As laparoscopic cholecystectomy (LC) has become widely practiced in Japan since 1990, we examined anomalies of the cystic duct likely to result in bile duct injury in LC. Date on 2,251patients who underwent ERCP in our hospital during past four years were reviewed. Of the 2,251, anatomical abnomalities of the cystic duct were detected in 63 cases (2.8%). Anomalies especially likely to cause disorientation or bile duct injury in LC were cystic duct draining to the right hepatic duct or the right posterior hepatic duct draining to the extrahepatic duct, high junction of cystic duct and special type. These four types were found in 36 cases; a large proportion (20 cases,56%)of the 36 were diagnosed as cholecystolithiasis. We must conduct ERCP actively because preoperative diagnosis of cystic duct anomalies is very difficult by DIC. For successful LC in cases of cystic duct anomalies, it may be effective to use intraoperative cholangiography by means of naso-bilialy tube or gallbladder puncture.

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The effect of Dai-saiko-to (TJ-8) on the cholesterol gallstone formation was investigated in hamsters fed a high glucose diet, as an experimental model for cholesterol gallstone formation. Animals were fed a normal chow or 75% (w/w) glucose diet (lithogenic diet) with or without 1% Dai-saiko-to (w/w) for 4 weeks. The gallstone incidence was 71% in animals fed a high glucose diet, whereas no stones were formed in the other groups. Thus, cholesterol gallstone formation was prevented by the treatment with Dai-saiko-to. The increase in tissue cholesterol (serum, liver, bile)by high glucose feeding was significantly suppressed by Dai-saiko-to. Further, the appearance rate of cholesterol monohydrate crystal in bile or on the surface of gallbladder was significantly reduced in animals treated with Dai-saiko-to. These findings suggest that Dai-saiko-to prevents cholesterol gallstone formation by reducing the bile cholesterol saturation index, and that the reduction in intestinal cholesterol absorption and hepatic cholesterol synthesis may attribute to such an action of Dai-saiko-to.

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In spite of recent advances in various techniques of biliary endoprosthesis in patients with malignant biliary obstruction, there still remain some problems such as insufficient relieving of jaundice, cholangitis, colgging of stent limitation to the patient's daily life, etc. Intraoperative retrograde transtumoral biliary endoprosthesis with 10 Fr. or 7.2 Fr. polyethylene tube was attempted in 6 cases of unresectable hilar bile duct carcinoma. In all of 5 cases with icterus, it's relief was achieved within a month. In the remaining nonicteric case, the procedure prevented the development of jaundice. In 3 cases who survived longer than 12 months (15,28,45 months), the tube maintained its patency for 12,21 and 41 months respectively. Except of one case who developed clogging of the 7.2 Fr. endoprosthesis, all the other patients enjoyed their life without any limitations.
Thus we conclude that our method of intraoperative retrograde transtumoral biliary drainage is an effective palliative treatment against unresectable hilar bile carcinomas.

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Patterns of union of bile ducts in the porta hepatis were investigated in 213 patients by direct cholangiography. Hepatic ducts and their proximal ducts in the porta hepatis had a bifurcating pattern in 70%. There was trifurcation in 14%. The right posterior duct joined the common hepatic duct in 5%, and the right posterior duct joined the left hepatic duct in 11%. In two patients (1%) with the bifurcating pattern, the inferior posterior right hepatic duct arose from the porta hepatis at the right hepatic duct. Another two patients (1%) with the bifurcating pattern had variant union at the porta hepatis. Such variations have been called accessory hepatic ducts; however, they can be thought of instead simply as unusual patterns of union. The term “accessory” is misleading, because these ducts have the same drainage functions as normal hepatic ducts. “Accessory” hepatic ducts could be better termed “variant” hepatic ducts.

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Thirty-two cases of the intraoperative bile duct injury consisted of 19 cases occurred in other hospitals and 13 cases at our Dept. have been treated during the period starting from January 1965 to August 1993. Occurrence rate of bile duct injury was 0.6% in the 2,163 operated cases of cholelithiasis during this period. The most common bile duct injury was caused by transection of the common hepatic duct. The injury noticed during surgery in 9 cases had repaired by end-to-end anastomosis of the bile duct in 8 and by end-to-side anastomosis of the bile duct in one cases. The injury was overlooked during surgery in 23 cases. The most common symptom was jaundice and the symptoms had appeared within 2 days in a half of cases. As to the technique of bile duct reconstruction, hepaticojejunostomy at porta hepatis was conducted in 15 and end-to-end anastomosis of the bile duct in 2 cases. Physiological end-to-end anastmosis of the bile duct should be selected as method of the first choice as a reconstructive technique of the intraoperative bile duct injury. Even if the injury was overlooked during the operation, end-to-end anastomosis of the bile duct is recommended if possible. However, a marked inflammatory finding or a big injury over 1.5 cm in size may induce a tension at the site of anastomosis resulting anastomotic breakdown or reconstriction and so on. Appropriate anastomotic technique between the bile duct and the gastrointestinal tract should be selected in this situation.

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Twenty-one patients with advanced carcinoma of the gallbladder (stage IV) underwent pancreatoduodenctomy with combined resection of the liver (HPD) from April 1980 to February 1993. The hepatectomy consisted of resection of the gallbladder bed in 13 patients, resection of S4a+5 in 5, and resection of more than two segments in 3. Seven cases showed direct invasion to duodenum or pancreas head. Twelve cases showed major vascular invasion. Resection and reconstruction of portal vein was performed in 3 cases and resection of right hepatic artery was performed in 7 cases. The rate of metastasis to No.12b₂ and No.13a lymph nodes was 57% and 67% of 21 patients, respectively. The rate of curative resection was only 28.6%. The major causes of non-curative resection were lymph node metastasis to n4, and residual cancer invasion into surrounding tissues (ew). All patients died within 2 years. However, the patients performed curative resection and relatively non-curative resection had sginificantly better prognosis than the patients done absolutely non-curative resection.

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A 47-year old male was pointed out a polyp in the gallbladder and visited our hospital at August,1992. A semipedunculated elevated lesion, about 20 mm in diameter, was confirmed by ultrasonography and ERCP. There was no evidence of metastasis and direct invasion in computed tomography. The lesion showed staining but no vascular encasement in angiography. Considering possibility of early cancer, a cholecystectomy was performed. A semipedunculated elevated lesion with papillary growth,18 mm in diameter, was seen in fundus of the resected gallbladder. Histologically, it mainly consisted of immature fibrous tissue covered with proper epithelium, and was diagnosed a fibrous polyp. Macroscopic differential findings from neoplastic lesion were smooth surface and yellowish in color. To clarify these findings clinically, cholecystoscopywas would be useful.

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We carried out laparoscopic cholecystectomy by lifting up the liver bed to diaphragma for the patient who had calculus incarcerated in the neck of gallbladder accompanied with inflammation of Calot's triangle.
A 44-year-old man came to our hospital with a complaint of a right hypochondralgia, and was diagnosed as cholecystitis caused by incarcerated calculus in the neck of gallbladder by abdominal ultrasongraphy. After conservative therapy for 23 days, he underwent an operation. Findings of severe inflammation of Calot's triangle suggested that exposure of the cystic duct and cystic artery would be difficult. Therefore, we sutured the serosa of the liver bed to diaphragma so as to lift up the right hepatic lobe to the cranial side and to secure the operative field. We could carry out laparoscopic cholecystectomy for the paitent with severe cholecystitis uneventfully.

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A case of hilar bile duct stricture mimicking primary bile duct carcinoma due to metastasis from carcinoma of the descending colon in a 44-year-old man is described.
The patient was referred to the Ryukyu University Hospital with jaundice and 9 kg weight loss in the last one month on March 15,1993. On admission, US and CT demonstrated mild dilatation of the bilateral intrahepatic bile ducts. ERC revealed hilar bile duct stricture indicative of primary bile duct carcinoma. On the other hand, barium enema studies and colonoscopy revealed carcinoma of the desending colon with endoscopic bioptic finding, because of his occult-blood positive stool.
Based on these findings, he was diagnosed to have a double cancer and consulted for surgery.
Laparotomy revealed colon cancer metastasizing to the hepatic (hilar) confluence. He had a palliative operation (ileosigmoidstomy) and was treated with adjuvant chemotherapy.
This may be arare, interesting case showing the findings similar to hilar bile duct carcinoma by direct invasion of colon cancer (poorly-differatiated adenocarcinoma). He is doing well without no evidence of jaundice to the present with chemotherapy.

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A 78-year old female was admitted to our hospital because of mild liver dysfunction with elevation of serum levels of carbohydrate antigen 19-9 (119U/ml). Ultrasonogram showed a tumor in dilated posterior segmental duct. Retrograde cholangiography through PTCD tube shows posterior segmental duct with no anostomosis between right or left hepatic duct, entering common bile duct. Posterior segmentectorny was done on bile duct cancer in aberrant posterior segment duct which is one of variations of bile duct confluence.

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A 21-year-old woman admitted to our hospital with a diagnosis of hepatolithiasis 9 months after surgery for congenital biliary dilatation. The operative procedures she had recieved, were resection of gallbladder and extrahepatic bile duct followed by hepaticojejunostomy. At the previous surgery no stones had been found in the intrahepatic bile ducts.
Several examinations revealed the stones in bilateral residual intrahepatic bile ducts. The stones were removed completely with percutaneous transhepatic cholangioscopic lithotomy (PTCL). There were two fibrous sticks passing through the stones like axis. It was thought that its origin was food. No stenosis was noted at the hepaticojejunostorny, but it was slightly narrower than that of residual intrahepatic bile duct. Stagnation of bile and reflux of intestinal contents was considered to be the cause of hepatolithiasis.
During the treatment, we also found a few mucosal bridge like lesions in the bilateral intrahepatic bile duct. This finding is very rare, and we found only one case report about this lesion in the literatures. Referring the literature, this mucosal bridge contains an artery. In our case, it was suspected with the intraductal ultrasonography that this lesion also contains somethiing in it. It is suggested that careless endoscopic resection of this mucosal bridge is risky.

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