Endoscopic Nd : YAG laser treatments were attempted in eight cases with gastic borderline atypical epithelium exceeded 20mm in diameter. These lesions were all broadbased protruded atypical epithelium in which high frequency current snare ectomy might be hazardous. Five lesions were on the antrum and the other three were on the lower body. The size of these lesions ranged from 25 x llmm to 65 x 60mm in diameter. Except for mild pain and hemorrhage, no remarkable complications were notified during and after the laser treatments. Laser-induced ulcers were healed within three to four weeks after the procedures, and the biopsies taken from the scars showed no residual atypical epitheliums, except for the case with the largest lesion which has been still receiving endoscopic laser treatment. Before the introduction of endoscopic laser treatment, surgical resection had been recommended for the borderline atypical epithelium exceeded 20mm in diameter, because minute carcinoma was occasionally found on surgical materials. However, because of its efficacy and safety, endoscopic laser treatment has become a method of choice, instead of surgical resection, for the patients with broad-based protruded borderline atypical epithelium, even the size of the lesion exceeded 20mm in diameter.

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The introduction of the selective proximal vagotomy (s. p. v.) to the surgical treatment of duodenal ulcer decreases the incidence of undesirable effect of truncal vagotomy. However, it has been so little known of its patho-physiology that one can evaluate the accurate postoperative state of the s. p. v.. In this respect, it is interesting to study thechange in gastric blood flow following the s. p. v.. Although there is a consensus concerning the reduction of the gastric blood flow following the truncal vagotomy, there is still unknown the effect of the s. p. v. on the gastric blood flow. The effect of the s. p. v. on the gastric submucosal blood flow was measured by a hydrogen gas clearance method through an endoscope in anesthetized dogs 4 weeks postoperatively. Pre-operative resting flow showed 0.7 ml/min/g in corpus and antrum, 0.6 in esophago-gastric junction. Immediately after the s. p. v., there was a 34% reduction in corporal flow (p<0.005), which restored to resting flow at 7th postoperative day. Furthermore, at 14th and 21st postoperative days, both corporal and antral flow showed transient but considerable increase which returned again to resting state at 28th postoperative day. It appears that an additional pyloroplasty did not affect the changes in flow which have been observed after vagotomy. From these results, the effect of the s. p. v, on the submucosal blood flow of the canine stomach seems to be transient and disappear within a month after operation.

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A computer system plays an indispensable role not only for correctly filing information of the radiographic and endoscopic diagnoses but also for referring to cases which should be placed on follow-up examination. It is also the best tool for a comparative study of the radiographic and endoscopic diagnoses. Modification of IRD (Index for Roentgen Diagnoses) was attempted in order to use the computer system for processing information of radiographic and endoscopic diagnoses of the gastrointestinal tracts, based on the result of the past year. IRD consists of anatomical fields and pathological fields. In this paper the anatomical fields are called "location codes" and pathological fields are called, "diagnosis codes". The main points of the modification are as follows. 1) Modification of the location codesCodes expressing the anterior wall, posterior wall, lesser curvature and greater curvature were made by adding a forth digit. A code for anastomosis and sature line was added. 2) Modification of diagnosis codesCodes expressing peptic ulcer were largely modified in order to reveal the present situation of radiographic and endoscopic diagnosis in Japan. Codes for erosion (s) were added. Codes for malignant neoplasm were vastly modified, following the classifications of Borrmann and early gastric cancer which should be used for cancer of the entire gastrointestinal tracts. A year of actual use and testing at our hospital has proven that the modified IRD is useful and practical on the computer. Establishment of the coding system for the diagnoses is very important as the first step of installing the computer system.

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Screen layout for data input was described, based on the modified IRD, and an outline of system esign was also described. Computer used in this study is IBM System/34. Input data include patient ID, name, year of birth, age and sex as a master file. It also includes necessary items for information of endoscopic examination such as date of examination, endoscope used, kinds of premedication and its side effect, etc. As to inormation of the diagnosis, performance of biopsy and/or polypectomy, number of biopsy fragment, size of polypectomized specimen, pathologic diagnosis of biopsy and/or poly pectomy, number of cancer-positive fragment are described in one step, in addition to the main diagnosis by the modified IRD. In the system design, various kinds of follow-up program for patients are includid. It also consists of many output programs including individual list of the diagnosis, list of number and case of each diagnosis, corresponding list of radiographic and endoscopic diagnoses, etc. Emphasis was laid upon the importance of mutual cooperation among doctors, system engineer and programer in the process from installment plan of computer to its system design.

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Recently, several reports have been published concerning endoscopic determination of gastric ulcer size. In spite of certain advances in its methodology, there seem no established methods with sufficient accuracy for this purpose. We examined a new instrument for the endoscopic measurement of gastric ulcer size developed by Machida Co, . This instrument is composed of special side viewing gastric fiberscope, microcomputer assisted calculating and operating system, graduated sensor probe insertable via forceps channel of the scope and automatic camera interlocking with the operating system. The essential function of the system is to measure the lense-object distance (LOD) by the sensor probe, by which magnification of the gastric lesion on the photograph is calculated. The error of the determination of LOD by this instrument was very small. The aberration ratio was from 1.8±1.7% to 3.2±2.6% in vitro determination of diameter of the reference area. On the other hand, this ratio was from 5.0±5.7% to 8.8±2.0% in vivo determination of reference area, and 7.8±6.8% when 20 gastric ulcers were measured actually. These results indicate that the accuracy of this instrument is sufficient to determine the healing process of gastric ulcer, and that in vivo evaluation should be needed for the examination of the new method or the instrument, because the error is considerably larger in vivo than in vitro.

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Among 131 patients with a polypoid lesion of the stomach whose biopsy diagnosis was classified into Group III (Borderline lesion), 63 patients with follow-up study were investigated to know whether these lesions showed any macroscopic and/or microscopic changes during a period of follow-up. In 15 of the patients (24%) a borderline lesion was finally diagnosed to be carcinoma. 8 of them were operated on within one-year of follow-up in which no apparent growth of the lesion was observed, indicating difficulty and limitation of an endoscopic biopsy to differentiate the borderline lesion from carcinoma at the time of initial biopsy. A repeated biopsy with careful observation of the lesion in a short-term follow-up should be performed to make a correct diagnosis of such lesion. On the other hand, the remaining 7 patients whose lesion was finally diagnosed to be carcinoma showed apparent growth of the lesion during a period of a long-term follow-up. In two patients followed up more than 9 years the lesions showed gradual but apparent growth and were disclosed to have focal carcinoma within the lesions, although the final biopsies were still diagnosed as Group III. In another patient gradual growth of the lesion was observed without histlogical changes by biopsy during a 6-year period. After absence from follow-up for 3 years, the lesion was found to be a Borrmann II type of advanced cancer with a supraclavicular lymphnode metastasis. From our experience in which 9 of 20 lesions followed up more than 3 years demonstrated apparent growth of the lesion and 7 of those were eventually diagnosed to be carcinoma, the borderline lesion could transform to carcinoma. Therefore, one should consider it as a surgical candidate, if apparent growth was observed in such a lesion. Even with negative biopsy for carcinoma, focal carcinoma may still be present. Finally, we would emphasize that biannual follow-up should be continued after a repeated diagnostic work-up at 3 month intervals in the initial 6 months.

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Little has been done in the field of laser spectroscopy for malignant tumors. Laser induced fluorescence of G. I. tract cancer was studied using both spectral and pathological analyses. Red, orange and yellow fluorescence were observed in fresh resected specimens of gastric or cob-rectal cancers without injection of probing reagents by argon laser. Several kinds of emission spectra were obtained from one specimen. These emission spectra were deviled into two groups (A, B). Within A group which comprised spectra obtained from the non-cancerous area, peaks of about 560, 600, 660nm were commonly recorded in all parts of the specimen. These readings were not characteristic of cancer. In group B, and in addition to these normal peaks, readings of about 630nm and 690nm were recorded, These readings were obtained only in the cancerous regions, especially in case of ulcerated cob-rectal cancer. These spectra, including peaks of 630nm and 690 nm, suggested that a red emission might be derived from the native porphyrin which accumulates spontaneously malignant tumors. The method involved the mesurement of fluorescent intensity taking normal mucosa as the median. Positive (above the median) readings were obtained for the following; submucosal layer, arterial wall, xanthoma, ulcer bed (exsudate, necrosis, vessel). Negative (below the median) readings were obtained in the following; muscle layer, marginal wall of the ulcer, blood, ulcer scar, polyp, ha type of early gastric cancer. These findings were in no way connected to the determination of G. I. cancer by histological diagnosis.

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The diagnostic ability for various gastro-duodenal lesions was studied by the Olympus GIF-K₂M (ten magnifications), remodeled GIF-K₂, GIF-HM-20 (twenty magnifications), remodeled GIF-HM and GIF-HM (thirty fjve magnifications) using dye-spraying technigues. The GIF-K₂M was satisfactory in observing the minute characteristics of early gastric cancer, gastric ulcer, gastric erosion, intestinal metaplasia of the stomach and villi of the duodenum. This instrument was useful not only for magnified observation, but also for conventional observation in the upper gastrointestinal tract. The GIF-HM-20 or GIF-HM was useful to observe the fine gastric mucosal patterns. In order to improve the diagnostic accuracy of minute gastric lesions, a low magnifying fiberscope using dye-spraying techniques should be used at the first endoscopic examination, as shown in Figure 10.

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We studied the laparoscopic observation of autofluorescence in human hepatoma and liver cirrhosis excited by argon laser light stimulation. In three cases of hepatoma out of 5, the autofluorescence was clearly observed just indentically in the area of hepatoma, stronger in the periphery. The autofluorescence was usually observed heterogenously, not homogeneously, in the tumor. In one case of liver cirrhosis out of 4, the autofluorescence was recognized on the cirrhotic nodule, in which hepatocelluar carcinoma was possibly ruled out. On the other hand, the same study was done on the cut surface of the three autopsied livers with hepatoma. In all liver cut surface of the three cases, the area of hepatoma showed the strong autofluorescence, which was sharply demarcated from the surrounding area. In the other non-cancerous areas, however, such as liver capsule, liver fibers and vessel walls, the autofluorescence was also recognized. It is not sure yet what of element the tumor does emit the autofluorescence and there is any difference in wave length between the autofluorescence observed in the tumor and other non-cancerous tissues. But these obtained experimental phenomena in the study would surely promise that the present method of laser laparoscopy is an useful diagnostic procedure for early detection of small hepatoma, only if it is located on the surface of the liver at least.

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Nitrous-oxide and oxygen has been widely used as an analgesic in midwifery and in dental surgery, and it has been used for relief of anxiety, fear and pain on endoscopic retrograde cholangiopancreatography (ERCP) at some hospitals. The conditions necessary for these satisfactory examinations are analgesia, freedom from abdominal distress and mental sedation without losing patient's cooperation. A study of the inhalation of Anesoxyn-30 has been undertaken in an inhalation group of 52 patients and has compared with that in a non-inhalation group of 41 patients. We were convinced that this inhalation analgesia was more effective in patients with fear for ERCP than in patients without it. With regard to the overall evaluation of the examiners, other data, and the safety, no remarkable side effect and no complications, the practical application of this inhalational analgesia seems very useful for patients and doctors, and a rapid recovery following of the inhalation indicates that ERCP can be safely and easily undertaken on ambulatory patients.

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A 63-year-old male was admitted to Hikari City Hospital because of hoarseness and tarry stool on April 1979. Upper GI series showed multiple gastric ulcer on the angulus and on the lower corpus. By endoscopy large shallow ulcer on the angulus and the small multiple ulcers on the lower corpus were found. Blood gas analysis revealed elevated PCO₂ and depressed P0₂. By laryngoscopy, laryngeal carcinoma was diagnosed and after irradiation, laryngectomy was performed successfully. Three months after admission multiple gastric ulcer were healed. Comparing with gastroduodenal ulcer associated with COPD (Chronic Obstructive Pulmonary Disease), etiology of this case is discussed.

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A 69-year-old woman was admitted to the hospital on Jan. 31, 1981 because of massive hematemesis. She had been known to have multiple gastric polyps since 15 months ago, when she visited the hospital due to nausea. Although one of her gastric polyps had prolapsed through the pyloric channel into the duodenal bulb, she had been followed under conservative management at an outside clinic. On admission, emergency endoscopy revealed three pedunculated polyps on the gastric antrum and a bleeding ulcer on the tip of the one polyp which had prolapsed into the duodenal bulb at the last occasion. Continuous bleeding necessitated partial gastrectomy. Macroscopic findings of the resected specimen was same to those of the endoscopy. Histologically the polyps were of hyperplastic type. However, a focal carcinoma was detected in the one polyp complicated with ulceration. Reviewing the 221 cases of gastric polyp examined in our clinic for the past 7 years, frequencies of bleeding and malignant change were significantly higher in polyps over 20 mm in size. When large gastric polyps are encountered, they should be removed either endoscopically or surgically because of their high possibilities of bleeding and malignant change.

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Acute kissing ulcer at the pyloric antrum shows frequently characteristic picture which must be differentiated from IIc type of early gastric cancer. And in rare cases, the ulcer scar may become elevated. In these cases, it may be difficult to differentiate from ha type of early gastric cancer by a short time follow-up. We have experienced a case of elevated type of gastric ulcer scar in the healing course of acute kissing ulcer at the pyloric antrum. A 35 year-old man visited our hospital on Nov. 2, 1981 complaining of abdominal pain, nausea and vomiting. The upper GI series revealed a polygonal ulcer with converging fold mimicking IIc type of early gastric cancer at the gastric antrum. Endoscopic examination confirmed acute kissing ulcer of the pyloric antrum (anterior and posterior wall) with prominent fold convergence. Biopsy study was performed from each lesion and showed nomalignancy. After one month therapy, re-examination of endoscopy was performed and revealed almost healed kissing ulcers with ha-like elevated lesions in the center of each fold convergence on both walls of the pyloric antrum. After two months follow-up, posterior lesion became a depressed red scar but anterior lesion was not and an elevated lesion persists even now on June 8, 1982 (namely, almost eight months since initialdiagnosis). The pathology of the elevated scar is thought to be compensated hyperplastic mucous glands and granulation in our case, but the difference of the pathogenesis between posterior and anterior lesion, concerning persisting elevated ulcer scar is not clear.

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A case of adenomyomatosis (segmental type) of the gall bladder and the peritoneoscopic findings were reported. The patient was 46-year-old female, and she admitted our hospital with complaints of upper abdominal pain and slight fever. Routine laboratory examinations showed no abnormality. Drip infusion cholecystography and endoscopic retrograde cholangiopancreatography revealed hourglass deformity of the gall bladder. Cholecystectomy was performed and the histological examination showed adenomyomatosis of the gall bladder (segmental type). Peritoneoscopic findings of adenomyomatosis of the gall bladder have not been reported. Peritoneoscopy of the gall bladder of this patient revealed enlargement, yellowish white and partly pinkish discoloration, many small blood vessels on the surface and subserosal bleeding. No adhesion was observed between the gall bladder and the surrounding organs.

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A case of 21 year-old female with tuberculous peritonitis was reported. She received lapar.oscopy 3 times at the following 3 stages ; zenith, after 3 months of the first laparoscopy and the healing stage. At the first laparoscopy, multiple miliary to rice sized yellow-whitish nodules were seen on her parietal and visceral peritoneum, the sorosa of the gall bladder and the bowel, and hepatic capsule. Tuberculous granuloma was proven histologically by biopsy of these nodules. She had been placed on SM, RFP and INAH until discharge. At the second examination, the nodules previously seen were diminished or decreased remarkably. "Zuckerguss" liver was seen on the surface of the right hepatic lobe. At the third examination, the TB nodules were completly diminished. "Zuckerguss" liver and peritoneal adhesion were seen. The healing of the disease was proven laparosco pically at this time. Although the incidence of TB peritonitis is quite rare in these years, it is very significant to observe chronological changes laparoscopically from the zenith to healing stage, once this disease is diagnosed.

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Ten cases of endoscopic sphincteropapillotomy (EST) were performed using a new type of papillotome (ASAHI KOGAKU : ID-1819, 2019) (Table 1). The new papillotome is characterized by its shark's fin shape and diameter (Figures, 1 and 2). The shark's finconfiguration of the papillotome makes it resistant to twisting or warping . The exposed wire portion of the papillotome extends from 15mm to 30mm from the tip of the cannula in which it is housed. This design facilitates cannulation of bile duct before and after EST and the oral longitudinal folds can be observed clearly . It is also easy to propel impacted concrements in the papilla towards the common bile duct . The convex side of the papillotome is employed for EST (Figure 3) and the tip of the shark's fin can be used for minute cutting . The concave side is covered with tef lon for insulation from the endoscope. There are two variants of the new papillotome, one is 1.8mm (ID-1819) and the other is 2.0mm (ID-2019). The former is easily rotated to the right and direction correction is more difficult than with the ID-2019. In all 10 cases the papillotomy orifices were long enough to remove concrements and to obtain biliary drainage. This new shark's fin papillotome facilitated all EST procedures in comparison to conventional papillotomes.

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An extension system of argon laser light was developed by Machida and Furukawa Co. LTD., and was put first to practical use in Jichi Medical School Hospital. With the extension system, argon laser light is distributed and extended to multiple terminals through the fiber cable, X-ray, operation and endoscopic rooms, 160, 135 and 55 meters away from the central room where the main apparatus of argon laser and distri buting system are located. In the central room, the selection of a laser light with certain wave length and a circuit to certain extension is arbitrarily performed. Other operations are smmothly manipulated through the remote controlling system equipped in the terminals in each extension room. Considering the safety for the people and fire prevention in case of unexpected severance of the fiber cable by any possibility, the whole system is well provided with double or triple safety devices. With this extension system of argon laser light, the indication of laser endoscopy has widely extended with a great advantage of economical efficiency, making it possible to perform the right procedure in the right place.

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Up to date, small intestinal fiberscope has been developed as three main types such as (1) push type, (2) rope-way type and (3) sonde type. However, none of them gives a perfect examination and we must choose one of them depending on the shape and location of a lesion in the small intestine. All three types of the instruments had better to be prepared for enteroscopy. However, it is economically difficult to equip with three enteroscopes at one hospital. During the last two years, a new enteroscope, type SIF-RP, which has features of both the rope-way type and push type f iberscope, has been used at our clinic. By the rope-way method, this scope was introduced into the small intestine even in pediatric patients. On the other hand, the upper jejunum was observed as the extension of upper G-I endoscopy in a short time. Therefore, SIF-RP having functions of both push and rope-way types, is regarded as a more economical enteroscope.

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