Kensuke Yamamoto

Intrahepatic periductal glands and their significance in primary intrahepatic lithiasis

Resected hepatic tissues of 24 patients with primary intrahepatic lithiasis were examined histo-pathologically. Calcium bilirubinate stones, cellular debris and mucinous substances occupied the lumen of large dilated intrahepatic bile ducts. Numerous mucin secreting glands were seen within or around the wall of these bile ducts. Similar structures were demonstrated in two patients with non calculous congenital dilatation of the intrahepatic bile ducts. Cholestasis was often absent in the hepatic parenchyma. Production of intrahepatic gallstones may be caused by not only biliary stasis and infection, but also by intraductal mucin and slow flowing bile in combination with cellular debris, bile pigment and other bile components.

Preparation of polyamine antibody and its use in enzyme immunoassay of spermine and spermidine with β-D-galactosidase as a label

An enzyme immunoassay for polyamines is described which uses beta-galactosidase labeled spermine and antiserum raised in rabbits against spermine-bovine serum albumin synthesized by coupling spermine to mercaptosuccinylated bovine serum albumin with a bifunctional cross-linker, N-(gamma-maleimidobutyryloxy)-succinimide. The lower limit of detection by this assay, which involves a double antibody technique for the separation of antibody-bound and free antigen, was 1 ng of spermine per tube. The anti-spermine serum showed 88% cross-reaction with spermidine but only 0.13% with putrescine, 0.08% with 1,3-diaminopropane, and 0.04% with cadaverine. The method has been used to measure serum polyamine levels in healthy subjects and cancer patients, in whom mean concentrations of 58.1 ng/ml and 94.8 ng/ml (as spermine), were respectively noted. This enzyme immunoassay is specific, accurate and easy to perform, and appears suitable for routine clinical use.

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepaticocholedochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The longterm results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.

The surgical treatment for carcinoma of the gallbladder: rationale of the second-look operation for inapparent carcinoma

Eighty-seven patients with carcinoma of the gallbladder treated in our hospital over a 15-year period were reviewed. Macroscopic curative resection was performed in 30 cases, 6 of which received second-look operations, and their cumulative five-year survival rate was 42.6 per cent. Histological and clinical analysis of our cases initially diagnosed by postoperative histologic examination revealed that the depth of carcinomatous invasion was the most important criterion for the indication of second-look operation, and that the second-look operation is mandatory for the inapparent carcinoma limited to the muscularis or subserosa. The surgical procedures of the second-look operation were: resection of the anterior inferior and medial inferior areas of the liver and dissection of the regional lymph-nodes. The presence of invasion of carcinoma to the cut end of the cystic duct or severe carcinomatous invasion to the lymphatic vessels were also important histopathologic findings for a second-look operation. Cases in which lymphatic invasions are remarkably observed, should receive an en bloc hepato-cholecystectomy plus a resection of the extrahepatic bile duct with neural tissues and soft fatty tissues in the hepatoduodenal ligament in a two-stage operation.

A case of a rare anomaly of the common bile duct associated with an abnormal arrangement of the pancreaticobiliary ductal union

A 39 year-old Japanese female patient with a duplication of the distal portion of the common bile duct is presented herein. Moreover, an abnormal arrangement of the pancreaticobiliary ductal union, congenital biliary dilatation and carcinoma of the gallbladder were all demonstrated by cholangiographic and endoscopical studies. The patient underwent radical surgery for advanced adenosquamous carcinoma of the gallbladder, and her postoperative course was satisfactory. A reflux of pancreatic juice into the bile duct was demonstrated, but it was eliminated and considered to be a contributory etiologic factor of the gallbladder carcinoma.

Surgical treatment for carcinoma of the extrahepatic bile duct.

Eighty-six patients with primary extrahepatic bile duct carcinoma operated on in the Second Department of Surgery at Nagasaki University Hospital during a recent 13.5-year period were reviewed. The patients were divided into five groups depending upon the site of the tumor. The operative mortality, resectability, postoperative survival period, and five-year survival rate in each group were studied. The lower third group had the highest resectability, lowest operative mortality and longest post operative survival period. The hepatic duct, the upper third and the extended groups, however, showed extremely poor results. The pathological features of these three groups are discussed here and an operative procedure for resection of the tumor is proposed. We emphasize that the development of methods of early diagnosis is necessary, and recommend aggressive surgical treatment for tumors of the hepatic duct, upper third, and extended groups.

Bilateral intrahepatic lithiasis without extrahepatic bile duct stones.

SummaryBilateral intrahepatic lithiasis is a rare condition, and for this reason a nationwide survey was conducted. Reports on 675 patients with bilateral intrahepatic lithiasis over a 10-year-period were collected. Among these, 258 patients with bilateral intrahepatic lithiasis having no extrahepatic bile duct stones were analyzed. The peak incidence was seen in the fourth to sixth decades. Males and females were equally effected. The stones removed were mainly calcium bilirubinate stones (75.6%). The main clinical symptoms were abdominal pain, fever and jaundice. Charcot’s triad was seen in 29.7%, while 12.4% of the patients had no symptoms. Visualization of each segmental duct of the liver by direct cholangiography was excellent in this survey and ranged from 88 to 97.3% of the patients. The most frequent site of stones was the left hepatic duct (60.1%). The site of bile duct dilatation coincided with the location of stones. The most common sites of stenosis were the central part of the lateral segmental duct (32.5%) and the left hepatic duct (37.6%). Hepatic resection was employed in 49.2% of the patients, and drainage procedures were added in 95.6%. Follow-up studies of 236 patients treated by surgery revealed good results in 67.4%, fair in 13.6%, and poor in 7.6%. In these patients, however, endoscopie lithotomy was often employed intra- and/or post-operatively. Conducting hepatic resection, with adequate biliary drainage procedure and cholangiofiberscopic lithotomy may help to improve the therapeutic results of bilateral intrahepatic lithiasis.

Therapeutic strategy for intrahepatic lithiasis

SummaryAmong the various benign biliary tract diseases, intrahepatic lithiasis is the most refractory condition to treat surgically. Recently, endoscopic treatment (mainly cholangiofiberscopic lithotomy) has been more and more frequently employed. A nationwide survey by questionnaire was conducted in 1985 to clarify the exact status of the current therapies for intrahepatic lithiasis in Japan. A total of 143 institutions (33.4%) responded to our questionnaire, and 2614 cases over a 10-year-period were collected and analyzed. Operation alone was performed in 53.8%, operation plus endoscopie treatment in 38.6%, operation plus dissolution therapy in 5.5%, operation plus endoscopie treatment and dissolution therapy in 0.04% and endoscopie treatment alone in 2.1%. The most common treatment was surgery. This was employed in 97.9% of all the patients, but endoscopie treatment was added in 40.7% of the cases to extract stones mainly intra- and/or post-operatively. Dissolution therapy was carried out occasionally, but with poor results. Conducting both adequate surgical biliary drainage and cholangiofiberscopic lithotomy may result in a marked improvement in the treatment of this intractable disease.

Clinical study of intrahepatic bile duct carcinoma.

肝内胆管癌15例の臨床像, 各種画像診断像につき検討した. 平均年齢は63±9.9歳であり, 男女比は1.5: 1であった.肝内結石合併例が6例, 手術既往例が2例をしめた. Ultrasonography像は境界不鮮明なhyperechoicでheterogenousな腫瘍エコーを呈することが多かった. computed tomography像はheterogenous pattemをもつlow density tumorとして描出された. CTは肝内結石合併例においても良好な診断率を示した. 血管造影ではencasement, stretching, neovascularization, 腫瘍欠損像, 門脈閉塞像が高率に認められた.リンパ節転移・肝内転移が高率に合併しており, 経門脈性肝内転移の存在が示唆され, 肝切除にあたっては広範なリンパ節郭清とともに系統的肝切除術が必要であると考えられた.

The pathological studies of hepatocellular carcinoma following transcatheter arterial embolization.

肝細胞癌に対する術前肝動脈塞栓術施行例25例と非施行例23例の病理学的検索を行った.スポンゼル単独使用群8例と, 抗癌剤併用群17例とは壊死率に差はなく, 手術を前提として肝動脈塞栓術を行う場合塞栓物質のみにて肝動脈塞栓術を行い早期に腫瘍を含む硬塞病変の切除を行うべきものと考えられた.壊死組織の診断には鍍銀染色が有用であり, 完全壊死例を含め肝細胞癌として特徴を示すものが多く診断価値があるものと考えられた, また肝動脈塞栓術から手術までの期間による組織修復過程は, 形態学的に経時的なパターンを示さなかった.これは結節の大きいものは修復過程の遅延が起るものと考えられた.