In order to clarify the pathophysiology of the hepatolithiasis, bile stasis and bacterial infection were loaded on partial lobe of the liver of mongrel dogs and the influence of bacterial infection on the intrahepatic biliary branches was examined.
The large bile duct in the group with combin e d infection of aerobic and anaerobic bacteria showed marked proliferative changes such as epithelial hyperplasia and many mucus glands, in addition to findings of severe chronic inflammation such as infiltration of inflammatory cells and periductal fibrosis. These findings were very similar to the picture of chronic proliferative cholangitis frequently seen in human hepatolithiasis. On the other hand, in the group with infection of aerobic bacteria alone, proliferative changes in the biliary epithelia were much milder than those in the combined infection group, although severe chronic inflammatory findings were observed.
From the above results, it is suggested that infection of anaerobic bacteria plays an important role in the proliferative changes in the biliary epithelia.

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A study on cell membrane damage by bile salts was performed using human red blood cells (RBC). Taurochenodeoxycholate (TCDC), taurodeoxycholate (TDC), taurocholate (TC), and tauroursodeoxycholate (TUDC) were co-incubated with human RBC, respectively, followed by measurement of release of cell free hemoglobin and morphological determination by transmission electron microscopy (TEM). The hydrophobicity of each bile salt was indexed by the retention time of a reverse phase HPLC.
Phosphatidylcholine (PC), cholesterol (CH), albumin, and mucin were tested for their ability to protect RBC' from damage by bile salts. Results were as follows; 1. The ranking of hemolytic effects of bile salt determined in stoichiometry and morphology was TDC> TCDC> TC> TUDC.2. A strong linear correlation between hemolytic effects of bile salt and their hydrophobicity was found (y=0.689x-0.054, r=0.991).3. PC and albumin reduced bile salt toxicity dose-dependently, but did neither CH nor mucin. Thus, we deduced that cell membranes including biliary systems are protected against hydrophobic bile salt toxicity by PC and certain proteins, i. e. albumin.

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To elucidate changes in bilirubin metabolism after biliary democompression for obstructive jaundice, choledochoduodenostomy with or without 70% hepatectomy was performed at 2 or 3weeks after ligating the common bile duct with cholecystectomy in dogs. Dogs with a long term jaundice or hepatectomy showed a prolonged jaundice after biliary decompression and poor prognosis. In serum bilirubin fractions after biliary decompression, as the period of obsturctive jaundice was elongated, bilirubin diconjugate (BDC) did not decrease suficiently. Moreover when hepatectomy was performed, bilirubin monoconjugate and bilirubin unconjugate did not decrease sufficiently either, accompanying decrease in ratio of delta bilirubin to direct bilirubin. Bilirubin fractions of bile in dogs with biliary decompression alone demonstrated little difference from those in normal dogs, but in dogs with biliary decompression and hepatectomy BDC decreased and bilirubin monoglucuronide increased in bile. An activity of uridine diphosphate glucuronyltransferase in hepatic tissue decreased during obstructive jaundice and it sufficiently recovered after biliary decompression, although its recovery was very poor in dogs with hepatectomy. Thus, the longer the period of jaundice became, excretion of BDC was impaired the more severely, and hepatectomy under these circumstances was considered to cause the further prolongation or aggravation of jaundice with impaired ability of bilirubin conjugation.

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Gastric surgery have been implicated in gallstone formation, although the association remains unproven. Whether gastric reconstruction affect in the formation of gallstones are still unknown. To evaluate the influence of reconstruction on forming cholelithiasis,92 patients were studied who were operated from 1978 to 1988 for cholelithiasis after gastrectomy. We classify these patients into three groups, A: proximal gastrectomy with esophagogastric anastmosis (3 cases) +distal gastrectomy with Billoth I anastomosis (24 cases), B: distal gastrectomy with Billoth II anastomosis (55 cases), C: total gastrectomy with esophagojejunostomty (9 cases). In alphabetical order, the incidence of cholelithiasis of bile duct and calcium bilirubinate stones was increased as well as the positive rate of the gallbladder bile incubation. The period from gastrectomy to gallstone formation of group C was more rapid than other groups, significantly. This study was done to underline not only gastrectomy but also gastric reconstruction have an influence on formation of gallstones.

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Recently, PTBE has been widely used for patients with unresectable malignant bilary obstruction. However, we sometime encounter several problems of complications in the management after PTBE. In this paper, we report the usefulness of PTBE connected to subcutaneously implantable Infuse-A-Port in two cases, resulting in good clinical course. The features of this technique are as follows: (1) washout of the endoprosthesis catheter and bile duct, (2) periodical cholangiography, (3) drug infusion into the bile duct and (4) clearance of the cause of troubles with PTBE. This technique seemed very useful for the mangement and follow-up after PTBE and improvement of the quality of life of the patients.

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The patient was a 48-year-old man with complaints of abdominal pain and fever. Percutaneous transhepatic cholangioscopy (PTCS) was performed. Stones were found in the left lateral posterior branch (B2) and removed by PTCS. The analysis of stone composition revealed that 90% of the stone was cholesterol. In this case, unusual severe stenosis was found on the root of cylindrically dilated B2. Cholangioscopic dilatation of stenosis was successfully performed. No recurrence of stones nor biliary stenosis has been found during the follow-up period of 1 year and 2 months. We believe that PTCS is useful for diagnosis and treatment of intrahepatic cholesterol stone.

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A 45-year-old man was admitted to our hospital complaining of epigastric pain and jaundice. Abdominal US and CT, scout film of the abdomen revealed limy bile with obstructive jaundice. Emergency percutaneous transhepatic cholangio-drainage (PTCD) was performed on the next day of admission. Yellow greenish clay-like substance drained throuhg the PTCD tube, which proved calcium carbonte by infrared spectorphotometer. The pH of the bile was 9.6. The cholangiogram revealed normal cystic duct. The limy bile drained through the PTCD tube for some days. Severeal modalities revealed no stones in the biliary system, and the PTCD tube was removed. He had been admitted due to liver dysfunction about 1 year before this admission. The scout film of the abdomen revealed limy bile in the bottom, and small stone in the neck of the gall bladder. We thought the alkalization of the bile and reversible obstruction of the cystic duct played an important role in producing limy bile in our case.

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The procedure for percutaneous transhepatic internal biliary drinage (PTIBD) is very useful for relieving obstructive jaundice in patients with incurable malignant obsturctive jandice. This procedure is less invasive than the procedure for surgical internal biliary drainage and is more physiological bile flow can be obtained comparing with that for external biliary drainage.
In this paper, the new tube with the reservoir at the distal end implanted in th e subcutaneous space, to be used for obtaining internal biliary drainage was introduced using saline containing antibiotics and urokinase can be easily carried out through the reservoir and was useful to prevent blockage of tube indwelled.
This new tube was used for 3 cases with incurable malignant obstructive jaundice consisted of 2 cases with biliary cancers and one with gastric cancer with lymphnodes metastasis.
In these 3 cases, the internal biliary drainage was nicely obtained for 28,48 and 164 days. During this period, the patient could be alive comfortably without any restrictions.

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A 55-year-old man was admitted to the hospital with an episode of colicky pain in the right upper quadrant. Laparoscopic examination showed that the intrahepatic tumor was morphorogically compatible with hepatocellular carcinoma (HCC). Endoscopic retrograde cholangiography (ERC) demonstrated filling defects in the common bile and common hepatic ducts. On the second ERC performed 16 days later, the filling defects in the biliary tree had completely disappeared. Autopsy confirmed the invasion of HCC into the bile duct.
HCC with invasion into the bile duct sometimes induced recu r rent icterus. Although this clinical episode is generally explained by the disappearance of filling defects on cholangiography. We presented here the first case of HCC with tumor invasion into the bile duct, in which filling defects on ERC were found to disappear during a follow-up period.

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A rare case of congenital hypoplasia of the right hepatic lobe associated with choledocholithiasis and ectopic gallbladder was reported.
A 68-year-old man, who had bee n diagnosed as having a congenital malformation of the right hepatic lobe with choledocholithiasis and ectopic gallbladder, consulted our department to undergo surgical treatment.
Recent ERC d emonstrated a filling defect at the remnant right hepaic duct, but no stones in the common bile duct.
Percutaneous tran s hepatic cholangioscopic lithotripsy(PTCS-L) was performed preoperatively.
The extracted stone fragments proved to be bilirubin-calcium in nature. Abdominal angiography disclosed the abscence of right portal vein and right hepatic artery, and the lack of parenchymograrn of the right hepatic lobe.
These preoperative diagno s tic imagings supported our diagnosis of a congenital hypoplasia of the right hepatic lobe. Cholecystectomy, choledochotomy, operative cholangioscopy and the resection of a parapapillary duodenal diverticulum were successfully performed. Surgery, also, confirmed the our preopeative diagnosis.
His postoperative course was uneventful, and he discharged on the 22 th postoperative day.

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Squamous cell carcinoma of the common bile duct have been reported infrequently since Cabot's first report in 1930. A 68-year-old male with jaundice who proved to have a tumor of the common bile duct. He underwent pancreatoduodenectomy combined with a resection of the haptoduodenal ligament including the bile duct, portal vein and hepatic artery. Histologically, the tumor was a well-differentiated squamous cell carcinoma of the intrapancreatic bile duct with no part of adenocarcinoma, infiltrated to the pancreas very sligytly. No lymph node metastasis was found. Postperatively he passed 25 months with no evidence of recurrence. Concerning the etiology of this tumor, it is theorized that the normal columnar epithelium of the bile duct under the chronic inflammatory stimulus can change into squamous metaplasia and eventually carcinoma. On the other hand, it is also considered that squamous cell carcinomas in these unusual sites are more likely to be due to squamous metaplasia of the adenocarcinoma itself than to malignant transformation of a previously benign metaplastic epithelium.

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We frequently experience the double cancer consisting in the stomach and the other organ. However, the gastric cancer is rarely combined with the bile duct cancer. We reported a case of the early gastric cancer simultaneously found with the middle bile duct cancer.
A 65-year-old male was admitted to our hospital because of obstructive ja u ndice. Percutaneous transhepatic cholangiogram revealed a marked stenosis of the middle bile duct. Endoscopic study of upper gastrointestinal tract showed a shallow depressed lesion at the antrum. These lesions were resected by pancreatoduodenectomy. Resected specimen showed a nodular infiltrating tumor,25 x 20 mm in size, at the middle bile duct and a superficial depressed lesion,14 x 6 mm in size, at the antrum. Microscopical examination revealed invasive adenocarcinoma at the bile duct and early adenocarcinoma at the stomach.
It seems important for the patient with the biliary cancer to have through work-up of the gastrointestinal tract.

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