The purpose of this study was to review our experience with laparoscopic common bile duct (CBD) exploration by the transcystic approach and choledochotomy. We selected the transcystic approach for patients whose CBD stones were less than five in number and smaller than 9 mm in diameter, and whose CBD was less than 15 mm in diameter on cholangiograms. Among 217 patients with CBD stones treated laparoscopically, the transcystic approach was performed successfully in 91 of 104 patients in whom it was attempted (87.5%). The other 126 patients underwent laparoscopic choledochotomy, followed by ductal closure with transcystic drainage in 59, T-tube drainage in 46, primary ductal closure in 19, and choledochoduodenostomy in 1. Choledochotomy was converted to open surgery in only 1 patient. The transcystic approach was associated with shorter hospital stay and less morbidity than choledochotomy. However, choledochotomy also had an acceptably low rate of complications. Bile leaks occurred more frequently in those with primary ductal closure than in those with transcystic drainage or T-tube drainage. Residual stones were found in 2 patients with the transcystic approach and in 10 with choledochotomy. The residual stones were removed through the T-tube tract by choledochoscopy in 7 of these 10 patients. From these results we conclude that laparoscopic management of CBD stones is feasible for almost all patients with CBD stones. It is considered to be safe and effective and has the advantage of being a single-stage procedure.

A case of lymphoepithelial cyst in the pancreas was reported. A 64-year-old man without any specific complaints was found to have a cystic lesion in the anterior portion of the pancreas, as revealed by ultrasonography of the abdomen at an annual medical examination in 1988. This was dissected easily from the pancreas. Histologically, it was diagnosed to be a benign lymphoepithelial cyst in the pancreas. Cysts of this type are rare, and their histogenesis is also not well understood.

This report demonstrates a case of undifferentiated carcinoma of the duodenal ampulla. A 74-year male experienced jaundice lasting for 3 weeks. An upper gastrointestinal series demonstrated a polypoid, ovoid filling defect in the second portion of the duodenum, and duodenoscopy disclosed a protruding mass involving the orifice of the papilla of Vater. Cholangiography demonstrated obstruction due to compression in the terminal common bile duct. Pylorus-preserving pancreatoduodenectomy was performed on the diagnosis of ampullary carcinoma. The gross specimen showed a polypoid mass, measuring 3.5 cm in diameter, in the ampulla, located mainly in the duodenal submucosal layer and invading the terminal common bile duct. Histologically, the tumor was small cell type, undifferentiated carcinoma, arising from the duodenal epithelium adjacent to the ampulla.

The radii of the splenic and proper hepatic arteries were estimated by means of selective celiac arteriography in cases of portal hypertension and of splenomegaly without portal hypertension.The results were evaluated in comparison with normal arteriograms.The estimated radii of the splenic arteries were in satisfactory agreement with the histometrical ones. It was concluded that the splenic and hepatic arterial flow could be proportional to the 2.7th power of the radii of the respective arteries on arteriograms, as in the histo metrical study.1,2 In cases of portal hypertension and appreciable increase in the radius of the splenic artery was demonstrated.In splenomegaly without portal hypertension, as in idiopathic thrombocytopenic purpura, hemolytic jaundice, such an increase in the radius of the splenic artery was not observed.In portal hypertension, the radius of the splenic artery could be correlated with the splenic weight, portal pressure, the grade of decrease in the portal pressure after splenecto my and the length of the splenic artery.In cases of liver fibrosis, dilatation of the splenic artery was not usually accompanied by dilatation of the proper hepatic artery, whereas in liver cirrhosis with or without giant splenomegaly, dilatation was noted not only in the splenic artery but also in the proper hepatic artery as well.arteriogram;portal hypertension;splenic blood flowIn previous publications, we reported on the estimation of splenic blood flow in cases of portal hypertension, especially in hepatic fibrosis (Banti's syndrome) and liver cirrhosis from the histometrical determination of the radius of the splenic artery. Splenic blood flow' was calculated therefrom by the formula of Suwa et al.2 It was pointed out in these reports that the splenic blood flow thus calculated was in good agreement with that obtained by dye dilution technic3 prior to splenectomy.In the present study, the radius of the splenic artery was measured in patients with portal hypertension on the films of selective celiac arteriography and the obtained values were compared with those of direct histometrical measurement on the splenic artery after splenectomy.4 The relation of the arterial radii to portal pressure and splenic weight was investigated in an attempt to gain insight into the significance of dilatation of the splenic artery in the pathogenesis of this syndrome.

No abstract

The objective of this study was to clarify the etiology of acute cholecystitis and the role of bacteria in the bile in this condition. We evaluated 52 patients with acute cholecystitis; 46 had cholesterol stones and 6 had no claculi. In the presence of cystic duct obstruction, circulatory disturbance occurs gradually, but circulatory disturbance alone cannot cause severe inflammation unless a bacterial infection is present. If there is no obstruction, rapid circulatory disturbance produces necrotic changes of the gallbladder wall, which are implicated in a fulminant course. In both instances, bacterial infection may play an important role in fulminant cholecystitis. Bacteria implicated in acute cholecystitis are usually present in the bile before the onset of this disease.

Experimental production of an arterio-venous fistula between the splenic artery and vein of the dog causes increased splenic arterial flow, and reduction of hepatic arterial flow . In the majority of clinical cases of splenomegaly of periportal fibrosis (Banti's syndrome) , selective celiac angiography reveals narrowing of the hepatic artery proper , and there is a significant negative correlation between the radii of splenic and hepatic arteries on the x-ray films. The results suggest reduced hepatic arterial flow in such cases. Two different mechanisms are taken into consideration for the expla nation of this circulatory condition:There may be some hemodynamical inter action between the portal system and the hepatic artery, or increased blood flow of the splenic artery, or increased blood flow of the splenic artery may reduce the hepatic share of celiac arterial flow. No arteriographical narrowing of the hepatic artery proper was demonstrated in splenomegalic cirrhosis even if high portal inflow is expected through the massive splenomegaly.A comparison of the radius of the hepatic artery proper and the percentage of intrahepatic shunted flow supports the view that the effective portal flow is unchanged in those cases. splenic artery; hepatic artery; portal flow Dilatation of the splenic artery in splenomegalic disorders is especially pronounced in cases of portal hypertension. In previous reports of ours (Yamauchi 1968;Yamauchi et al. 1970) a remarkable increase in the radii of the splenic arteries in periportal fibrosis accompanied by increased blood flow and concomitant narrowing of the proper hepatic artery was arteriographically or histometrically demonstrated.The purpose of this paper is to examine possible interaction between the splenic and hepatic arterial systems in the clinical and experimental portal hypertension. MATERIALS AND METHODS Clinical investigationsMeasurement of splenic blood flow: Splenic blood flow was measured at laparotomy by means of the dye dilution technique (Koyama 1967) or a square wave electromagnetic flowmeter (Nihonkoden MF-5) in 14 cases of periportal fibrosis, 6 cases of splenomegalic Received for publication,

Mesenchymal tumors of the appendix are very rare. Mesenteric fibromatosis is the most common diagnosis in the case of isolated proliferative fibroblastic lesion found in this region. However, the differential diagnosis between fibromatosis and well-differentiated fibrosarcoma (Grade I) can be difficult in some borderline cases. A rare case of proliferative fibroblastic lesion involving the appendix and mesoappendix is presented, and its origin, diagnosis and differential diagnosis are discussed.