Four hundred and sixty eight cases of colorectal cancer were operated in the past ten years in our Institute. A preoperative colonoscopy was performed for two hundred and eighty two of them. The indications and associated problems of colonoscopy for colorectal cancer were studied. The insertion rate of the colonoscope up to the cancer was high in the left colon, it was, however, low in the right colon. Therefore total colonoscopy was said to be not necessarily the best way for a screening method of colorectal cancer. The indications of colonoscopy were for the following cases; 1) Equivocal barium enema. 2) Cases in which rectal bleeding persists in spite of nomal barium enema. Moreover, it was found that the colonoscopy up to the splenic flexure was important to detect colorectal cancer as screening for the patients over forty years old having bloody stool. Right colon cancers were often too advanced at the time of the examination. Hence it was deduced that the low insertion rate of the colonoscope for it was derived from abdominal dissemination, poor movability of adjacent loop due to invasion of the cancer and adhesion between abdominal wall and cancer. Barium enema should be performed to these cases of unsuccessfull colonoscopy as stated above, or to the cases whose bleeding sources were not specified.

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Hydrogen gas clearance method is a applicative method to measure gastric mucosal blood flow though endoscope. But, it is necessary to stick a needle electrode into gastric wall as much as 2 mm depth in order to stabilized the electrode. The tip of it may be in the submucosa and the mucosal blood flow cannot be measured precisely. The authors designated a special electrode. This has two needle electrodes, the longer one (A-electrode) and the shorter one (B-electrode). A-electrode is 1.5 mm longer than B-electrode. So when the tip of A-electrode is located in 2 mm depth, the tip of B-electrode will be located in 0.5 mm depth from the mucosal surface. On this situation, when the gastric blood flow is measured with this electrode by hydrogen gas clearance method, the mucosal blood flow will be reflected in B-electrode. As a result, there was no difference between the values in two electrodes. Blood flow of gastric body is greater than that of gastric antrum in every cases. The authors concluded that the depth of the tip of the electrode did not affect the the results within 2 mm depth from the mucosal surface.

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For the past two and half yeas, we have experienced 54 cases of urgent colonoscopy which was performed within 72 hours of the onset of anal bleeding. For its preparation, warm water enema was given to 46 patients, and cathartics were given to 8 patients. The following cases were included: 15 cases of drug induced colitis, 8 cases of colitis of unknown etiology, 5 cases of ischemic colitis, and 4 cases of infectious colitis. These cases usually demonstrated a rapid course and the origin of bleeding may well be obscure, when examined after bleeding has ceased. Urgent colonoscopy is, therefore, very useful. As a bleeding site was in most instances beyond the reach of a proctoscope, actually existing in the proximal colon, the colon must be examined as deep as possible until a bleeding point has been found. Urgent colonoscopy is very useful not only for an early diagnosis and treatment of acute colonic diseases, but also for solution of their pathophysiology. Urgent colonoscopy should be done more frequently, because it seems safe under cautious performance.

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We have reported that an ordinal peritoneoscopy has a limitation to observe the entire liver surface. Moreover, an ultrasonograph is not always suitable for detection of a localized lesion of the liver just beneath the diaphragma, although it is exactly an useful examination for the diagnosis of hepatoma. Therefore, if a probe of ultrasonograph is incorporated into the laparoscope, the diagnosis of hepatoma will be very much improved by means of the image. Up to now, we have developed two kinds of instrument with cooperation of Machida Co. and Toshiba Medical Co. The characteristics of the instruments are as follow. 1) linear scanner type of ultrasonograph. 2) forward viewing type of optical system. 3) flexible fiberscope system. 4) panning system. In conclusion, present status of ultrasonic laparoscope developed in our laboratory is not sufficient because of its hard handling in the abdonimal cavity and slightly rough image as compared with ultrasonogram examined on the body, although this apparatus clearly showed an increased diagnostic ability for a localized lesion.

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We treated twenty-seven cases of gastric protruding lesions by laser endoscopy. These cases consisted of twenty-four of polyp, one of adenoma and two of early gastric cancer. We successfuly treated them without any accidental complications. A patient with early gastric cancer was 69 years old. Radiological and endoscopical examination revealed a IIa-type lesion, approximately 7mm in size, on the posterior wall of the gastric angle. The biopsy specimen was interpreted as tubular adenocarcinoma. However, the patient refused surgical operation because of angina attacks. Therefore, YAG laser treatment was given to this patient, the lesion completely disappeared and an ulcer scar was formed after the treatment. Biopsy materials were taken from this scar on several occasions and no cancer cells were found until the present time. It seems that endoscopic YAG laser therapy was available to early gastric cancers in patients who refused surgical operation and was not candidate for operation. Although polypectomy of three pedunculated polyps was performed and polyp were recovered, laser coagulation of the stalk took a long time and needed large radiation doses. It seems that it's efficacy for pedunculated polyp was not superior to that of the high frequency electric current. It is conclueded that endoscopic laser therapy is desirable for removing polyps of Yamada I, II type and small multiple polyps.

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It is well-known that in the Western countries left sided diverticular disease is common whereas in Japan right sided diverticular disease is more frequent. Pressure study of the sigmoid colon together with histologic observations have clarified the pathogenesis of left sided diverticular disease, however no answer has been given as to the pathogenesis of right sided diverticular disease. We measured intraluminal pressure of the ascending colon with catheter-tip transducer (Mikro-Tip transducer) by using colonoscope (Figure 1a, 1b). Ten patients with right sided diverticular disease and 7 nomal controls were examined. At resting state the mean colonic motility index of the diseased segments was greater than that of controls but the difference was not statistically significant (Table 4, Figure 7). After intravenous injection of neostigmin methylsulfate higher pressure waves were more frequently observed in the diseased segments than in the ascending colon of controls and the mean colonic motility index was five times greater than that of controls (Table 5, Figure 7). Histologic examinations of surgical specimens of 15 patients with right sided diverticular disease revealed that all 48 diverticula were pseud-dverticula protruding through the circular muscle (Figure 10). Radiografies of operative specimens useing intraarterial barium injection showed an arterial branch arched over the dome of the diverticulum (Figure 11). These investigations were the same as the results of studies on left sided diverticular disease in the Western countries. We conclude that the abnormality of motility and the high intraluminal pressure in the ascending colon seemed to play an important role in the pathogenesis of right sided diverticular disease.

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A 29-year old man was admitted to our hospital because of acute epigfattrric and retrosternal pain with fever. On the 2nd day after the onset, an esophageal ulcer or laceration and a small gastric ulcer were confirmed by endoscopy. Chemotherapy was started immediately. On the 8th day the diagnosis of Boerhaave's Syndorome was established by the leakage of barium meal into the mediastinum under fluoroscopy. He was treated only by intravenous antibiotics and peroral antiacid administration without surgical intervention. Endoscopic examination was repeated on the 19th and 42th day. At the last examination, only scar remained in the esophagus. In Japan, there are 117 reported cases of Boerhaave's Syndorome untill today and 22 cases (including ours') of them were observed by endoscopy. Eight among the 22 cases (36%) were healed by conservative way. However 4 of 14 patients who underwent surgical intervention were died. Boerhaave's Syndrome is required to be diagnosed and treated within 24 hours after its onset for saving the life. We emphasized the role and safty of early but careful endoscopy to confirm the position and dimension of esophageal rupture.

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Five patients developed Barrett-like epithelium following the operation of lower esophagus. The period between the operation and the development of Barrett-like epithelium ranged from 4 year 7months to 14 years following their initial operations. The age of the patients ranged from 33 to 75 of age, and one was male and four were females. Their primary diseases were gastric cancer in three cases and achalasia in two cases. The operative procedures were total gastrectomy with β-anastomosis in three cases, and gastric patch in two cases. Among three totally gastrectomized patients, the Barrett-like epithelium was observed in the portion between the anastomosis and the points which were 8 cm, 6 cm and 4 cm apart orally from the anastomosis. Among the patients with gartric patch, the Barrett-like epithelium was observed in the portion between the top of gastric patch and the points which were 2 cm and 1 cm apart from the top of gastric patch. All the cases were complicated wich esophagitis. Following medical treatment, the retrogression of the Barrett-like epithelium was comfirmed in the patients of cardia type of Barrett epithelium with biopsy. Since the rate of malignant regeneration to adenocarcinoma is relatively high among the Barrett epithelium, a long term follow-up for more than ten years is recommended for the patients with the operation of lower esophagus.

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It has been known that, unlike usual gastrointestinal malignancies, carcinoid tumor is one of the functional or hormone-producing tumor. In this paper, we presented a case of carcinoid tumor of the stomach, associated with primary biliary cirrhosis. The patient, a woman 56 years of age, visited our hospital in 1977 complaining of nausea. X-ray pictures revealed the protruded lesion, measuring 2.3 × 1.8 cm, at the anterior body of the stomach. Endoscopic examination revealed the protruded Yamada's type III lesion at the anterior body and the small protruded lesions at the lesser curvature and posterior wall. By endoscopic polypectomy in 1980, it was diagnosed carcinoid tumor, and she was operated on. In histological finding of polypectomized specimen, the neoplastic cells showed medular, trabecular, and glandular patterns. In resected stomach, four small carcinoids formed trabecular pattern and non-argentaffin, argyrophil cells were shown by silver impregnation by Grimelius method. The levels of gastrin and histamine were high in blood and normalized after operation. By wedge biopsy of the liver at operation, serial sections revealed bile duct destruction with periductal cellular reaction, and it was diagnosed primary biliary cirrhosis.

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Metastatic carcinoma of the alimental canal, except for direct invasion, is uncommon. We have experienced a case of gastro-esophageal metastatic carcinoma diagnosed by radiological and endoscopical studies of the upper GI tract. A 59 year-old female was admitted to our hospital with complaints of nausea and emaciation. The upper GI series disclosed several protruded lesions with central depression mimicking verrucous gastritis at the gastric antrum. The panendoscopy revealed a flat elevated lesion with central ulceration on the mid esophagus and revealed several similar lesions on the stomach. Biopsy study was performed from each lesions, and disclosed signet ring cell carcinoma. A diagnosis of metastatic carcinoma to the esophagus and stomach was made. Further investigation was not allowed because the patient's physical status was progressively worsened and died on the 15th hospital day. On necropsy study, a definite tumor was found at the neck of the gall bladder and this tumor was considered to be the primary site, because there were no detectable tumors present in the other organs. Histology of the tumor was signet ring cell carcinoma. At the nodular lesions of the esophagus and stomach, signet ring cell carcinomas were distributed in the submucosal layer and were partly invaded to the mucosa. With routine usage of radiology and endoscopy, the detection of gastro-esophageal lesions is easy. However, the differentaial diagnosis from metastatic carcinoma in the esophagus and stomach to protruded early cancer, submucosal tumor and verrucous gastritis etc. is difficult without biopsy study.

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With recent advancement in diagnostic procedures, an increasing number of cases of "early cancer" of the gallbladder have been reported. This is a case report of three cases of "early cancer" of the gallbladder diagnosed preoperatively by endoscopic cholangiopancreatography. Case 1, a 78 years old female, presented with fever, abdominal pain and jaundice. Cancer of the gallbladder was diagnosed by FRCP. Cancer was confined to the mucosal layer. Case 2, a 58 years old male, presented with epigastric pain. Ultasonography revealed a tumor in the gallbladder which was diagnosed as cancer by ERCP. Cancer was confined mostly in the mucosal layer with minimal submucosal invasion. Case 3, a 43 years old male, presented with epigastric pain. Ultrasonography demonstrated gallstones and a tumor in the gallbladder which were diagnosed as such by ERCP. Cancer was confined mostly in the mucosal and submucosal layer with minimal muscle layer invasion. No metastasis was found and curative operation was performed in all cases. The most efficient approach to the early diagnosis of the gallbladder cancer proved to find lesions by utrasonography and then to make the differential diagnosis by ERCP.

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A case of amebic colitis showing varied appearance on colonoscopy was presented. These lesions were composed of aphthoid erosions, varioloif orm lesions and ulcers appearing intermediate type of both. Then, the literatures on the colonoscopic findings of amebic colitis was reviewed. It is difficult to make a correct diagnosis of amebic colitis by colonoscopy, because the colonoscopic findings of amebic colitis are manifold and non-specific. Therefore, amebic colitis should be kept in one's mind and managed carefully when one encounters any of inflammatory or infectious bowel disease.

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The investigation (in September, 1980) about the endoscopy section in Europe disclosed the following outlook. 1. There was an endoscopy section in each of 78 departments except one in 66 hospitals in 13 European countries. 2. In West-Germany, Italy and Hungary, there are independent endoscopy departments. 3. In Europe the endoscopy department will be appearing as an independent medical section.

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