Hidenori Udaka

Congenital dilatation of the biliary tract; new classification and study with particular reference to anomalous arrangement of the pancreaticobiliary ducts

SummaryYotsuyanagi’s theory is often quoted in the discussion of the etiology of congenital dilatation of the biliary duct (CDBD), but there has been no established etiology as yet. With particular reference to the relationship between anomalous arrangement of the pancreaticobiliary ducts and CDBD, Babbitt collected 19 cases of CDBD. Ihe authors also observed the anomalous arrangement in 10 of 24 cases of CDBD (42%). Analysis of 570 CDBD cases collected in Japan disclosed that the anomalous arrangement was present in 183 of them (33%), dilatation of the intrahepatic bile ducts in 236 (42%), and narrowing and malformation of the bile duct in the hepatic hilum in 58 (10%).The authors have proposed a new classification, including these morphologic anomalies of the whole pancreaticobiliary ductal system. This classification provides useful indices in selecting the surgical procedures.The effect of the anomalous arrangement was pathophysiologically studied on dogs. The static internal pressure of the dog pancreatic duct was 14.6 ± 5.5 cm H2O, and that of the dog bile duct, 8.9 ± 3.4 cm H2O. Puppies were then operated on by shunting the pancreaticobiliary ducts. As the result, the biliary tract was devastated by pancreatic juice, giving rise to similar pathologic changes to those clinically observed.

Relation of patient age to premalignant alterations in choledochal cyst epithelium: Histochemical and immunohistochemical studies

Forty patients with choledochal cysts, 17 children and 23 adults, were treated by cyst excision in this institution (1972 to 1982). Histochemical and immunohistochemical studies were performed on tissue from the walls of these 40 cysts. The type and degree of histologic changes observed were found to correlate with patient age at time of cyst excision. Specimens from four patients less than two years of age at time of excision revealed epithelial desquamation, fibrosis, and minimal evidence of inflammation. Among specimens from 13 patients, 4 to 15 years of age, only two had an intact epithelial lining. Marked inflammation and intramural glandular structures were observed. Specimens from 23 patients, more than 15 years of age at the time of cyst excision, showed marked acute or chronic inflammation and destruction of the epithelial lining. In this age group, intramural glandular structures with goblet and argyrophil cells were regularly observed within the cyst walls, and gastrin and somatostatin-like immunoreactivity was detected in cells of these metaplastic glands. In association with these changes, in five of the 23 patients in the oldest age group, adenocarcinomas were observed in the cyst walls. These studies establish the increasing rate of epithelial metaplasia in the walls of choledochal cysts with advancing age, and suggest that these changes are a continuing process with malignancy one of the end results.

Histochemical and immunohistochemical studies on development of biliary carcinoma in forty-seven patients with choledochal cyst—Special reference to intestinal metaplasia in the biliary duct—

Histochemical and immunohistochemical studies on 47 consecutive specimens excised for choledochal cyst were performed to clarify possible metaplastic changes of the biliary duct in relation to carcinogenesis. An anomalous arrangement of the pancreaticobiliary ductal system was observed in all 39 cases examined. Among the 47 patients, 5 (10.6 per cent) had biliary carcinoma. 27.3 per cent mucous gland, 13.0 per cent goblet cell and 9.5 per cent argyrophil cell in 23 children. On the other hand, 81.8 per cent exhibited mucous gland, 41.7 per cent goblet cell and 27.3 per cent argyrophil cell in 24 adults. These metaplastic changes seemed to be an intestinal metaplasia and increased with age. Immunoreactive-gastrin or-somatostatin were evident immunohistochemically in 4 adults. These findings confirmed that intesinal metaplasia may develop in the biliary duct in cases of choledochal cyst. Although direct evidence between intestinal metaplasia and the development of biliary carcinoma was not found, reflux and stasis of pancreatic enzymes in the biliary duct may relate to the development of intestinal metaplasia and be an important factor related to the carcinogenesis of choledochal cyst.

ZOLLINGER-ELLISON SYNDROME;TUMOR GROWTH AND SERUM

肝転移を伴うZollinger-Ellison症候群患者に胃全摘出術を施行することにより, 術後3年6ヵ月の現在経過良好である1例を報告する. 同時に, 本邦で報告されているZollinger-Ellison症候群51例について集計し, 胃全摘出術の効果について検討した. その結果, 転移のある症例においても胃全摘出術を施行する必要がある.また, 胃全摘出術後の腫瘍の消長ならびに血清ガストリン動態とセクレチン, Ca負荷との関係について文献的考察を加えた.