This study was carried out to clarify the influence of incomplete bile duct obstruction (IBDO) on theoccurrence and proliferation of cholangiocarcinoma and to evaluate the effect of release of IBDO at anearly stage, using 175 Syrian golden hamsters. These hamsters received 500mg/kg body weight ofdiisopropanolnitrosamine (DIPN) once weekly for 10 weeks, and then were divided into 3 groups,consisting of the simple laparotomy group (SL group), the IBDO group and 2 week IBDO group, inwhich IBDO was released after 2 weeks. The occurrence rates of cholangiocarcinoma at 20 weeks were42&#37; in the SL group, 76&#37; in the IBDO group and 30&#37; in the 2 week IBDO group. The mean numbersof tumors per hamster in the IBDO group were significantly greater than those in other groups (p &#60;0.05). Both occurrence rates and numbers of tumors in the 2 week IBDO group were similar to those inthe SL group. The proliferation of bile ductules and isolation of bacteria from bile in the IBDO grouphad higher rates at 15, 20 weeks than those found in the other groups. These results suggest that IBDOhas an influence, as promoter, on the occurrence of cholangiocarcinoma induced by DIPN, and thedisappearance of its promoting effect is caused by release of the obstruction.

Yoshio   Kinami

Yoshinao   Ashida

Keitaro  Seto

Shigeki  Takashima

Ichiro  Kita

The Effect of Incomplete Bile Duct Obstruction on Diisopropanolnitrosamine&#8212;Induced Cholangiocarcinoma

To clarify the changes in pancreatic hormones and their role in the regeneration of the liver after partial hepatectomy, we measured the portal levels of insulin and pancreatic glucagon and their responses to a glucose load after about 40% hepatectomy in dogs. The changes in the A and B cells of the islets of Langerhans were examined histologically. In the early stages after hepatectomy portal insulin levels decreased significantly, and the response of portal insulin to a glucose load was lower than in the control sham-operated dogs. Both islet size and the number of B cells increased significantly after hepatectomy. Portal pancreatic glucagon levels increased significantly after hepatectomy, and the response of pancreatic glucagon to a glucose load was not suppressed. The number of A cells also increased significantly.Thus, there were differencies between insulin and pancreatic glucagon in their morphological and functional effects after hepatectomy. Although this difference is not clearly understood, there is a possibility that insulin consumption is accelerated in the remnant liver after hepatectomy. Insulin and pancreatic glucagon appear to play important but different roles in the regenerating liver from the morphological point of view.

Tetsuya Hirano

Tadao Manabe

Takayoshi Tobe

Morphological and Functional Discrepancies in Endocrine Pancreas After Partial Hepatectomy in Dogs

The so-called &#8220;Postcholecystectomy Syndrome&#8221; may be due to various pathological biliary causes. Theaim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often along (&#62;1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomyin our patients. Three hundred and twenty two patients underwent a second operation on the bileducts after cholecystectomy in the last ten years. In 35 patients (10.8&#37;) a striking finding was a longcystic duct stump (&#62;1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cysticduct stump, was found on exploration. Out of these 24 patients there were 14 with common bile ductstones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitiswas the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder orcystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one asuture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was theonly pathological finding. Four years after reoperation this patient is still suffering from the sameintermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause forrecurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence ofpostcholecystectomy symptoms.

M. A.  Rogy

R.  F&#252;gger

F.  Herbst

F.  Schulz

Reoperation After Cholecystectomy. TheRole of the Cystic Duct Stump

Cholesterol gallstone disease is extremely common. Three major stages are recognized for stoneformation, namely bile that becomes supersaturated with cholesterol, cholesterol nucleation leading tocrystal formation and finally retention of the crystals in the gallbladder resulting in stone formation.Supersaturation is common but nucleation into crystals probably requires protein nucleating factors.Impaired motility of the gallbladder causes crystal retention and is probably very important in stoneformation.

Steven M. Strasberg

Pierre-Alain  Clavien

P. Robert C. Harvey

Pathogenesis of Cholesterol Gallstones

T.  Ezaki

G. P. Stansby

 K. E. F. Hobbs

Regional Differences in Hepatocellular Carcinoma and its Surgical Treatment

Twenty patients underwent a pylorus-preserving pancreatoduodenectomy for benign or malignantperiampullary and pancreatic disease. Eighteen patients had a partial and two patients a totalpancreatectomy. There were 19 elective and 1 emergency operations.Post-operative mortality was 4&#37; (1/20 patients) and the median follow up was 31 months (range, 15&#8211;75 months), during which period 8 patients with a malignant disease died.Pylorus-preserving pancreatoduodenectomy did not compromise survival in ampullary cancer.One patient developed a marginal ulcer during the study period and one of twelve patients, examinedby technetium scintigraphy (done more than 3 months after the procedure), had delayed gastricemptying. Two patients presented with a gastric retention as the first sign of recurrent pancreatic cancer.The result of the operation was judged as excellent in 7 patients, good in 8 and as bad in only 2 of the17 patients who survived more than <em>6 months</em> . Body weight was studied in 15 patients surviving morethan <em>one year</em> after operation; five patients had gained weight, two had lost weight and in 8 there was nodifference.Pylorus-preserving pancreatoduodenectomy seems to be a valuable alternative in the treatment ofpatients with benign and selected malignant pancreaticobiliary disease.

J.  Lerut

P. J. Luder

L.  Kr&#228;henbi&#252;hl

 P. H. Gertsch

L. H. Blumgart

Pylorus-Preserving Pancreatoduodenectomy. Experience in 20 Patients

Karl A. Zucker

Should Laparoscopic Surgery be an Outpatient Procedure?

From 1980 through 1988, biliary surgery was performed in 197 patients with acute gallstone disease and
concomitant elevation of serum glutamic oxalacetic transaminase (SGOT) or serum glutamic pyruvic
transaminase (SGPT) of over 300 Karmen units. In 137 patients, anatomic inspection and liver biopsy
were performed during the acute stage of the disease. Impacted and floating bile duct stones were found
in 69 (50%) and in 43 (32%) of the 137 patients, respectively. The main liver histology was necrosis of
liver cells. After surgery, high serum transaminase fell rapidly with immediate recovery in 99% of the
patients. In the remaining 60 patients, their signs and symptoms settled soon after initial conservative
treatment and surgery was performed after an average time of 21 days. At laparotomy, impacted bile
duct stones were found in 2 (3%) and liver histology revealed regeneration of liver cells.These findings suggest that marked elevation of serum transaminase in patients with acute gallstone
disease might be due to an acute inflammatory liver cell injury caused by impacted bile duct stones or
migrating stones, which would be transient and reversible after early resolution of the bile duct
obstruction.

Masatoshi Isogai

Kitao Hachisuka

Akihiro Yamaguchi

Satoshi Nakano

Etiology and Pathogenesis of Marked Elevation of Serum Transaminase in Patients With Acute Gallstone Disease

Thomas  Diamond

Brian J. Rowlands

Endotoxaemia in Obstructive Jaundice

J. A. Myburgh

The Warren Shunt: Effect of Alcoholism on Portal Perfusion

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distalsplenorenal shunt &#40;DSRS&#41; has become one of the more commonly performed portal-systemic shuntingprocedures in the treatment of variceal hemorrhage throughout the world. In addition to selectivedecompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portalperfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolledseries and the majority of controlled randomized studies have demonstrated a lower incidence ofencephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of theDSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a lessformidable procedure. None of the studies have shown an advantage to this shunt with respect to longtermsurvival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series haveshown that survival is significantly improved in patients with non-alcoholic cirrhosis compared tononselective shunt procedures in the same population. Controlled trials comparing the DSRS toendoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initialtherapy for most patients as long as shunt surgery is readily available if sclerotherapy fails.

Gongliang  Jin

Layton F. Rikkers

Selective Variceal Decompression: Current Status

John  Terblanche

P. C. Bornman

K-J.  Paquet

J. Mike Henderson

Yasuo  Idezuki

Longterm Management of Portal Hypertension: Therapeutic and Prophylactic Treatment: A Panel Presentation

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