To assess the gallbladder motility during enteral hyperalimentation and total parenteral nutrition, biliary ultrasonographic studies were performed in 22 entrally fed patients and in 12parenterally fed patients and in 15 controls. Enteral infusion was continuous (continuous ED)in 10 cases and intermittently (intermittently ED) in 12 cases (8 AM to 12 PM). Gallbladder are was measured by planimeter in the ultrasonograph bihourly between 8 AM and 10 PM. At the same time, plasma CCK and serum Gastrin level were measured.
The maximal contractile ratio of gallbladder was 85.2±.10.0% in conrols,74.6±6.9%in intermittently ED patients and 59.9±33.6% in continuous ED patients. But it was 8.5±16.6% in TPN patients, significantly reduced. The maximum change in gallbladder area was significantly reduced in TPN patients and continuous ED patients.
Higher plasma CCK levels were found in continuous ED patients, lower serum gastrin levels were found in TPN and ED patients.
In patients of long-term continu o us ED plasma CCK levels were reduced, and contractile ratio of gallbladder was decreased. Gallbladder hypomotility during the treatment of TPN and continuous enteral hyperalimentation may facilitate bile stasis and biliary complications.
Consequently, enteral hyperalimenation should be carried out intermittently to prevent gallbladder complications.

View full abstract

We measured the bile viscosity by using our own method. In our series of 89 clinical cases, it was seen that the bile viscosity depends upon the bile hexosamine contents, not upon the cholesterol, phospholipid, total bile acid contents, and lithogenic index in cholelithiasis. Acoording to present experiment it is suggested that the bile viscosity was determined by the bile mucine, because bile hexosamine is one of the components of bile mucine.
In our experimental studies, bile viscosity was found altered a c cording to the bile pH and conductance, suggesting that the bile viscosity is under the influence of pH and charged particles in the bile.
But in the hydrops and empyema vesicae felleae, bile viscosity did not vary according to it's hexosamine contents. And though the viscosity correlated with hexosamine contents, the viscosity of infectious bile was lower than that of sterile bile. These facts denote that there are other factors that influence bile viscosity.

View full abstract

This study was aimed to clarify prognosis-regulating factors of patients with gallbladder can. cer. One hundred fifty-seven patients with gallbladder cancer microscopically confirmed, in which curative resection was performed, were subjected to this study.
Generalized Wilcoxon's test demonstrated that the d i f ference of postoperative survival rates was statistically significant in the degree of depth of cancer infiltration (p<O.05), hepatic infiltration (p<0.05), the infiltration of hepatoduodenal ligament (p<0.05), lymph node metastasis (p< 0.05), histologic type (p<0.05), lymphatic invasion (p<O.05), venous invasion (p<0.05)and perineural invasion (p<0.05).
Cox's proportional hazards m odel demonstrated that the degree of depth of cancer infiltration (chi square 9.4762) and perineural invasion (chi square =5.2697) are good indicators to identify the group of patients with a high risk of cancer death. Especially, in the patients with gallbladder cancer invading the submucosal layer, Cox's proportional hazards model demonstrates that lymph node metastasis (chi square = 4.0627) and perineural invasion (chi square =4.1447)are good indicators to know the patients with a high risk of cancer death.
I concluded that the degree of depth of cancer infiltration, peri n eural invasion and lymph node metastasis are very important factors to predict the prognosis of patients with gallbladder cancer.

View full abstract

The criticism of standrd cholecystectomy (SC) are a large scar and the long duration of recovery. But, there can be overcome by laparoscopic cholecystectomy (LC) or mini-cholecystectomy (MC). We present an experience with these techiniques. From February 1991 to August 1992, there were 67 patients who were underwent cholecystecsomy. Twenty-one patients (31.3%)underwent SC and 20 patients (29.9%) had MC and 26 patients (38.8%) had LC. However, in cases of 20 patients from April 1992 to August 1992, who were examined by laparoscopy and made choice of surgical approach for cholecystectomy. As a result,14 patients (70.0%) underwent LC. Rate of conversion to open cholecystectomy from LC was 16 percent and to SC from MC was 5 percent. There were no serious complicatons in either group of MC and LC. The newer operative techniques of LC and MC have the advantages of less postoperative pain, shorter convalescence and greater acceptability to the patient than SC. The results of our current experience confirm the safety and efficacy of less invasive cholecystectomy.

View full abstract

Out of the 77 cases of surgically resected gallbladder cancer during past 17 years,37 cases (48.1%) were found to have cancer invading into the subserosal layer (ss cancer). The 5-year survival rate of curatively resected ss cancer patients was 31.7%. We investigate, further more, the relation between extent of cancer and prognosis depending on invading facto rs. The 5year survival rate of patients without microscopical hepatic infiltration of cancer cells (hin fnegative patients) among those who were resected curatively was 38.5% whereas one year and eight months was the longest survival for patients with hepatic infiltration of cancer cells (hinf-positive patients). The 5-year survival rate for patients without invasion into the hepa toduodenal ligament (binf-negative patients) was 36.4%, whereas that for binf-positive p atients was 16.6%. The 5-year survival rate for patients without lymphnodes metastasis (n-n egative patients) was 40.1%, while that for n-positive patients was 14.2%. With regard to venous and lymphatic vessel invasion, there were no differences between positive patients and ne gative paients. These results suggest that the operation for gallbladder cancer patients should include not only lymphnodal dissection but also combined resection of the liver, bile duct, duo denum and pancreatic head according to extent of hinf and binf factors.

View full abstract

In addition to the therapeutic results obtained in 7 cases with bile duct carcinoma at the porta hepatis who had had major hepatic resection in our Hospital,29 cases survived for more than 5 years after curative surgery reported in the Japanese literatures are reviewed in this paper.
In our cases, malignant potential of carcinoma of the hepatic duct confluence was l ower than that of the middle and lower third of the extrahepatic bile duct. Our cases showed high five-year survival rate of 71%. Major hepatic resection was done in all cases and caudate lobectomy was additionally performed in five cases; right trisegmentectomy (n=3), extended right lobectomy (n = 2), middle bisegmentectomy (n =1) and hepatic hilar subsegmentectomy (n=1). In long survival cases in Japan, seven-year survival rate in major hepatic resection was better than that of the cases in which only bile duct resection was performed (73% versus 35%).
These results indicate that major hepatic resection provides a long survival and a g ood quality of life for the patients with carcinoma at the hepatic duct confluence with low malignant potential.

View full abstract

As laparoscopic cholecystectomy (LC) has become widely practiced, intraoperative bile duct injury associated with this new technique is being realized. In this paper, six patients (2 were in our hospital and 4 were in other hospitals) who sustained bile duct injury were reviewed. Total eight injury sites in these patients were devided into 2 types. Five places (62.5%) of bile duct injury occurred at the proximal bile duct (left hepatic duct-1, right hepatic duct-2, bifurcation of hepatic ducts-2). Furthermore, right hepatic arterial injury was combined in this type and postoperative hepatic damage followed. While, three places (37.5%) of bile duct injury occurred at the distal bile duct (common hepatic duct-2, the division of cystic duct-1). The incidence of proximal type of injury in LC was more frequent than that (14%) in open cholecystectomy. Most of bile duct injuries in LC happened by misidentification of common hepatic duct for cystic duct. LC can be performed safely, and it can be associated with life-threatening complication such as bile duct injury. In order to prevent bile duct injury, proper patient selection, meticulous technique and an accepting attitude toward conversion to open cholecystectomy should be needed.

View full abstract

Extracorporeal shock wave lithotripsy (ESWL) under X-ray guidance using Dornier MPL9000 was performed on 13 patients with bile duct stones. Previous to ESWL, endoscopic nasobiliary drainage (ENBD) was performed on 12 patients, and percutaneous transhepatic cholangiodrainage (PTCD) was performed on one patient for the purpose of visualising the stones by injection of contrast medium. Shock waves were discharged until the stones were disintegrated enough for usual endoscopic extraction. In 11 of the 12 patients with naso-biliary catheter the stones were successfuly disintegrated and extracted by peroral endoscopic procedure. In one patient with PTCD fragmentation was successfully done and the fragments were extracted using percutaneous transhepatic cholangioscope (PTCS). In one failure case the stone was finally extracted duodenoscopicaly using several methods for lithotripsy. We did not experience serious adverse effect of shock waves.
Our conclusion is th a t ESWL is one of the choice for the treatment of bile duct stones especially such stones as difficult for usual endoscopic extraction.

View full abstract

Several treatments have recently been introduced for the treatment of cholelithiasis. Definitive indications for each of these modalities should be established. Our flow-chart illustrates the indications for extracorporeal shock wave lithotripsy (ESWL) treatment for gallbladder stones.
A stone is first examined ultrasonographically. Cholesterol stones (type I a acco r d ing to Tsutsiya's classification) are the stones suitable for ESWL while pigmented stones (type III) are generally not. For other types of stones ( Ib, Ic, II), radiography is indicated and calcified stones are excluded from the candidates of ESWL. If a stone does not appear to be calcified on X-ray films, a CT scan should be obtained whenever possible. Evidence of calcification on the CT scan indicates that the stone is rather unsuitable for ESWL. In contrast, an uncalcified stone is likely to be responsive to ESWL treatment.

View full abstract

Two cases of solitary cystic dilatation of the intraheaatic bile duct are reported.
In case 1, operation was performed on account of the suspicion of h epatic tumor, and solitary cystic dilatation of the intrahepatic bile duct containing biliary sludge was identified. In case 2, the patient was admitted because of right hypocondriac pain and jaundice. ERC revealed solitary cystic dilatation communicating with the intrahepatic bile duct.
Solitary cystic dilatation of the intrahepatic bile duct must be differentiated from the other cystic lesions such as simple cyst, cystadenoma and cystadenocarcinoma. In the imaging diagnosis, cholangiography which is able to demonstrate the communication with the intrahepatic bile duct is the most useful modality for differential diagnosis.

View full abstract

A 58-year-old woman was admitted to our hospital with complains of general fatigue and jaundice. US and CT revealed a mass at the bile duct of the hepatic hilum and atrophy of the left lobe of the liver. Hepatic arteriography demonstrated obstruction of the left branch of the portal vein. Left hemihepatectomy and caudate lobe lobectomy with resection and reconstruction of the portal vein was performed. The tumor, measuring 1.8×1.5 cm, was located in Blsr and diagnosed histologically as moderately differentiated adenocarcinoma invaded to the portal vein (vs²) and hepatic parenchyma (hinf²).
She is alive with no recurrence 27 months after the operation.
In this paper, the importance of resection of vessels a t the porta hepatis was discussed in the bile duct carcinoma of the hepatic hilum to get a better surgical results.

View full abstract

A 54-year-old woman was admitted to our hospital because of obstructive jaundice due to cholecysto-choledocholithiasis. Gallstones were extracted from the common bile duct and cystic. duct immediately after endoscopic sphincterotomy (EST) using a wire basket. Endoscopic procedure was completed without any hemorrhage. However, massive hemorrhage from the papilla of Vater occurred suddenly 3 days after EST. Prothrombin time and hepaplastin test values were 17.9 and 2.4%, respectively, indicating severe clotting abnormalities. Vitamin K is required for blood-coagulation regulation, and its depeletion due to antibiotic therapy as an example results in a bleeding tendency. Since its involvement was considered in the present case, the antibiotic administration was interrupted and vitamin K was intravenously infused. Conseuently hemostasis was immediately obtained. It should be kept in mind that vitamin K absorption in obstructive jandice is disturbed because bile salts reuired for absorption fail to enter the intestine. Therefore, before and after EST of patients with obstructive janudice and/or administration of antibiotics, coagulation status must be assessed taking possible vitamin K deficiency into account.

View full abstract

4 cases of pleomorphic carcinoma of gall bladder were morphologically and immunohistologically examined. Case 1 was 81 years old woman complaining rt-costal pain, case 2 was 86years old man complaining abdominal tumor, case 3 was 81 years old woman complaining upper abdominal pain, case 4 was 78 years old woman complaining rt-costal pain. Case 1,2 and 3had died of carcinoma, and autopsy had undergone. Case 4 was cholecystected under the diagnosis of cholecystic stone.
Microscopically, tumor cells showed pleomorphic figure without cellular cohesiveness associated with numbers of mitosis. Most tumor cells showed mononucleated and some showed so-called bizarre cell with single or multi atypical large nucleus. Moreover, foreign body type giant cells with numbers of small nucleus were seen in case 1.
Immunohistologically, most tumor cells and B i z arre cells showed positive to EMA or keratin, and also positive to vimentin antibody. Foreign body type giant cells showed negative for EMA and keratin, but focally positive to KP-1 (anti macrophage antibody) and vimentin.
These results suggest that pleomorphic carcinoma of gall bladder origi n ate from cholecystic mucosa and show sarcomatous reaction or de-epithelialization such as presence of vimentin positive cells. Furthermore, histiocytic reaction such as foreign body giant cells is considered also to be the component of pleomorphic carcinoma.

View full abstract