Bougienage is commonly used as the primary therapy for benign esophaseal stricture in USA. In Japan, however, this methed is not familiar. The purpose of this report is to introduce the bougienage therapy using Maloney mercury-filled tapered bougie (soft bougienage) and wire-guided metal dilator (metal bougienage) with our experience in 25 patients with esophageal and esophageal anastomotic stricture (benign stricture in 21 patients and malignant stricture in 4 patients). The patients with benign stricture were divided into three groups. Group I included 9 patients Who had a pin-hole like tight stricture and were required metal bougienage. Group II consisted of 9 patients whose stricture yielded to soft bougienage. Group III included 4 patients treated by soft bougienage after endoscopic incision with therapeutic failure in one patient who was successfully dilated by subsequent metal bougienage. All but one patient were remained to be asymptomatic during an average follow-up period of 11 months (range from 1 to 26 months). No complications were encountered. In patients with malignant stricture, bougienage therapy has satisfactory as palliative treament which can improve and maintain the condition of oral intake.

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We studied to explore the possibility of combining our technique of microwave tissue coagulation (MTC) with endoscopy and applying this combined technique clinically for treatment of upper gastrointestinal bleeding and gastric cancer. The findings of the experiment using mongrel are briefly described as follows: 1) The maximum diameter of blood vessels that could be coagulated was 2 mm. 2) Vascular tissues were not carbonized by MTC. 3) The coagulated perivascular zone was within 3 mm in width. 4) A coagulation necrosis or thermal wound of 3 mm in width produced by MTC in the gastric wall healed in two weeks. 5) A similar wound of less than 8 mm produced in the focal area of ULII (ulcer involving the submucosa) de in four weeks. Our experiences with MTC suggest that a combination of MTC and endoscopy is useful for ceasing hemorrhage from the upper digestive tract or malignant tumors of the stomach by means of coagulating and necrotizing the involved tissues. Our microwave tissue coagulator has distinctive characteristics which permit clear distinction from an electrocautery or a laser coagulator in its usage: the tip of its monopolar antenna is punctioned into the tissue. Therefore, the target tissue can be coagulated accurately with our tissue coagulator as compared with either an electrocautery which is applied decumbently or a laser which does not contact with the target tissue. The characteristics of our device are brief as follows: 1) The lenght of the antenna is variable. 2) The power output can be modulated. 3) A coaxial cable of suitable thickness can be selected. As stated above, MTC is a new technique that can be easily and safely used in endoscopic surgery.

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Two hundred and forty-four patients with bleeding gastric ulcer were encountered at emergency endoscopy during the period from February 1975 to August 1981. Emergent surgical operation was necessitated in 44 patients and 3 of them died after surgery. The other 15 of 244 patients underwent elective operation. The remaining 185 patients were treated by medical measures alone which resulted in death in 3. Thus, 182 patients were followed up endoscopically under medical treatment. Within 3 months, the healing rate in these patients reached 74.2%, which approximated that of non-bleeding gastric ulcers reported by others. Of the 128 patients followed up for 1 to 6 years, 49 recurrences were observed in 37 patients and 19 of them had 26 episodes of rebleeding. Incidence of ulcer recurrence associated with bleeding was significantly higher in patients of 60 years of age or over than those under 60 years. Cummulative rates of recurrence and bleeding were getting higher as the follow up period became longer. Out of 19 patients with rebleeding, 3 were subjected to emergency operation and 2 underwent elective operation. Bleeding gastric ulcers, especially in the aged, require careful observation not only for ulcer recurrence but for rebleeding.

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Removal of a huge and hard common bile duct stone is often difficult even with the aid of retrograde basket extraction. Electrohydraulic surge current may be used to crush such a stone and facilitate the removal. An experimental study was undertaken in 12 dogs to investigate its effects and hazards using LITHORON (Walz Elektronik GmbH, West Germany) as an electrohydraulic surge current generator (Figure 1). After an in vitro study to choose an appropriate energy level (Table 2), cholesterol pigment calcium stones were crushed in the canine bile duct dilated by one-or two-week distal ligation. No single case of perforation was encountered (Table 3). Gross observation demonstrated localized redness of the bile duct mucosa in four of six animals where "ligation cholangitis" was minimal (Figure 4), which corresponded to an area of edema, submucosal hemorrhage and congestion revealed by a histological examination (Figure 5). Mucosal damage could not be identified in the remaining four due to diffuse cholangitic changes. Bile duct pressure monitored by infusion manometry via a cystic duct catheter unexpectedly showed a transient decrease on crushing the stone (Figure 6). Surge current ignition alone caused no remarkable pressure change. After the experimental study, the method was applied to a 36-year-old woman with a residual stone left unremoved even after repeated basket extraction procedures. The stone was crushed into several fragments and later easily removed. Electrohydraulic surge current is effective and relatively safe for endoscopic lithotripsy in the common bile duct, although care should be taken to avoid possible bile duct injury and the basket of the lithotripsy probe currently available needs to be improved to facilitate intraductal manipulatton.

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In this paper, peritoneoscopical findings of the liver in 4 patients recovered from f ulminant hepatitis are reported. Case 1, 25-year-old, female : The surface of the right lobe was waved, while, there were localized icteric spots on the left lobe which were slightly elevated and appeared yellowish green in colour. Case 2, 27-year-old, male : No gross changes were observed on the both lobes. Case 3, 57-year-old, female : A large localized depression with thickened liver capsule was seen on the dorsal surface of the right lobe. Case 4, 37-year-old, male : An enlarged white liver was seen peritoneoscopically, however, submassive hepatic necrosis was noticed histologically. In 2 of 4 cases, some peritoneoscopical changes of the liver were revealed, presumably indicating that severe hepatic necrosis had existed during the acute stage of fulminant hepatitis.

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In our previous report we demonstrated the usefulness of endoscopic retrograde balloon catheter cholangiography for better filling of intrahepatic bile ducts. The present article shows recent improvements of the technique on two points. First, an endoscope was removed, leaving the balloon catheter in the bile duct. Second, contrast medium was slowly infused at a constant rate using a heavy-duty infusion pump. The extended use of the improved technique for pancreatography is also described. To date we have performed the procedure on 39 patients, including 28 with prior shincterotomy or sphincteroplasty, to overcome poor visualization of the bile duct or pancreatic duct due to back flow of contrast medium on standard ERCP (37 patients), or to facilitate simultaneous pancreatography with percutaneous transhepatic portography (PTP) (2 patients). In 33 patients, where standard ERC failed to fill the intrahepatic ducts in most cases (inadequate visualization, 23 patients; hepatolithiasis suspected, 9; hepatolithiasis, 1), cholangiography under pressure with the balloon catheter successfully visualized the intrahepatic branches, confirming the presence of intrahepatic stones in 16 patients, cystic dilatation of the intrahepatic ducts in 2, and the absence of hepatic lesions in 15. The indwelling method diminished the patient's discomfort and facilitated the posture change while taking radiographs. Meantime, retrograde pancreatography with the balloon catheter was performed on 6 patients, and complete filling of peripheral branches was possible. A spot film study by compression in the supine position and simultaneous investigation by pancreatography and PTP have become feasible with the aid of the indwelling technique. No serious complicattion was encountered in the cholangiography group. One patient who underwent balloon catheter pancreatography developed infection to a pseudocyst of the pancreas, requiring percutaneous drainage under ultrasound guidance. Although great care should be taken to prevent possible adverse reactions, the indwelling balloon catheter procedure would be of benefit to improve duct visualization and to facilitate combined radiologic studies.

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A fiberoptic colonoscope was used for the treatment of sigmoid volvulus. In 5 patients with sigmoid volvulus, treatment under colonoscopic control were performed in 10 times from 1977 to 1980. Four were female and one was male. Their ages ranged from 31 to 72 years old and the mean age was 49.4 years old at first episode of volvulus. The symptomatic period before admission ranged from 2 to 7 days and averaged 4.9 days. The main symptom was abdominal fullness and prominent physical finding was abdominal distension in all cases. Four of five patients had significant neurologic or psychiatric disorder. A plain X-ray film of abdomen taken at the time of admission revealed remarkable sigmoid volvulus in all cases. One patient revealed mild leucocytosis, but remaining four did not show any imflammatory evidence in blood cell count and serum chemistry. Saline enema was given as intial treatment in every cases, but all failed to replace the volvulus. A colonoscope was immediately introduced for the purpose of gas reduction. In one patient, the colonoscope was inserted into the splenic flexura and a double stiffening tube was introduced along the colonoscope after straighting the sigmoid colon. That tube was left for 12 hours to prevent recurrence of volvulus. In the remaining cases the excess gas in the extended colon was attempted to be removed. Elective sigmoid resections were performed in 2 patients who were suspected of presense of gangrenous change on bowel wall and recurrence. The remaining 3 patients were followed without surgery, 2 cases of them had no episode of recurrence since then and one patient recurred 5 times during the following 2 years. If neither signs of peritonitis nor gangrene are present, replacement using a colonoscope should be actively attemped as an initial therapeutic approach.

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A 68-year-old female was admitted to the Hashimoto Municipal Hospital on October 8, 1980 with complaints of general fatigue and anorexia. Laboratory examinations showed the elevation of serum IgG (4, 300mg/dl) (Table 1), the presence of M component of IgG-λ type by immunoelectrophoresis (Figure 2) and the proliferation of plasma cells in bone marrow (Figure 1). Roentgenographic and endoscopic examinations revealed a small protruded lesion on the posterior wall of the esophagus 30 cm distal from upper incisors (Figure 3, 4). The patient was diagnosed as carcinoma of esophagus associated with IgG-λ type myeloma. An esophagectomy was performed on October 27. The removed tumor was 3.8×1.5×0.5 cm in size (Figure 5). The histological study revealed squamous cell carcinoma and there were no cancerous invasion to the submucosa and no metastasis in any lymph node and the other organs (Figure 6-a, b). The incidence of early carcinoma of the esophagus associated with myeloma is very rare and, to our knowledge, this is the first case in Japan. The pathophysiological relationship between cancer and myeloma and the indication of surgical treatment of cancer associated with myeloma were discussed.

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Seven patients with localized telangiectatic lesion of the stomach were found endoscopically during the past 2 years. None of these cases had the evidence of the RenduOsler-Weber syndrome. The age of 7 cases (4 women and 3 men) ranged from 48 to 83 years, with an average of 67 years old. Persistent anemia was observed in 4 cases. Of these, 2 cases have shown recurrent episodes of hematemesis and melena. Two cases were associated with aortic stenosis. Endoscopically solitary lesion was discovered in each case. These lesions were seen as a flat and bright red spot ranged from 3 mm to 7 mm in diameter. Close-up observations of the lesions revealed dilated vascular network. In 4 cases with anemia the lesions were treated with the endoscopic electrocoagulation. There has been no recurrence of G. I. bleeding and anemia after the treatment. These mucosal vascular lesions may be more common than previously realized, and should be considered as one of the causes of G. I. bleeding paticularly in elderly patients.

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A 62 years old female with irritable colon syndrome and rheumatoid arthritis developed bloody stool soon after having had a barium enema study. Eight months later, abdominal plain X-ray film showed a dense round shadow (5.2×2.8cm) over the pubic bone. Barium enema study and endoscopic examination of the rectum were carried out to ascertain the nature of this abnormal shadow. Double contrast films of barium enema study revealed a slightly protruberant plate-like shadow on the anterior wall of the rectum, just above the area where the enema tip contacted the wall of the rectum. By endoscopic examination, a well demarcated white-yellowish elevated lesion with a reddish depressed area in the center was seen on the anterior wall of the rectum, at 5cm from anus. Two and half years later, this elevated lesion still existed, but was not so well demarcated as the previous time. Histological findings of the biopsied specimen showed proliferation of macrophages and histiocytes with phagocytosed barium crystals. These findings were compatible with that of a barium granuloma.

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Two cases of solitary ulcer of the rectum are presented. Reviewing the literatures, the following conclusions are obtained. 1) Thirty-two cases of SUR have been reported in Japan. 2) Sex ratio, male to female, is 2: 1. Average age of male and female is 49.1 and 47.7, respectively. 3) A single ulcer is seen in 72%. The ulcers located on anterior wall in 65%. 4) Bleeding on defecation is the most common chief complaint. 5) Five out of 32 patients had psychic disturbances. 6) The pathogenesis of SUR remains unknown. Many investigators have made posturates in regard to its pathogenesis. The authors consider Rutter's postulation, namely, mucosal prolapse caused by excessive strain at stool is most reasonable. This postulation, however, can not explain the location of ulcers on lateral and/or posterior wall. 7) Endoscopy is the most reliable means for the diagnosis of SUR. 8) Drugs, such as steroid and salazopyrin, have no efficacy to SUR. 9) Indication of operation must be carefully decided, since functional disturbance of anal sphincter frequently occurrs as a complication of the operation.

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The Olympus forward-viewing panendscope (GIF-XQ) has a caliber of 9.8mm in outer diameter of the distal end with a biopsy channel of 2.8mm in diameter. This instrument has a wide angle view field (100°). Because of the size of biopsy channel, every accessory such as biopsy forceps and high-frequency current snares etc., for GIF-Q and GIF-D4 are available, and any laser probe of comercial companies can be used for this instrument. During the recent three months, this instrument was used 250 times in 202 patients for panendoscopy and endoscopical treatment. It might be concluded that this instrument was quite suitable for multiple purposes.

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