The black gallstones are mainly composed of a polymer of bilirubinates and inorganic calcium salts.
86 cases of black stones were classified into 3 types according to macroscopic features and the analysis of infrared spectroscopy. In 48 cases, the black stones contained inorganic calcium salts and in 37 cases, contained calcium carbonate mainly of the calcite type.
On the other hand, the calcium carbonate stone cases including limy bile cases were mainly composed of calcium carbonate (aragonite type).
The black stone with or without calciu m carbonate tended to have mild inflammation in gallbladder pathologically, compared with calcium carbonate stones. From these results of the comparative studies it was suspected that the black stones with calcium carbonate differed from the calcium carbonate stones in the pathogenesis of gallstone.

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We attempted to make 3 dimensional images (3-D images) of intrahepatic bile ducts which were reconstructed from cholangio-CT using a 3-dimensional imaging pogram. In this report,8 cases of 3-D images of bile ducts were studied. In the 3-D image, closer bile ducts appear white and as the distance increases, bile ducts appear gradually grey to black. This is useful for comprehension of bile duct division, and all subsegmental bile duct branches were clearly detected because 3-D images could be made from randomized angles. The image which obained the subsegmental division and the full length of branch was defined as excellent, and the excellent angle for every subsegmental branch was determined. To demonstrate intrahepatic bile ducts,8 angles from 0°to 330°were ncccssary in 3-D images of CT cholangiography.

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Bile analysis was evaluated to examine the pahophysiologyy of 14 cases with high output of bile. These cases were characteristic of increasing of volume per day of HCO3, Cl^-, and Na⁺, and concentration of HCO3 and Cl^- in bile. On the other hand, one group with the bad efficacy of bile drainage in these cases was injured bile acid and bilirubin secretion, but volume per day of HCO3, Cl^- and Na⁺, and concentration of HCO3 and Cl^- in bile increased more than the other group with the good efficacy. For the above, it is suggested that ductular bile secretion, which is very similar to the choleretic mechanism of sccretin, increases in cases with high output of bile. Furthermore, it is speculated that in one group with the bad efficacy of bile drainage, canalicular bile secretion is damaged but ductular bile secretion more increases to supply the damaged canalicular bile secretion than the other group with the good efficacy.

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The results of thirty nine resected cases with gallbladder cancer were investigatd. The cumulative survial rate of 1,3 and 5 years in all resected cases were 68.0, 50.3 and 50.3%. The 3 year survival rate in early cases whose cancer was confined to the mucosal or submucosal layer, in moderate cases and in advanced cases whose cancer has infiltrated the serosal layer were 100, 66.2 and 14.7% and that in curative cases, relativ nonculative cases and absolute nnculative cases, all which were judged histologically, were 90.9, 100 and 0%.
These results demonstrated that when the extented radicall opration wa s performed aiming for the curative or relative nonculative operations in stead of the absolute nonculative operation, the best opportunity for cure was obtained.

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This study was carried out to clarify the influence of incomplete bile duct obstruction (IBDO) on the occurrence of cholangiocarcinoma induced by diisopropanolnitrosamine (DIPN)and to evaluate the effect of release of IBDO.
In the first experiment,320 male Syrian golden hamsters were divided into 2 groups, consisting of the simple laparotomy group and the IBDO group. These groups were administered with subcutaneous injection of 500 mg/kg body weight of DIPN weekly for 20 weeks after preliminry procedures.
In the second experiment,170 hamsters were administered with subcutaneous injection of 500 mg/kg body weight of DIPN weekly for 10 weeks. There hamsters were divided into 3 groups, consisting of the simple laparotomy group, the IBDO group and the 2 week IBDO group, in which IBDO was released at 2 weeks after procedure. In both experiments, the occurrence rates of cholangiocar cinoma at 15 and 20 weeks in the IBDO groups were significantly higher than those in other groups. The mean numbers of tumors per hamster at same weeks in the IBDO group were significantly larger than those in other groups. Besides, in the second experiment the simple laparotomy and 2 week IBDO group indicated similar coccurrence rates and numbers of tumor.
The above results suggest that IBDO has an in fluence, as promoter, on the occurrence of cholangiocarcinoma induced by DIPN, and that its promoting effect disappears caused by release of obtruction.

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Ionized calcium is an important factor in calcium-containing gallstone formation. Total calcium, ionized calcium, total bile acid, phospholipid and cholesterol concentration and pH of human common bile duct bile obtained intraoperatively from 22 patients undergoing cholecystectomy were measured in order to analyze the factors affecting the ionized calcium concentration in human bile. The concentration of ionized calcium was correlated to the concentration of total calcium. Trapping of ionized calcium by bile acid and phospholipid seems to be an importa nt regulatory mechanism for maintaining the concentration of ionized calcium in human bile. pH and cholesterol appear not to have an important role. Our data also suggest that biliary secr etion of calcium is influenced by bile acid and phospholipid.

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The estrogen receptor (ER) was immunohistologically investigated in biliary tract cancer, pancreatic cancer and benign gall bladder disease with monoclonal antibody. The ER was detected in greatly varying percenages of 90.9% for gallbladder can cer,50% for bile duct cancer,50% for cancer of papilla of Vater,11.1% for pancreatic cancer and 11.1% fornormal gallbladder. Intracellular loalization of the ER was less frequently observed within the nucleus but more commonly observed within the cytoplasm. ER positive cancer did not show any definite tendency in its macroscopic and histological type and infiltrative proliferation mode.

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We studied on the safety of methy1 tert-buthyl ether (MTBE) infusion into the gallbladder in mongrel dogs.
Results w ere as follows; During the MTBE infusion,
1) no remarkable change was found in the c i rculatory system,
2) the serum level of MTBE did not exceed 100 ppm. After 3 hours' infusion of MTBE,
3) no histological evi d ence of the canine gallbladder damage was found by either light microscopy or scanning electron microscopy.
On basis of our experiments i n dogs, we treated 3 patients with radiolucent gallstones with MTBE, to successfully dissolve those stones in 3-12 hours.In addition, no recurrence of gallstones has been detected by ultrasonography for at least 1 year.
In conclusion, MTBE has encouraging potential as a safe and highly effective gallstone dissolution solvent.

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Elderly patients with acute cholecystitis are well recognized as having high morbidity and mortality rate. In this paper, the management of acute cholecystitis in 31 patients 65 years of age and over was studied. Preoperative severe complications such as liver abscess, right subpherenic abscess, shock, toxic dermatitis and gastrointestinal hemorrhage were found more frequently in elder aged patients. Early operation was needed in 52% of elder aged patients, while in 17% of younger aged patients.
In the elderly, it seems to be necessary to diagnose acute cholecystitis and to perform early operation as soon as possible.

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We have performed extracorporeal shock wave lithotripsy in 60 cases of cholecystolithiasis. Here, we report the study. A lithotripter, MPL-9000, spark systemin water, was usedd.35cases showed complete disappearance of the stone. The pure cholesterol stone was the most likely to disapper, showing 100% disappearance. In a mixed stone, or combination stone, favorable results were recognized in cases with a single stone of less than 15 mm. However, a bilirubinate stone or strong calcificated stone did not disapper. In follow-up obserbation, recurrence has been recognized in 2 cases. Concerning complications, upper abdominal pain due to extraction of a crushed fragment was seen in 18 cases. However, severe impairment of tissure, due to shock wave, such as cystic submucous hematomaor intrahepatic hematoma was not recognized. Cholecystography after the treatment became impossible in 10% of the total cases.

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Extracorporeal shock wave lithotripsy for gallstone (GS) using the second generation spark discharge system (MPL-9000, Dornier) was performed in 50 patients (Male 24, Female 26). They had 1-7 GS (range 4∼37 mm mean16.3 mm). After disintegration, the patients received adjuvant dissolution therapy, with ursodeoxycholic acid,600 mg/day orally. The results were as follow; 1) the average number of impulses were 1,704 shock waves, the average generation voltage was 17 kv.2) general or epidural anaesthesia for ESWL were replaced by intravenous pentazocine analgesia (80%) or no medication (20%). 3) in 46 cases of 50 patients (92%), stones could be disintegrated under 4 mm in diameter after ESWL.26% of the patients were retreated because of large residual fragments.4) after ESWL, transient hematuria occurred in 26 patients (52%). Transient increase of CPK (48%), transaminase (23%) were observed. Abo ut one tenth of the patients had episodes of biliary pain after ESWL.5) Endoscopic retrograde cholangiography was performed in 25 cases 3 days after ESWL. In 8 cases out of 25 patients, some fragments by ESWL were found in common bile duct.6) within a follow-up of 9 months after ESWL, stones were disappeared in 4 cases (8%) and nearly completely disappeared in 3 cases (6%). And diminished size and number of fragments group were 30 (60%). In conclusions, ESWL using second generation spark discharge system combined dissolution therapy could be a safe and effective treatment of cholesterol gallstones.

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A 62 years old woman was admitted to our hospital complaining of jaundice and general fatigue. Chest and abdominal X-ray findings showed situs inversus totalis.
US and CT showed tumor shadow at the hepatic hilum, dilatati n of bilateral intrahepatic bile duct and preduodenal portal vein. Stenosis of the extrahepatic bile duct and shortened common bile duct was observed by ERCP and PTC. Preoperative PTCD was performed and cystologic examination of the bile revealed malignant cells.
The patient underwent cholecystectomy and rese c tion of extrahepatic bile duct and was reconstructed by bilateral hepaticojejunostomy.
The postoperative course was uneventful and the patient has been fine for seven months after operation.

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