In order to make clear pathogenesis of the bleeding on the esophageal mucosa in patients with liver cirrhosis, the authors have clinically examined it on the fine net-work pattern of the capillary on the esophagus using magnified technique under esophagoscopy. The results were summarized as follows: In the normal cases, each capillary was observed straightened in parallel on the lowest part of the esophagus and they jointed together and looked like branches on its upper part. But in the cases with liver cirrhosis, these above-mentioned findfngs of capillary vessels changed irre-gularly. That is : 1) In the cases without esophageal varices and those with slight varices, these capillaries were proliferative and hyperemic endoscopically and their edges became unclear. Much dilated capillary or red-brown spots were observed in some cases. Histologically, they corresponded to the dilated capillary in the proprial layer of the mucosa. It seems that the slight erosion on the esophageal mucosa and acceleration of plasmin activity in peripheral blood made bleeding easily. 2) In the cases with moderate and marked esophageal varices, in addition to abovementioned findings, small red elevations with smooth surface were observed. Histologically, they were equivalent to the much en-larged capillaries or to one part of the varices which were under the thin stratified squamous epithelium. Most of them were observed on the lower part of the esophageal mucosa. It seems that they would be injured easily by mechanical or chemical irritation. The authors emphasized that the detailed observation of the capillary on the surface of the esophageal mucosa in bleeding cases with liver cirrhosis was extremely im-portant.

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By analyses of 37 cases with the spontaneous internal choledochoduodenal fistula near Vater's papilla, clinical significance of the state was defined as follows. 1) The fistula was apt to occur more frequently in the aged and preferably in the female with a ratio to male of 1.6 to 1. Twenty three cases (16%) with a history of the operation to the bile duct system in the past have suffered longer diseased period than those of 14 cases (380) without previous history of the bile duct operation. 2) Cholangiography revealed cholelithiasis in 23 cases (620). In many cases there was a sign of a stricture in terminal portion of common bile duct or its distension indicating a high association with papillitis. 3) The fistula was seemed to be formed mainly in the process of spontaneous abortion of the choledocus stone, and less frequently due to the chronic inflammation of the terminal bile duct by the stone which was not to be aborted. 4) Surgical treatment including operative procedure to the fistula should be considered positively for the cases with retained stone or with recurrent papillitis.

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A laparoscopic diagnosis of the liver should coincide with a histological diagnosis of the liver. For this ultimate destination of the laparoscopy, the observation power of the standard instument was not satisfying enough. We have originally designed a new instrument, magnifining laparoscope with cooperation of Machida Endohcope Co., mainly improving magnification and resolution powers. As for the efficiencies of the new instrument, it has become possible to observe minute structures of the liver surface at the resolution level of hepatic lobule. The main characteristics of the magnif ining laparoscope are as follows : The visual angle is greatly narrowed down to 25 from 60 degrees of the standard type. The magnification is 10 times at the distance of 10 mm, being equal at 95 mm apart from an object. In order to secure the sharpness of the image, a visual adjusting apparatus is provided at the ocular part. With this mechanism, the visual distance has greatly widened, the range being from 0 to infinite. In other words, it has become possible to perform a close up observation as well as a standard observation continuously and simultaneously with a single scope of the present magnifining laparoscope. The other major function is a measuring apparatus. Crossing measures are incorporated at the plane of the eyepiece, one graduation corresponding to 1 mm of an object at the distance of 10 mm apart. The measuring function will give a great advantage for the accurate diagnosis and follow up of the hepatic diseases, providing objective informations of fine structures of the liver surface such as blood, lymph vessels, hepatic lobules or nodules. With successful improvements of observation power of the instrument, it has now become possible, in the strict sense, to perform a comparative study between endoscopic findings of the liver surface and its histological findings of the liver biopsy under direct vision, prospecting further progress in new aspects of the laparoscopic diagnosis.

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In order to elucidate the clinical implication of no visualization of the gallbladder, the study was performed to 316 patients who were investigated by ERCP because of suspected biliary diseases. Among these patients, there were 72 patients whose gallbladder was not visuallized entirely orr partially, despite sufficient opacif ication of the bile duct, and such cases were one of main f aotors reducing diagnostic accuracy of ERCP. All of these 72 patients were included in 262 pstients who were diagnosed as having biliary disease from the findings of autopsy, operation, clinical investigations and/or clincal course. In all of 54 patients who were diagnosed as non-biliary diseases, the gallbladder was visualized. Fifty nine of non-visualized cases underwent operation. On the basis of surgical and retrograde cholangiographic findings, 59 patients were referred to two different groups; group A 24 patients with stone(s) or stenosis in the choledocus, group B : 35 patients with minimal or no abnormality in the choledocus. The pathological findings of the gallbladder confirmed surgically were (1) stone(s), (2) cholecystitis without stone in the gallbladder, (3) cancer, (4) congenital absence and (5) minimal abnormality. In group A thrse findings were found in 14, 5, 2, 0 and 3 patients, and in group B 27 5, 2, 1 and 0 patients respectively. Among biliary lesions found in these 59 patients, 56 including two resectable gallbladder cancer had indication to surgical treatment, two with hepatic invasion of gallbladder cancer had no indication of radical operetion and in one case with congenital absence of the gallbladder surgery was not indicated. Therefore, when a case of no visualization of the gallbladder is experienced, it is desirable to exclude surgically untreatable biliary lesion from the findings of retrograde choledochogram or other examinations. On the occasion that such lesion is ruled out or is failed to be clarified, surgical treatment or laparctomy may be needed.

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Clinical and histological studies on gastric carcinoma has been reported by many authors, but we have as yet limited information of gastric carcinoma in the young with special reference to early stage. In this paper 50 cases of gastric carcinoma patients less than 30 years of age in our hospital during 15 years period from 1962 to 1976 will be reported with comparative statistics. The cases were divided into two groups. One is the early carcinoma group in which cancerous invasion limited within submucosal layer. Another is the advanced carcinoma group in which deeper cancerous invasion than submucosal layer was detected. The incidence of gastric early carcinoma in the young was in 10 (1.4%) of 737 patients detected by gastric resection, and in 6 (1.2%) of 481 male and 4 (1.6%) of 256 female with early gastric carcinoma. As the initial symptoms in early gastric carcinoma group, gastric pain were present in 800. The duration of the symptoms were less than 6 months in 20% and longer than 1 year in 400. Macroscopically, all cases were of depressed type (IIc or IIc+III). Protruded type (I, IIa) early carcinoma could not be found in the young. Histologically, 9 out of 10 cases showed mucocellular adenocarcinoma, mostly having ulcer and ulcerscar in the center of depressed cancerous invasion. The degree of cancerous invasion was 6 in the mucosal layer and 4 in submucosal layer and no lymphatic metastasis was found except 1 case. Young early carcinoma was most often seen on the lesser curvature side, especially in the middle portion. Distribution pattern of intestinal metaplasia in the surrounding mucosa of gastric carcinoma was examined histologically, and metaplasia were shown in 6 cases of 10 specimens. In advanced carcinoma group, 40 cases of advanced carcinoma were studied, and this corresponds to 1.8 percent of all surgical cases in our experience. The female outnumbered male in ratio of 23 to 17. Gastric resection was performed in 31 of the 40 patients treated by laparotomy, and in 16 of 17 male, 15 of 23 female with laparotomy. Macroscopically, Borrmann f, Borrmann iV type carcinoma were predominantly found compared with other age groups. Especially Borrmann IV diffused type was seen in 320. We have no case of Borrmann I type which were found frequently in old patients. Lymphatic metastasis is positive in 34 cases of 40 cases. Histological investigation revealed mucocellar adenocarcinoma in 740. The entire stomach or middle portion of the stomach was predominantly involved region in advanced carcinoma group similar to that of early carcinoma group. Five year survival rate was noted in 200 of the 31 resectable cases of advanced carcinoma. Further studies of a greater number of gastric carcinoma in the young might be necessary.

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A 61 year old man was admitted to our clinic on June 1, 1972, with chief complaints of epigastric distress for 4 months, fever and jaundice for a month. He was hospitalized twice in the past, and on the second admission choledochoduodenostomy was performed. By the use of ERCP and PTC, he was suspected as having carcinoma of the common bile duct, and pancreatoduodenotomy was done on July 20, 1972. Histological stndy revealed that there was no metastasis to the liver or regional-lynphnodes and it was thought that he would have the chance of 5 year survival, however he expired on Nov. 24, 1974, 2 years and 6 months after surgery. Following Snbjects were discussed.1) The symptomes : not characteristic of the common bile duct carcinoma.2) Need for PTC and ERCP before and during the operation.3) The diagnosis of pancreatic cancer by the palpation during the operation.4) Prognosis of early common bile duct carcinoma.

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A 4-year-old infant visited our clinic complaining of foreign body in the gastrointestinal tract which had swallowed accidentally one week previonsly. In the plain X ray picture, a coin shadow was revealed at the corpus of the stomach, but as the infant had no subjective symptoms, special treatment was not applied. When he revisited our clinic after one month, The Coin was demonstrated in plain X ray film, which was still remaining in the pyloric antrum. We removed it with forward-view endoscope which was used for adults, because it had not been passed through the pylorus over the period of one month.

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