We observed the thin sections of many gallstones microscopically, and detected the common network-structure of acidic mucin in the stones, also in the calcium carbonate gallstones. However, PAS-dominant staining mucin without networkstructure was observed slightly in the pancreatic calculi.
We measured hexosamine and total nitrogen of the mucin in the stones. The ratio of them showed similar patterns, on the graph in pure cholesterol gallstones, black stones and calcium bilirubinate gallstones, but the graphs in the pancreatic calculi and calcium carbonate gallstone were different from each other. It was suggested that the quality of the mucin in the pancreatic calculi was different from that of calcium carbonate gallstone.
We made a model of calcium carbonate stone and a model of pancreatic calculi using natural calcite, in order to study their response to ESWL. Both model show the same content of mucin and polymorphs of calcium carbonate as human stones. Each of 7 pancreatic model-stones was destruct ed into many small fragments with 500 shots (18 kV) of ESWL, but 5 calcium carbonat-e model -stones were not destructed. It was suggested that the destructivity of stones by ESWL is based on the quantity and quality of mucin in stones.

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In order to achievea better result of bile acid dissolutionth erapy (BADT), we have established a new protocolf or patient selectionu sing the combinationof our ultrasonographic classification with CT findingso fg allstonesP. atients received 600mg of ursodeoxycholiacc idp er day, as a single bedtimed ose. Based on our protocol, we performedp rospectivelyB ADT for 41 patientsw ith CT -radiolucentm ultiples tones. Furthermore, we performedr etrospectivelya matchedc ase-control study to evaluate the efficacy of stone clearance in the patients with ≥ 2 stones in number between BADT and extracorporeal shock-wave lithotripsy (ESWL). According to the method of Kaplan-Meier, a cumulative rate for complete (complete plus partial) clearance by BADT was 20 % (85 %)at a year and 45 % (100 %) at 2 years. No significant difference in stone clearance was noted between BADT and ESWL. The rate of biliary colic during the periods of treatment occurred at a significantly lower rate in the BADT-patients than in the ESWL-patients.
We conclude that BADT appears to be the first option to treat the patients with multiple stones, especially those with ≥ 5 stones in number. Our new protocol of BADT for multiple stohes is considered usetul and cost-effective to achieve a better result of stone clearance.

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The nuclear DNA content of 72 papilla vater carcinomas, receiving curative resection, was measured by flow cytometry. DNA ploidy pattern was compared with histopathological findings, depth of cancer infiltration and prognosis. Among 72 cases,49 (68.1%) were diploid tumors and 23(31.9%) were aneuploid tumors. There was no statistically significant differences between histopathological findings and ploidy pattern except for venous invasion rate which is higher in aneuploid tumors. However there was statistically significant differences between the increase of aneploid tumors and depth of cancer infiltration. In overall cumulative survival rates the patients with diploid tumors had a statistically worse prognosis than those with aneuploid tumors, however, regarding the patients with cancer infiltrating to the pancreas both had worse prognose regardless of their ploidy pattern. These results suggest that the DNA ploidy pattern is one of the independent prognostic factors in papilla vater carcinomas. It must be noted however that in cases o f carcinoma infiltrating to the pancreas the DNA ploidy pattern is irrelevant.

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Bile flow was evaluated in sixty-five biliary reconstructed patients using hepatobiliary scintigraphy. The patients were divided into three groups; Group I consisted of 40 patients without complications, Group II 17 with regurgitating cholangitis, Group III 8 with hepatolithiasis. Veinbiliary biliary reconstrusted jejunum transit time was significantly delayed in Group III compared with Group I. But no difference was seen in bile stasis in biliary reconstructed jejunum, reflux into the intrahepatic bile ducts and reversed peristalsis at cholangiojejunostomy among the three groups. Then we calculated the coefficient, named “Slope” from time activity curve as a slope of approximated straight line. The decline of the “Slope” represents bile flow and the values both in hepatic parenchyme and intrahepatic bile ducts showed significantly poor in Group II and III. However, there was no significance in bile flow at biliary reconstrusted jejunum. In conclusion, quantitative analysis of hepatobiliary scintigraphy using “Slope” is valuable for following up postoperative patients underwent biliary reconstraction.

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To evaluate the effects of ursodeoxycholic acid (UDCA) on gallbladder contractility, we selected 27 patients carrying slude or tiny stones during UDCA dissolution therapy with a dose of 600 mg per day. The patients underwent ultrasonographic examinations on the gallbladder volume twice shortly before and 2 months after dissolution therapy. At the same time, the serum bile acid fraction was studied to monitor compliance of UDCA. According to the two factors for evaluating gallbladcontractility, fasting volume (FV) and emptying, the mode of gallbladder contractility was separated into 4 patterns: Type I a-increased FV, adequate emptying (44 %); Type I b?-increased creased FV, inadequate emptying (30); Type II a-unchanged FV, adequate emptying (19 %); Type II b-unchanged FV, inadequate emptying (7 %). The present study suggests that during treatment with UDCA, fasting volume of the gallbladder mostly (74 %) increases, but residual volume, ejection volume or contractility vary in cases showing each type.

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All patients were divided into two groups, Group 1 (69 patients who underwent cholecystectomy between April and December 1992) and Group 2 (180 patients who underwent cholecystectomy between January and December 1993). Preoperative spiral CT scanning after drip infusion cholangiography (DIC-SCT) and laparoscopic cholangiography were attempted for all patients in Group 2. An ultrasonic cutting coagulation system (Harmonic scalpel: HS) was used to eliminate thermal injury of the surrounding tissue. Moreover, an argon beam coagulator (ABC) was used to control bleeding from the liver bed or bleeder. The performance rate of LC was 87.0% (60/69) in Group 1and 100% (180/180) in Group 2. The success rate of LC was 91.7% (55/60) in Group 1 and 98.9%(178/180) in Group 2. The junction between the cystic duct and the common bile duct could be seen in 154 cases of 180 (85.6%) cases with DIC-SCT. The success rate of laparoscopic cholangiography in Group 2 was 96.1% (171/178). Three cases of biliary duct injury in Group 1 were noted, but no severe complications were recorded in Group 2. Improvement of the surgeon's technical skills, the combined use of preoperative DIC-SCT and laparoscopic cholangiography, and the application of HS or ABC may extend the indications of LC.

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in vitro CT scans were performed on 48 gallstones removed at surgery. Disintegration of these stones by a piezoelectric lithotripter (ESL-500A, Toshiba) was followed, until all fragments measured 2 mm or less in diameter. Some fragments were subjected to chemical analysis. The CT image appearances were categorized as follows: isodense, faint, rimmed, laminated and dense patterns. The mean and maximal CT-values, the, percentages of cholesterol or calcium contents, and the number of shock waves to complete disintegration were compared with CT patterns. The cholesterol contents of isodense, rimmed, and laminated groups were more than 80% and the number of shock waves per stone volume did not differ among these groups. The dense pattern group showed the poorest efficiency for the number of shock waves. As CT analysis, of gallstones can be a reliable prediction of gallstone chemical composition and its structure, CT image appearance can be predictive for fragmentation outcome.

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Staging of gallbladder cancer was attempted using an important prognostic factor “binf”, and the most appropriate basic forms of surgery was considered in 40 patients. On the basis of our new staging method, cases of gallbladder cancer were divided into the following four groups: group A with lesions restricted to within the gallbladder [binf₀, hinf(-) ], group B with infiltration into the hepatic floor [binf₀, hinf (+) ], group C with slight infiltration into the hepatic portal [binf₁1]and group D with severe infiltration into the hepatic portal [binf_2,3]. According to this new classification, the percentages of patients treated by curative resection in these groups were 100 %,57 %,27 % and 0 %, respectively. The long-term results in terms of the 2-year survival rate differed significantly among these groups, with rates of 100 %,58.8 %,9.1 % and 0 %, respectively. Taking into account the curability and mode of recurrence related to each group, we believe that the basic forms of surgery indicated for these groups are as follows: group A, full-thickness cholecys+ R₁ dissection; group B, subsegmental hepatectomy+R_2-ex dissection; group C, extended right hepatic lobectomy pancreatoduodenectomy+portalresection+R_3-ex, dissection; 3group D, en bloc resection of the hepatoduodenal ligament. This classification proved useful for obtaining the prognosis and for selecting the most appropriate basic surgical technique.

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We experienced a case of leiomyosarcoma of the common bile duct. A 56-year-old woman was admitted to our hospital with epigastric discomfort. Abdominal ultrasonography and CT showed a mass of the head of the pancreas which was approximately 3 cm in diameter, round and homogenous and had a smooth margin. They showed no regional lymph node swelling. Endoscopic retrograde cholangio-pancreatography revealed lower bile duct stricture under pressure, angiography revealed moderate neovascularization and digestive canal-derived hormones levels were within normal limits. Therefore non-functioning islet cell tumor was suspected and an operation was performed. A hen-egg sized tumor was found in posterior superior portion of the head of the pancreas and pylorus-preserving pancreatoduodenectomy (PPPD) was done. Histopathologically leiomyosarcoma of low grade malignancy was diagnosed (1-5 mitoses per 10 high power fields) and because the tumor was situated within the bile duct wall, its origin was thought the common bile duct. Leiomyosarcoma of the common bile duct is very rare and our case is the only fith one in the world in the literature. Surgical resection is one of the best treatments, and PPPD and bile duct resection are indicated. The prognosis will be different by the number of mitoses and it is hoped this case will have a better course.

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We report a case of bile duct stone treated with endoscopic sphincterotomy (EST) and briefly review the partinent literature. The patient was an 81-year-old man with a Billroth II partial gastrectomy, who suffered from epigastralgia. Ultrasonography showed dilatation of the extrahepatic bile duct. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed a juxtapapillary choledocho-duodenal fistula. A papillotome could be introduced through the fistula and extended from the papilla orifice. EST was easily and safety performed with our method.
Only 2 cases have been reported of bile duct stones treated by the method we used, but no details were provided. This method enables us to perform EST easily even if patients have a Billroth II partial gastrectomy.

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A 66-year-old woman was admitted to our hospital because of epigastric pain. Ultrasonography showed a low echo mass 2 cm in size in the medial segment of the liver and percutan eous cholangiography revealed an irregularly shaped stenosis from the left hepatic duct to the confluence of the cystic duct. Celiac angiography showed a mild irregularity on the right hepatic artery and an obstruction of the left portal vein. Percutaneous transhepatic cholangio-drainage (PTCD) w a s performed since a jaundice appeared. Cholangiography after PTCD revealed multiple shad ow defects in the anterior segmental branch of the bile duct. Under a diagnosis of cancer of the h epatic hilus, extended left hepatectomy, caudate lobectomy, and resection and reconstruction of the right hepatic artery was performed. There were many small stones in the anterior segmental branc h of the bile duct. A cut surface of the resected specimen showed a 1.8 x 1.7 cm sized mass on the le f t hepatic duct and histologic examination disclosed a moderately differentiated tubular adenoc a rcinoma. Postoperative celiac angiography showed a pseudoaneurysm of the gastroduodena l artery. Therefore, transcatheter arterial embolization was performed in the common hepatic artery. Subsequently, an abscess of the liver was arisen and percutaneous drainage was needed.

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