1. The distensibility of the gastric wall was evaluated from both sides, serosa and mucosa, using a intragastric pressure stabilizer. Greater curvature of the f ornix, anterior wall of the upper body and greater curvature of the prepyloric region showed the higher distensibility than other parts, and there-fore named as "endoscopic over-distended areas." Distention of these areas results in the exaggeration of atrophic changes endoscopically which is confirmed by the comparison of endoscopic view and histological findings. A parts of them is well known as "liver area." 2. The correlation between intragastric pressure and the mucosal features of the upper part of the stomach was investigated by the use of controlled gastric insufflation. In 20 cases of almost normal and / or slight atrophic gastritis as histologically diagnosed, at minimal pressures, the gastiric rugae were tortuous, and the anterior and posterior wall at the gastric cardia started undergoing distention. On raising the pressure, the fornix became gradually more distended, and the esophagogastric junction (EGJ) began to dilate at pressure of 11mmHg. The branching of blood vessels was more obvious at 13 mmHg, and the liver area as described by Palmer took on a green appearance at 15mmHg. At maximal pressres, 21mmHg, the distention of the upper part of the stomach became complete and EGJ underwent maximal opening. Then, the opening of EGJ will be 22mmHg in diameter, and the junction can be clearly identified. From these dynamic observation, mucosal changes of the upper part of the stomach and the function of the cardia can be easily diagnosed by the difference from these normal findings. 3. The diagnostic evaluation of the gastric mucosa, especially in cases of atrophic gastritis, giant rugae and intestinal metaplasia of the stomach, should be done in relation to the distention of the gastric wall by air insufflation. A pressure stabilizer was designed to control intragastric pressure and was connected to a gastroscope. This is a portable, and compact unit with a pressure gauge with controls reom 5 to 30 cmH 20. The results showed the accuracy of coorresponding intragastric pressures indicated by the stabilizer. The resistance of the insufflation channel on the FGS-BL was negligible. Clinical application was simple and this was useful in the diagnosis of atrophic gastritis and giant rugae. 4. The mucosa of the upper part of the stomach was investigated from the part of acid producing f untion. For that purpose, the patterns of gastric acid production was observed endoscopically by the discoloring reaction of congored and biopsy. For the sake of convenience, we have taken the liberty of calling the cardiac staining pattern which is similar to that of the pylorus "the cardiac border." The cardiac border can be classified into 4 types (I-IV), that is, type 1: Those restricted to EGJ with an irregular shaped red zone surrounded by the black colored zone. Type II: Those extending further into the upper body and fornix than type I. Type III: This case shows an increased spreading of the red zone surroundings of the EGJ. Type IV: Those showing an extensive spreading of the red red zone to include the greater curvature of the fornix. Therefore, the black colored zone is either restricted to the greater curvature of the body or not observed. And they were closely related with pyloric atrophic patterns. Histologically, the black colored zone was composed of fundic glands and normal gastric mucosa, and the red zone was composed of both cardiac and f undic glands. Fundic glands in the red zone showed a decrease in glandular activity or severe atrophic and inflammatory changes. We must take care of the fact that this cardiac border does not means the boundary of the fundic glands and cardiac glands. This theref oro have to be regard as the border between atrophic and non-atrophic zone within the f undic gland in the upper part of the stomach. 5. 59 cases diagnosed as esophage

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On the basis of studies on some 6000 cases of gastric ulcers biopsied in our clinic for past five years incidence of the ulcer, rate of recurrence and its direction (means which site in the neighborhood of initial ulcers is involved in recurrence) were revealed as follows. In attempt to give histological evidences to the endoscopic findings degree of decrease in diameter of the blood vessels and extent of submucosal fibrotic hyperplasia were measured under microscope. Incidence of the ulcer in general, observed by region was high dominantly in the corpus while multiple ulcers were seen more frequently in the antrum than solitary ulcers. Rate of recurrence, studied by region, was highest in the antrum characteristically among young patients. Studies on direction of recurrence in 285 cases revealed that 95% of antral ulcers recurred in the oral side of initial ulcers and 42% of ulcers seen in the angle and lower portion of the corpus showed the same atitude as the above, while of recurrent ulcers 42% appeared in anal side and 28% in oral side of the initial ulcer. In second recurrence the majority of ulcers occured in the same site as the previous ones. This tendency was especially marked in recurrent ulcers which appeared within 6 months. Microscopic measurement of extent of submucosal fibrotic hyperplasia revealed that ulcers site in the corpus were acompanied with the more intensive fibrotic hyperplasia in the oral side than in the anal one. This was especially marked in initial ulcers. In the neighborhood of initial ulcers decrease in diameter of the vessels was more marked in the oral side of ulcers of the antrum, angle and the lower portion of the corpus while more marked in the anal side of ulcers of the middle and upper corpus. In the neighborhood of recurrent ulcers, there were seen no significant difference by region. It is probable from the above-described results that disturbance of blood stream caused by decrease in size of vessels and submucosal fibrotic hyperplasia on regulative factors on recurrence of ulcer and its direction in addition to other unknown mechanisms.

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We performed the endoscopic cholangiography in 57 cases with benign biliary tract diseases and obtained results as follows: 1) Cannulation was performed successfully in 42 cases (74%) out of 57. In 29 cases (70%) out of 42, the common bile ducts were revealed. Among these 29 cases, the cystic were ducts detected in 21 cases (72%). In the 13 cases, only the pancreatograms were obtained. 2) The cystic duct formations were diveded into three types-TypeI(62%) with an acute angle formation, Type II(19%) with a parallel formation and Type III (19%) with a spiral formation. 3) In 11 cases with pre-and post-operative endoscopic cholangiogram, cystic duct remnants were detected in 43% of Type I, 100% of Type II and 50% Type III. 4) In 6 cases with cystic duct remnants, 2 cases in 3 of Type I complained of upper abdominal pain and the other one did diarrhea. 2 cases each of Type II complained of upper abdominal pain and diarrhea. One case of Type III complained of upper abdominal pain, constipation and anorexia. These 6 cases complained of some complaints. Otherwise in 5 cases with no cystic duct remnant, 3 cases complained of nothing.

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Having had an opportunity of using Olympus Kogaku's GIF-D, we used it in the endoscopic examination of 410 clinical cases during a 10-month period and obtained the following valuable information. The endoscope, with its advantage of being of direct vision type, permits inspection of the esophagus, stomach and duodenal bulb simultaneously. It can be introduced into the esophagus with safety even in the presence of a high degree of curvature of the vertebral column. With this instrument, it is possible to obtain an adequate frontal vision of the gastric angle by strong angle manipulation although there is some difficulty in examining the pyloric antrum at its lesser curvature side and the posterior walls of the angle and body. Because of an excellent closing effect it proves to be of great use in the examination of the pylorus and its neighboring areas and is also turned round with ease. It can be used particularly efficiently in the inspection of the greater curvature at bulbar level and bulbar phthisis, both of which are usually difficult to observe with endoscopes of lateral vision or right angle type. Permitting a very close observation, it proves to be efficient for the observation of such minute structures as villi and minor projections and recesses. The interior of the upper portion of jejunum in cases with partially resected stomach (Billroth II) may also be viewed with this instrument. As an interesting case an ascaris discovered in and eliminated from the intestine during endoscopy was displayed. With this endoscope, pancreato-cholan-giography was performed successfully in 13 (86.7%) of 15 cases with partially resected stomach (Billroth II). Lastly, it exerted its characteristic power as a panview fiberscope in emergency endoscopy.

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We carried out peritoneoscopic examination in 770 patients and performed direct cholecystography and transhepatic cholangiography in 100 out of these patients who were suspected of diseases of biliary tract. Direct cholecystogaphy was utilized a Kiyonaga's instrument for gallbladder puncture and sucked juice in gallbladder as large quantity as possible, then 30% Biligrafin solution (20% in cases suspected stones) was injected approximately same of absorbed juice. Transhepatic cholangiography was injected 40-60 ml of the same contrast media through a needle (external diameter 0.8 mm) introduced into the intrahepatic bile duct under peritoneoscopic control. Direct cholecystography was successfully perf ormd in 69 of 96 cases. In 30 cases with the contracted or lumped gallbladder, puncturing was so difficult that direct cholecystography was successful in only 14 cases. Transhepatic cholangiography was successful in 20 of 24 cases in which the intrahepatic bile ducts were dilated and in 2 of 6 in which the ducts were not dilated. Recently using of a fine polyethylene catheter (internal diameter 1.5mm) for sucction of intrahepatic bile juice is bringing about a good result. Unsuccessful contrast filling of bile ducts by direct cholecystography was obsered in 6 cases. Five cases were stones of the gallbladder and one case was carcinoma of the common bile duct. In one case with stone of the neck of gallbladder, swelling of the duodenal papilla caused jaundice was observed by transhepatic cholangiography. In these cases the cause of obstructive jaundice was unknown on direct cholecystogram, so adoption of transhepatic cholangiography at the same time was important. Thirty cases with extrahepatic obstructive jaundice were investigated the distal end of common bile duct on cholangiograms. The types of obstructive end were as follows : carcinoma of the pancreas head, mainly U-shaped type; choledocholithiasis, round translucent or contrary U-shaped type and carcinoma of the duodenal papilla, contrary U-shaped type in all cases. Impacted stone at ampulla was differentiated from carcinoma of the duodenal papilla in demonstration of a figure like to eagle nail. For prevention of bile leakage 4 ml of oily tetracyclin was injected into the wall of gallbladder on direct cholecystography and stop a needle below the hepatic capsule a few minutes on transhepatic cholangiography. Bile peritonitis as a result of bile leakage was observed in one case. Serious bleeding into the peritoneal cavity was not observed.

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Percutaneous transhepatic cholangiography is an important diagnostic method for the differential diagnosis of the obstructive jaundice. This technique can be applied to percutaneous transhepatic cholangiodrainage (PTC-D), which decreases jaundice safely and successfuly. We have performed PTC-D in 62 cases with severe obstructive jaundice and the results were satisfactory. Recently, we have experienced percutaneous transhepatic cholangioscopy and cholangiobiopsy through the draining tube for the purpose of the new approach to accurate diagnosis for the biliary diseases. We used Machida's fiberbronchoscope (FBS 2.5) and Olimpus' kidney'fiberscope (K. F.). These were 2.5mm in diameter and have an angledeflector, but without washing and suction devices and biopsy channel. Using these small caliber fiberscopes, we could performed percutaneous transhepatic cholangioscopy through the draining tube in 8 cases with severe obstructive jaundice. Of these 8 cases, we could observe tumorous changes in 4 cases, but the other 4 cases we could not gain clear observation. As these fiberscope have no forceps-channel, after cholangioscopy we have introduced forceps through the draining tube under fluoroscopic control. In this way, we have performed percutaneous cholangiobio psy in 7 cases, among which we have got the tumors tissues in 2 cases. As complications, we have experienced slight bleeding from the bile duct in some cases, but no severe ones such as intraabdominal bleeding or bile peritonitis. We also discussed percutaneous transhepatic cholangioscopy and cholangiobiopsy, which were made possible during the application of PTC-D. More accurate diagnosis could be accomplished if these techniques would be applied. Improvement of the fiberscope itself would be also beneficial.

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The flexible esophagofiberscope has been developed which made the esophagoscopy easier and lessened the distress of the patient. The esophagoscope was sufficient for the diagnostic procedures at the points that it had no blind area in observation of the esophagus, the small lesion 2-3 mm in size could be diagnosed definitely and the aiming biopsy was modified more exactly. A small and soft foreign body could be removed with the fiberscope by sucking it to the top of the scope. In this report, for removing the hard and large foreign bodies, the special forceps which was designed to be applied to the esophagoscope was reported with special reference to its instrumentation and to our clinical experiences. The forceps consisted of a spiral-shaped outer wire tube of 2.2 mm in diameter through which the inner forceps was introduced, the tip of which would open because of its elasticity when it came out. The full opening distance of the tip was 1.5 cm. The forceps was introduced into the esophagus and stomach through the biopsy canal of the fiberscope. The grasping power of the forceps was strong enough to hold a weight of one kilogram. The number of foreign bodies removed with the esophagofiberscope was 57, among which the food mass was mostly frequent. The others included the false teeth, the PTP drug wrapping, coins, a coin-like plastic plate, toys, a spoon, seeds of pickled apricots, and so on. The superiorities of the esophagofiberscopic manipulations could be listed as follows:(1) the esophagofiberscope could dilate the esophageal lumen and could magnify the object for detailed examination, thus removing the foreign body in better conditions, (2) such as object as floating in the lumen could be removed without any difficulty, (3) the foreign body in the stomach could also be removed with the same technique.

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