Three-dimensional kinematics analysis of blind football kicking.

The purpose of this study was to identify critical technical points that lead to increased ball speed in a maximal toe kick with no run-up (a 'static kick') in blind football. Six visually impaired male players and eight sighted male players participated in the experiment. All participants wore a blindfold to fully remove visual information and performed the static kick. The motion was captured three-dimensionally using an optical motion analysis system. Our results demonstrated that ball speed, maximum linear velocity of the kicking-side thigh, and maximum angular velocity of the kicking-side shank for the sighted player group were significantly greater than those for the visually impaired player group. The sighted players tended to perform the static kick in a similar motion pattern, which was characterised by a backwards rotation of the torso to adequately extend the kicking-side hip joint during the back-swing phase and a stable posture of the lower torso on the frontal plane during the forward-swing phase. This motion pattern is critical to both acceleration of the kicking-side foot and orientation of the foot for a more precise ball contact position.

Plummer-Vinson syndrome successfully treated by endoscopic dilatation.

Plummer-Vinson (Paterson-Brown-Kelly) syndrome is uncommon nowadays. Although iron repletion improves its symptoms, endoscopic dilatation of associated esophageal webs is sometimes required. The case is described of a 69-year-old woman with Plummer-Vinson syndrome who was successfully treated by endoscopic bougienage. The patient had a longstanding history of anemia and slowly progressive dysphagia of solid food. Laboratory data on admission showed iron deficiency anemia (red blood cell count 402 x 10(4)/microL, hemoglobin 6.8 g/dL, serum iron 8 microg/dL, and serum ferritin 2.4 ng/mL). Radiographic esophagography revealed two circumferential webs at the level of the cervical esophagus. Upper gastrointestinal endoscopy showed a severe upper esophageal stricture caused by a smooth mucosal diaphragm. The patient was prescribed 40 mg of intravenous iron supplements daily for 30 days; her anemia improved but the dysphagia did not. Endoscopic bougienage was performed with the use of Celestin dilators of serially increasing diameters. The webs were easily disrupted without complications. The patient's dysphagia resolved shortly after the treatment and did not recur. This experience indicates that endoscopic bougienage is safe, effective, and relatively easy to perform in patients with severe esophageal stenosis.

Recovery of hepatic function determined by cytochrome P450-dependent drug metabolism lags after compensatory hepatic volume changes after portal vein ligation in rats.

BACKGROUND: Clinically, portal vein embolization has been proven to be useful as a preoperative treatment for major hepatic surgeries with impaired liver function. However, its effects on the metabolism and elimination of various drugs after portal vein embolization or ligation remain to be elucidated. MATERIALS AND METHODS: A portal vein branch that perfuses the central and left lobes of the liver of male Wistar rat was ligated, and changes in the weights of ligated and nonligated lobules as well as hepatic levels and activities of cytochrome P450 (CYP) isoforms, such as CYP3A2 and CYP2C11, were determined. To evaluate in vivo the effect of PVL on hepatic drug metabolism, the narcotic activity (sleep time) of midazolam, a specific substrate for CYP3A2, was measured. RESULTS: Although plasma levels of alanine aminotransferase and hepatic weight returned to basal levels at day 7 after the portal vein ligation, hepatic activities of CYP3A2 and CYP2C11 still remained low (53% and 54% of control levels, respectively), and returned to their initial levels after about day 14. The metabolism of midazolam was prolonged by approximately three times at day 7 after ligation and returned to basal levels at day 14. CONCLUSIONS: Because hepatic CYP-dependent drug metabolism by CYP isoforms recovered more slowly than the apparent recovery of hepatic volume and plasma alanine aminotransferase levels, the therapeutics of drugs metabolized by the CYP isoforms should be used carefully in patients who receive major hepatectomy with portal vein branch embolization.

Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer.

BACKGROUND: The oncologic benefit of avoiding allogenic blood transfusion in oesophageal cancer resection has not been studied. METHODS: The medical records of 68 patients (Auto group) who underwent a potentially curative oesophageal cancer resection without allogenic blood transfusion from 1996 to 1999 receiving 800 g of autologous blood donated preoperatively, and 97 patients (Allo group) who underwent the same operation with allogenic blood transfusion from 1990 to 1995 were compared. RESULTS: There were no differences in age, gender, stage of disease, number of retrieved nodes, or perioperative hemoglobin concentration between the two groups. The survival of the 45 patients with nodal involvement in the Auto group was better than that of the 59 patients in the Allo group (p=0.0435), and the survival of the 35 patients with T3 or T4 lesions in the Auto group was better than that of the 61 patients in the Allo group (p=0.0408). According to logistic regression analysis, allogenic blood transfusion correlated with tumour recurrence in patients with either nodal involvement or a T3-4 lesion. The natural killer cell activity remained higher in the Auto group than in the Allo group (p<0.05). CONCLUSION: Avoidance of allogenic blood transfusion favorably effected the survival of patients with oesophageal cancer at risk for recurrence.

Pseudoaneurysm of the dorsal pancreatic artery with obstruction of the celiac axis after pancreatoduodenectomy: report of a case.

Pancreatoduodenectomy can be difficult in patients with obstruction of the celiac axis because of the development of collateral arteries around the head of the pancreas. Bleeding from a pseudoaneurysm is a rare and serious complication of pancreatoduodenectomy. We report a case of a pseudoaneurysm of an enlarged dorsal pancreatic artery, which formed as a result of obstruction of the celiac axis after pancreatoduodenectomy. We assumed that a weakness in the wall of this dorsal pancreatic artery caused by the dissection led to the formation of the aneurysm. Although transcatheter arterial embolization (TAE) could not treat the aneurysm or stop bleeding from the aneurysm completely, it achieved transient hemostasis, whereby the patient's condition improved, making laparotomy safe. This case demonstrates that the dissection of arteries that have developed around the head of the pancreas must be considered in patients with obstruction of the celiac axis.

Clinicopathologic features and outcome after liver resection for hepatocellular carcinoma in patients with concurrent versus previous chronic hepatitis B.

PURPOSE: We compared the clinicopathologic features affecting outcome after surgery for hepatocellular carcinoma (HCC) between patients with concurrent and previous chronic hepatitis B. METHODS: Group A consisted of 58 patients with concurrent chronic hepatitis B, defined by seropositivity for the hepatitis B surface antigen (HBsAg), and group B consisted of 18 patients whose HCC was detected after disappearance of the HBsAg. We assessed the influence of various characteristics on outcome. RESULTS: The mean age and percentage of patients suffering from alcohol abuse or diabetes mellitus were significantly greater in group B than in group A, whereas histologic hepatitis activity, hepatic fibrosis, and alanine aminotransferase activity were significantly lower in group B than in group A. The tumor-free survival rates were similar between the two groups, but the risk factors of recurrence differed. In group A, relative youth, high aspartate aminotransferase activity, low platelet count, multiple tumors, large tumor size, portal invasion, cirrhosis, nonanatomic resection, and positive surgical margin were risk factors. In group B, large tumor size and poor differentiation were risk factors. CONCLUSION: Hepatitis B status, tumor factors, and the type of operation affected cancer recurrence after surgery for HCC in patients with concurrent chronic HBV, as opposed to only tumor factors in patients with previous chronic hepatitis B.

Evaluation of blood flow by color Doppler sonography in free jejunal interposition grafts for cervical esophageal reconstruction.

The failure of the vascular anastmoses is a devastating complication in free jejunum transplantation. We used color Doppler sonography to estimate blood flow in free jejunal grafts in 21 patients who underwent radical pharyngoesophagectomy. Fast Fourier transform (FFT) analysis of blood flow, the pulsatility index (PI) as a measure of peripheral vascular resistance, and thickening of the graft wall were evaluated for predictive value. The arterial wave patterns were classified into three types based on systolic-diastolic differences and magnitude of flow. Type I was physiologic flow, type III overtly pathologic, and type II intermediate. The three patients who required vascular reanastomoses intraoperatively had a type II pattern that degenerated to type III within 15 minutes. The PI increased to 3.5 to 4.5 over 1 hour. In the one patient who required retransplantation, the wave pattern became type III by 18 hours and had disappeared by 24 hours, at which point the PI could not be measured. Jejunal thickening increased from 1.0 mm to 5.0 mm after 24 hours, even in healthy grafts. Monitoring blood flow during the 24 hours after surgery is critical. A type III wave pattern or a PI >2.5 is an indication for reexploration. Doppler sonography offers a noninvasive way to measure blood flow in jejunal grafts semiquantitatively and can predict free jejunal graft failure.

Type IV collagen 7s domain as a predictor of poor efficacy of portal vein embolization before major hepatectomy.

PURPOSE: We investigated the correlation between serum concentrations of type IV collagen 7s domain (7s collagen) and changes in the volume of the nonembolized liver lobe after subsequent portal vein embolization (PVE). METHODS: The relationship between the pre-embolization results of laboratory tests and the increase in the left lobe volume was evaluated in 32 patients who underwent preoperative PVE via the right portal vein. RESULTS: By 2 weeks after PVE, the mean volume of the left lobe had increased significantly (P < 0.001). The percent increase in the left lobe volume correlated negatively with the pre-embolization serum concentration of 7s collagen (r = -0.472, P = 0.0063). In three of four patients with high serum concentrations (>8 ng/ml), the percent increase was less than 100% and right lobectomy was not performed. The serum 7s collagen concentration correlated with the histologic activity score (r = 0.469, P = 0.0061) and the histologic fibrosis score (r = 0.425, P = 0.0145). CONCLUSION: The serum concentration of 7s collagen may predict the efficacy of PVE. Performing PVE before right lobectomy may not be indicated in patients with high serum concentrations of 7s collagen because the increases in left lobe volume may be insufficient.

Risk factors for postoperative delirium after liver resection for hepatocellular carcinoma.

We investigated risk factors for delirium in 100 patients who underwent liver resection for hepatocellular carcinoma. Postoperative delirium developed in 17 (17%). Univariate analysis revealed that advanced age (especially = 70 years old), a history of smoking, a decreased serum albumin concentration (especially < 3.8 g/dl), advanced cancer stage (II-IV), major hepatectomy, prolonged operating time, and large intraoperative blood loss were possible risk factors for postoperative delirium. When patients' preoperative condition and laboratory test results were subjected to multivariate analysis, only advanced age [odds ratio (OR) 1.201; confidence interval (CI) 1.063-1.357] and a decreased serum albumin concentration (OR 0.151; CI 0.025-0.900) were independent risk factors for the delirium. The percentages of patients with high aspartate and alanine aminotransferase activities, a high indocyanine green retention rate at 15 minutes, a low platelet count, and advanced cancer stage (II-IV) were higher in patients with a low (< 3.8 g/dl), rather than high (= 3.8 g/dl) serum albumin concentration. These findings indicate that multiple factors, including advanced age, impaired liver function, and advanced cancer stage, affect the development of postoperative delirium after liver resection for hepatocellular carcinoma.

Curative resection of a huge bile duct cancer without pancreatoduodenectomy.

A 71-year-old woman was admitted to our hospital with obstructive jaundice. Magnetic resonance cholangiography revealed a 9-cm spindle-shaped tumor in the common bile duct. Laboratory examination noted a high concentration of total serum bilirubin. Although the serum concentration of carcinoembryonic antigen was within normal limits, the serum concentration of carbohydrate antigen 19-9 was elevated. We diagnosed the lesion as an extrahepatic bile duct cancer and performed a laparotomy. The anterior wall of the common bile duct was incised, and the tumor was found to have a small base in only the posterior wall of the duct, and spread within the duct was from the common hepatic duct to the intrapancreatic bile duct. Bile duct resection, cholecystectomy with lymphadenectomy and hepaticojejunostomy were performed. Frozen sections of the proximal and distal surgical margins of the bile duct were free of cancer. Macroscopically, the lesion was an expansive polypoid tumor measuring 9x3cm in diameter arising from a 5-mm base. Histologic examination revealed that the tumor was a well-differentiated tubular adenocarcinoma that had infiltrated the fibromuscular layer at its base. Longitudinal spread was more extensive hepatopetally than hepatofugally. The patient is alive and well without any complaints 8 months after surgery.

Effect of H. pylori on COX-2 expression in gastric remnant after distal gastrectomy.

BACKGROUND/AIMS: Helicobacter pylori infection is known to induce gastritis, oxidative stress, and cyclooxygenase (COX)-2 expression in the gastric mucosa. However, the effect of H. pylori infection on remnant gastritis has not been studied. We investigated whether the severity of remnant gastritis and COX-2 expression were affected by H. pylori infection after distal gastrectomy. METHODOLOGY: The study included 97 patients with gastric cancer who underwent curative distal gastrectomy with lymphadenectomy in our department between May 1999 and April 2001. All patients underwent endoscopic examination 2 weeks before and 12 weeks after surgery. The presence of H. pylori infection was determined by urease activity, hematoxylin-eosin staining, and immunochemical staining. Histologic remnant gastritis was graded based on the degree of neutrophil infiltration using the updated Sydney System. COX-2 expression was estimated immunohistochemically. RESULTS: Both the degree of neutrophil infiltration and the level of COX-2 expression were significantly higher in patients with than without H. pylori (p<0.05). There was a significant correlation between the degree of neutrophil infiltration and the degree of COX-2 expression (p<0.001). CONCLUSIONS: H. pylori eradication may become a treatment for preventing both remnant gastritis as well as remnant gastric carcinoma after distal gastrectomy.

Duodenogastric reflux eradicates Helicobacter pylori after distal gastrectomy.

BACKGROUND/AIMS: Patients who undergo distal gastrectomy often develop duodenogastric reflux and preoperative H. pylori infection is eradicated spontaneously after distal gastrectomy in some patients. However, whether a causal relationship exists has not yet been studied. This report examines the correlation between H. pylori eradication and the amount of duodenogastric reflux following distal gastrectomy. METHODOLOGY: Among 72 consecutive patients who underwent curative distal gastrectomy with radical lymphadenectomy for gastric cancer, 37 patients had H. pylori infection preoperatively and were included in this study. The period of bile reflux (percent time) into the gastric remnant was measured with the Bilitec 2000 under standardized conditions on the 14th day after the surgery. Endoscopic examination was performed to determine the presence of H. pylori infection on week 12 after surgery. RESULTS: The percent time was higher in patients whose H. pylori infection had been eradicated after distal gastrectomy (58.1+/-9.2%) than in patients who had H. pylori infection after distal gastrectomy (33.8+/-5.7%). CONCLUSIONS: Duodenogastric reflux correlates with spontaneous eradication of H. pylori infection following distal gastrectomy.

Previous or occult hepatitis B virus infection in hepatitis B surface antigen-negative and anti-hepatitis C-negative patients with hepatocellular carcinoma.

PURPOSE: We investigated the clinical and virologic findings in hepatitis B surface antigen (HBsAg)-negative and anti-hepatitis C virus antibody (anti-HCV)-negative patients with hepatocellular carcinoma (HCC) to investigate the role of previous or occult hepatitis B virus (HBV) infections in the development of HCC. METHODS: We examined sera and HCC samples from 40 HBsAg-negative and anti-HCV-negative patients. Sera were tested for some viral markers, and genomic DNA was extracted from the HCC samples. HBx RNA was also extracted from the HCC and amplified by a polymerase chain reaction with reverse transcription (RT-PCR). RESULTS: Hepatocellular carcinomas from five patients with anti-HBc (group 1, 25 patients) and nine patients without anti-HBc (group 2, 15 patients) were examined for HBx RNA. HBx RNA was detected in four of the five HCC samples from group 1 and in four of the nine HCC samples from group 2. CONCLUSION: These findings suggested that previous or occult hepatitis B virus infection is common in HBsAg-negative and anti-HCV-negative patients with HCC.

Clinicopathologic characteristics of small intrahepatic cholangiocarcinomas of mass-forming type.

We investigated the clinicopathologic characteristics of and outcome after treatment for small intrahepatic cholangiocarcinomas of mass-forming type (3cm or smaller) in nine patients to study appropriate treatment. In seven of the nine patients, the cancer was detected during follow-up for hepatitis C virus-related disease. One patient was seropositive for anti-hepatitis B core antibody alone. One patient had alcoholic cirrhosis. Three patients also had hepatocellular carcinoma. Seven patients underwent liver resection and two other patients underwent microwave coagulation therapy. In the resection specimens, no vascular or lymphatic invasion, or invasion of perineural spaces, was evident pathologically. No patient had intrahepatic metastasis or lymph node metastasis; all had hepatic fibrosis. Lung metastases developed after surgery in one patient whose surgical margin was positive for cancer. In one patient with both type of carcinoma, the hepatocellular carcinoma recurred. Screening for not only hepatocellular carcinoma but also intrahepatic cholangiocarcinoma is necessary in patients with hepatic fibrosis, especially those infected with hepatitis C virus. For small intrahepatic cholangiocarcinomas of mass-forming type located peripherally in the liver, partial resection or ablation therapy with care to obtain a negative surgical margin may be appropriate.

Limitation of portal vein embolization for extension of hepatectomy indication in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: Although percutaneous trans-hepatic portal vein embolization (PTPE) expands the candidate pool for hepatectomy in patients with hepatobiliary malignancies, the role of PTPE in patients with active hepatitis or cirrhosis has yet to be determined. METHODOLOGY: Records of patients who underwent PTPE of the right portal vein between 1984 and April 2001 were reviewed retrospectively. To determine the indication for PTPE and subsequent hepatectomy, clinical variables, including serum concentrations of hyaluronic acid (HA), procollagen type III peptide (P-III-P), and the 7S domain of type IV collagen (7S-IV), were compared between patients who underwent right hepatectomy (group A; n=44) and the other patients (group B; n=17). RESULTS: The scores for prediction of postoperative liver failure (prediction score) and serum HA and P-III-P concentrations were different in the two groups. Thirteen of 30 patients (43%) whose prediction score was more than 50, the limit of the hepatectomy without PTPE, successfully underwent right hepatectomy following PTPE. The resectability ratios increased to 75% and 100%, when the HA concentration was < or = 100mg/L and the P-III-P concentration < or = 0.7/mL. CONCLUSIONS: Serum HA and P-III-P concentrations are useful guidelines for identifying candidates for right hepatectomy following PTPE.

CD44 and VEGF expression in extrahepatic metastasis of human hepatocellular carcinoma.

BACKGROUND/AIMS: We investigated the correlation between vascular endothelial growth factor (VEGF) and CD44 expression in hepatocellular carcinoma (HCC) and the frequency of extrahepatic metastasis, in order to evaluate the influence of vascular growth and adhesion molecules in facilitation of distant metastasis. METHODOLOGY: We obtained materials from primary lesions of HCC with no extrahepatic metastasis (control group) and primary lesions and metastatic lesions with extrahepatic metastasis (metastasis group). Immunohistochemical staining was performed using anti-human CD44v3 monoclonal antibodies and anti-human VEGF ab-3 monoclonal antibodies. Although pathological parameters such as tumor size, differentiation, capsule formation, and vascular invasion were analyzed, there was no marked difference among the groups. RESULTS: Percentages of nodules with VEGF-positive tumor and sinusoidal cells were low in primary lesions of the control and metastasis groups, while high in metastatic lesions in the metastasis group. On the other hand, percentages of nodules with CD44-positive tumor and sinusoidal cells were low in primary lesions of the control group, while high in primary lesions and metastatic lesions of the metastasis group. CONCLUSIONS: The present study demonstrated that CD44 expression in primary lesions is related to a higher frequency of extrahepatic metastasis, suggesting that this is a clinicopathologically useful parameter in predicting the occurrence of distant metastasis.

A clinicopathological study of inflammatory pseudotumors of the liver with special reference to vessels.

BACKGROUND/AIMS: Inflammatory pseudotumor of the liver is rare, and patients with inflammatory pseudotumor frequently undergo unnecessary surgical resection as a result of misdiagnosis of malignancy. In this study, we therefore investigated inflammatory pseudotumor clinicopathologically to clarify its characteristics. METHODOLOGY: Twenty patients including 3 with inflammatory pseudotumor and 17 with various malignant liver tumors were studied. We further investigated tumor vessels by means of immunohistochemistry using monoclonal antibodies against CD34, factor VIII-related antigen and alpha-smooth muscle actin. RESULTS: Although serum levels of alkaline phosphatase were significantly higher in inflammatory pseudotumor patients than in other patients, the laboratory data alone could not precisely distinguish inflammatory pseudotumor from other hepatic tumors. On imaging studies such as ultrasonography and computed tomography, significant changes in tumor size, especially size reduction, during relatively short follow-up periods were often observed in inflammatory pseudotumor but not in other liver tumors. An enhancement of the peripheral regions of inflammatory pseudotumor was frequently observed in the early phase of contrast-medium dynamic computed tomography. This might be due to abnormal vessels located in the peripheral regions of inflammatory pseudotumor which might result from obliteration of some pre-existing vessels in portal tracts within inflammatory pseudotumor. Immunohistochemical analysis further revealed that abnormal vessels in the peripheral regions of inflammatory pseudotumor were positively stained with CD34, factor VIII-related antigen and alpha-smooth muscle actin as were tumor sinusoids within hepatocellular carcinoma and tumor capillaries in other malignant liver tumors. CONCLUSIONS: Although inflammatory pseudotumor seems to have some features in imaging studies, a biopsy is needed for a correct diagnosis of inflammatory pseudotumor.

Correlation between duodenogastric reflux and remnant gastritis after distal gastrectomy.

BACKGROUND/AIMS: Many patients who undergo distal gastrectomy develop remnant gastritis. This report describes the correlation between remnant gastritis and the amount of duodenogastric reflux and looks at the relationship between Helicobacter pylori infection and duodenogastric reflux in remnant gastritis. METHODOLOGY: Sixty-two patients who underwent curative distal gastrectomy for gastric cancer with radical lymphadenectomy were studied. The period of bile reflux (percent time) into the gastric remnant was measured with the Bilitec 2000 under standardized conditions. Remnant gastritis was semi-quantified using the neutrophil infiltration score based on the updated Sydney System, and the presence of H. pylori infection was determined 12 weeks after the surgery. RESULTS: Overall, the correlation was not significant between the neutrophil infiltration score and the percent time (p=0.08). Similarly, the correlation was not significant in patients with H. pylori infection (p=0.30), but it was significant in patients without H. pylori infection (p=0.03). CONCLUSIONS: Duodenogastric reflux after distal gastrectomy can cause remnant gastritis in patients without H. pylori infection. Reconstruction with biliary diversion is protective against the development of remnant gastritis.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2002 and March 2003].

Tendency of isolated bacteria from infections in general surgery during the period from April 2002 to March 2003 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 334 strains were isolated from 131 (75.3%) of 174 patients with surgical infections. One hundred and seventy-one strains were isolated from primary infections, and 163 strains were isolated from post-operative infections. From primary infections, anaerobic Gram-positive bacteria were predominant, while aerobic Gram-positive bacteria were predominant from postoperative infections. Among aerobic Gram-positive bacteria, although the isolation rate of Staphylococcus aureus was the highest, followed by that of Enterococcus faecalis from primary infections, the isolation rate of E. faecalis was the highest from postoperative infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa in this order, and from postoperative infections, E. coli was the most predominantly isolated, followed by P. aeruginosa, Enterobacter cloacae, and Citobacter freundii. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both types of infections. The isolation rate of aerobic Gram-negative bacteria from primary infections and that of aerobic Gram-positive bacteria from postoperative infections were high in the last several years. We noticed no vancomycin-resistant Gram-positive cocci nor P. aeruginosa producing metallo-beta-lactamase. But we noticed cefazolin-resistant E. coli probably producing extended spectrum beta-lactamase.

Self-expanding metallic stent for benign biliary strictures: seven-year follow-up.

We report two cases of benign biliary strictures managed by metallic stent placement because the patients refused surgical repair. One patient is a 67-year-old man who had a stricture of the right hepatic duct and a bile leak following a cholecystectomy. The second patient is a 50-year-old man who had a stricture of the left hepatic duct following a right hepatic lobectomy for hepatolithiasis. For treatment of these bile duct strictures, a Gianturco-Rosch Z stent was placed in the former case and a Wallstent in the latter. Luminal patency of the stent was maintained for 7 years in the former case but in the latter, luminal stenosis of the stent was induced soon after placement. However, in the former, bile stasis in the left hepatic duct system, which emptied into the side of the stent, gradually developed without signs or symptoms of cholangitis or biliary obstruction. Therefore, the use of metallic stents for benign biliary stricture remains controversial. However, if metallic stent placement is the only therapeutic option, it is necessary to maintain bile flow not only through the stent but also in the bile ducts which flow into the side of the stent.