[in Japanese]

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Liver damage induced by extracorporeal shock wave focusings was evaluated preclinically using 22 mongrel dogs. Hemorrhage was observed in the subcapsular layer of the liver and gallbladder bed in the case of over 500 shock focusings. Furthermore, parenchymal focal bleeding and coagration necrosis were also observed in the outside of high pressure zone at the shock focusing. On the other hand, when 1,000 focusings/case were carried out intermittently for two or three times, the parenchymal damage was significantly less than the continuous 1,000 focusings. One of the mechanisms of tissue damage is primarily thought to be direct high pressure itself. Another important mechanism in liver damage during shock wave focusing is suggested to be the piercing effect of a liquid microjet with impact velocity of more than 200 m/sec, which is formed through the interaction of a tiny bubble and a shock wave.

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Between 1973 and 1988, endoscopic retrograde cholangiopancreatography (ERCP) were performed on 73 children with various pancreatobiliary disorders. Endoscopic appearance of the papilla of Vater was compared in children and adults. In newborn and milk age children, longitudinal fold was not identified in 94.4% whereas it was seen in 98% of adults. The papilla of Vater was histologically examined on autopsy specimen both in childen and adults. Longitudinal fold consisted of sphincter choledochus inferior and intraduodenal bile duct. These structures were not well developed in children. This caused difference of endoscopic appearace of the papilla of Vater in children and adults.

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Recently, an increase in the occurrence of biliary disorders, especially cholelithiasis, has been reported to follow the prolonged administration of intravenous hyperalimentation (IVH).
To clarify the reason, we have studied gallbladder motility and bile compositi o n in the cases with IVH and compared them with those of controls and those of gallstones as well. On IVH cases: 1) An enlargement of gallbladder and a reduction in contractility were seen.2) Gallbladder bile remained sterile.3) Lithogenic index of gallbladder bile increased but the value was lower than 1.0.4) Total bilirubin level in gallbladder bile was significantly high in cases of IVH and black gallstones. These data may explain that the majority of gallstones developing after long term IVH are black gallstones.

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Radiological and macroscopical comparison on diagnosis of an abnormal pancreatico-choledocho-ductal junction (APCDJ) was studied in twelve autopsied or operated cases including biliary tract carcinoma in, eleven and pancreatic carcinoma in one. APCDJ was identified in nine cases with both radiologically and macroscopically. The length of their common channel macroscopically ranged between 3.3 and 1.5 cm. However, APCDJ was radiologically misdiagnosed in another two cases as follows: rather long common channel,1.5 cm in length, ran mainly in the submucosal layer of duodenum in a patient with pancreatic carcinoma, and carcinomatous infiltration into the pancreas in a patient with bile duct carcinoma resulted in abnormal closing between the common bile duct and the pancreatic duct. In remaining one case APCDJ was only identified in macroscopic study, not in X-ray, because of rather short common channel and terminal common bile duct carcioma. Therefore, APCDJ was clearly identified in cases with long common channel, whereas difficult in short common channel.

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The 5 year-survival rate of the total cases studied was 23%. The break down is as follows: 100% in 4 cases of hepatic duct lesion,0% in 10 cases of superior,24% in 14 cases of middle and 13% in 19 cases of lower portion lesion of extrahepatic bile duct.
The main cause of deaths in the patients with proximal bile d uct cancer was recurrence at the anastomotic region due to the remaining cancer cells. The cause in the patients with middle or lower bile duct cancer was hepatic or sytemic metastasis, which occurred in connection with vessel invasion and advanced lymphnode metastasis. Furthermore, carcinomatous peritonitis occurred even in curative patients whose tumors showed moderate or severe lymph vessel invasion and perineural involvement.
These findi n gs indicate that the aggressive surgical approaches such as curative hepatic lobectomy including vascular resection and reconstruction for the proximal part of bile duct, and curative extended pancreatoduodenectomy for the distal part of bile duct followed by systemic chemotherapy offer the best opportunity for cure.

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The resectability of carcinoma of the gall bladder is increasing by performing an extended surgery with hepatectomy and pancreaticoduodenectomy. However, it is the fact that the rate of surgical death is increasing
There are two points to decrease the rate of surgical death. Firstly, the range of hepatectomy should be limited to an anatomical subsegmentectomy or more less. Secondly, pancreaticoduodenectomy should be avoided when metastasis of paraceliac, parasuperiomesenteric and paraaortic lymph nodes are remarkable.
CEA doubling time is very useful index as a malignant potential and a prognosis. Slow growing carcinoma of gall beadder which has a 180 days or more of CEA doubling time is a good case for an extended surgery with henaticonancreaticoduodenectomv.

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The usefullness of endoscopic ultrasonography (EUS) in the diagnosis of polypoid lesions of the gall bladder (GB) was evaluated. EUS was carried out in 37 cases with polypoid lesions of GB which had been confirmed histologically after surgery. EUS findings of them were compared with the pathological findings. EUS findings were classified into 5 types as follows. I type: small round high echoic mass, II type: mass composed of high echoic granules or short stripes, type: solid high echoic mass, IV type: solid low echoic mass, V type: solid low echoicI II m ass with scattered anechoic small cysts. Out of 22 cholesterol polyps,2 cases showed I type and others were II type. Adenomas and carcinomas in adenoma were described as IV type. Out of 3 carcinomas,1 case demonstrated II type and others were IV type. Adenomyomatosis showed V type. From above results, I and type were revealed in cholesterol polyps, IV type was mainly shown in carcinoma and adenoma, V type was often seen in adenomyomatosis. It was thought that polypoid lesions of GB could be qualitatively diagnosed by EUS to some extent

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Biliary extracorporeal shock wave lithotripsy was performed in 60 patients with gallbladder stones using an electromagnetic membrane system. Selection criteria for gallbladder stones were (i)radiolucent, (ii) ≤ stones and (iii) ≤30 mm in diameter, however slightly radioopaque larger multiple stones were included when gallbladder function was well preserved. Fragmentation was attained in 92% of patients. Multiple larger stones could be fragmented by increasing numbers of shock waves. Fragmentation was not restricted by a slight calcification of stones. The stone-free rate in overall patients was 28% at the 3 months follow-up period. Side effects included pain at shock wave passage in 51%, arrhythmia in 3%, elevation of biochemical findings in 2-11%, and biliary pain in 10%. Howeve, all of these side effects were transient and reversible, which did not interfer the scheduled treatment. These results indicated that the lithotripsy using the electromagnetic membrane system was an effective and safe treatment for gallbladder stones.

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Three cases of benign stenosis of bile duct were reported. Two cases were membraneous stenosis of common hepatic duct, the other was choledochal stenosis and not mebraneous.
All three cases had not been operated previously and had no other abnor m al findings which cause bile duct stenosis.
By histological examinaton of bile duct wall, there were no neopastic change nor remarkable inflammation, but well-developed smooth muscle was seen. These histlogical findings suggested that the stenosis of these cases to be congenital.

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Reports of primary intrahepatic cholesterol stone have been increased in recent years. However, cases of early age onset were found only a few. We experienced an early age onset case of primary intrahepatic cholesterol stone.
The patient was 23 years old man w ho had right hypochondralgie and liver function disorder. Ultrasonogram showed small high echo lesion in the gallbladder, and also showed high echo spot and acoustic shadow in right posterior hepatic lobe. Under a diagnosis of cholelithiasis and intrahepatic stone, operation was performed. Many minute stones were found in right posteriorinferior branch at operative cholangiography.
Cholecystectomy was done, and postoperatively we tried endoscopic lithotomy through sinus tract of the T-tube. However lithotomy was not successful. Two months later from the first operation, the right posterior lobectomy was performed. In the resected specimen, minute cholesterol stones were confirmed in the right posterior-inferior branch. The stones contained 98% of cholesterol according to the result of analysis of stone by infared spectum.

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We reported 2 cases withs anomalous arrangement of the pancreaticobiliary ductal system (AAPB). One was a 56-year-old female with cancer of the gallbladder, and received complete resection, the other was a 60-year-old female with unresectable cancer of the gallbladder. ERCP of the both revealed that the end of the common bile duct connected to the termination of the Wirsung duct and moreover Wirsung duct joined to Santorini duct through a small duct, and through the communication the main pancreatic duct in the body and tail was demonstrated with contrast. Their bile ducts were not dilated. The fashion of the communication with the bile duct and the pancreatic duct is suggestive to the ontogenic study of this anomaly.

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A 73-year-old man was admitted and examined because of a four-day history of right hypochondralgia, general malaise. Abdominal rentogenogram revelaed a gas bubble in the gall bladder, which was not detected by ultrasound. Abdominal CT imaging revealed gas and several small stones in the gall bladder. The examination of upper gastrointestinal series and lower intestine did not show abnormal communication between the biliary tract and gastrointestinal tract. Cholecystectomy was performed under the diagnosis of emphysematous cholecystitis.
Emphysematous cholecystitis is an uncommon variant of acute c h olecystitis in which the causative organisms are gas forming-bacteria.
The treatment of choice of emphysematous cholecystitis is early surgery combined antibiotic therapy, because the disease implies a risk of gangrene and perforation of the wall of the gallbladder.

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