During the past nine years, from Feb. 1965 to the end of 1973, gastroscopy with various endoscopes such as FGS-A, GT-V, GT-Va, FGS-B, FGS-S, FES-L, FGS-CL, FGS-BL, FGS-SL, FDS, PFS, JFB, was used more than 9200 times upon the patients with epigastric distress in Taipei Municipal Jen-Ai Hopital. The results of the examinations show early gastrie cancer in 19 cases (25 cancer nests), advanced gast-ric cancer 281 cases, gastric ulcer 1047 cases, gastric polyps 60 cases and others. The ratio of advanced gastric cancer to early gastric cancer was 14: 1. However in the year of 1973, the number of detect-ed and operated early gastric cancer cases increased up to the ratio 11: 1. Among these 19 cases, 25 cancer nests early gast-ric cancers, 16 lesions belonged to minute early gas-tric cancer if defined a size less than 2 cm in dia-meter, and 12 out of 16 minute cancers being less than 1 cm. Seven cases out of 19 were single or solitary lesions of depressed type, and most of them were rather easily diagnosed having characteristic feature of superficial depressed IIC nature. But be-fore making diagnosis of early gastric cancer IIC, one must carefully differentiate from "Reactive Lym-phoreticular Hyperplasia" of the stomach by the aid of endoscopic biopsy. In addition, in case of antral polyposis (Type III of Nakamura) one must care-fully consider the possibility of multicentric early gastric cancer of IIa type.

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Palmer (1964) reported the esophageal marking by silver brain clip. The rigid esophagoscope was adequate for the manipulation of these clips because of its wide lumen. The biopsy canal of the esopha-gofiberscope was small about 3 mm in size, so the use of the big forceps was impossible. The special injector through the biopsy canal of the esophago-fiberscope was devised. The radiopaqne substances, such as tantalum tips, were injected into the sub-mucosal layer of the esophagus. The injector was 2.5 mm in size and the tantalum tip packed into the needle was pushed out by the mandolin of the needle. The clinical application of the esophageal marking was the diagnostic co-working with the radiology and the decision of the irradiations field in the cobalt therapy.

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We gastroscopically observed 139 cases of hemorr-hagic erosions of the stomach in the last four years. We classified endoscopically the hemorrhagic ero-sions into four types ; variolif orm 9 cases (6.4%), punctiform 87 cases (62.6%), linear 16 cases (11.6 %), and irregular-shaped 27 cases (19.4%) . Their frequency rate, localization, clinical symptoms, occa-sion, and characteristic gastroscopic findings were dis-cussed.(1) There was no age preference among varioli-f orm, punctif orm, and linear types, but some pre-ference of the wide-spread irregular one to the second decade was seen.(2) Epigastric pain, nausea, vomitting, and anore-xia were common subjective symptoms of hemor-rhagic erosion. Frequency of severer subjective complaints was especially higher in the irregular-shaped. Hematemesis and/or melena occurred in 30 cases (20.6%) .(3) Hemorrhagic erosion was most frequently ob-served at the antrum.(4) Alcohol, acetylates, and stress were thought to be the common occasions of the hemorrhagic ero-sion.(5) The gastroendoscopic examination of the wide-spread irregular-shaped hemorrhagic erosion re-vealed very edematous uneven mucosa covered with many irregular blood clots, whitish exudate, and diffuse mucosal hemorrhage and showed narrowing of the antrum. So, it is necessary for the irregular-shaped one to be diff erenciated from an advanced cancer.(6) The wide-spread irregular-shaped was seen to heal endoscopically within 10 days except for 10 cases which progressed to antral acute symmetri-cal ulcers.

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There seem to be some confusions concerning the criteria for endoscopic diagnosis of gastritis in postoperative stomach. Some authors claim that reddening of the stoma suggests the presence of acute inflammation, and discrepancy between endoscopic diagnosis of atrophic gastritis and histological findings is claimed in some reports, which mostly employed blind suction biopsy for histological assessment. For the study of the gastric remnant with poorly distensible areas and a narrow lumen, a prudent choice of areas for assessment and an accurate locational correspondence between endoscopic and histological findings are indispensable. To solve those diagnostic problems, a correlative study was undertaken between endoscopic and direct vision biopsy findings. The materials consist of 81 subjects, in total, who underwent partial gastrectomy ; the operative procedures are Billroth I in 34 and Billroth II in 47 cases. The gastrocamera with fibrescope GTF was used to visualise and photograph the lumen of gastric remnant. The gastrofibrescope for biopsy GFB was then used to obtain tissue specimens under direct vision from 1) the stoma itself, 2) anterior wall of mid-segment of gastric remnant and 3) anterior wall in the vicinity of the stoma. Three or more specimens, within 1 to 2 cros apart from one another, were taken from each area. Endoscopic evaluation was made on reddening of the stoma, as well as on the degree of atrophy in the anterior wall of the mid-segment of gastric remnant and in the anterior wall near the stoma. Using the same criteria as in the non-operative stomach based on visible vessels and mucosal discolouration, the degree of atrophy was graded as (-) for normal mucosa, (+) for mild and (++) for marked atrophic gastritis. With the biopsy specimens from the stoma, atrophy, polymorphonuclear leukocyte infiltration and capillary dilatation were evaluated. As for the other areas, the histological findings of atrophy were studied. The histological degree of atrophy was judged from multiple specimens obtained from the same area and graded as atrophy (-) for normal mucosa, atrophy (+) for mild decrease in gastric glands and atrophy (+) in the case of glands less . than half of normal amount including complete disappearance. Inflammation of the Stoma : Reddening was compared with the infiltration of polymorphonuclear leukocytes, which revealed no significant relation between the two. A correlation between reddening and capillary dilatation was then tested. Capillary dilatation was more frequent in reddening cases (28/43) than in those without reddening (6/15), but this was not statistically significant. The stomal reddening, therefore, is not suggestive of acute gastritis, but may reflect an artificially induced local circulatory disturbance, when compared with our experiences that the reddening becomes prominent with air insufflation at the time of endoscopy, and, in particular, following repeated vomiting. Endoscopic Diagnosis of Atrophy and Histology : Comparison was made between endoscopic and histological assessments of atrophy in the anterior wall of midsegment of gastric remnant, to find a highly significant correlation between them (p<0.005) . Similarly, endoscopic assessment of atrophy was compared with the histological findings in the anterior wall near the stoma and a statistically significant correlation (p<0.025) was found. However, 10 of 19 endoscopically normal cases had mild degree of atrophy histologically, and 17 of 30 endoscopically mild cases had histologically marked atrophy, thus our endoscopic criteria of atrophic gastritis, as far as the vicinity of the stoma is concerned, seemed to have a less sensitivity than required. Furthermore, the biopsy specimens from the stoma almost always revealed marked atrophy, but its endoscopic diagnosis was difficult ; it may correspond to mucosal granularity occasionally seen in a close-up view of the stoma. The present study confirmed the validity of endo-sc

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The dyeing of the duodenal mucosa with methylene blue solution was performed during duodenoscopy for evaluation of the duodenal lesions. The instrument used was GIF-D (Olympus). 10 ml of 0.5% methylene blue solution was sprinkled on the duodenal mucosa through the duodenoscope under visual control: Several minutes later, washing with 40 ml of water was carried out and then the fluid in the duodenum was aspirated. The duodenoscopically normal mucosa was stained well into dark' blue when methylene blue was introduced. A finger, leaf or ridge shaped villi were recognized remarkably on dvein in this area. The dyeing was less effective in the circumference of duodenal ulcer or at the erosive changes, island of gastric mucosa, small elevation due to hyperplasia of the lymph follicle and white colored villi. This phenomenon made it easier to recognize the range of erosive changes and to find the small lesions like gastric mucosal island. Biopsy was then undertaken, and the specimens were observed under the dissecting microsiope before fixation and were made into cryostat preparations. This examination revealed that methylene blue was taken into the cytoplasm of epithelial cells.Dissecting microsopic observation with hematoxylin staining of biopsy specimens and histological examination showed abnormalities in the areas of the uptake diminution. The mucosal villi around the duodenal ulcer were observed to be low in hight and were changed into a bunch, doughnut or gyrus form. Histological examination revealed these.deformed villi to be regenerated epithelium. Low villi were also observed in the cases of erosive changes. The surface of gastric mucosal island showed the sulcioral or f oveoral pattern and became red by PAS staining. In the case of white colored villi, histological examination showed the leaf shaped epithelium, swollen lamina propria and hyperplasia of glandular crypts. The epithelial cells over the hyperplastic lymph follicle were swollen. In conclusion, fiberduodenoscopy with introduction of methylene blue makes it easier to recognize the regenerated mucosal area around duodenal ulcer, the range of the erosive changes and the small lesions like gastric mucosal island. Dissecting microscopic observation of biopsy specimens teaches us not only accuracy or inaccuracy of biopsy but also gives much information about the shapes ;of villi at j normal and abnormal mucosa.

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Two cases of choledochoduodenal fistulas were reported, and findings of duodenofiberscopic obser-vations were described. In case 1 the fistula was atributed to common duct calculi, and duodenofiber-scopy revealed a markedly swollen papilla of Vater with redness and edema, and a prominent, swollen longitudinal fold. The fistula was found on the lon-gitudinal fold of the papilla. In case 2 upper gastro-intestinal series showed air and barium reflux into the biliary tract. Duodenofiberscopy revealed a fistula on the outside of the longitudinal fold of the papilla. In both cases contrast medium was injected through the fistula, and retrograde cholangiogram was obtained. There are few reports on the endoscopic obser-vation of internal biliary fistula. Duodenofiberscopic examinatoin should be made in cases in which air or gas shadows within the biliary tract on the radio-gram of the abdomen or barium reflux into the bile duct on upper gastrintestinal series were found.

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A 38 year old female was admitted to this hos-pital with the complaint of discomfort of upper abdomen lasting for one and a half year. She was found a semicubic tumor, which was covered with normal gastric mucosa, at the posterior wall of antrum of the stomach by the radiologic as well as endocopic examination. Bridging folds of mucosa were also seen. These findings indicated submucosal tumor of the stomach. Gastrectomy was performed immediately.The removed stomach revealed a tumor locating in submucosa and the tumor was semicubic in shape measuring 3.5×3.0×1.2 cm in size. The consistency of the tumor was elastic soft. Histologically the tu-mor showed sheetlike arrangement of glomus cells intermingled with vascular channels. In the literature 17 cases of glomus tumor origi-nated from the stomach have been reported in Ja-pan. Their age ranged from 28 to 74 years old. Their sexes were distributed about equally. The most of the patients complained some kinds of gas-tric distress, such as epigastric pain, discomfort, nausea and vomiting. These tumors varied from 0.8 to 7.0 (mostly 1.0 to 4.0) cm in greatest diameter (localized in submucosa of the antrum) and their consistency was usually elastic soft. Ulcer of the mucosa overlying the tumor was noted in only one case recorded in the literature.

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This is a case report of adenoma of Brunner's glands in the duodenal bulb. A 71-year-old female was admitted to my hospital with chief complaints of melena and severe anemia for a few months. Upper gastrointestinal X-ray series showed a ro-und shaped, irregular surface, filling defect in the duodenal bulb. This was believed to be a polyp. Hypotonic duodenography revealed a pedunculated polyp like lesion in the posterior wall of the duode-nal bulb. A round but well lobulated, protruding lesion with pedicule was seen by Duodenoscopy in the duodenal bulb. Erosion was noticed over the surface of this lesion. At operation, a pedunculated tumor, 4.0×4.0×3.5 cm in size, was found in the posterior wall of the duodenum immediately distal to the pylorus. The tumor was resected by Billroth-I method. Histologically it was diagnosed to be adenoma of Brunner's glands. Endoscopic examination is very useful for the dia-gnosis of duodenal tumor, however, special attension must be given in case's involving submucosal type of benign duodenal tumor.

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