Several problems on gastric mass survey combined with gastrocamera and photofluorography were discussed, and the usefulness of applying U-turn techniqne during gastrocamera examinations was studied.1. Gastric mass survey was proceeded among 1, 175 individuals who were over 40 years of age. U-turn technique was applied in 545 cases during the gastrocamera examinations with type PF or PA 2 gastrocamera.The results were compared with that of non U-turn group.2. The results of this survey were as follows : gastric carcinoma 6 (0.5%) including 2 cases of early gastric carcinoma, gastric polyp 15 (1.3%), open gastric ulcer 40 (3.4%), healed gastric ulcer 95 (8.1%) and duodenal ulcer 73 (6.2%) .3. Five cases of upper gastic lesion were found. They consisted of a case of type I early gastric carcinoma, two cases of gastric ulcer and a case of gastric pol-yp. The useuf ulness of U-turn technigue was recogni-Zed, because all of them were detected by this tech-nique.4. U-turn technique should be applied during the gastrocamera examinations since it can be done easily and requires little time.5. There was no difference in the usefulness of gastrocamera between type PF and PA 2. However, attension should be focused on taking the photograph of greater curvature portion of the stomach.6. Photof luorography in gastric mass survey with gastsrocamera can be limited to the two positions, namely, upright frontal and upright first oblique position with the stomach filled with barium when gastrocamera examination is combined.

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The purpose of this paper is to describe endoscopy of the upper gastrointestinal truct in geriatric patients. We had fifty five endoscopic examinations in fifty one persons from Oct. 1972 to Oct. 1973 at the Tokyo Metropolitan Geriatric Hospital (YOUIKUIN). Of fifty one patients, sixteen were associated with neuropsychiatric disease, nine with muscloskeletal, five with cardiovascular, and twenty one with miscellanaeous. All of them were well tolerated for endoscopic approaches, and any complications hod not occured. Indications for endoscopy included; (1) clinically suspected ulcerative or maligmant lesions of the upper part, (2) radiologically suspected gastric cancer, (3) active upper gastrointestinal haemorrhage, (4) obstructing disease of the esophagus and stomach, and gastric remnant following gastrectomy. In order to examine the aged more safely and more easily, and to make them tolerate better for it, we had the examinations in their bed side using thinner fiberoptic instruments. In twenty three patients with active upper gastrointestinal haemorrhage, vigorous endoscopic approaches were performed, and in result, one haemorrhagic esophagitis, nine bleeding erosive gastritis, twelve gastric ulcer, two duodenal ulcer, one gastric cancer and one miscellanaeous lesion. In nineteen patients with mental or motor disturbance endoscopic examinations were done before barium meal, since radiographic procedure had been disappointed as a technic for accurate diagnosis in these patients. We made correct endoscopic diagnosis without any complications. This performance disclosed four erosive gastritis, two gastric ulcer, four polypoid lesion of the stomach, three gastric cancer, seven miscellanaeous lesion. In nine patients with radiologically suspected gastric cancer, endoscopic examination revealed three gastric cancer, two gastric polyp and four miscell a naeous lesion. Being used many kind of instruments, more thinner and more flexible tool was proved to be desirable for the aged. In this way the our premier instruments, long pediagastrof iberscope -S and Gastroduodenalfibe rscope-P were currently used. The lPGF-S was a side viewing f iberoptic instrument of 5.8mm in maximal diameter, and the GIF-P, end viewing of 7.2mm in it. Both of them were made by the Olympus Corporation and were good instruments for aged persons.

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For the experiment of artificial ulcer formation in stomach, dogs were used under anesthesis of Ketamine and various agents were injected to the dog's stomach via gastrofiberscope. Healing state of the artificial ulcer was followed-up endoscopically, then sacrificed to check the depth of ulcer. To summerize the characteristics of the artificial ulcer caused by submucosal injection of 95% ethanol, 1) immediate change in the mucosa, 2) easy to control the depth and size, 3) rapid repair, 4) easy and safely to handle for popular material. By using this technique of ulcer formation, obliteration of gastric protuberant lesion was attempted clinically. Obliteration of the lesion was comfirmed by gastrofiberscopy intruding biopsy and aspiration cytology. In some cases, histological examination of the resected stomach was done after operation. Treatment by submucosal injection of 95% ethanol was successfully performed in 51 of 54 cases. Successful cases were intruded not only hyperplastic polyps but also 16 cases of atypical epithelial hyperplasia and 2 cases of early gastric cancer type II a. Complete healing was seen within 6 weeks in every cases and no massive bleeding nor perforation was experienced. Since the technique of thermoelectrical polypectomy was introduced to gastrof iberscopy, excision biopsy is most desirable in narrow-based and pedunculated polyps, however for wide-based polypoid growths, the satisfactory results have not been reported yet. Our trials of polypectomy by using this technique is a kind of steps for management of a small early gastric cancer in poor risk patients. Recent follow-up study revealed the low incidence of malignant change from gastric polyp or atypical epithelial hyperplasia. However follow-up term is not long enough to deny their malignant changes, today. Long term follow-up examination like more than 10 years is not easy for both patients and doctors. Therefore in a patient who is difficult to followed-up for other complications and/or who feels uneasy about the gastric polypoid growth, treatment by submucosal injection of 95% ethanol is recommended. Additionally in a case, of elevated type of early gastric cancer less than 2 cm in diameters, of which depth involvement is confined within mucosal level, it is reasonable to obliterate the cancer nests by making Ul-II ulcer, if the patient is in poor risk for surgical operation.

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This report is concerned with studies on sixteen cases of a spontaneous choledochoduodenal fistula with an orifice at the major papilla which were preoperatively diagnosed ' by an endoscopic observation and retrograde pancreatocholangiography. Followings are the summaries.1) These fistulae were divided into three types. Type I has an orifice just proximal to the normal bile duct opening of the major papilla, whereas type B at the longitudinal fold and type III just proximal to the longitudinal fold. Endoscopic appearance of the orifice enabled us to divide these fistulae into two groups : freshly formed fistulae and old ones. The former were noted as soft granulation tissue with inflammatory reaction and no epithealial covering yet. The latter were noted as wide openings with epithelial covering and no inflammatory reaction Our data suggest that the former types heal to close or to form the latter type of openings in four to nine months. Ten of the sixteen cases showed the latter type of opening, suggesting of difficulty encountered by the fistulae to close.2) Incidence was high in female and in the population over fifth decade.3) Twelve of the sixteen cases had a history of gall stones over three years.4) Thirteen cases showed a triad of abdominal pain, jaundice and spiking fever. Thirteen cases showed a characteristic clinical episode to suggest a formation of the fistula. Time-lapse between the characteristic episode and an endoscopic examination was one month to fourteen years.5) Air or barium in the biliary tract was revealed in six cases on X-ray examination 6) It was emphasized that a cannule should be inserted with a strong bent upward through the fistula to obtain a satisfactory retrograde cholangiography.7) It was suggested that presenting symptoms were caused by ascending cholangitis in two cases, necessitating some surgical intervention to prevent such an ascending infection.8) No cases showed any deterioration in liver functin test during the follow-up periode ranging from one to twenty-four months.9) It was proposed that this type of fistula would not be so rare as to be estimated by a scarcity of re ported cases and that more cases would be f ould in future by a careful duodeno-fiberscopic examination. This type of fistula may be revealed in some of cases which were reported as insufficiency of sphincter of Oddi.

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The colonofiberscope in the present use has a nearly orthoptic optical system (10° optical axis deviation). Although the fiberscope with right grade deviation of the optical axis (90°) was first attempted as is the gastrofiberscope, it was unsuccessful because of its narrow visaual field and of the difficulty in its insertion to the proximal portion of the colon. Secondly, the fiberscope with orthoptic visual field was tried with an insufficient result for its narrow visual field and for its short distance from the mucosa. Following them, a new fiberscope was evaluated with changeable viewing directions, that is, orthoptic and rectangular angle deviations either by changing the top lens or by rotating the prism of the instrument. Finally the fiberscope with 10° optical axis deviation was adopted. Although 20°-30° axis deviation system was most desirable, degree of deviation was limited to 10° because of its technical difficulty. This 100 deviation system, however, has some problems : Namely, observation is sometimes difficult at the strongly bending portion of the intestine or behind the prominent haustrae, and a frontal view of the lesion with a wide scope can hardly be obtained. Lately, by co-operation with optical engineers, the authors have made a fiberscope with 30° deviation optical system because the technical problems had been dissolved. It becomes possible to get a frontal view of the wide area by this new fiberscope, and there is no blind portion for observation even behind hastrae. This instrument can take a clear close-up picture, so it is thought to be useful for a close-up and magnifying observation. It is also easy to observe a same lesion from several directions. Moreover the authors can observe the intestine cylindrically as through a usual fiberscope by changing the working angle of the tip of the instrument. Therefore it has a great clinical significf ance to have increased an angle of optical axis deviation of the fiberscope from 10° to 30°.This fiberscope can be advanced very easily from the sigmoid to discending colon. In most cases, observation of the left-side colon as far as distal transverse colon is possible in a short time without fluoroscopic control. Tle anchors can see the lighting of the tip of the scope through the abdominal wall even in the descending colon and can easily confirm the position of the tip. Easy insertion of the scope to proximal colon is thought to be based on its optical system and its special shape of the tip of the instrument. So this suggests that the improvement is needed of the shape of the tip of the currently used colonofiberscope.

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A case of hemangioma of the stomach is found in stomach mass survey is presented. Only a few such a case could be found in the lite rature, but its case are on the gradual increase recencly. In our case the diagnosis was not correctly made preoperatively by X-ray, gastrofiberscopic and angiogra phyc examination, but its diagnosis was correctly made after operation. We collected as many case as possible from the literature and studied on hemangioma.

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A 64 year old male presenting with epigastric pain was seen at the Aichi Cancer Center Hospital in June 1969. Upper gastrointestinal series revealed a IIa+IIc like lesion on the posterior wall of the distal antrum. Endoscopically, the lesion appeard an early gastric cancer of IIa+IIc type. However, gastric biopsy done at that time was interpreted as gastritis. The third biopsy examination done in November 1972 demonstrated atypical epithelium and the lesion had since been followed up as a border-line lesion until the eighth biopsy in May, 1973 raised a suspicion of gastric cancer (interpreted as group IV). The endoscopic appearance of the lesion seen as ha +IIc type early gastric cancer had not been changed during the follow-up period. A Billroth I gastric resection was performed and the resected specimen demonstrated a IIc like depressed lesion, 25 x 30mm in size, on the posterior wall of the natrum. Histologically, the lesion represented a slight depression covered by atypical epithelium. Atypical epithelium of depressed type has been rarely reported and simulates an early gastric cacer of IIc type in gross appearance.

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Recently ancylostomiasis is relatively rare. A case of ancylostomiasis, which was found in a patient with severe anemia by duodenofiberscopic examination, is presented. Hookworms usually attach themselves to the mucosa of the jejunum. In this case, however, they were found in the 2nd portion of the duodenum. Case Report ; This 59-year-old woman was sent to our hospital for evaluation of anemia. At the time of her admission, she was found to have severe hypochromic anemia, eosinophilia, occult blood in the stool and reversal of the albumin to globulin ratio. No other laboratory abnormarities were found. Radiologic examination of gastro-intestinal tract revealed no pathological changes. Endoscopic examination by duodenofiberscope revealed many hookworms attached to the mucosa of the 2nd portion of the duodenum actively sucking blood. Characteristic eggs of ancylostoma were demonstrated in the stool. Bephenium hydroxynaphthoate (Alcopara) was given.

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Endoscopic follow-up was made of rectal carcinoid in a male aged 38 at the first examination : The first endoscopy showed a semi-pedunculated firm tumour with yellowish hue over the surface; tiny, somewhat protruding yellow spots were found on close-up observation. No ulceration was found but easy bleeding of the tumour was marked. The tumour revealed marked alteration during the course, giving rise in 2 years and 3 months to the findings closely resembling those of carcinoma with marked ulceration and extensive adherance of necrotic materials but the tiny yellow spots, or tiny yellowish white nodules persisted. The tiny yellow spots over the tumour, therefore, appear to characterise the endoscopic appearance of rectal carcinoid.

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