A study was made on the significance of either ERCP or SAG and combied use of both techniques in the diagnosis of 48 cases of tumors of the pancreas. Results obtained are as follows. 1) Successful diagnosis of cancer of the pancreas by ERCP reached 93% of 42 cases studied when combined by gastroduodenal endoscopy, while that by SAG, which was applied to 40 of the 42 cases, was only 65% (26 cases). 2) As to tumors of the pancreas other than cancer, such as cyst (2 cases), insulinoma (2 cases), cystoadenocarcinoma (1 case), and metastatic cancer (1 case), there was no substantial difference in the successful diagnosis between ERCP and SAG. 3) Next, diagnosability of cancer of the pancreas was compared between ERCP, SAG and combination of both techniques. a) Diagnosability of the presence or absence of cancer The diagnosability of the presence or absence of cancer was higher by ERCP than by SAG, when the cancer is in the central part of the pancreas along the main duct, whereas it was higher by SAG than by ERCP, when the cancer is in the peripheral area or in the viscinity of the margin of the pancreas. Accordingly, it was indicated that the diagnosabilility of the entire pancreas was much higher when ERCP and SAG were combined. b) Diagnosability of the nature of cancer : ERCP was found to provide much more important informations on not only changes of gastroduodenal, pancreatic and biliary tracts, but also on anastomosis at the time of surgical operation, while it did not contribute to the diagnosis of the tumor size, way of infiltration of cancer cells and/or presence or absence of metastasis. In contrast, SAG provided much more inf ormations on the latter or on resectability of cancer. From these results, it was concluded that the combined application of ERCP and SAG was essential for the exact diagnosis of tumors of the pancreas.

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Chronic inflammatory lesions of the pancreas similar to human chronic pancreatitis were made by a direct injectin of Freund's complete adjuvant into the parenchyma of the pancreas of dogs. Using these experimental models of chronic pancreatitis, the pancreatograms were studied in comparison with results of pancreatic function test and histology. The conclusions obtained were as follows: 1) A diagnosis of chronic pancreatitis was valid if any remarkably abnormal localized finding was present. When such pronounced changes were not visualized, it was necessary to interpret various trivial findings compatible with chronic pancreatitis. in the whole pancrea-togram. 2) Dilatation of a pancreatic duct has usually been considered as one of the chracteristic findings of chronic pancreatitis. However, it seemed not necessarily true, because a simple dilatation of the pancreatic duct was frequently found in cases with negligible abnormalities in histology and/or pancreatic function. It was seen even without any other abnormalities. 3) Diminution of the number of branches of the ducts showed a good correlation with periductal fibroses in histology or an impairment of pancreatic function. It is desirable to visualize pancreatic ductal systems to know an aspect in the branches.

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Since August 1977, the new technique of endoscopic papillotomy (EPT), named PTPT : Percutaneous Transhepatic papillotomy, was successfully performed on patients who had percutaneous Transhepatic Catheterization of the bile duct (PTCD). The procedure of PTPT is as follows At first, PTCD is performed for the patient who has CBD stones complicating cholangitis. Then a papillotome is inserted into a PTCD catheter. And a duodenofiberscope is inserted via oral rout. Under duodenoscopic observation, papillotomy is performed by the papillotome previously inserted through the PTCD catheter. It is difficult to perform emergent EPT for a poor risk patient who has severe cholang-itis. And it is also difficult for a Billroth II gastrectmized patient. In such a case, PTPT is rather easier and safer to apply than ordinal EPT. We introduced the new technique of EPT named PTPT, and reported the exellency of PTPT in poor risk patients.

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It has been difficult to intubate the small intestinal fiberscope (SIF-B) into the deep jejunum because the fiberscope usually makes a loop in the stomach. Only the monorail tech-nique over a transintestinal probe, which is known as rope-way procedure, has been a method to pass the instrument into the lower portion of the small intestine and to take biopsy specimens, even though the trouble is that it takes 2 to 3 days to pass the transintestinal intubation. It is therefore advisable to use an active maneuver of peroral instrument, if only the intubation into the deep jejunum becomes possible. A new technique for intubation of the instrument into the lower portion of the intestine was successfully developed. The procedure in which the sliding tube is intubated into the descending portion of the duodenum is shown in Fig. 3 or Fig. 4 to 9, and the results in Fig. 13. In cases in which the instrument was intubated into the jejunal loop with counterclockwise rotation, the examination was done successfully in the mean extent of 80 cm (116 cm in the maximum) distal part from the duodenojejunal flexure, whereas 40 cm with clockwise rotation. The time required in intubation was only 25 minutes in average. Failure or complication has not been experienced. An advantage of this method is that reintubation or exchange of SIF-B for other more soft and long instrument as SIF-B long shown in Table 1 can be done easily.

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This is a study on the rate of positive biopsy in cases of colorectal cancer and possible causes of false-negative results. In our Institute, 327 patients with advanced carcinoma of the large intestine were operated radically in the period between January 1970 and June 1978. A preoperative endo-scopywith biopsy was performed in 179 patients among them. The biopsy was positive in 162patients (90.50) and negative in 17 (9.5%). If seen from the viewpoint of forms of cancer, f alse-negative results were obtained in one out of 24 cases of polypoid form (4.2%) and 16(10.5%) out of 152 cases of ulcerated form, but none in three cases of scirrhous form.There was a tendency that false-negative biopsies were seen more in the ulcerated form thanin polypoid one. In order to see the mode of exposure of the cancer on the surface of the anal margin, these ulcerated carcinomas were classified into three groups:(A) carcinomatous tissue was completely covered with mucosa, (B) carcinomatous tissue was partially exposed, (C) carcinomatous tissue was completely exposed. Among 16 cases with false-negative biopsy, six were (A), four were (B) and five were (C). There was one case with remarkable necrosis which could not be classified in this way. Above results may indicate that the mode of exposure of the carcinomatous tissue at the anal margin does not necessarily affect the rate of false-negative biopsy. Number of biopsy specimen taken from a cancer may play a role in a false-negative result, for existence of carcinomatous tissue was in only 378 (66.2 %) of total 571 biopsy specimens which were taken with the intention from the suspected part of the cancer. Actu-ally only one perticle was taken in seven out of 17 false-negative cases. Thinking of the existence of false-negative cases even in group (C), it will be necessary to take at least more than one biopsy perticle from different parts on the top of the elevated margin of the carcinoma. Exf olliative cytology will, also, be useful.

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This paper presents experiences with a new f iberscope, FG-28A, Asahi. This f iberscope is forwardviewing and f ixedf ocusing. The effective length is 1, 130 mm and the angle of view is 76°. One of the most important characteristics of this fiberscope is a medium-sized caliber of the shaft (9.5 mm), in order to reduce the disadvantages of other types of fiber-scope with too large or too small caliber. This fiberscope has been used clinically in 289 cases of routine upper G-I. examinations including 7 cases of EPCG. The insertion with this FG-28A was as easy as that with other conventional small-calibered f iberscopes. The stomach and duodenum were entirely observed, but the most difficult part in observation of the stomach was middle and lower posterior wall of the body. It was also rather difficult to observe the greater curvature of the duodenal bulb just distal to the pyloric ring. These would be a common disadvantages with forward-viewing fiberscopes. The image of this scope is sharp enough and photography with this scope is almost satisfactory. EPCG was also possible though it was more difficult to obtain the duodenal papilla from the anal side with thid scope than with other small-calibered scopes. Biopsy specimens taken were large enough in size for pathological evaluation even though a biopsy forceps for this scope is somewhat small (2.4 mm).

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The association of gastrointestinal polyposis, alopecia, and nail dystrophy was first reported by Cronkhite and Canada (1955). Since then, to the best of our knowledge, 21 other cases of Caucasian have been reported (1977). In Japan, 32 cases of Japanese have been reported. This paper presents a case of Cronkite-Canada syndrome and the endoscopical studies of the upper G-I tract, and reviewed the literatures with reference to the clinical aspects. The patient, a 61 year-old male, was admitted with complaints of taste disorder, nail deformities, and general malaise in April, 1978. Five years before admission, the patient had the same complaints and a gastrectomy was performed under a diagnosis of gastric polyposis. Immediately after the operation, all fingernails and toenails became brittle and were broken off. His family history was negative for gastrointestinal and dermal diseases. On physical examination, alopecia, hyperpigmentation of the skin, nail deformities were noted. Laboratory findings revealed iron deficiency anemia, lactase deficiency, disturbed V.B12 absorption due to intrinsic factor deficiency. But, serum protein and electrolytes levels were within normal limits. Gordon test was, also, normal. Although primary hypothyroidism was sus-pected because of elevated fasting level of serum TSH, it could not be examined further. Röntgenograms showed multiple small filling defects in the gastric stump and large intestine, and polyposis in the entire duodenum and a part of the ileum. Endoscopy, also, demonstrated gastric polyps and duodenal polyposis. Endoscopical mucosal dyeing method using 0.2% methylene blue showed that the mucosal surface of the polyps was not dyed by methylene blue. Biopsy of the duodenal polyps revealed flat villi, cystic dilatation of the glands and stromal edema histologically.

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After the introduction of f iberoptic endoscopy and its fully accepted use as an instrument of great diagnostic ability, we are now in an era where the same instrument is providing us with a route for a mode of therapy. The electrosurgical removal of polypoid lesions from the upper gastrointestinal tract with the fiberoptic endoscope has proven to be a safe and effective procedure. Since May 1976, we have experienced more than 150 cases of endoscopical gastric poly-pectomies, and among them the same procedure was performed on a polypoid mucosal cancer, which we classify as an early gastric cancer type IIa. A 79 year old man visited our hospital, and was diagnosed to have a polypoid cancer of 14 mm in diameter at the antrum. He refused to be treated surgically, but was very eager to be treated by removing the lesion endoscopically. The 1st endoscopic polypectomy was performed on Feb. 1977, however, a small piece of cancerous lesion was left on his stomach unfortunately. One year and 3 months after the 1st polypectomy, the same-sized polypoid cancer appeared on the center of the converging folds. Then, the second endoscopic polypectomy was performed on May 1978. The procedure was satisfactory, and the whole polyp-oid cancer was removed with the surrounding mucosa. Histologically, the cancer was well differentiated adenocarcinoma, and there were neither lymphangious nor venous inf iltrations. The patient recovered uneventfully. When a polypoid cancerous lesion is suspected to be limitted within the mucosal layer and less than 15 mm in size, the authors of this paper would like to recommend the endos-copical electrosurgical snaring removal of the lesion. Of course, the careful follow-up study including endoscopical biopsy must be followed.

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