To evaluate the severity of acute cholecystitis, we have applied the ultrasonographic findings. In this paper, our 112 patients of acute cholecystitis were classified to three grades accoding to ultrasonographical findings as follows. Grade 1; sonographic Murphy sign, significant gallbladder distention and gallbladder wall thickening. Grade 2; sonolucent layer, gallbladder sludge, subhepatic and intramural pericholecystic abscess. Grade 3 intraabdominal pericholecystic abscess, intraperitoneal fluid collection, acute cholangitis and liver abscess. These sonographic grading had a relation with clinical severity and APACHE II score system. Sonographic grade 1 ranked clinical mild, grade 2 moderate and grade 3 severe. Most patiente of grade 1 had mild inflammatory change in/along gallbladder at operation. About half patients in grade 2 and all in grade 3had inflammatory gallbladder at operation. Laparoscopic cholecystectomy was attempted in seven patients. Five patients (71%) underwent successful laparoscopic cholecystectomy. Elective operation included laparoscopic cholecystectomy should be applied to the ptients in grade 1 or 2. Urgent or early operation should be indicated to the patients in grade 3.

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The incidence of gallstones after gastrectomy is 11.8%. The average interval between its onset and detection is relatively early,24 months. But the rate of spontaneous disappearancee is high,34.8%. In cases with total gastrectomy in resection procedure, Roux-en-Y and nonphysiological reconstruction, and lymphadenctomy at a degree of R2 or greater reveals significantly higher incidence rates. There was a tendency toward a postoperative increase in the cholecystic area under fasting conditions. The study of the postopeative kinetics of intrinsic cholecystic conraction showed a rapid contraction and a relaxation in the early phase, reveals significantly hypotonic state. The kinetics of the CCK secretion after gastrectomy was characterrized by early transient hypersecretion in response. In conclusion, the important facters involved in the pathogenesis of gallstones after gastrectomy were a reduction of cholecystic contractility and hypotonic state of gallbladder due to vagotomy associated with lymphadenectomy and a reduction of sensitivity in gallbladder wall to the CCK.

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Histological analysis of proliferated bileductules in the syndrome of disappearing intrahepatic bileducts (9 cases of PBC,10 cases of CBA) had done.
Histologicaly,2 types of proliferated bileductules were seen in PBC and CBA. One was bileductules with clear cytoplasm seen in cross sections (type-1), another with dark cytoplasm seen in longtudinal section continued to hepatocytes (type-2). In PBC, Mallory bodys were seen in the later ones as hepatocytes. The ratio of 2 types of bileductules was different in PBC and CBA. Type-2 were dominant in PBC, enlarged type-1 were dominant in CBA. Immunohistologically, type-1 showed the same staining as to bile epithels, type-2 as to hepatocytes.
Electromicroscopically,2 types of bileductules were seen. One originate bileducts showing poor intracellular organs with basement membrane, another originte hepatocytes showing numbers of large mitochondria without basement membrane.
These findings suggest that type-1 derived from bile epithels and type-2 from hepatocytes. Both bile epithel and hepatocyte have a potential to deriver bileductules, whose appearances depend on the primary portion of obstructed bileducts.

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The diagnostic ability of endoscopic ultrasonography (EUS) for gallstones was examined.
1) Three phantom images scanned with a 3.5MHz probe of extracorporeal ultrasonography (US) and 7.5 and 12MHz probes of EUS were compared on 11 extracted gallstones. When echo frequency was rasen, the surface echo of cholesterol gallstoneshowed thin and strong, and the inner echo disappeared. The surface echo of calcium bilirubinate stones showed thick and strong, the acoustic shadow was clarified and the inner echo disappeared. Black stones remained as high echo all over the stones but the acoustic shadow appeared by 12 MHz.
2) EUS was clinically implemented to patients with 20 cholecystolithiasis and 10 choledocholithiasis. Two cases of stones in the neck of the gallbladder were diagnosed only by EUS. All of 10 cases of stones in the common bile duct were clarified. Thus, the accuracy rate in the qualitative diagnosis of gallstones was 87%, and EUS was useful for the diagnosis of choledocholithiasis.

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Biliary extracorporeal shock wave lithotripsy (biliary ESWL) has been carried out for treatment of gallstone disease in testing attempts in Japan. To make further development of biliary ESWL to a clinically available method of gallstone treatment, the effectiveness and the safety should be confirmed on the basis of data acquired in the attempts. So, we made a questionire study on the biliary ESWL proceeding in 19 hospitals in which the treatment had been carried out for over 20 patients with gallstone.

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Five patients with diffuse type of bile duct carcinoma underwent hepato-pancreatoduodenectomy with intraoperative radiation therapy (IORT). IORT was given to the dissected portions, such as the stump of the bile duct or dissected area of the hepatoduodenal ligament where residual tumor cells were revealed histologically at the operation. The policy of adjuvant radiotherapy is to give IORT a safe dose of 1,500 cGy, to prevent adverse side effect, and to add external irradiation for a sufficient tumorcidal dose. One patient survived for 3.3 years and one patient with mucosal spread carcinoma is alive and well for 1.5 years after surgery, however, the effect of this treatment modality was questionable in the other three patients without significant prolongation of the survival time. We are going to continue this approach with more cases for estimating possible effect of TORT.

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Percutaneous transhepatic retrograde biliary drainage (PTRBD) was performed in 12 patients with biliary malignant obstruction (consisted of extrahepatic bile duct carcinoma in 11 and papilla Vater carcinoma in one patient. ) All patients had had the biliary radicles not nicely drainaged with previous PTBD in the opposite lobe. In those patients, the biliary duct was selectively catheterized using an angiographic catheter and radifocus guidewire inserted through the PTBD sinus tract previously produced. And then, a stiff guidewire was reintroduced pheripherally, to perforate the wall of the biliary radicle, liver parenchyma, and liver capsule, into the abdominal cavity, retrogradely. A guidewire was captured with forceps under fluoroscopy and brought out through the abdominal wall. After subsequent dilatation of percutaneous tract was done along the guidewire extracted PTBD tube was placed in the biliary tract.
PTRBD was useful method for creating the route of PTCS, intraluminal irradiation and expandable metallic stenting. And no significant compliacation was observed in this series.PTRBD was feasible method of creating second route especially in the patients with biliary trees which should be decompressd.

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The patient was a 52-year-old male, who sometimes developed periumbilical pain after meals. Abdominal ultrasonography, abdominal CT, ERCP, PTC and PTGB were performed. The lumen of the gallbladder was partitioned irregularly by many thin septa and we diagnosed "multiseptate gallbladder". Abdominal angiography revealed an image resembling a tumor stain in the anterior region of the right hepatic lobe, so cholecystectomy and excision of the anterior hepatic resion was performed, but there is no tumors in the excised liver specimen. We reportd a recent case of multiseptate gallbladder, which is extremely rare condition, and included some discussion of the literature.

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A 58-year-old female complaining severe upper abdomial pain was hospitalized to affiliated hospital of our university. Examination revealed acute gallstone pancreatitis. Cholecystectomy and retroperitoneal peripancreatic drainage were perfomed. Intraopertive cholangiogram demonstrated abnormal pancreatobiliary duct uion. Histological examination of the resected gallbladder showed carcinoma invading to the subserosal layer. After 8 weks second-look operation was performed. The extrahepatic bile duct and liver bed were resected and lymph nodes were dissected. Histology of the resected bile duct disclosed minute carcinoma at the site of T-tube insertion. Ras staining was positive for atypical hyperplastic epithelium and cancer cells. Mechanical stimulation of the T-tube might be responsible for development of bile duct carcinoma. High incidence of carcinoma of the gallbladder has been reported in pancreaticobiliary maljunction without dilatation of the bile duct due to mucosal inflammation caused by pancretic juice. In such particular condition bile duct mucosa may also be high risk state for carcinoma.

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A 24-year-old male was admitted to our hospital complaining of left abdominal pain and diarrhea. Ultrasonography showed marked thickening of the wall of the gallbladder. ERCP revealed abnormal connecting branch between the common bile duct and the pancreatic duct those were normal in size. The comon channel and the main pancreatic duct opened individually at the main papilla. The gallbladder was slightly enlarged and segmented. Cholecystectomy was performed. Histopathology revealed fibrosis of the body and the fundus of the gallbladder and hyperpasia of the mucosa. Anomalous arrangement of the pancreaticobiliary ductal system should be considered with the paients who have thickening of the wall of the gallbladder.

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