Hepatic metastases are common in patients with cancer of the hepatobiliary pancreatic region, and also obstructive jaundice commonly developes in such patients. Obstructive jaundice reduces the reticuloendothelial function of the liver which may be concerned with the development of hepatic metastases. Therefore, we studied the implantation and growth of metastases in rats' livers with obstructive jaundice, using a model in which rat ascites hepatoma AH 130 cells were transplanted into the portal vein which consistently induces hepatic metastases.
Thirty nine male Donryu rats were assigned to a test group and a control group. The test group's bile ducts were ligated for 7 days before tumor implantation and the control group underwent sham operations. The serum bilirubin level of the test group was 10.1±2.1mg/dl. The number of hepatic metastatic lesions at 11 days after tumor implantation and the control group underwent sham operations. The serum amounted to 59.2±30,0(SD) in the test group and 9.0±13.3 in the control group. These data showed significant differences between the two groups. The values of W3/13HLK⁺, W3/25HLK⁺ and OX₈-HL⁺in peripheral blood T cell subsets and values of prothrombin time (PT), activated partial thromboplastin time (APTT), fibinogen and fibrin degradation product (FDP) in peripheral blood before tumor implantation showed no significant differences, except for the APTT between the two groups.
Obstructive jaundice increased the incidence of liver metastases development in the rats given injections of tumor cells, but the mechanism of this phenomenon is still unclear. We think that in patients with obstructive jaundice, treatment for liver metastases could be more important and biliary drainage should be requested in the early stages of obstructive jaundice.

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In 23 resected cases of the gallbladder carcinomas, preoperative angiographic findings were evaluated to assess the reflectability of histological tumor spread. Histological findings of tumor spread, especially the extent of hepatic invasion (hinf) and of biliary invasion (binf) were related of angiographic findings.
1) Dilatation of the cystic artery was seen in 75% of“hinf₀”cases. Encasement of cystic artery was seen in 80% of“hinf-positive”cases (hinf_1∼3), but none of hinf₀cases.
2) Tumor staining was seen mainly in“hinf-positive”cases.
3) Encasement of intrahepatic arteries and intraportal branches were seen only in“hinf₂and₃”cases.
4) All of the cases with encasement of the trunk of the cystic artery were“binf-positive”cases.
In conclusion, preoperative angiographic findings could be valuable to predict the histological tumor invasion to the liver and biliary duct.

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Between August 1983 and December 1987, endoscopic sphincterotomy (EST) was performed in 129 patients with choledocholithiasis. In those 22 patients cholescintigraphy using Tc-99m-E-HIDA was performed to evaluate bile flow before and after EST. In 8 patients cholecystectomy had been performed before EST, and in 14 patients the gallbladder was not removed. Cholescintigraphy was performed before and after EST, and in 15 patients cholescintigraphic follow-up study was carried out in the period of 4 months to 46 months with an average of 24.2 months. Cholescintigram revealed significant improvement of bile flow after EST. Long term follow-up showed that in patients without gallbladder bile flow remained normal but in patients with gallbladder bile flow impaired. Cholescintigraphy is useful in the assessment of bile flow after EST.

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Three methods of choledochal drainage were compared statistically for the patients after choledochotomy during a six-year period. We used tubes through the cystic duct with primary closure of the common duct (group C, n=16), T tubes (group T, n=14), and Nelaton tubes (group N, n=16). All the seventeen preconditional factors were comparable between groups C and T, but two factors in group N were different from those in groups C and T. Patients in group C had their tubes removed and were discharged from the hospital earlier than in groups T and N (p<O.05); patients in groups C, T, and N were discharged on postoperative days 28,44, and 33, respectively. The analysis of other outcome factors supported that drainage via the cystic duct after choledochotomy is superior to T tube drainage.

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Percutaneous transhepatic biliary drainage (PTBD) was performed 405 times on 346 patients during the period of 1980 to 1987. Our methods of PTBD were as follows.
A method (257 cases): PTBD via the frontal approach using double tube under X-ray control
B method (69 cases): PTBD via the frontal approach using Seldinger's method under US
C method (79 cases): PTBD via the lateral approach using Seldinger's method under US
Dislodgement of the drainage ube occurred in 22 cases (5.4%). The rates of dislodgement of the drainage tube in A, B and C method were 3.9%,0.0% and 15.2% respectively. These rates were not influenced by the position of the drainage tube in the bile duct excepting gallbladder. Bile peritonitis occured in 5 patients. PTBD using B method proved to be very safe from dislodgement of the drainage tube. Therefore, this method would be the preferred procedure, but A method should be chosen in the case with obstruction locating in the right hepatic duct. It seems to be necessary to devise the PTBD tube itself to prevent the dislodgement of it in case of undergoing C method.

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During the period of 24 months from December,1986, we performed ultrasonically-guided percutaneous transhepatic cholecystography and drainage in 24 cases. In this article, our experience and results of these procedures were reported.
The cases were as follows: cholecystitis with cholecystolithiasis in 15 cases, cholecystitis without cholecystolithiasis in 4, obstructive jaundice in 2, choledochal cyst in one, carcinoma of gallbladder in one and carcinoma of common hepatic bile duct in one.
US-guided PTCC and aspiration cytology were useful in the diagnosis of gallbladder diseases. PTCCD was useful in the treatment of acute cholecystitis and obstructive jaundice without dilatation of intrahepatic bile duct. We also successfully performed percutaneous transhepatic cholecystoscopic lithotripsy utilizing PTCCD fistula in two cases, which indicates the effectiveness of this non-operative procedure.

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We monitored blood pressure, heart rate and electrocardiogram (ECG) before, during and after endoscopic retrograde cholangiopancreatography (ERCP) in 42 patients and measured the levels of plasma cortisol and noradrenaline before and after ERCP in 10 of 42 patients.
Systolic and diastolic blood pressure during ERCP were significantly higher than those before ERCP. Heart rate tended to be increased during ERCP. Twenty-four patients (57.1%)showed heart rate over 100 beats per minute. The changes in blood pressure and the depression of ST-T segment and the frequency of arrythmia during ERCP were more remarkable especially in patients over 60 years of age and in patients who had received the therapy for hypertension. The depression of ST-T segment in these patients was seen most frequently during the infusion of the contrast medium into the common bile duct.
Plasma cortisol level was significantly elevated after ERCP as compared with that before ERCP (p<0.001). Plasma noradrenaline level tended to be increased after ERCP.
Those changes in blood pressure, heart rate and ECG were transient during ERCP and disappeared after ERCP.
In summary, it was considered that ERCP was safety examination, but it is necessary to give care to the complications of the circulatory system in aged or hypertensive patients.

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Between 1986 and 1988, 4 early carcinomas of the extrahepatic bile duct have beeen studied. In all patients the diagnosis was histologically confirmed at operation. Two of 4 patients had initially obstructive jaundice. In 2 others, one patient presented slight fever and another had no significant symptom. US defined biliary dilatation. EUS was the more reliable modality for picking up wall abnormality of the extrahepatic bile duct. Direct cholangiography and biliary double-contrast radiography showed exactly abnormality of wall contour and fine reticular pattern of the mucosa. Biliary double-contrast radiography diagnosed quality and extent of the abnormal lesion in more detail. Combination of EUS, biliary double-contrast radiography and angiography was most useful for detection of resectable bile duct carcinomas.

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Thirty seven cases with cholecystolithiasis and a case with choledocal stone were treated with extracorporeal shock wave lithiotriptor (Direx, triptor X1). Successful fragmentation, defined as all residual fragments measuring less than 8 mm in greatest dimension, was obtained in 66 per cent of cases. When size of stone was smaller and calcification was fewer, better fragmentation was seen. Number of stone was not always obstacle to successful treatment.
No complication was observed other than transient cutaneous petechiae and microscopic hematuria.

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The simultaneous determination of CDCA and CA pool sizes and fractional turnover rates was performed by the isotope dilution method after oral administration of [11,12-²H₂] CDCA and [2,2,4,4-²H₄] CA. Bile was sampled after the administration of the ²H-labeled bile acids. In six healthy male volunteers' pool sizes(mean±SD) of CDCA and CA were 14.0±4.8 and 13.5±3.7mg/kg, respectivcly. The corresponding values for the fractional turnover rates were 0.15±0.04 and 0.14±0.02day^-1.

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We performed trans-luminal (per PTCD tube) chemotherapy and biopsy on a patient with inoperable, end-stage bile duct cancer. For chemotherapy, we used a needle tube for sclerotherapy of esophageal varices which can pass through PTCD tube and inject directly into a tumor (cholangiographical obstructive end point) under fluoroscopy. We also used a device for biopsy needle through PTCD tube to obtain a cytologic specimen. We repeated above procedure on the patient and finally obtained a recanalization of obstruction of bile duct cholangiographically with the patient's clinical improvement. No serious complication had been encountered.
We thought the procedure was effective for the patients with end-stage, advanced obstructive bile duct cancer. We present here methods of the procedure and one successful case.

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A case of the double cancer developing in the common bile duct and in the gallbladder is presented. The patient was a female,67 years old. Her jaundice was pointed out by the family physician, and she was admitted to our hospital. The cancer of the common bile duct and the gallbladder was diagnosed by ERCP, US and CT, respectively. Both of these lesions were resected by pancreatico-duodenectomy. The reasons for diagnosis of the double cancer in this case were as follows: 1) There was no continuity between these lesions; 2) These cancers were developed from the mucosa to the deep layer; 3) There were dysplasia around these lesions. In the analysis of the DNA pattern, the aneuploid pattern was demonstrated from the cancer of the gallbladder by the flow cytometry, while the diploid pattern was demonstrated from the No 12 b2lymphnode, which was metastasis of the cancer of the common bile duct.

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Over the past 16 years,4 cases of hepatolithiasis complicated by intrahepatic cholangiocarcinoma were encountered at our hospital. In all of these cases, the definite diagnosis of intrahepatic cholangiocarcinoma could not be passed before histological examination during or after surgery. In 2 cases, hepatectomy was performed. In the remaining 2 cases, surgical treatment of the carcinoma was impossible. In one case, cholangiocarcinoma was detected by biopsy during endoscopic lithectomy, suggesting the importance of repeated endoscopic biopsy of the biliary tract in patients with hepatolithiasis for the detection of complication by cancer. In another case, chronic proliferative cholangitis and papillary growth of the epithelium of the bile duct were found in the cancer-free areas, suggesting an association between calculus-caused chronic stimulation and carcinogenesis.

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A case of intrahepatic bile duct stone attributable to roundworm eggs is presented. The patient, a 41-year-old female, had undergone cholecystectomy at 36 years of age. Stones were not found during the surgery. The patient consulted our department with complaints of pain in the right upper quadrant, nausea and fever. Left intrahepatic bile duct stone was diagnosed, based on findings of a detail examination. Left lateral segmentectomy of the liver was carried out. The intrahepatic bile duct in the resected liver were dilated, thickened and filled with bile residue in which roundworms and their eggs were observed. In this case, stones were observed only in the left lateral segment of the liver, and the bile ducts were not narrowed. Round worms were found only sporadically in the left lateral segment. Bile was retained in the intrahepatic ducts at the lesion.
These findings strongly suggested the involvement of roundworms in the formation of intrahepatic bile duct stones.

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A 58-year-old male was admitted to our hospital for workup of gallbladder tumor pointed out by complete physical examination. Ultrasonography and CT-scan showed an elevated lesion with irregular margin about 3 cm in diameter. In enhanced CT, the same elevated lesion was visualized as high density area. Abdominal angiography demonstrated tumor stein without encasement in the gallbladder. A diagnosis of carcinoma of the gallbladder was made, and extended cholecystectomy was performed. Histopathology revealed that the main elevated lesion ( I ) was well differentiated adenocarcinoma. However, two small polypoid lesions ( II_a) and broad flat cancerous lesions ( II_b) were pointed out around the main lesion.

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