Nobuhiko Komi

Does the Type of Anomalous Arrangement of Pancreaticobiliary Ducts Influence the Surgery and Prognosis of Choledochal Cyst

A new classification of the anomalous arrangement of pancreaticobiliary ducts (APBD) has been proposed following amendments and modificiations of the previous one. Fifty-one cases of choledochal cyst complicated with APBD were extensively examined and analyzed for clear visualization of the APBD system to make a standard classification. APBD were classified broadly into three types: type I, type II, and type III with their subtypes. Type I of APBD was seen in 18 (35.3%), type II in 11 (21.6%) and type III in 22 (43.1%) cases, respectively. A radical operation, including complete excision of the dilated biliary duct followed by reconstruction of the biliary tract was the surgical treatment of choice, because the reflux of the pancreatic juice into the biliary tract is prevented. However, a dilated common channel or accessory pancreatic duct, according to the new Komi type Ib, IIb, and IIIc3 of APBD, could be the cause of relapsing pancreatitis leading to chronic pancreatitis, due to the formation of a protein plug or pancreatic calculus in the dilated duct, even after this radical operation. In two complicated cases of type IIIc3 of APBD in choledochal cyst, we performed a pylorus-preserving pancreatoduodenectomy as one of the operative methods of choice. Long-term follow-up, more than decades, is essential to evaluate the results of surgical procedure for choledochal cyst, especially in those complicated cases with type Ib, IIb, and IIIc3 of APBD according to the new Komis classification.

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.

Choledochal cyst: Anomalous arrangement of the pancreaticobiliary ductal system and biliary malignancy

Congenital biliary dilatation (CBD) or choledochal cyst has previously been considered a rarity; however, the number of cases reported in the literature has been increasing. It is generally accepted that there is a predominance in Japanese, as more than one‐third of the cases are from Japanese literature.

Postoperative adjuvant immunochemotherapy with mitomycin C, tegafur, PSK and/or OK-432 for gastric cancer, with special reference to the change in stimulation index after gastrectomy

In order to evaluate the efficacy of combined immunochemotherapy with mitomycin-C, tegafur, PSK and/or OK-432 as an adjunct for curatively resected gastric cancer, a prospective randomized controlled study using the envelope method was performed, in which 266 institutions from around Japan participated. The 3 year survival rates for all cases, and for ps(+)·n(+) cases, were insignificantly higher in the immunochemotherapy groups receiving PSK and/or OK-432 than in the control group. However, because 28.2 per cent of the cases were excluded from the final statistical analyses, the results of this study may have questionable statistical credibility. Changes in the stimulation index (SI) suggest that the administration of PSK may result in an inhibition of the immunosuppressive activity of cancer patients. The high SI group showed a significantly higher 4 year survival rate than the low SI group.

Left diaphragmatic hernia associated with lower esophageal atresia

A case of combined left diaphragmatic hernia and lower esophageal atresia, which is an unusual occurrence, is described. The preoperative diagnosis was difficult because of the presence of an abnormal air bubble, thought to be the stomach, in the chest. The surgical management is discussed.

A case of biliary stricture caused by cavernous transformation of the portal vein

A case is reported of extrahepatic obstruction of the portal vein with the unusual complication of obstructive jaundice that resulted from compression of the common bile duct caused by cavernous transformation of the varicose network. It is surgically impossible to repair choledochal stenosis resulting from enlarged varices in the vicinity of the common bile duct. In this case, internal drainage from the biliary duct to the duodenum using a silastic tube and a reservoir implanted in the subcutaneous space successfully eliminated the jaundice.

Monoclonal antibody against human enterokinase and immunohistochemical localization of the enzyme

SummaryA monoclonal antibody, hek-1, was raised against enterokinase or enteropeptidase that had previously been partially purified from human duodenal fluid. Hek-1 showed staining of two glycoprotein bands of relative molecular weights of 260,000 and 240,000 on immunoblot analysis of partially purified enterokinase and of ammonium sulfate fraction of duodenal fluid. An enzyme immunoassay for human enterokinase was developed, making use of hek-1. Sensitivity to enterokinase was 20 times higher than that of the conventional assay where BAPA was used as a substrate. The immunohistochemical study with hek-1 showed staining of the brush border membrane and some goblet cells of the duodenum and upper jejunum but no staining of the colon epithelium.

Congenital segmental dilatation of the colon: report of a case and review of the literature

Segmental dilatation of the colon is a rare lesion. A patient with this lesion complicated by chronic constipation from birth is described. Although the clinical picture and radiographic studies are indistinguishable from Hirschsprungs disease, anorectal manometric studies and a rectal mucosal biopsy are of paramount importance for the diagnosis of this condition. This disease can be cured by resection of the dilated segment.