Caudate lobe involvement of biliary tract cancer was studied using Stereo-Biplane PTC and Cholangio-CT. In 47 cases of resected biliary tract cancer at liver hilum, Stereo-Biplane PTC findings were assessed on resected specimen. Preoperative PTC demonstrated 15 bile ducts with stenosis and 31 normal ducts of caudate lobe. Histology showed cancer invading to caudate lobe in 15 of 15 bile ducts with stenosis and 2 of 31 normal bile ducts. Where caudate lobe bile ducts were not visualized by PTC, Cholangio-CT was performed after injection of contrast medium into the bile ducts through drainage catheter. In those patients CT demonstrated dilated caudate lobe branches which were not visualised by PTC due to obstruction. Caudate lobe invasion of bilialy tract cancer was histologically comfirmed in 30 of 32 patients (94%) with caudate lobe branch stenosis or obstruction. When stenosis or obstruction of caudate lobe branches are demons trated by PTC or CT, caudate lobectomy should be indicated in patient with bile duct cancer at liver hilum.

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The result of 29 resected cases of gallbladder carcinoma with at least systemic lymphnode dissection (R₂) were investigated. No lymphnode metastasis was found in patients whose carcinoma was limited to the muscle layer, while patients whose carcinoma had spread beyond the muscle layer had a hige rate of lymphnode metastasis. The metastatic rate of an each regional lymphnode was as fbllows. (13) a 38%, (12) b 31%, (12) ap 21%, (8)21% and (16) 5/14. The lymphatics from the porta hepatis were classified into two groups. The right lymphatics passing through the hepatoduodenal ligament((12) b→(13) a→(16)) was thc main route of lymphnode metastasis, and the left lymphatics ((12) ap→(8)→(9) or (7)→(16)) communicated at (13) a, (8) with the right lymphatics. The five-year survival rate was 47.9% in patients of curative operation, and 0% in patients of non-curative operation. In the cases whose carcinoma had spread beyond the muscle layer, more extensive lymphnode dissection(R₂ with (9), (13) b, (14) a, (16))should be performed for the purpose of curative operation.

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To evaluate the indications and limits of choledochoscopic removal of intrahepatic stones via the ommon bile duct, we analyzed the treatment results in 68 patients with intrahepatic stones treated by this method in terms of the location of stones, and stenosis, dilatation, and abnormal arrangement of the intrahepatic bile ducts. Complete removal of stones was possible in 51 patients (75%), but 7 patients (10%) underwent re-operation due to incomplete removal. In 10patients (15%), since intraoperative choledochoscopy showed that complete removal of stones was impossible, major surgical method such as hepatic resection was selected as the initial operation. Bile duct stenosis most markedly affected choledochoscopic removal of sones. Treatment was more difficult in patients with stenosis than in those without stenosis. The site of stones was the second most important factor. The right type or the bilateral type of intrahepatic stones were more difficult to treat than the left type. Dilatation of the intrahepatic bile ducts only slightly affected choledochoscopic removal. Therefore, hepatic resection or hepaticojejunostomy with resection of the stenotic site may be indicated in the patientss with bile duct stenosis or abnormal arrangement of the intrahepatic bile ducts.

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It is certain that the most favorable results can be obtained by hepatic lobectomy in the cases with intrahepatic stones, but the number of patients for whom it can be indicated is practically limited because of the risk of patients or the site and extent of lesions. In those patients in which hepatic lobectomy was impossible to perform, stone-extraction technique suing cholangioscopy is the technology indispensable to get a better therapeutic results.
Since 1974,104 cases of intrahepatic stones have been endoscopically treated in our institute, and stone extraction had been failed in 14 cases. The failure of endoscopic stone-extraction were caused by; 1) accidental removal of the tube placed to maintain the fistula for insertion of cholangiofiberscope in 2 cases,2) the difficult location of lesion for endoscopic stone extraction technique in 7,3) liver cirrhosis in 2, and 4) multiple organ failure (MOF) in 3 cases. The latter 5 cases had passed away. In one of the patients died of MOF due to sepsis caused by liver abscesses, pancreas carcinoma was revealed by autopsy. The causes of the patients who had had these fatal and disastrous complications are attributable to; (1) delayed timing of treatment, (2) insufficient biliary drainage, (3) inadequate selection of surgical procedure, (4) incomplete stone extraction, and (5) coexistence of incurable diseases. These facts suggested how much important the preoperative evaluation of biliary architechture is to get the informations necessary to decide an adequate therapeutic plan. Moreover, importance of complete extraction of stones at the time stones were detected is strongly advocated, because the prognosis would be deteriolated if life threatening complications such as purulent cholangitis, liver abscesses or biliary cirrhosis did once occur.

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The purpose of this study was to investigate the sequential changes of granulocyte elastase and the effect of protease inhibitor: ulinastatin during biliary drainage. The levels of plasma granulocyte elastase were measured in 13 patients of obstructive jaundice due to malignant tumors.5 patients in 13 were given ulinastatin (100,000 units/day) for 2 days following biliary drainage. There was relationship between the level of granulocyte elastase and the level of total bililubin and the count of white blood cell (p <0.01). The level of granulocyte elastase increased during the first day and then declined. This increase of granulocyte elastase was inhibited by the administration of ulinastatin. One patient showed high level of granulocyte elastase after biliary drainage and died with sepsis and multiple organ failure due to the poor drainage. Propriate biliary drainage should be necessary for obstructive jaundiced patients and ulinastatin may be clinically beneficial for the control of granulocyte elastase of these patients.

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Two traumatic bile duct strictures were dilated percutaneously with dilators. The dilation was performed with fluoroscopic guidance in a radiology suite. After removal of dilators, stent tubes were left in place across the stricture. The stent size was 12 Fr. and stents remained in place for 5-6 months. After stent removal, symptoms disappeared without recurrence of the stricture for 12-33 months. Nonoperative endoprosthesis of traumatic bile duct strictures is a relatively safe technique that results in lasting stricture patency. Although long-term follow-up is also important, it may be that this technique represents an effective alternative to surgery.

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UDCA was administered at 300 mg/day for at least 7 days before cholecystectomy to 30 of 60 patients with gall stones in the gallbladder. The other 30 patients received no UDCA and served as control.
1. Total bile acid (TBA) and phospholipid levels increased in the UDCA group, while cholesterol levels increased in the untreated group, but there were no significant differences between the two groups.
2. TBA levels in peripheral and portal blood samples and bile samples taken from the gallbladder during surgery increased in the UDCA group, with the UDCA/TBA ratio being 50.8%,35.7% and 31.9%, respectively, in these samples. These ratios were significantly higher than those in the untreated group (less than 5 %).
3. Serum GOT, GPT and ALP decreased significantly after surgery in the UDCA group. T. Bil., LAP and γGTP were also suppressed at lower levels than in the untreatcd control group, although differences were not significant.
These findings suggest that preoperative treatment with UDCA changes the bile acid composition in bile and blood and favorably affects postoperative hepatic function.

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The importance of second-stage operation for gallbladder cancer was evaluated in 7 out of 42 cases whose lesion was resected in our hospital. One and three year survival rate of the patients who had had the second-stage operation were 83.3% and 20.3% respectively. These rates were significantly better than those of the patients treated with only simple cholecystectomy (p<0.05).
Five cases had infiltrative poorly differentiated adenocarcinoma, and in 4 of 6 cases of advanced cancer, carcinoma had invaded the regional lymph nodes of 2 nd group. Therefore, it is considered that the second-stage operation should be indicated in the majority of cases because the infiltrative type of which preoperative diagnosis is difficult to make is predominant. This fact is responsible for short survival periods. These facts suggested that aggressive radical operation accompanied with extended dissection of regional nodes must be indicated for the patient with advanced gallbladder cancer to obtain a better therapeutic results.

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A 57-year-old woman to our hospital was admitted because of jaundice. On laboratory data level of biliary enzyme was elevated. US demonstrated dilation of intra and extrahepatic bile duct. PTCD was nextly performed. An obstructed duct with concaved end was revealed. But extensive axial spread cannot be defined on direct cholangiogram. Double contrast study showed small polypoid lesion with irregular surface. Invasion forward to middle and upper portion of a CBD was not recognize on double contrast cholangiogram. To assess the full extent of tumor, angiography and EUS was performed. No definitive abnormality was seen angiogaphycally. EUS disclosed minimal deep-spread to pancreas beyond bile duct. Typical pancreatoduodenectomy was performed. Cut surface of resected specimen disclosed localized polypoid mass in bile duct. Pathologically papillay adenocarcinoma combined with partially undifferenciated compornent was defined. Extent to pancreatic parenchymal was confirmed.

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A 46-year-old man was admitted to the hospital with the chief compliant of right hypochondriac pain. Ultrasound examination revealed the presence of a mass with a diameter of 8 cm in the right lobe of the liver. Further detail examinations, the patient was diagnosed of having unoperable hepatocellular carcinoma (HCC) accompanied with type B liver cirrhosis. Transcatheter arterial embolization was performed for the treatment of HCC. During a follow-up period, computed tomography found metastases to the hepatoduodenal lymph nodes. The lymph nodes gradually increased in size and obstructive jaundice developed 5 months after the discovery of the lymph node metastasis. Endoscopic retrograde cholangiography demonstrated the stenosis of the common bile duct without any intraductal masses. The obstructive jaundice was therefore considered to have been caused by the enlarged lymph nodes, and endoscopic retrograde biliary dranage was perfomed.
The development of clinical symptoms caused by lymph nodes metastasis is rare in HCC. This case provides interesting information in considering the mechanism of obstructive jaundice in HCC.

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A case of hepatocellular carcinoma with hemobilia, following obstructive jaundice and acute emphysematous cholecystitis, is reported.
A 66-year-old man was admitted to our hospital complaining of abdominal pain and hematemesis. US and CT showed gas in the gallbladder wall and intrahepatic bile duct, but no mass in the liver. Cholangiogram revealed a blood clot in the whole biliary tree. Cholecystectomy and T tube drainage was performed, showing neither calculi nor hepatic mass. Follow-up CT, three months later, showed a hypoechoic lesion in the posterior segment of the liver. Subsegmentectomy of the liver segment S6 was performed, and histology revealed trabecular type hepatocellular carcinoma (Edmondson type III).

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A 19-year-old student was admitted because of right upper abdominal pain. Ultrasonography showed highly echogenic masses accompanied by acoustic shadows in the periphery of the anterior and posterior branches of the right intrahepatic bile duct. ERCP and PTC revealed radiopaque images in the periphery of B₅ and B₇7, but there were no radiopaque objects in the gallbladder or the common bile duct. The posterior segment branch was confluent to the extrahepatic bile duct, and the cystic duct showed anomalous fusion at the root of the posterior branch. One branch in B₅ filled with many small stones had a filamentous and angular portion at its Junction. Right anteroinferior (B₅) and posterior (B₆,₇) subsegmentectomy was performed. No stones were found in the gallbladder on the common bile duct. The calculi were determined to be “pure cholesterol stones” with over 90% cholesterol content by the KBr-tablet method, but a radiating crystalline pattern in the cut surface was not detected. Primary intrahepatic pure cholesterol stones are rate, and only seven cases under 30 years of age have been reported. Our patient was younger than those previously described in the literature.

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