From 1974 to 1979, 7 patients with achalasia of the esophagus have been treated solely by the technique of pneumatic dilatation using a pneumatic dilator. The pneumatic bag was inflated under fluoroscopic control to 80mmHg at the first day, then to 160mmHg and, finally to a pressure of 260mmHg repeatedly every other day for at least 2 weeks. Evaluation for the treatment was based synthetically on symptoms, a radiological examination, an endoscopic examination and esophageal manometric studies. Following these evaluations, we obtained good results in all patients. The effects were classified as excellent in 4 of the 7 patients and good in 3. (Table 3) (Figure 8-13) The best result was obtained in a patient with a history of 50 years, and in this case the pneumatic bag was covered with streaks of bright red blood after forced dilatation of the cardia though the pneumatic dilator. (Figure 10) A case of the slightly sigmoid-shaped type in which the pneumatic bag could not be introduced accurately at the beginning of treatment, obtained a good result with this technique. It is concluded that forceful dilatation using a pneumatic dilator should be first attemped for the treatment of achalasia.

View full abstract

Correlation between gastric submucosal blood flow and penetration depth into canine gstric wall by Nd-YAG laser radiation were studied using three mongrel dogs. The Nd-YAG Laser (Medialas ; M. B. B.) was fired through the biopsy channel of gastrofiberscope (GIF-D₃; Olympus) by an optical fiber with coaxial jet of CO₂ at the power of 30W, 50W, and 80W with exposure duration of 4 seconds. The gastric submucosal blood flow was measured using H₂ gas clearance method with a hydrogen elctrode which was stuck into the submucosal layer through the serosa at the middle body under lapalotomy. The gastric submucosal blood flow in three dogs showed variation from low value under 40ml / min. / 100g to high value over 70ml / min. / 100g. The lower value of submucosal blood flow showed the dog, the deeper was the mucosal damage in propotion to the exposure power. After the administration of betazole hydrochloribe (2mg / kg, i.v.), gastric submucosal blood flow increased. The higher is the ratio of increasing, the more shallow and localized was the histological damage. These data may suggest that the blood flow in gastric wall plays an important role form the viewpoint of efficacy and safety in the radiation of Nd-YAG laser since it has cooling effect against the mucosal damage by laser radiation.

View full abstract

First we reported to use of a YAG laser in treating bleeding gastric ulcers, stess ulcers, gastric polyps and early gastric cancer. Eight cases of polyps in the colon and 2 cased of early cancer of the colon were treated with a YAG laser and achived satisfactory clinical results. we think these results rationalize a wider use of laser for lesions of the distal colon. Experimental studies were made on light microscopy and scanning electron microscopy of prepared specimen of canine esophagus, stomach, duodenum and colon after laser irradiation. The high risk of perforation was noted in the esophagus and duodenum. The colon and stomach followed respectively. Laser treatment more for lesions in the colon rather than the stomach seems to be mandatory for prudential management. The espohageal mucosa is white which consists of squamous cells, and is different from the other viscera, and it is responsible for the least mucosal alteration.

View full abstract

Although ultrasonic examination has recently made much progress, it is not always available for diagnosis of diseases in the abdomen when severe obesity, intestinal gas or ribs iffterferes the ultrasound quality. In order to overcome these problems, an approach from the inside of the abdomen has been required. On laparoscopic examination, a combination with ultrasonography will be also useful to obtain the inner information of the lesions observed on the surface. We have developed a system equipped with an ultrasonic laparoscope in collaboration with olympus Optical Co. and Aloka Co.. Resolution of 7.5 MHz scanner of this system was examined using a test apparatus. Two point discrimination was laterally 1.0 to 1.3mm up to 2.5cm deep in water and was much more sharp as compared with Model RT-2000 (ultrasonic equippment made in Yokokawa Co., 3.5 MHz) with which it has 3.0 cm at 1.0cm deep in water, though the axial discrimination was not different from each other. When compared with ultrasonic examination from the outside of the abdomen using experimental models of gallbldder stones, biliary obstcuction, liver cyst and granuloma in dogs, this system was proved to provide much more fine and shapa images. In a patient with liver cirrhosis in whom an irregularly nodular lesion on the liver surface suggesting hepatoma was observed by laparoscopy, examination with this systm was performed on the lesion. There found strong echoes around portal vein suggesting liver cirrhosis, and tumor echo was not detected. Surgical biopsy disclosed liver cirrhosis without tumor. During the experiments with this system, we found out several problems in operability, and based on the experience obtained here we have developed an improved model of this system.

View full abstract

For the early diagnosis of Crohn's disease, it is important to investigate its early and / or initial lesions correctly. However, initial inflammatory involvement of Crohn's disease is scarcely inspected clinically. There are two methods for the substitution to know the early inflammatory changes of Crohn's disease; one is to inspect the small lesions which occur at the distant intestine from the main site of Crohn's disease and another is to investigate the early changes of the recurrence after the surgical excision. For these purposes, early mucosal changes of the recurrent Crohn's disease were examined endoscopically and radiologically. During the last 20 years, 6 patients with Crohn's disease were operated in our clinic. The initial anatomic involvement were (1) small intestine, 1 patient. (2) ileocolic, 4 patients and (3) colon, 1 patient. There were postoperative recurrences in 4 cases (66.7%); 1 case with the small intestinal pattern and 3 cases with the ileocolic pattern. All of the recurrence were seen at the anastomotic region ; a tiny aphthoid ulcer was inspected in Case 4 and solitary or multiple ulcers, in Case 1, 3 and 6. The anastomotic lesions were quite different from the typical macroscopical appearances of Crohn's disease (longitudinal ulcer with cobble-stone appearance). Skip lesions were detected in Case 1 and 6 about 1 year after the detection of the anastomotic lesions. The appearance of the skip lesions resembled the lesions that had occurred in the previously resected intestine. Therefore, it was supposed that the pathogeneses of the recurrence of Crohn's disease at the anastomotic area and skip area are somewhat different.

View full abstract

A 76-year-old man complained of an epigastric pain and hematemesis. X-ray examination of the upper gastrointestinal tract revealed a gastroduodenal fistula communicating between the lesser curvature of the prepyloric region and the superior part of the duodenal bulb. A tentative diagnosis of doble pylorus was made. We subsequently confirmed this diagnosis by endoscopic canulation through the gastroduodenal fistula. Considering this patient's age and favorable general condition, he was placed on an ulcer regimen. Five months later, a repeated endoscopy showed a healed gastric ulcer without a gastroduodenal fistula. To our knowledge, this is the first patient cured by a conservative therapy alone in Japan. He has been uneventful for a year until now. Eight cases including this case reported in Japan on this subject were briefly reviewed.

View full abstract

The authors present 5 cases of double pyloric channel diagnosed in the Digestive Endoscopy Unit of the Real Hospital Portugues de Pernambuco, Brazil, out of 8, 000 examinations carried out from September 1973 to July 1980. Two etiopathogenic possibilities are discussed and the authors conclude that, in the light of the clinical and endoscopic findings, all their cases seem to be of acquired origin. In conclusion, they suggest that the terms “double pylorus”and “antrobulbar fistula” are the most appropriate designations for, respectively, the congenital cases and the acquired ones.

View full abstract

A 70 years old man was admitted to our hospital in order to evaluate a filling defect of duodenal cap found unexpectedly by a routine upper gastrointestinal examination. A duodenal polyp with cauliflower-like appearance, belonging to type IV of Yamada-Fukutomi's classification, was endoscopically confirmed at the greater curvature of the duodenal cap. The biopsy specimen was histologically diagnosed as a differentiated adenocarcinoma. A pedenculated polyp, 2.5 × 1.5 × 1.0cm in size, was surgically removed. The greater part of the polyp consisted of papillary adenoma and two small areas near the surface were composed of well differentiated papillary adenocarcinoma localized in the duodenal mucosal layer (m). No metastatic lesions in the liver, lymph nodes, peritoneum, etc. were found during operation. The present case in the 7th patient of early cancer in the duodenal cap reported in Japan up to date and the pathological findings suggested the existence of a adenoma-cancer sequence (cancer in adenoma) in the duodenal polyp. In addition, the characteristic features of patients with early duodenal cancer reported in Japan were also reviwed shortly.

View full abstract

Duodenal varices were demonstrated by percutaneous transhepatic portography in a case of liver cirrhosis with immunological abnormalities. A patient, 69-year-old female, has suffered from occasional left flank pain. She visted us complaining of general malaise. Liver function tests suggested liver cirrhosis. Filling defects were found in the second portion of the duodenum by upper G-I series. Duodenoscopy showed them as elevated tumors. The tumors had smooth surfaces and had bridging folds. PTP revealed duodenal varices supplied by the inferior pancreaticoduodenal vein and drained to the inferior vana cava. The liver was a large nodular liver by peritoneoscopy and revealed liver cirrhosis of active form by hisology of the liver specimen. Many cases of duodenal varices have been observed by G-I series. However, portography has demonstrated duodenal varices in 10 cases. In most of them, duodenal varices were supplied by the hepatofugal superior pancreaticoduodenal vein. Only 1 case of duodenal varices has been reported to be supplied by the inferior pancreaticoduodenal vein. This case is the 2nd reported case of duodenal varices which were supplied by the inferior pancreaticoduodenal vein.

View full abstract

Concerning the efficacy of medical treatment to intestinal Behcet, definite conclusion has not been drawn at this time, and the necessity of surgical procedures has been emphasized even if medical treatment is temporarily effective. This report is a case of intestinal Behcet who responded to medical treatment with steroid and salazopyrin. Patient is 51-year-old female who was diagnosed as neuro Behcet 10 years ago. Steroid was given twice with good response. Four years ago, she had dull pain in the lower abdomen accompanied by melena and diagnosis of intestinal Behcet was established Two years ago lower abdominal pain recurred and surgical tretment was performed against the perforation of the intestinal ulcers occurred due to intestinal Behcet. Postoperative course was uneventful. However, abdominal pain and melena relapsed suddenly 3 months ago. She was admitted to Hirakata City Hospital and transferred to Osaka Medical College for further evaluation of intestinal Behcet. Multiple ulcers in the ileum were found by both x-ray and endoscopic exminations. Treatment with steroid and salazopyrin was undertaken and symptoms improved quickly. The healing of multiple ulcers was confirmed by endoscopic and x-ray examinations done on the 30th and 40th day after the beginning of the treatment, respectively.

View full abstract

The development and improvement of a peroral cholangioscope have been performed with a great effort in our department since the technical establishment of endoscopic papillotomy. After several processes of trial and error, we have succeeded now in producing a new fibercholangioscope (FDS-CP), which is easily introduced into the common bile duct via sphincterotomized papilla of Vater under the rope-way guidance of a balloon-catheter. With the present scope, it is not necessary any more to use a combination set of supplementary devices of inner and outer guiding tubes which were indispensable in the previous developmental stages. FDS-CP is 1, 400mm in its effective length with 50mm apical part of fairly small diameter (6.0mm ∅). The proximal part other than the apical part is slightly bigger with 8.5 mm∅ diameter. There are two angle mechanisms, the first angle being located at from 6.5 to 44.5mm from the tip, flexing 90°up and down respectively, and the second angle being located at from 57 to 105mm from the tip, flexing 4 directionally, 180° up and 90° down, and 90°bilaterally. We succeeded in introducing the scope into the common bile duct in all 12 cases tried. The time required for introduction is, on the average, 5 minutes for a balloon-catheter fixed in the common bile duct through the ordinary f iberduodenoscope (FDS), and 8 minutes for the main scope (FDS-CP) introduced up there under the guidance of a ballooncatheter. Among 12 cases examined by FDS-CP, we experienced one case of the left intrahepatic bile duct cancer, which was successfully diagnosed by mean of biopsy with the present scope, one case of stones in the common bile duct and one case of intrahepatic biliary stones, both of which were successfully treated by removing or crushing down the stone with a basket forceps through the scope. With the present scope FDS-CP, it has now become possible to perform minute observation and accurate biopsy of the common bile and the partially main intrahepatic bile ducts, and also to try to remove stones located in the biliary tracts.

View full abstract

This report is the presentation of newly deviced small intestinal fiberscope (SIF-6b). This equipment was made on the purpose of observing the distal small intestine and minimizing the discomfort of the patient during the procedure. The characteristics of this fiberscope was as follows; outer diameter was 6.1mm, and metallic olive-shaped hood was attached to the tip of this f iberscope. Biopsy equipment was not connected. By the insertion of this f iberscope, polyvinyl tube with an outer diameter of 10mm and a length of 1, 000 mm was used as sliding tube. Fiberscope which was covered by polyvinyl tube was inserted orally, and when the tip reached into the second portion of the duodenum, polyvinyl tube was fixed, while fiberscope was further inserted by pushing forward. Fifteen-two cases who necessitated endoscopic examination of small intestine were selected for this study. The results were as follows; Fiberscope was inserted until the 2nd portion of the duodenum in 2 cases (4%), 3rd to 4th portion of the duodenum in 10 cases (19%). The tip of the fiberscope reached to 20cm beyond the Treitz ligament in 25 cases (48%). In the remaining 15 cases, the tip reached to more distal portion of the jejunum. During this procedure, slight pain occurred in 37 cases (71%), and moderate in 15 cases (29%). None developed severe pain. Therefore, it might be said that the discomfort was much less in comparison to commonly used fiberscope. Accomplishment of new fiberscopic equipment combined push method with sonde method will be strongly desired in order to make the insertion more distal with ease and lessen the discomfort of the patient during procedure.

View full abstract