For the perfect observation of the intricated gastric lining, a flexible endoscope was inevitable. The very difficult question how to convey an image along a curved axis had been solved by G. Wolf, a cystoscope-maker in Berlin and R. Schindler in Munich for the first time. Rudolf Schindler is a man who devoted all his life for the completion of a safe gastroscope, for the establishment of the techniques for painless examination and the endoscopic diagnostics of every gastric pathology. He well claims the name 'the father of gastroscopy.' Their flexible gastroscope was completed in 1932. It was 78 cm long and over 44 lenses were incorporated inside. Its distal half could be curved gently until 34°. The observation of the pyloric ring was possible in over 80% of the cases. Their flexible gastroscope was introduced to every country in a short period of time. H. Nakatani, a surgeon of Tokyo University, brought it back to Japan in 1933 after he had took the Schindler's short course on it. In 1934 S. Kirihara, a surgeon of Nagoya University, and M. Takei, a cystoscope-maker in Tokyo, succeeded to make its copy and in 1937 they improved its flexible portion to be controllable. In 1943 the first Japanese textbook on gastroscopy was written by Kirihara. However a flexible gastroscope was used only by few hands of selected university hospitals. In 1889, M. Einhorn in New York introduced an electric bulb into the stomach and estimated the size of the stomach and its position by the light on the abdominal wall. He named it as 'gastrodiaphany.' In 1898, F. Lange and D. Meltzing in Munich made a miniature camera installed in the tip of a flexible gummy tube. Over 50 gastric photographs 4 mm in diameter were taken on a strip of film. However they failed to get satisfactory pictures. In 1930, F. G. Back, J. Heilperin and 0. Porges in Wien made an instrument named as 'gastrophotor'. Eight pair of black and white stereo-photographs were taken by one shot of flash. This was used in Europe and United States for some time but soon discarded in the presence of the Schindler's gastroscope. In 1950 T. Uzi, a surgeon of Tokyo University Branch Hospital, M. Sugiura and M. Fukami, engineers of Olympus Optical Co., invented a camera to be inserted into the gastric cavity and called it as 'gastrocamera.' Twenty five to thirty pictures can be taken on a strip cf 30 cm long film. Photographing of the various parts of the stomch was conducted by referring to the flash transilluminated through the abdominal wall. The utilization of newly developed materials after the 2nd world war, especially that of colorfilm in 1953, made it of practical use. S. Tasaka, a professor of Tokyo University and his disciples T. Sakita, S. Ashizawa et al played an active part for the improvement of the gastrocamera, how to use it and the propagation of their technique. After the completion of the 5th model of the gastrocamera (GT-V ), it was used by many doctors even for mass-survey against stomach cancer in Japan. The easy interpretation of its sharp color photographs was one of the reasons for its big success. The Gastrocamera Study Club established in 1955 by S. Tasaka and T. Hayashida, a professor of Tokyo University Branch Hospital, developed to Japanese Society of Gastrocamera, in 1971 to Japanese Society of Gastroenterological Endoscopy. In 1964 a fiberscope was incorporated to the gastrocamera (GTF) and photographing under visual control became possible. In 1966 the first International Congress of Gastrointestinal Endoscopy was held in Tokyo. The transmission of light along a curved glass-rod was known since Grecian age. The first experiment of image transmission with a bundle of flexible quartz fiber was undertaken by H. Lamm, a medical student of Munich University in 1930. He tried its application for a gastroscope but it was not materialized. In 1954 N. S. Kapany, a physicist in London and van Heel, a physicist in Holland reported on an opticalfiber-bundle

View full abstract

To investigate the laparoscopic changes of liver surface directly related to the early hepatocellular carcinoma(hepatoma)during hepatocarcinogenesis, we examined laparoscopically the rat liver surface continuosly fed with 0.06 % 3'-methyl-4-dimethylaminoazobenzene, and clinically investigated chronic liver diseases, 23 cases of chronic inactive hepatitis, 61 cases of chronic active hepatitis, 61 cases of liver cirrhosis and 29 cases of hepatoma. In the experimental study, the unevenness and localized red spots were recognized on the liver surface at the 7th week from the onset, histologically the hyperplastic foci which were focused as the ultimate precancerous lesion were seen in this stage. The red spots were corresponded with the more productive cell population as compared with surrounding tissue by means of the liver biopsy under laparoscopy. As time passed, the liver surface showed slight irregularity and this appearace resembled to so called “patchy liver” in man. From these findings, the red spots seems the important finding with prodution of hepatoma during hepatocarcinogensis. In clinical study, patchy marking was observed in 30% of total cases of chronic liver diseases. Moreover, patchy marking was seen in 48.1% of positive cases (27 cases) for liver cell dysplasia which has been focused as possible precancerous lesion, on the other hand it was also revealed in 37.9% of hepatoma bearers. The elevation of serum α-fetoprotein over 200 ng/ml was seen in 30.0% of cases associated with patchy marking, while it was shown only in 10.4% of the cases without patchy marking in chronic liver diseases. Regarding to these findings, it may be concluded that the patchy marking is very important factor to set up a concept of high risk group for the development of hepatoma in the cases with chronic liver diseases.

View full abstract

Highly magnifying peritoneoscope was made in order to get more detailed findings of the living human liver and studied in clinical cases after routine peritoneoscopic examination. This scope is able to observe the objects at a distance, and also able to zoom-up to 50 times. So, it was easy to handle this scope in the abdominal cavity and magnify the objects which examiner wanted to see. The pictures taken by this scope were very clear even at 50 times magnification. By using this scope, the relationship between portal tracts and sinusoids can clearly be observed. The relationship between hepatic arteries and portal tracts or sinusoids in the living human liver was observed. I found that number of portal tracts apparently increased in the whitish markings of the chronic hepatitis or liver cirrhosis. These results mentioned above may signify that this highly magnifying peritoneoscope will be useful to study microcirculation of the living human liver and to investigate the pathophysiology of human liver diseases.

View full abstract

From 1959 to 1979, a total of 153 patients with multiple primary cancers of the stomach (189 lesions) were observed in our clinic. Multiple cancers were frequently observed in male patients of 60 years old or more. Grossly early cancer type IIb or minute cancers of 5mm or less in diameter were most common, and they were not infrequently seen proximal to the main cancer. When early cancer type IIb, IIa, I or IIc without converging folds, or advanced cancer type Borrmann I was found, it is necessary to observe the whole stomach carefully, because other cancerous lesions can be presents occasionally. Although there were many endoscopic diagnostic techniques available, a correct diagnosis of multiple cancers of the stomach was sometimes difficult. However, the endoscopic Congo red-methylene blue test developed in our clinic could raise a diagnostic rate up to 76.5% from 27.5% by the routine endoscopy. Endoscopically most of the cancer our foci bleached Congo red methylene blue sprayed over their surface, thus appeared in sharp contrast to the unaffected mucosa. The endoscopic Congo red-methylene blue test makes more accurate diagnosis of multiple gastric cancers than other methods, because a target area can be reached with greater certainty by biopsy.

View full abstract

With the wide spread use of endoscopic gastric biopsy and cytology under direct vision in the diagnosis of gastric cancer, early gastric cancer has been recognized with increased frequency. Although there are many endoscopic diagnostic techniques available, a correct diagnosis of minute cancers is still very difficult. Minute cancer is defined as carcinoma of 5 mm or less in diameter. From 1959 to 1979, minute cancer was found in 52 patients (54 lesions) in our clinic. In the present paper, the diagnostic accuracy of the routine endoscopic examination combined with biopsy and cytology was compared with that of the endoscopic Congo red-methylene blue test developed in our clinic. A corrct diagnosis of the minute cancers by routine endoscopy was made in only 25.9% of them. However, combination of this method with dyeing endoscopy raised the diagnos-tic rate up to 70.0%. Endoscopically all of the minute cancers bleached Congo red and methylene blue sprayed over their surface, thus appeared in sharp contrast to the unaffected mucosa. The endoscopic Congo red-methylene blue test makes more accurate diagnosis of the minute cancers than other methods, because a target area can be reached with greater certainty by biopsy.

View full abstract

The upper gastrointestinal bleeding is a medical emergency where often surgical intervention is the final choice of the treatment. However, if massive and uncontrorable bleeding occurs in patients with poor surgical risk, it creates one of the most difficult medical problem. The pure ethanol injection method, previously reported by Asaki et al, plays an important role in this kind of situation. The following case report submitted to illustrate this point. A 64-year-old man was admitted to our hospital with the chief complaints of thirst and abdominal discomfort. The patient was followed in outpatient department of our hospital for his diabetes mellitus which was detected 28 years ago and difficult to control. The patient also had a gastric ulcer 4 years ago. Laboratory findings on admission showed severe anemia, hypoproteinemia and hyperglycemia. Emergency endoscopic examination revealed the presence of a bleeding gastric ulcer. Immediately, pure ethanol injection was done with satisfactory hemostasis. Ethanol injection into the surrounding tissue close to the bleeding vessels, a few injecting sites selected usually at 1 to 2mm away from the bleeding vessel, 0.1 to 0.2m1 at a time, could instantly suppress the bleeding. The giant, penetrating and bleeding ulcer indicated the necessity of surgical intervention, however, it was judged at that time, the patient was in poor risk for surgery because of the severe anemia, hypoproteinnemia and poorly controled diabetes mellitus. Even under these conditions, pure ethanol injection method was easily carried out with successful result and the patient was discharged 2 months later without further complications. This method, if applyed by a skilled endoscopist, will contribute in the management of upper gastrointestinal bleeding.

View full abstract

A case of early cancer in the 2nd portion of the duodenum is reported. A 68-year-old man had received upper GI series periodically, which revealed abnormal shadow in the 2nd portion of the duodenum. Hypotonic duodenography, endoscopic examination, and biopsy under direct vision proved peduncular early cancer in the 2nd portion of the duodenum. Endoscopic polypectomy was performed and histological examination revealed early cancer with depth of invasion into the submucosal layer and cancer in adenoma. Later surgical treatment was performed in addition because of invasive cancer. But filings of cancer or adenoma were not detected in the resected specimen or regional lymph nodes. In addition, we collected early duodenal cancer from the Japanese literature and referred to the present state and the future of its treatment. And then we referred to problems of endoscopic polypectomy in the 2nd portion of the duodenum.

View full abstract

A 40-year-old female had been complaining of epigastric vague discomfort for several years. She underwent a barium-meal examination, and was found to have a bezoar, approximately 6 × 4 × 4 cm in size. In the endoscopic examination (Olympus GIF-P₂), the bezoar was hardly f orcepsed because of its mobility. Therefore the 2-channel gastrofiberscope (Olympus TGF-2S) was applied to hold it by the equipped snare with success. The bezoar was broken into several pieces, followed with excretion into the stool. On histological examination the excreted bezoar resembled a persimmon, and the analytical study of it proved to contain a tannin providing a diagnosis of persimmon bezoar. Bezoars, many of them are caused by persimmon in Japan, have been generally treated with laparotomy. Recently, several papers on the endoscopic treatment of bezoars have been presented. A large bezoar should be broken, however, its mobility often disturbs the procedure. In such a case, 2-channel gastrof iberscope appears to be a tool of choice.

View full abstract

A 30-year-old woman visited our hospital with a chief complaint of epigastric pain. An X-ray examination of the stomach showed an egg-sized defect in the second portion of the duodenum. An endoscopic examination also demonstrated a smooth mass with bridging folds above the anterior wall of the papilla of Varter. A touch of the site by a biopsy forceps suggested cystic properties of the mass. This finding was supported also by an ultrasonic examination result. No communication was found on the ERCP between the mass and either the pancreatic duct or the bile duct, nor were any abnormal findings noted on either duct. From the results of various examinations, a duodenal duplication was suspected and a surgical operation was performed. The enucleated cyst was found to contain white turbid fluid. Histopathological examination of cystic wall revealed that the internal surface of the cyst was covered by the duodenal mucosa and the cyst held the muscular tunics common with the duodenal internal cavity. From this, duodenal duplication was diagnosed. 17 cases of this disease has been reported so far in Japan and we reviewed the 18 cases including this case.

View full abstract

A 64-year-old female was admitted to hospital because of lumbago. Serum and urine amylase levels were increased. Gastroduodenal endoscopy revealed a remarkable extraluminal compression on the posterior wall of the stomach and enlargement of the orifice of the minor papilla where greenish and viscous pancreatic juice was impacted. These changes of the minor papilla and its orifice disappeared 2 weeks later. Endoscopic retrograde pancreatography (ERP) was performed by cannulation of both major and minor papilla. A dorsal pancreatogram obtained by cannulating into the minor papilla showed a remarked dilatation and sclerosis. On the other hand a ventral pancreatogram was normal. Basic pressure of both ventral and dorsal pancreatic ducts were measured endoscopically, using an open-tip pull through infusion method. Average pressure of the dorsal pancreatic duct, minor papilla and major papilla were 8cmH₂O, 12-17cmH₂O and 30-38/17-25cmH₂O (peak/trough) respectively. Some reporters emphasized that the high incidence of pancreatitis and pancreatiticlike pain in patients with pancreas divisum (a case with fusion-anormaly of the pancreatic ducts) may be due to the very small ampulla of the duct of the pancreas draining the majority of the pancreas which results in elevated ductal pressure. In the obstructionhypersecretion theory, this elevating ductal pressure was considered as a pathogenesis of the chronic pancreatitis. Therefore, measurement of the trans-papillary pressure in these patients is considered a clue to the pathogenesis of chronic pancreatitis occurred in the dorsal pancreas. In our case, the pressure of dorsal pancreatic duct was not elevated contrary to theoretical expectation. This finding may be explained by a decrease in exocrine pancreatic secretion due to severe chronic pancreatitis, and dilatation of the pancreatic duct and an orifice of the minor papilla. This is the first report to measure pancreatic ductal pressure in the case with chronic pancreatitis occurred in the dorsal pancreas associated with fusion-anormaly of the pancreatic ducts.

View full abstract

A 55-year-old male patient was admitted to our hospital with thrombing pain in the lumbodorsal region. Ultrasonic examination and ERCP were carried out for a high CEA level in the screening examination. Both examinations revealed a cancerous lesion of the pancreas head. We performed celiac and superior mesenteric angiography to judge the operability. Both angiography clarified that the tumor invaded the common hepatic artery, pancreaticoduodenal artery, superior mesenteric vein and portal vein. We therefore diagnosed it to be an unresectable cancerous lesion of the pancreas head. On the other hand, the patient took obstructive jaundice with increasing serum bilirubin level from 0.5 mg/dl to 19.3 mg/dl in the following 3 weeks after admission. Then we carried out endoscopic retrograde biliary drainage after EST. Serum bilirubin level decreased 3.0 mg/dl during 2 weeks after ERBD. Now the patient is well without trable for 2 months.

View full abstract

We experienced two cases of the rectal carcinoid. One case was a 49-year old male and the other case was a 73-year old female. After usual colonoscopic observation, we endoscopically scattered methylene blue solution on these tumors. In both cases, usual colonoscopic view showed a yellowish submucosal-tumor-like lesion with a small depression on the surface. By a method of methylene blue scattering, these tumor surfaces were stained like the nomal rectal mucosa. We also scattered methylene blue solution on some rectal carcinomas, and these lesions were not stained or stained like the abnormal rectal mucosa. Therefore, the methylene blue scattering method is useful to differentiate rectal carcinoid from carcinoma.

View full abstract

We used a new wide-angled f ibercolonoscope FCS-L 3 (Machida) in 52 cases without any fluoroscopic guidance, thus evaluating its of f icacies as to introduction, manipulation, observation and documentation. The effective length of scope FCS-L 3 is, 1, 310mm, being consisted of three parts (proximal, middle and distal) of different flexibility. The proximal part of the scope is the lowest in flexibility, and the more distal, the more flexible. The gradient of the flexibility is continuous and smooth along the scope, from the proximal to the distal part. The visual angel is widened up to loo from 75 degree of the conventional scopes. With these mechanical improvements in the present new scope, good results were obtained in its clinical use, the introduction rate up to the caecum being 88.5 per cent (46 out of 52 cases), the introduction up to the terminal ileum being 61.5 per cent (32 of 52) and the mean time required to reach the caecum being 13.8 minutes. From the clinical experience, it could be enough concluded that the new fibercolono-scope FCS-L 3 is the suitable scope especially for the observation of the deep parts of the colon, including the terminal ileum at most.

View full abstract

Fundic-pyloric mucosal border (F-PB) of 1, 000 clinical cases were determined by dye endoscopy, and the relationships between F-PB and gastro-duodenal diseases were studied. The frequency of the open type of F-PB increased with age, while the rate of the closed type decreased. The rate of Co decreased sharply from -29 y. o. to 30-39 y. o. but stabilized at 5.7-9.5% after that in each age group. Gastro-duodenal diseases could be divided into 3 groups in relation to the type of F-PB. In the 1st group (gastric cancer, gastric polyp), the frequency of the diseases increased as the F-PB shifted to oral side. In the 2nd group (gastric ulcer), the frequency remained almost the same. In the 3rd group (duodenal ulcer, erosive gastritis), the frequency decreased according to the F-PB's shift. Almost all of undifferentiated gastric cancers were noted near F-PB in the stomach with type C₂-O₃, and almost all of differentiated gastric cancers were located far from F-PB in O₂-O₃. Most of gastric ulcers in pyloric mucosa far from F-PB were linear and intractable for treatments. Duodenal ulcers were seen in the cases with closed type (96.4 %) but 15.8% of duodenal ulcer scars were seen in the cases with open type. Recognizing F-PB, we can estimate prevalent lesions and their localization, and can examine the stomach and the duodenum systematically. Recognition of F-PB will be useful for treatment as well as diagnose of gastro-duodenal diseases.

View full abstract