Excision Of Extrahepatic Bile Duct Research Articles

Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy -

The standard surgical procedure for congenital biliary dilatation (CBD) consists of excision of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy (HJ). However, alternative reconstructive operations for CBD includes hepaticoduodenostomy (HD). We compared postoperative complications and therapeutic outcomes of these two operations at our institution. From 1981 to 2009, there were 23 traceable patients who underwent operation for CBD, They were divided into an HJ Group (n = 15) and an HD Group (n = 8). Demographic and outcome data were compared. There were no significant differences in postoperative complications(cholangitis, pancreatitis, and anastomotic stenosis) and current blood test data (AST, ALT, Total Bilirubin, Direct Bilirubin, Amylase) between the two groups. Current abdominal pain and carcinogenesis were not observed in either group. Intrahepatic stones occurred in one patient in each group, both > 25years post-operation. HD is considered to be an acceptable reconstruction method compared to HJ, based on our results. There has been a suggestion that inadequate diversion in HD might increase the risk of cholangiocarcinoma. To date, in this series, that has not happened.

Intraductal papillary neoplasm in common bile duct opening into the stomach

AbstractEctopic bile duct openings are uncommonly encountered and due to limited reports, the incidence and work up are not well delineated. We therefore present our experience in the assessment and management of one such case. A 62‐year‐old lady presented with obstructive jaundice. Final investigation results revealed intraductal papillary neoplasm of the bile duct (IPNB) in an ectopic common bile duct (CBD) inserting ectopically into the lesser curve of the stomach with a normal pancreatic duct opening into the duodenum. Anatomical delineation and staging was done using computer tomography (CT) scan and endoscopic cholangiopancreatography (ERCP). Robotic distal gastrectomy, extrahepatic bile duct excision with porta lymph node dissection, and hepaticojejunostomy with Roux‐en‐Y reconstruction was performed. The blood loss and operation time were 200 mL and 301 minutes, respectively. Pathology showed IPNB with high grade dysplasia and clear margins. After transient gastroparesis, the patient recovered and was disease‐free at 1 year postoperatively. Ectopic biliary drainage into the stomach is extremely rare, but its recognition may help identify the cause of certain clinical conditions and prevent bile duct injury during surgery if required.

1331 Choledochal Cyst in an Adult Female

INTRODUCTION: The incidence of biliary cyst (BC) is 1:100,00 to 150,000 making it a rare medical condition. BC are most commonly diagnosed in the pediatric population but can occasionally present in adults. A multi-disciplinary team approach including a gastroenterologist and a hepatobiliary surgeon is ideal in treating patients with this diagnosis. CASE DESCRIPTION/METHODS: We present a case of a 38-year-old female with past medical history significant for gastroesophageal reflex disease and migraine who was admitted for evaluation of worsening epigastric pain. Patient was noted to be one week after a total abdominal hysterectomy with bilateral salpingo-oophorectomy. A comprehensive metabolic panel was ordered on admission displaying liver chemistries elevated with AST of 258 IU/L (Ref: 9-45 IU/L), ALT of 260 IU/L (Ref: 17-63 IU/L), alkaline phosphatase of 230 IU/L (45-117 IU/L) and total bilirubin of 3.2 mg/dl (Ref: 0.2-1.0 mg/dl). The patient obtained a RUQUS, which did not show any gallbladder stones or sludge. Patient was still having pain throughout her admission, so a magnetic resonance cholangio-pancreatography (MRCP) was ordered for further evaluation. The MRCP revealed a fusiform dilation of proximal half of the common bile duct (CBD) with a diameter of 15 mm and normal intrahepatic ducts. The pancreatic duct could not be visualized on MRCP and hence unable to comment on length of common channel. There was no evidence of stone or stricture in the CBD. At this point, the patient was diagnosed with Type I choledochal cyst. Patient then underwent a laparoscopic extrahepatic bile duct excision with Roux-en-Y hepatico-jejunostomy and cholecystectomy. On follow up evaluation, the patient had been doing well with normal liver chemistries. DISCUSSION: Although rare, choledochal cysts can cause many complications and need to be treated as soon as possible. These complications are due to bile stasis and/or reflux of pancreatic enzymes into the CBD resulting in recurrent cholangitis and other problems including CBD strictures, rupture, stones and secondary biliary cirrhosis. Additionally, there is an overall 10-30% risk for cholangiocarcinoma in patient's with this diagnosis. This case is a good example of successful treatment of a choledochal cyst in a young female.

A video presentation of right hepatectomy with caudate lobe excision with extrahepatic bile duct excision and lymphadenectomy for hilar cholangiocarcinoma

A video presentation of right hepatectomy with caudate lobe excision with extrahepatic bile duct excision and lymphadenectomy for hilar cholangiocarcinoma

Mirizzi Syndrome can Mimic Cholangiocarcinoma

Introduction: Mirizzi syndrome (MS), extrinsic compression of the common hepatic duct (CHD) by a stone impacted in Hartman's pouch or cystic duct, is often not recognized preoperatively.1 This leads to significant morbidity and biliary injury.2 Typical symptoms include jaundice, fever, and RUQ pain. In this report, we present a patient with obstructive jaundice with high suspicion for cholangiocarcinoma (CCA) until he underwent a resection. Case presentation: A 75-year-old man with PMH of diverticulitis, resolved HBV infection, CAD, HTN, hyperlipidemia presented to the ED with epigastric/RUQ pain, jaundice, anorexia, and nausea of 3 week duration. The patient endorsed a 15-pound weight loss over two months, but denied fevers or chills. He consumes three alcoholic beverages per week for multiple years. Family history was positive for colon and breast cancers in his mother and skin and laryngeal cancers in his brother. Vitals WNL. Physical exam: scleral icterus, mild tenderness in the RUQ; negative murphy, negative fluid wave or organomegaly. Labs: CBC/BMP/Lipase/Amylase WNL. Total bilirubin 10.9, direct bilirubin 4.4, ALP 508, gamma-GT 320, AST 184, ALT 274. US: gallstones-containing contracted gallbladder. CBD 7 mm. no cholecystitis. Murphy negative. MRCP: no mass, thickening of the intrahepatic right hepatic duct and CHD, contract gallbladder with gallstones, compression of CBD at hilum. ERCP: high-grade stricture in CHD at the level of the confluence, cystic duct not visualized. Stent was inserted. Brushings showed atypical cells. Patient underwent excision of extrahepatic bile duct, segmental liver resection and hepaticojejunostomy. Pathology report: positive for cystic duct obstruction with a stone and negative for neoplasm. Discussion: MS can be confused with CCA (as in the patient we described above). Although MRCP is the test of choice with highest sensitivity, MS can still be misdiagnosed preoperatively. Therefore, high suspicion is needed in patients with obstructive jaundice particularly with a history of cholelithiasis. Conclusion: Mirizzi syndrome can mimic cholangiocarcinoma and high suspicion is needed.

Heterotopic Pancreas within the Proximal Hepatic Duct, Containing Intraductal Papillary Mucinous Neoplasm

We report a unique first case of benign heterotopic pancreas arising within the proximal hepatic bile duct, containing a focus of intraductal papillary mucinous neoplasm (IPMN). The condition was diagnosed on pathological explant after left hepatic lobectomy with total extrahepatic bile duct excision.

Anomalous union of the pancreaticobiliary duct without choledochal cyst: is cholecystectomy alone sufficient?

Anomalous union of the pancreaticobiliary duct (AUPBD) is frequently associated with choledochal cyst and biliary tract cancers. Management of AUPBD with choledochal cyst consists of extrahepatic bile duct excision and cholecystectomy. In cases of AUPBD without choledochal cyst, cholecystectomy alone is usually recommended.This study aimed to evaluate the occurrence of biliary tract cancer in AUPBD patients in order to assess the validity of the currently recommended operative management. Of a total of 10,255 endoscopic retrograde cholangiopancreatography cases performed at two Korea University hospitals from 2001 to 2010, 55 (0.54 %) cases of AUPBD were identified. Patients with AUPBD were divided according to its subtype (P-C union and C-P union) and the presence of choledochal cyst for analysis. The occurrence of benign and malignant disease was evaluated and compared between the groups. Gallbladder stones were more frequently found in AUPBD patients without choledochal cyst (p=0.032). Biliary tract cancer occurred more frequently in P-C union (p=0.050),especially the common bile duct cancer (p=0.023). When analyzed according to the presence of choledochal cyst, biliary tract cancer occurred more frequently in AUPBD patients without choledochal cyst (p=0.005), with bile duct cancer being significantly more common (p=0.015). However, there was no difference in the presence of gallbladder cancer between the two groups (p=0.318). Since cancers of the biliary tract occur more frequently in the AUPBD group without choledochal cyst,cholecystectomy alone may not be protective of the future occurrence of bile duct cancers, and thus, vigilant surveillance is necessary in this population group.

Laparoscopically assisted extrahepatic bile duct excision with ductoplasty and a widened hepaticojejunostomy for complicated hepatobiliary dilatation

Complicated hepatobiliary dilatation is characterized by congenital cystic dilatation of the biliary tree extending to involve the intrahepatic biliary channels. Some studies have reported on laparoscopic excision for common choledochal cyst, yet there are little reports on laparoscopic surgery for congenital choledochal cyst with intrahepatic bile duct dilatation. In this paper, we present our experiences in laparoscopic extrahepatic bile duct excision combined with ductoplasty and hepaticojejunostomy for complicated hepatobiliary dilatation. We retrospectively studied 153 children (age ranged between 3months and 12years) who had undergone laparoscopic cholangiopancreatography and radical choledochal resection in our institute from 2002 to 2012. A co-existing extra- and intra-hepatic dilatation was found in 26 patients. After resecting the extrahepatic dilated duct and widening the portohepatic or intrahepatic ductal lumen (ductoplasty) under the laparoscopic video, a widened hepaticojejunostomy at the hilum was performed using a Roux-en-Y jejunal limb. Laparoscopic procedures were successfully performed in all children with complicated hepatobiliary dilatation and their ductal stenoses at the hilum were corrected. In 13 patients with a stricture that converged into the common hepatic duct, the stenotic segment was incised and a wide hepaticojejunostomy was completed at the porta hepatis. A constrictive confluence of the right and left hepatic duct was observed in eight cases, a bi-ductal portojejunostomy was achieved at the bifurcation after making incision in the bilateral stenotic hepatic ducts to create a large stoma. A downstream stricture of the left hepatic duct was identified and incised from the hilum to the dilated segment along the lateral wall in three cases, so that a long hepaticojejunostomy to left intrahepatic duct lay in an oblique orientation. In two cases, a septum was found in the right hepatic ductal terminal and excised through the hilar orifice. Postoperative complications were observed in two children including temporary bile leakage and hepaticojejunal anastomotic stricture each one. The intrahepatic duct dilatation was remarkably reduced in size during the follow-up. Laparoscopic cholangiopancreatography is a valuable method in offering an accurate delineation of complicated hepatobiliary dilatation associated pancreaticobiliary maljunction and only necessitates simple equipments. With the aid of the magnified laparoscopic view, the radical resection of extrahepatic biliary duct and correction of the portohepatic bile ductal stenosis can be exactly performed. Laparoscopic hepaticojejunostomy at the hilum is effective and safe for children with complicated hepatobiliary dilatation.

分流手術後の膵側遺残嚢腫内結石に対しPpPDを施行した膵・胆管合流異常,先天性胆道拡張症(戸谷I型)の1例

分流手術後の膵側遺残嚢腫内結石に対しPpPDを施行した膵・胆管合流異常,先天性胆道拡張症(戸谷I型)の1例

Use of preoperative, 3-dimensional magnetic resonance cholangiopancreatography in pediatric choledochal cysts

Standard choledochal cyst (CC) operations involve dilated extrahepatic bile duct excision followed by biloenterostomy. However, biliary variants and associated intrahepatic bile duct (IHBD) stenoses or dilatations triggering postoperative sequelae require additional procedures. The usefulness of preoperative 3-dimensional magnetic resonance cholangiopancreatography (3D MRCP) and virtual cholangioscopy (VES) for observing biliary morphology and pancreaticobiliary maljunction (PBM) was evaluated. In 16 pediatric CC patients (age range, 4 months to 9 years; median, 3 years), visualization of PBM and aberrant bile duct anatomy and IHBD morphology at the hepatic hilum (HH), umbilical portion (UP), and posterior branch (POST) were compared between 3D-MRCP and intraoperative cholangiography (IOC). VES and intraoperative cholangioscopy (IOS) findings were compared. HH, UP, and POST visualization rates were 100%, 94%, and 94%, respectively, by 3D-MRCP, and 100%, 69%, and 69%, respectively, by IOC. IHBD stenosis detection rates at each region were 38%, 13%, and 13%, respectively, by 3D-MRCP, and 25%, 0%, and 9%, respectively, by IOC. IHBD dilatation detection rates at each part were 75%, 47%, and 60%, respectively, by 3D-MRCP, and 88%, 82%, and 91%, respectively, by IOC. PBM was confirmed in 56% and 93% of cases on 3D-MRCP and IOC, respectively. Both 3D-MRCP and IOC showed biliary variants in 5 cases (31%). VES showed membranous strictures at HH, UP, and POST in 6, 2, and 2 cases, respectively, whereas IOS did so at HH in 4 cases and POST in 2. Preoperative 3D-MRCP and VES accurately depict biliary morphology, allowing concrete operative planning in pediatric CC patients, complementing IOC and IOS.

Systematic review: Should routine resection of the extra-hepatic bile duct be performed in gallbladder cancer?

Background /Aim:Complete surgical resection is associated with improved outcomes in gallbladder cancer. Whether the extra-hepatic bile duct (EHBD) should be routinely excised for gallbladder cancer is unclear. Objective: To analyze literature concerning EHBD excision to determine if it is associated with survival advantage and hence can be routinely recommended.Materials and Methods:A systematic search using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1988-2008.Results:EHBD excision was reported to be performed routinely for T1-4 in some studies, while others reported resection to facilitate lymph node clearance or if the EHBD was grossly involved by disease that remained otherwise resectable. While one study demonstrated 100% survival in T1 disease, other reports do not demonstrate any survival benefit of EHBD excision in T1 disease. Four studies (level IV-V) demonstrated 60% to 90% five-year survival for routine excision in T2 disease, while three other studies demonstrated no survival advantage but increased morbidity due to the procedure. In T3/4 disease, one study (level IV-V) demonstrated a benefit in T4 disease only, and another study (level IV-V) reported a survival advantage in patients in whom the bile duct was not involved; five other studies showed no impact of routine EHBD excision on survival but reported morbidity following anastomotic leaks.Conclusions:Available evidence does not support routine resection of EHBD in gallbladder cancer. EHBD excision should be performed in the presence of specific indications, viz., to achieve an R0 resection of the primary tumor and/ or to aid complete lymph node dissection that would compromise the EHBD by devascularization.

Invasive cholangiocarcinoma identified in congenital biliary dilatation in a 3-year-old boy

We herein report a 3-year-old male demonstrating invasive cholangiocarcinoma (CC) associated with congenital biliary dilatation (CBD). A 3-year-old Japanese boy was admitted to our hospital with abdominal pain and vomiting. Computed tomography and magnetic resonance imaging demonstrated a dilated extrahepatic bile duct. A diagnosis of Todani's type 1a CBD was made. Intraoperative cholangiography demonstrated the presence of pancreaticobiliary maljunction but could not reveal any tumor lesion in the bile duct. The excision of extrahepatic bile duct and gallbladder and Roux-en-Y hepaticojejunostomy were performed. On gross inspection, we could not find any tumor lesion in the resected specimen. However, the postoperative histopathologic examinations confirmed the presence of well-differentiated tubular adenocarcinoma with lymphovascular invasion. Most of the carcinoma remained within the mucosal layer, and the carcinoma was identified at both the distal and proximal surgical margins of the bile duct. We scheduled additional surgery to eradicate the residual carcinoma, but informed consent for the extra surgery could not be obtained. A close follow-up with abdominal computed tomography has been going on without either additional surgery or adjuvant chemotherapy about for 1 year. The patient has so far been clinically doing well without any obvious symptoms of recurrent disease. To our knowledge, this report is the youngest case of CC associated with CBD.

Delayed Upper Gastrointestinal Bleeding After Laparoscopic Treatment of Forme Fruste Choledochal Cyst

Delayed upper gastrointestinal (UGI) bleeding after surgery is a catastrophic event with high mortality unless diagnosed early. In this paper, report a case of massive UGI bleeding 1 month after the laparoscopic treatment of a forme fruste choledochal cyst (FFCC). A 8-year-old girl presented at our attention because of acute pancreatitis. Ultrasound and magnetic resonance cholangiopancreatography diagnosed an FFCC. Once serum amylase and lipase were normal, a laparoscopic extrahepatic bile duct excision (EHBD) with a Roux-en-Y hepaticojejunostomy was performed without intraoperative complication. One month later, the patient had massive UGI bleeding, and laparotomic treatment of duodenal bleeding was necessary because of hemodynamic instability. Despite intravenous omeprazole and somatostatin, 1 week later, a new massive UGI bleeding occurred during hospitalization and an antral gastric resection with gastrojejunostomy (Billroth II) was performed. The patient was discharged 3 weeks later and she is well at 18-months of follow-up. EHBD excision with a Roux-en-Y hepaticojejunostomy is the treatment of choice for FFCC; laparoscopic approach is feasible and effective in children, too. The severe complication reported seems not related to the minimal invasive approach; in fact, it can occur after pancreatic or biliary surgery.

Biliary Carcinoma Risk in Patients with Pancreaticobiliary Maljunction and the Degree of Extrahepatic Bile Duct Dilatation

Background and Aim: In patients with pancreaticobiliary maljunction (PBM), pancreatic juice frequently refluxes into the bile duct. This results in a high risk of biliary carcinoma. No consensus has been reached on whether preventive resection of the extrahepatic bile duct is necessary in PBM cases without dilatation of the extrahepatic duct. The aim of this study is to examine the biliary complications of patients with PBM in relation to the degree of extrahepatic bile duct dilatation and thus to determine appropriate management. Patients and Methods: We have treated 98 patients (21 males and 77 females, average = 48.0) with PBM. The PBM cases could be divided into 5 groups according to the maximum diameter of the extrahepatic bile duct:≤10, 11-15, 16-20, 21-30, ≥31mm. The clinicopathological findings of biliary carcinomas associated with PBM were examined and compared with 232 cases of gallbladder carcinoma and 159 cases of bile duct carcinoma that were not associated with PBM. Results: Gallbladder carcinoma occurred in 36 of 65 patients (55%) with PBM whose maximum diameter of the extrahepatic bile duct was ≤30 mm, but no gall bladder carcinoma occurred in patients with PBM whose maximum diameter of the extrahepatic bile duct was ≥31 mm. Bile duct carcinoma occurred in 6 of 52 patients (12%) with PBM whose maximum diameter of the extrahepatic bile duct was ≥21 mm, but no bile duct carcinoma occurred in patient with PBM whose maximum diameter of extrahepatic bile duct was ≤20 mm. The age at diagnosis of the patients with gall bladder (58.9 ± 8.8 vs. 69.4 ± 8.7 years old, p < 0.01) or bile duct carcinoma (54.8 ± 14.3 vs. 68.8 ± 9.1 years old, p < 0.01) associated with PBM was significantly younger than those without PBM. Gallstones were rarely detected in patients with gallbladder carcinoma associated with PBM (8% vs. 62%, p < 0.01). There were no significant differences between cases of gallbladder carcinoma associated with and without PBM in the location and histology, incidence of multiple biliary carcinoma. Multiple biliary carcinomas frequently occurred in the patients with bile duct carcinoma associated with PBM (50% vs. 4%, p < 0.01). Conclusion: PBM with an extrahepatic bile duct diameter ≤30 mm is associated with a high risk of gallbladder carcinoma. Furthermore, PBM with an extrahepatic bile duct diameter ≥21 mm is associated with a high risk of bile duct carcinoma. The treatment of choices for PBM with biliary dilatation is excision of extrahepatic bile duct and gallbladder with Roux-en-Y reconstruction of the biliary tree. However, given the present study, only cholecystectomy should be recommended as prophylactic treatment for patients with PBM without biliary dilatation.

Congenital Dilatation of Extrahepatic Bile Ducts in Children. Experience in the Central Hospital of Hue, Vietnam

The authors present a study of a series of cases in children with congenital dilatation of the extrahepatic bile ducts (CDEBD). Between November 1998 and October 2002, 38 children aged between 50 days and 15 years suffering from CDEBD, admitted to the Central Hospital in Hue, Vietnam, were treated surgically with a minimum follow-up of one year. Diagnosis was based only on ultrasonography which was 100% accurate. According to Miyano's classification, 26 cases presented as cystic dilatation of the main bile duct (MBD) associated with dilatation of the intrahepatic bile ducts, while in the other 12 cases the dilatation of the MBD was of the fusiform type. The surgical treatment of choice was extensive excision of the dilatated extrahepatic bile ducts and biliary drainage according to the Roux-en-Y method in 36/38 patients. The other two patients underwent surgery for internal biliary drainage without removing the cysts. During follow-up we observed one case of pancreatitis out of the 36 patients who underwent excision of the dilatated extrahepatic bile ducts, while the two patients who had internal biliary drainage without removal of the cysts suffered from numerous attacks of cholangitis. The reflux of bile in the dilated biliary tree plays an important role in the etiopathogenesis of CDEBD. Excision of the extrahepatic bile ducts and internal biliary drainage by Roux-en-Y has proved a satisfactory surgical method.

Preferable operative age of choledochal dilation types to prevent patients with pancreaticobiliary maljunction from developing biliary tract carcinogenesis

Pancreaticobiliary maljunction (PBM), which frequently accompanies choledochal dilation, is a high risk factor for biliary tract (gallbladder, bile duct) carcinoma because of the continuous reflux of pancreatic juice into the biliary tract. The aim of this study was to clarify the preferable operative age in PBM patients for the prevention of biliary tract carcinogenesis, with reference to the dilation types of bile ducts. There were 165 PBM patients in total studied, including 92 pediatric patients (< or =15 y) (cystic, 63; spindle-like, 29; nondilation, 0) and 73 adult patients (>15 y) (cystic, 45; spindle-like, 18; nondilation, 10) who underwent operative excision of extrahepatic bile ducts or cholecystectomy. We investigated incidence by age of biliary tract malignancies and the risk according to types of dilation. In the pediatric group, no carcinoma case could be found preoperatively or postoperatively (mean follow-up period, 11.7 y). In the adult group, bile duct carcinomas could be detected in 6 cases of a cystic type (6 of 45; 13.3%) (3 preoperative, 3 postoperative). Among the bile duct carcinoma cases, the youngest patient was a 21-year-old woman who had undergone excision of an extrahepatic bile duct 3 years previously. Gallbladder carcinomas were detected in 16 patients: 3 of 45 cystic (6.7%), 6 of 18 spindle-like (33.3%), and 8 of 10 nondilation (80.0%), in whom the youngest patient was a 41-year-old woman with a spindle-like type. To prevent biliary tract carcinogenesis in PBM patients, cystic-dilated choledochus should be excised in childhood before the development to a precancerous stage. In spindle-like and nondilation types, cholecystectomy is absolutely necessary in early adulthood before age 40.

Forme fruste choledochal cyst: long-term follow-up with special reference to surgical technique

Purpose: Forme fruste choledochal cyst (FFCC) is a choledochal cyst that has minimal or no dilatation of the extrahepatic bile duct (EHBD) and is associated with pancreaticobiliary malunion (PBMU). The authors reviewed the long-term outcome of their patients with FFCC. Methods: Inpatient and outpatient records of 281 patients with choledochal cyst were reviewed. In this study, minimal dilatation of the EHBD was defined as its maximum diameter being less than 10 mm. Results: There were 17 cases of FFCC identified. In all 17 patients, PBMU was present. The mean age at EHBD excision was 2.9 years. Fourteen patients had hepatico-jejunostomy, and three had hepatico-duodenostomy. The histology of the excised EHBD showed mucosal ulceration/sloughing (in 35.3% patients), fibrosis (52.9%), and inflammatory cell infiltration (41.2%). Over a mean postoperative follow-up period of 9.8 years, there have been no episodes of cholangitis or anastomotic stricture formation. Conclusions: The treatment of choice for FFCC in children is EHBD excision and hepatico-jejunostomy. There is little surgical morbidity if performed carefully.

Clinical problems in the surgical treatment of pancreaticobiliary maljunction

The results of surgical treatment of pancreaticobiliary maljunction at our department are described. The 67 patients who underwent surgery for this disease were divided by age into an adult group (45 patients, aged 16 years and over) and a pediatric group (22 patients, aged less than 16 years). The incidence of concomitant carcinoma before surgery and the incidence and severity of postoperative cholangitis were compared between these two groups. In addition, the cell proliferating activity of the biliary tract epithelium in cancer-free patients was compared between the two groups, using the proliferating cell nuclear antigen labeling index (PCNA LI). Ten patients (all adults) were diagnosed with cancer (gallbladder carcinoma in 7 and bile duct carcinoma in 3) before surgery. The surgical techniques used for reconstruction in the cancer-free patients were: in the adult group, hepaticoduodenostomy in 9 patients, Roux-en-Y hepaticojejunostomy in 17, jejunal interposition in 8, and another technique in 1. In the pediatric group, hepatico-duodenostomy was performed in 17 patients. Roux-en-Y hepaticojejunostomy in 3, and jejunal interposition in 2. Postoperative cholangitis occurred in 6 adults (including 2 with severe form) and 1 child (mild case). The PCNA LI of the biliary tract epithelium was high compared to control findings in the biliary tract epithelium of 10 adult patients without pancreaticobiliary maljunction. In the adult group with dilated extrahepatic bile ducts (n=10 examined) this index was 11.4% for the bile duct epithelium (control, 1.5%) and 12.7% for the gallbladder epithelium (control, 1.4%). In the adult group with non-dilated extrahepatic bile ducts (n=5 examined) it was 5.9% for the bile duct epithelium and 13.1% for the gallbladder epithelium. In the pediatric group (n=10 with extrahepatic bile duct dilatation) it was 7.5% for the bile duct and 9.7% for the gallbladder epithelium. (Differences from control values were all significant.) These results suggest that surgery for this disease should be performed as early as possible and that extrahepatic bile duct excision and biliary reconstruction should be performed whether or not extrahepatic bile ducts are dilated.