consecutive series of 118 cases of intraoperative cholangiograms were studied to determine the relationship of pancreatico-biliary reflux and amylase activity in bile. Intraoperative manometric study was also performed. Pancreatic duct reflux was observed in 36.4% of 43 intraoperative cholangiograms. Significant elevation of amylase activity in bile was found in 39.4%of 33 cases with pancreatic duct reflux, whereas, such elevation was found in only 13.0% of 54cases in absence of pancreatic duct reflux. In those cases in which the presence of bacteria in bile was correlated with amylase activity, we found that bacteria were demonstrated more frequently in the cases with high amylase activity than in those with low amylase activity. With regard to manometric study, those cases with pancreatic duct reflux also had a tendency to present higher systolic pressure and amplitude of sphincter of Oddi. Those appeared to be a correlation between pancreatic duct reflux and the presence of biliary diseases.

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We already reported that the canine model of dilated bile duct without disturbance of bile flow could be produced by cholecystectomy and stripping extrahepatic bile duct from surrounding tissue. The purpose of this study is to define the factors of bile duct dilatation, the diameter of bile duct in 4 types of canine models such as (1)control group, (2) cholecystectomized group, (3) stripping bile duct group, and (4) cholecystectomized with stripping bile duct group were compared. Bile duct did not came to dilate in cholecystectomized group and stripping bile duct group. But significant dilatation was recognized in cholecystectomized with stripping bile duct group. There were no significant differences in the values of residual pressure (P)and resistance (R) in every group. It was supposed that the papillary function was preserved.
Therefore, the loss of gallbladder function as the reservoir of intraductal pressure and the weakness of bile duct wall are considered to be concerned with dilated bile duct without disturbance of bile flow.

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Extracorporeal shock wave lithotripsy of gallstones was performed with a combination of ursodeoxycholic acid and chenodeoxycholic acid.53 patients with a single cholesterol stone were treated by under water spark gap system (GM-1). Gallstones smaller than 20 mm in diameter and pure cholesterol gallstones showed high disappearance rate. Most of these CT values were lower than 20 Hounsfield Units. Some of gallstones after shock wave lithotripsy disappeared in a few days, others required long medical dissolution therapy. Pure cholesterol gallstones tend to disappear in short term. Endoscopic examinations were done just after lithotripsy. Fragments of gallstones disintegrated by shcok waves were observed in the duodenal contents microscopically. Some fragments were the same size as cholesterol crystals in the bile. These fragments were so small as to pass through the cystic duct, common bile duct and papilla of Vater. The greater part of cholesterol fragments could mainly disappeared by evacuation in short period.

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Forty-eight cases of carcinoma of the gallbladder treated in our department during the past 8 years and 7 months were analyzed. There were 21 (43.8%) surgical cases, comprising 15cases of resection (71.4% of all surgical cases) and 7 of curative resection (33.3%). Among these patients,8 of 10 at stage III and W underwent extended surgery. The surgical techniques used were hepatic floor resection in 1 case, medioinferior and anterioinferior resection plus bile duct resection in 3, and extended right lobectomy plus bile duct resection in 4. Pancreaticoduodenectomy was added in 4 cases, right hemicolectomy in 2, and portal resection in 1. The cancer in 4 of the patients for whom curative resection was possible was characterized by mild infiltration into the hepatodudenal ligament, although direct infiltration into other organs including the liver was marked. One patient died of hepatic sufficiency, but the other patients who underwent curative resection survived for 13.7 months on average (26 months at longest) in comparison with an average of 4.5 months for patients who did not. Although the surgical technique employed for advanced gallbladder carcinoma varies according to the mode of progression of the lesion, we advocate fundamental active extended surgery using extended right lobectomy or medioinferior and anteroinferior resection combined with pancreaticoduodenectomy.

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A 69-year-old woman with choledocholithiasis was subjected to percutaneous transhepatic cholangiodrainage (PTCD) into the left intrahepatic bile duct (B₃). A guide wire was advanced through the channel of the cholangioscope into the right intrahepatic bile duct (B₆) as much peripherad as possible. A 14 Fr percutaneous transhepatic cholangioscope (PTCS) catheter was advanced over the guide wire into the B₆ and the wire was removed. Microwave coaxial cable was pushed into the PTCS catheter into the B₆ followed by coagulation of the ductal wall and liver tissue to prevent an unexpected bleeding. Next, the rigid portion of the guide wire was put into the PTCS catheter, penetrating the bile duct and liver capsule, into the abdominal cavity, retrogradely. A clamp inserted into the minute incised wound nearest to the wire tip grasped and pull it out. The 12 Fr PTCS catheter was advanced over the guide wire from the counter side (B₆).
No adverse effects were obtained for the patient. We named the method PTRBD. PTRBD was very available for cloudy field by crushed fragments and intraductal decompression.

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Seven cases of Mirizzi syndrome and seven case of confluence stone were operated on between 1973 and 1986.
The incidence o f these complication of cholelithiasis is 0.35% respectively in non malignant biliary tract disease.
Mirizzisy ndrome is sometimes difficult to be differentiated from the malignant lesion of gallbladder and bile duct preoperatively becouse of persistent jaundice and chronic inflammation. But ERCP and FTC play a diagnostic role by visualizing broad curved impression on the lateral aspect of bile duct.
At operation, adhesion was strikingly dense, there is major difficulty in dissecting the gallbladder neck from the main bile duct.
In confluence stone, the preoper a tive diagnosis is rare because of no paticular clinical picture. At operation, the gallbladder, fused to the main duct, was difficult to dissect from it and sometimes the cystic duct can not be isolated. A T-tube was inserted through the fistula in 4 cases and through the intact bile duct in one after partial cholecystectomy. In one case, the defect of main bile duct wall was closed by utilizing the proximal part of the gallbladder, and in one case a hepatojejunostomy was performed because the tissue loss was too great to close the bile duct primarily.

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Seeding metastasis may occasionally occur along the tract after percutaneous transhepatic biliary drainage for malignant obstruction.
It must be considered that cancer cells in bile juice are implanted on the inner surface of the sinus tract. Therefore, ethanol injection procedure with use of a tripple-lumen balloon catheter has been developed in order to kill seeding cancer cells.
The sinus tract is completely closed between the balloon in the bile duct and the stopper attached to the skin, then ethanol is injected into the sinus tract through the side hole just proximal to the balloon. Ethanol injection procedure has been performed safely, and the effects of the procedure will be clarified by long term follow-up and/or some experiments.

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Biliary endoprosthesis of a silicone T-tube was placed under PTCS guidance in two cases of carcinoma of the hepatic bifurcation and one of gallbladder carcinoma involving the hepatic hilum. As a first step, two external and internal biliary drainage were performed through the left hepatic duct, and the tip of each catheter was placed in the right intrahepatic bile duct and the common bile duct. Then these catheters were exchanged for a silicone T-tube as a biliary endoprosthesis.
A T-tube of appropriate length is available for all occasions and fixed right in the hepatic hilum. Therefore, the biliary endoprosthesis can be maintained for a long time.

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A 78-year-old female with gallbladder perforation caused by biliary ascariasis is reported. Two days prior to admission the patient complained of severe abdominal pain which was initially diagnosed as pancreatitis. However, her condition deteriorated to shock. On examination the systolic blood pressure was 46/mmHg (by palpation) and signs of generalized peritonitis were present. Ultrasonography and CT-scan showed large amount of fluid collection in the abdominal cavity. During operation the perforated gallbladder was found and approximately 1,500 ml of green fluid was drained. Intraoperative cholangiography revealed a coiled-filling defect of the common bile duct and a linear-filling defect of the pancreatic duct. Duodenotomy was done and two ascarides were removed from the papilla of Vater. Roundworm infestation was discovered upon further examination of the intestine and twenty-one ascarides were removed. Cholecystectomy and T-tube drainage were performed. Four days later an oral vermifuge (Pirantel Pamoate) was administered.

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The cancer of Papilla Vater results from mostly adenocarcinoma. Pure squamous cell carcinoma is very rare in the cancer of Papilla Vater. We reported here a case of pure squamous cell carcinoma arising in Papilla Vater.
In spite of extended radical p a ncreat-duodenectomy for advanced cancer, the patient died because of bone metastasis in such a short time of 6 months after operation. This case suggests a possibility that squamous cell carcinoma of Papilla Vater has a poor prognosis compared with adenocarcinoma.

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