In order to contribute to the preoperative determination of the extent of carcinoma infiltration in the wall of the stomach, endoscopical findings at margins of carcinoma spread was reviewed comparing with macroscopical and histological findings of 27 surgical specimens. Analyzed were 30 lesions of 27 cases with diffuse type carcinoma which had well preservation of superficial covering epithelium, though there were carcinoma infiltration in and below the mucosa. According to the mode of carcinoma invasion in the wall of the stomach, these lesions were divided into following 4 groups; Group 1, carcinoma tissue confined within the mid or deep layer of the mucosa, Group 2, carcinoma invaded from the mucosa into the submucosa or deeper layers, Group 3, carcinoma tissue was not found in the mucosa, but in and below the submucosa, Group 4, carcinoma tissue was found neither in the mucosa nor submucosa, but in the proper muscle coat and/or subserosa. Finely irregular uneven surface was observed endoscopically in the Group 1 and 2. There was no distinct difference between Group 4 and areas without carcinoma invasion. As to the superficial characteristic in the level of an area gastricae, there observed no difference between cancerous and non-cancerous mucosa in the Group 1. Slightly rough elevations and sulcation around elevation were, however, conspicuous in the Group 2 and 3. In the Group 4 enlargement of elevation was recognized but sulcation was not so sharp as in the Group 2 and 3. Redness or patchy redness of surface was seen in 9 of 10 cases in the Group 2. In one third of the Group 1 there observed the same redness as in the Group 2. In the Group 3 and 4 the color of the surface was similar to that of non-carcinomatous area.

View full abstract

We have observed twelve cases of unusual acute ulcers in the corpus of the stomach. These ulcers showed characteristic shapes, by fluoroscopy, endoscopy and specimens of resected stomachs, which were wide superficial and irregular shapes such as trench, map-like or tongue-like, and it was often difficult to distinguish from them to the depressed early gastric cancer, . The patients had been accopanied with severe clinical symptoms which were heavy epigastric pain, hematemesis and melena etc. They were nine male and three female in sex, ranging from twenty-six to seventy-three old-year in age. And they were almost hospitalized as an emergency because of these severe clinical symptoms. Three cases were operated under diagnosis of suspicion of malignancy that was early gastric cancer, IIc or IIc+ III. Histologically they were wide, superficial and shallow ulcers, so clled Ul-II, except for a bit of area that was so c.lled Ul-III. Stress had been suggested as an inducement in six cases, drugs in two cases, repeated vomitings in one case, but unknown in three cases. Though it would be thought that stress, drugs and vomitings induced these ulcers, we had no experiences of these types in stress-induced ulcers, drug-induced and vomiting-induced, too. Now the pathogenesis of gastric ulcer has not been obscure, so it is more difficult that we investigate the genesis of these cases. But, if allowed, it would be supposed that the diturbance of regional blood flow in the corpus might be related to these ulcers because they were rare shapes in the limited area.

View full abstract

The dissecting microscopic pattern of capillaries and gland openings in cancer and sarcoma of the stomach was studied by a new method utilizing India ink infusion in addition to ordinary observation. Material and Method A total of 162 cases inclusive of 127 with adenocarcinoma, 30 with carcinoma simplex, and 5 with sarcoma were studied: India ink was infused in 8, 1 and 1 respectively. 1) Immediatly after resection the blood vessels were infused with gelatin-added India ink after washing by heparin-added saline solution. 2) The resected stomach was soaked in cold 10% formaimn solution for two hours, and then frozen sections were made in horizontal and perpendicular planes. 3) The forzen section were observed by dissecting microscopy after spraying with methylen blue solution. Result 1) Depressed type of Adenocarcinoma: Gland openings were highly irregular in form and distribution, a capillary running between tow glanc openings. Total capillary picture showed irregular reticulate pattern with vessels of various caliber. 2) Protruded type of Adenocarcinoma: Surface structure showed congregated. pattern of small petal-like projections each of which contained a short arc-shaped capillary. Total capillary picture showed irregular wave-like pattern. 3) Carcinoma simplex: Carcinoma simplex showed hard, rough, and structureless surface. Capillaries are intensely irregular in caliber, form, and distribution, running singly or branchingly on occasion. 4) Reticulumcell: Sarcoma showed similar picture to that of carcinoma simplex.

View full abstract

There were 1623 cases of initial gastric ulcer, 113 cases of recurrent. ulcer, 29 cases of second recurrent ulcer and 44 cases of relapsing ulcer in past six years (from 1967 to 1973). Their classification and stage in 77 cases comparing with pathological finding after operation are investigated and illustated as follows: 1) Stages of gastric ulcer in operated cases are pathologically classified with four stages: active, intermediate, healing and scar. Comparing, with endoscopic classification 79.7% of operated cases are consistent with endoscopic stage. 2) Fibrinoid degeneration are disclosed in active stage (++), and intermediate stage (++)-(-). No fibrinoid degeneration is found in healing and scar stage. Those are useful to decide the healing stage of ulcer. 3) Gastric ulcer with acute bleeding is belong A I or A II in endoscopic classification and its lacking in the fibrinoid degeneration so it showed be considered as an acute ulcer. Clinically, it is important to comf irm the existence of f ibrinoid degeneration by biopsy. 4) Incidence of the six stages of gastric ulcer: AI 8.4%, AII 28.3%, HI 11.8%, HII 10.9%, HIII 8.9%, S31.3%. 66.7% of total cases of gastric ulcer located inangle and lower body. Location of ulcers showes a tendency of the high percentage in gastric body and it is parallel with ages especially in female. 5) Incidence of the stage of recurrent in active stage within one year is 31.1% but over one year is 59.2%, second recurrent within one year 38.9%, over one year 63.6 %, relapsing within one year 65.9 % and over one year 54.5%.

View full abstract

Fiberoptic examination of the upper gastrointestinal tract were carried out on 279 consecutive patients using a newly devised forward-oblique viewing endoscope (GIFType K), which has angles of view directed obliquely 30 degrees from the longitudinal axis of the instrument. In this series, a forward viewing instrument (GIF-D2) and side viewing ones (GTF-S2, GF-B2, and JF-B2) were also employed with GIF-K in 85 and 110 patients respectively to evaluate this new instrument in comparison with other ones. Moreover, in order to campare the diagnosis in the upper gastrointestinal tract by x-ray with those by endoscopy, GIF-K was employed in 134 of 279 patients of this series without previous reading of the x-ray pictures taken before endoscopy. The following conclusions were obtained from the data and pictures presented here. (1) The new scope (GIF-K) presented no difficulty in introduction into the esophagus, in routine manners in the stomach, and in entry into the bulb and descending duodenum because of its finger-shaped tip. (2) This scope was suitable for observing the esophagus with slightly downward flection of the tip as well as a forward viewing instrument (GIF-D2). (3) The instrument was very satisfactory and much better than GIF-D2 in the observation of the entire stomach because of its forward-oblique viewing system with wider visual/field and stronger upward flection of the tip. (4) In most cases the duodenal bulb was/easily examined wth GIF-K as well as GIF-D2; frequently the superior or anterior aspects of the bulb was better visualized by this new instrument. (5) The biopsy forceps could be oriented directly and less obliquely toward a mucosal surface because of the device for forceps elevation. (6) The instrument was not satisfactory for ductal cannulation in routine manners, however, it was very suitable for cannulation in patients with gastrojejunostomy. (7) Endoscopy with GIF-K made better results than x-ray in the examination of the upper gastrointestinal tract. (8) GIF-K was suitable not only for/diagnosis but also for therapeutic and other special employments in the upper gastrointestinal tract.

View full abstract

The purpose of this paper is to describe a methods for the endoscopic study of gastric mucosae in patients with various forms of gastic diseases under the intravascular injection of fluorescesceium-natricum and autofluorescence, and to report some preliminary observations made by this method. Materials and Methods: Thirty patients were examined: 19 patients had gastric ulcer, 3 gastric cancer, one early gastric cancer, 5 primary atrophic gastritis, one an operated stomach of gastroduodenostomy and one an erosive gastritis of antrum region. The f ibergastroscope used in the present study were FGS-BL, FGS-BL-1000, FGDS, PFS-A, PFS-F and the light source for the fiberscope was RX-500G (Machida Co. Tokyo). To observe the localization and distribution of the fluorescence in the gastric mucosa FITC interference filter and yellow filter were employed. In each patient, a control and autofluorescence examination under the optimal activating wave length 495nm by FITC interference filter were performed to injection of f luoresceinum-natricum. Then, yellow filter was attached to the fibergastroscope. 5ml of 10% f luoresceinum-natricum were rapidely injected into an antecubital vein. The first fibergastroscopic photograph was taken when a fluorescence appeared in the gastric mucosa and a serial photographs of 1-2 second intervals for approximately 3 minuts. Ektachrome high speed color films (ASA 160) were used. Results: The blue-white autofluorescence were observed on the coat of gastric ulcer and of early gastric cancer of llc, the erosion and specif is type of intestinal metaplasia under the optinal activating wave 495nm. The time of visualization of fluorescence from the injection into the antecubital vein varied from 10 to 15 seconds and after 30 seconds, these mucosal fluorescence were spread on all mucosal surface except those of the coat of gastric ulcer and cancer lesion. However the latter two conditions showed red color regions. The most striking yellow fluorescence were seen on the marginal mucosal surface of the gastric ulcer and of erosion. During the mucosal fluorescence phase, themorphological feature of mucosal surface showed the cleared appearance than conventional fiber-gastroscopic findings. Discussion and Conclusion: On the surface of gastric mucosa, autof luorescence and fluorescence of fluoresceinum-natricum were demonstrated with optinal activating wave by FITC interference filter. This technique clearly demonstrated the different patterns of luminascence with various gastric diseases. Those findings have not yet been demonstrated with conventional endoscopic methods. This method may be a new tool for the early diagnosis of small gastric mucosal cancer and mucosal diseases.

View full abstract

It is the purpose of this study to improve the diagnosis of the duodenal ulcer. By using x-ray examination, endoscopy and excisional material we made a comparative study of the formation of duodenal ulcers, its process of healing and deformed bulbs. 268 cases of duodenal ulcers, examined at the department of endoscopy, Nihon University of Medicine, April 1971 March 1974, were reviewed. Duodenal ulcers of our series are found most often in the anterior wall and then in the lesser curvature, 51.3% and 38.7% respectively. But they are found less in the posterior wall and in the greater curvature, 9.2% and 0.6 % respectively. The location of these ulcers detected by endoscopic examination consists with its location from excisional material at the accuracy of 93.8%. The deformity of pyloric ring and the appearance of the folds on the ring are found in approximately 91% of duodenal ulcers. These are apparent when the ulcer become scar and that is supplentary to its diagnosis. The overall cure rate of duodenal ulcers are 67%. Compared with single ulcer, multiple ulcers remain unsatisfactory for its cure rate at the point of 3 month of the course. But there is no clear difference between them at the respect of spontaneous recurrence. Not infrequently nodularity, which is the sign recognized by endoscopy, is present in the group including persistent ulcers and recurrent ulcers. Pocket formation (Tashe) is classified into two types, or type I and type II Type I is not observed in the group of single ulcers, but frequently in the group of the multiple ulcers, which are located in the anterior and lesser posterior wall simulataneously, and it has a bridge formation between the ulcers. Type II is observed in the group of big and deep ulcers. It has not a bridge formation.

View full abstract

We have developed a pressure sensor based on a semiconductor for the purpose of mesuring the function of the papillary region. When the function of terminal part of the choledochus was examined by the use of the pressure sensor, the wave type in the patients free from biliary disease showed a regular pattern, whereas the wave type in the patients with choledocholithiasis showed an irregular pattern. An irregular-wave pattern was seen in 53% of the 19 patients with duodenal ulcer. These findings suggest that there is a close correlation between the functional disorder in the papillary region and pathologic manifestation of the surrounding organs. In the diagnosis of the functional disorder in the papillary region, the pressure sensor method should be worthy of trial ak' ig with other clinical and laboratory examination.

View full abstract

Tuberculosis of the stomach is a rare disease. The diagnosis is difficult to establish clinically. The condition may be confused with peptic ulcer and with neoplasm of the stomach. In most cases an accurate diagnosis is made only after surgery. The following case seems worth recording. A 35 year-old woman was admitted in Jan. 1974, with complaints of nausea after meals and easy fatiguability. Roentogen study of the stomach showed not only an enlarged gastric angle with irregular rigidity of the lesser curvature but also tiny barium flecks. Endoscopy demonstrated an extensive area of shallow ulceration on the lesser curvature from the level of lower body of the stomach to gastric angle. The floor of the ulcer was granular and its margin was partly elevated. The gastric angle was markedly thickened. These findings were suggestive of either II c like advanced carcinoma or sarcoma. Biopsy under direct vision demonstrated tuberculous lesions. Chemotherapy was commenced with PAS and INAH. After 20 weeks it was not possible to detect any lesions endoscopically, but treatment is being continued. Further investigation revealed no overt sign of another tuberculous focus.

View full abstract

A case of reticulum cell sarcoma which is very rare in the duodenum was reported in this paper. A 63-year-old man was first seen Oct. 9th 1974, because of 3 months duration of epigastralgia and vomitting. The physical examinations disclosed right hypochondrial tenderness, but tumor was not palpable. Barium meal duodenogram revealed a longitudinal crater with irregular contour in the oral half portion of C-loof along the inside and several polypoid lesions on the mucosa close to the crater. Rentogenological impression was a malignant tumor of the duodenum or encroached cancer of the head of pancreas to the duodenum. Duodenoscopic examination also showed a largecrater with irregular margin and yellow and white floor with blood clots which strongly impressed malignancy. Histologic diagnosis of the biopsy specimen from the duodenal wall was reported as reticulum cell sarcoma. Cytodiagnosis by aspiration method was malignant lynphoma. The patient underwent operation on Nov. 26th 1974. Histopathological studies of the resected material exactly coinsided with preoperative diagnosis. Postoperative course was uneventful. The patient was discharged on Dec. 24th 1974, and is in satisfactory condition now three months after the operation.

View full abstract

Duodenal polyps are rare disease and laparotomy was required to treat these patients untill recently. However, we have successfully treated a patient with duodenal polyp by use of endoscopic polypectomy. case 56-year-old, male. Since 4 years before admitting N.C.C. Hospital, he have suffered from upper abdominal distress and epigastralgia. On admission he was healthy appesrence and there were no abnormalites in physical examination but glucose tolerence test disclosed that he had mild diabets mellitus. Upper G.l, series did not show any abnormalities, but x-ray examination of hypotonic duodenography demonstrated tumor shadow at the 2nd portion of the duodenum. Endoscopically it was observed that the tumor had long stalk and its head sometimes entered into the duodenal bulb. The head was round shape about 2cm in diameter and its surface was nodular, but there was no erosion on it. We used a fiberscope, Olympus, JF-D. The snare was passed through the instrumental channel connected its outer end to the high frequency wave coagulator and cut the polyp electrically. The resected polyp was cought with the widend snareloop and brought outside easily except slight troubles encountered when it passed through the pyloric ring. 2 week later, he left the hospital without any complications.

View full abstract

Despite progress in instrumentation of flexible Choledochoscope, many problems still remain to examine the interior of the bile duct, probably because of complicated operation and mechanical troubles. The reason for this is considered that conventional choledochof iberscope was originally developed as a bronchoscope, in principle, a miniature of gastrof iberscope. Improved Choledochoscope Medel I, II, III, were develped with a close co-operation of Olympus Optical Company to eliminate the disadvantage of conventional choledochofiberscope by permiting more easier exploration. Choledochoscope Model I has a flexible working length of 165mm at distal end and a diameter of 5.4mm. This instrument does not provide a means of recording and angulation of the tip. It was designed for only examination of the interior or the biliary duct at the time of surgery. This instrument is very light and very easy to handle. Choledochoscpe Model II has a flexible working length of 150mm at distal end and a diamter of 6.6mm. It has a large channel of 2.6mm which allows the use of balloontipped catheter, stone grasping forceps and biopsy forceps. This instrument provides a means of recording and the short distal tip deflects to 60 degree in two derctins. This instrument was designed for operative or post-operative choledoscopy. Dis advantage of this instrument is that observation of distal portion of common bile duct has been missed in some cases. Choledochoscope Model III has a 180mm flexible part at distal end and a diameter of 4.5mm. The short distal tip deflects to 90 degree in two derections, but it does not provide a means of treatment for residual stones. This Model III made it possible to observe the distal portion of common bille duct. In our department, post-operative choledochoscopy as well as operative choledochoscopy has been done routinely at the time T-tube was removed to avoid residual stone preblem by using these instrument. In this paper, these improved choledochoscopes were introduced. Moreover importance of employing operative and post-operative choledochoscopy adjunctively with cholangiography was strongly emphasized.

View full abstract