In order to discover the minute cancer of the stomach, magnified endoscopy has been performed in 148 cases since 1980. GIF-HM (olympus) with magnifying power by 35 at maximum, has been used. The mucosal pattern could be usually divided into 4 groups as followed; "dotty pattern", "stick-like pattern", "mazy pattern" and "net-like pattern". Each pattern reflected histologically closer relationship with glandular constitution, for instance, dotty pattern was seen in fundic gland area, stick-like pattern in a mixed area of fundic and pyloric gland, mazy and net-like pattern in pyloric gland area. The lesions with redness were observed with magnification to make differentiation between malignancy and benignancy. According to magnifying view at the margin, six type could be calssified. 1) Peripheral redness is observed in superficial gastritis and hyperplastic polyp. 2) Tile-like appearance is observed in erosion, ulcer, ulcer scar and hyperplastic polyp. 3) Fence-like appearance is seen in erosion, ulcer scar and canncer. 4) Irregular type is seen in erosion, ulcer, ulcer scar and cancer. 5) Destructive type is always seen in cancer. 6) Vascular type means teleangiectasia. Irregular and destructive type would be considered as characteristic feature of cancer.

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For the purpose of differentiation between benignancy and malignancy in minute erosions, endoscopic magnification was attemped in 104 cases. The study has been carried out in cases which showed a red spot of the gastric mucosa in 41 cases of early gastric cancer, 31 cases of gastric erosion, 16 cases of gastric ulcer scar and 16 cases of so called red patch. Endoscopic differentiation between minute cancer and benign gastric erosion could be made as follows. Benign erosions were seen at their margins as "tile-like" and "fence-like" type in 13 of 31 cases in magnified view. In minute cancer, "irregular" and "destructive" types were seen in 5 of 6 cases, but the remaining one was demarcated with a zigzag border. It is considered that an irregular, destructive and zigzag border indicates a characteristic feature of malignancy.

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This study was undertaken in order to establish the possibility of applying endoscopic surgery as radical treatment for certain types of early gastric cancer. Clinicopathological study with special reference to lymph node metastasis was carried out on 179 cases with early gastric cancer operated on at our hospital between January 1967 and December 1982 (Table 1). Correlation was investigated between lymph node metastasis and such fuctors as gross types of early gastric cancer, depth of cancer invasion, size of cancer, association of peptic ulcer (“Ul”) within cancer, size of “Ul”, and depth of “Ul”. The results obtained from the present study are as follows; 1) Lymph node metastasis was demonstrated in two (2.1%) of 95 cases with intra-mucosal cancer and in eleven (13.1%) of 84 cases of carcinoma with submucosal invasion. The rate of lymph node metastasis in a total of 179 cases of early gastric cancer was 7.3% (Table 2). 2) With regard to histological types of early gastric cancer, metastasis to lymph node was found in three (3.3%) of 91 cases with well differenciated types of adenocarcinoma. No lymph node metastasis, however, was disclosed in any of 58 cases of intramucosal cancer with well differenciated type of histology (Table 4). 3) In relation to the size of cancer, the rate of lymph node metastasis in cases of early gastric cancer less than 2.0cm and greater than 2.lcm in the greatest diameter was 1.7% (1/59) and 10% (12/120), respectively (Table 5). 4) Two of 50 cases of intramucosal cancer with ulcer or ulcer scar within cancer were proved to have lymph node metastasis. On the other hand, no lymph node metastasis was detected in 45 cases of intramucosal cancer without association of ulcer (Table 6). From these results, we consider that well differenciated type of intramucosal cancer without association of ulcer is a good candidate for radical endoscopic treatment, Among various endoscopic methods for radical treatment of early gastric cancer, endoscopic resection which enables adequate pathological study of resected material seems to be most appropriate.

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Small cell carcinoma of the esophagus is a rare tumor. Since McKeown reported first two cases of this tumor, about thirty cases have been reported in literatures. Ten cases (1.7%) of small cell carcinoma were found in 606 cases of primary esophageal carcinoma in our clinic. Endoscopic examinations were performed in 7 cases of them. Small cell carcinomas appeared as submucosal tumors in the early phase, but when advanced, it cannot be differentiated from squamous cell carcinomas endoscopically. Therefore, biopsic diagnosis is important for accurate diagnosis. Aspiration cytology of the tumor is also useful for accurate diagnosis : A combination of histological diagnosis and aspiration cytology of the tumor raised the diagnostic rate to 85.7%. But diagnosis of the submucosal type is very difficult. We treated a patient with small cell carcinoma of the esophagus with vincristine and cyclophosphamide alone. The esophageal tumors were markedly reduced in size and he survived for about 5 months after beginning of the chemotherapy. A combination of multi-drug chemotherapy and other treatments should probably improve the prognosis of patients with small cell carcinoma of the esophagus.

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The exposed vessels of the upper G-I tract bleeding cases were classified into 4 types. 1) Type A : protruded red, fresh. 2) Type B : protruded, black, reddish. 3) Type C : almost flat, black. 4) Type D : flat, white, ruin. Daily observations were made endoscopically to 40 bleeding lesions after treated with pure ethanol local injection hemostatic method. Active bleedings were stopped instan-taneously. Almost all of the unstable exposed vessels such as Type A and B changed to the stable ones such as Type C and D within 1 or 2 days, however, several ones did not change, probably due to inadequacy of injections. Therefore, additional ethanol local injection was successfully given changing them to Type C or D. We rarely observed the enlargement or deepening of ulcers by additional ethanol local injection. In conclusion, we have to observe the bleeding lesion or exposed vessels carefully until they become to be the stable states, and if still unstable, it is necessary to do the additional injection. Then we can manage the bleeding case successfully.

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Hepatic surface color under peritoneoscopy has been judged by subjective evaluation of the peritoneoscopist. We have studied, therefore, to evaluate the hepatic surface color objectively by a color and color difference meter, OFC-1001DP made by Nippon Denshoku Company in Tokyo (Figure 1). The color meter has a sensor, 2 mm in diameter and 30 cm in strength. It is able to measure the color of the normal rat liver unto 2-3 mm in depth from the liver surface (Figure 3). The materials studied were 5 cases with acute hepatitis, 9 cases with chronic hepatitis, 2 cases with liver cirrhosis, one cases with fatty liver and symptomatic HBs Ag carrier. The color of hepatic surface was expressed by three index : L, a, b, according to Hunter UCS. The color of normal gallbladder was expressed as L 35.1 + 3.0 (n =10, m ± SD), a 0.92 ± 4.6, b -3.24±1.9, which meant whitish blue. L value of the color in gallbladder was significantly increased in the cases with whitish cloudy serosa compared with normal gallbladder (p<0.01). The color of hepatic surface expressed by the color meter was almost equal to the color observed under peritoneoscopy. The color of white star-like acinous marking was increased in L value compared with other liver surface. The color of prenodular pathcy marking was observed to be decreased in brightness and increased in reddness (b value). Thus, it is suggested that an objective evaluation of hepatic surface color enabled us by the color and color difference meter.

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An attempt to evaluate objectively the hepatic surface color with cholestasis under peritoneoscopy was conducted by expressing it to three index using a color and color difference meter. Materials studied were 6 cases with normal liver, 6 cases with cholestasis and 2 cases with fatty liver. By the color meter the surface color of normal livers was expressed as slight low lightness, red hue, dull saturation. The color is so-called black-brown. Cholestatic color was expressed as low lightness, yellow-red hue, bright saturation. Fatty liver was expressed as high lightness, yellow-red hue, bright saturation. Thus color difference was obvious among the three. The color of hepatic surface expressed by the color meter was not different from the color observed under peritoneoscopy. The color meter enabled us to evaluate the color of cholestatic liver surface ob-jectively.

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Endoscopic appearance of forty-eight flat tumors (adenoma or early carcinoma) of the large intestine were studied. Among 568 cases of polypectomized specimens with their size more than 5 mm, flat tumors were 8 per cent. Flat tumors comprized 35 (73 %) benign adenomas. 9 (19 %) mucosal cancers and 4 (8 %) submucosal cancers. We subclassified flat tumor (FT) into four ; pure FT, FT with incision, conglomerated ha-like and FT with central depression. The rate of early cancer increased together with the increase of the size of FT. No early cancers were found among the conglomerated ha-like group. Submucosal cancers were found only among pure FT and FT with central depression. All FT (9cases) whose surface showed marked redness proved to be early cancer. On the contrary, no cases of benign adenoma showed superficial redness. Hence, it can be stressed that flat tumor with superficial redness are early cancer and cases without superficial redness are benign. However, there were several cases of early cancer without superficial redness. Superficial redness is very important in the distinction of benign adenoma and early cancer. However, there were no parameters useful in the differencial diagnosis between mucosal and submucosal cancers.

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We have developed a new small diameter laparoscope in cooperation with Machida Co. and investigated its utilities in various kinds of cases. Capacity of this laparoscope was as follows ; The effective length is 300 mm with an overall diameter of 2.0 and 2.1 mm, composed of 10000 fibrils. The viewing angle is 60°and 90°. Furthermore, the following benefits were proposed. 1. The new small diameter laparoscope could be applied safely, even to an infant of four months old. 2. Sensor of ultrasonic laparoscope could be placed more precisely on the target portion in combination with this laparoscope. 3. We could perform laparoscopic examination by this equipment in the cases in whom ordinary laparoscopy was difficult because of adhesion. In conclusion, the small diameter laparoscope can offer better diagnostic ability for cases or localized lesions on the liver where is otherwise difficult to observe by ordinary laparoscopes. Therefore, it would be desirable that institusions performing laparoscopy may keep this type laparoscope in addition to ordinary one.

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The authors already reported that the use of a complementary filter is not only effective to reduce the fatigue of color sensation of the endoscopist during G. I. endoscopy, but gives the images similar to those obtained by spraying die. This time, we applied the complementary filter to colonofiberscopy, and obtaind the same beneficial effects as in G. I, endoscopy.

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A case of gastric carcinoid and a case of duodenal carcinoid are reported. Case 1: A 57-year-old woman had hematemesis. Upper GI series disclosed a protruded lesion in anterior wall of the gastric body, and an emergency partial gastrectomy was performed for uncontrolled hematemesis. Case 2 : A 69-year-old man with epigastralicpain underwent both upper GI series and endoscopic examination followed by gastrectomy, revealing a submucosal tumor of the duodenal bulb. The tumors in both cases were non-argentaf f ine carcinoids.

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Recently we experienced a case of "vanishing tumor of the stomach" first reported by Yamazaki, et. al. This case was reported because we observed it closely and determined the probable cause. The patient was a 49-year-old woman with a chief complaint of epigastric pain. The first gastric X-ray and endoscopic examinations revealed a mass suggestive of a malignant submucosal tumor complicated by a large ulcer in the upper angulus of the stomach. However, eosinophilic granuloma was detected by a biopsy, and parasitosis was suspected. In a follow up study concerning the indication for surgery, no mass was obrerved upon a second examination two weeks later, and the mucosa in this area returned to normal after four weeks. This condition seems to be categorized into the vanishing tumor of the stomach. It is presumed that the mass of this patient was an eosinophilic granuloma that developed from localized allergic edema caused by a parasite perforating into the wall of the stomach, and that it was rapidly reduced by necrosis beginning at the central area followed by histological restoration.

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A 47-year-old man was admitted to Tokai City Hospital because of the precise examination of gastric polyp. Carcinoid tumor was suspected by endoscopic biopsy two years earlier. Gastroscopy disclosed two sessile polyps on the lesser curvature of the body. Biopsy revealed typical features of carcinoid tumor. Biochemical analysis including urinary 5-HIAA were all normal. Subtotal gastrectomy was performed and two sessile polyps of 4.2 mm and 4.8 mm in size respectively were noted. Histologically, the tumor cells were uniform and formed a ribbon-like arrangement. Both tumors were confined to mucosa and submucosa. Among 147 reported cases of gastric carcinoid tumor in the Japanese literatures since 1963, there were 8 cases of minute carcinoid tumor of the stomach. The diagnosis was established by endoscopic biopsy in only 3 out of these 8 cases prior to gastrectomy. When a gastric carcinoid tumor, even minute, is detected, careful endoscopic observa-tions would be necessary to rule out other carcinoid lesions because of its multicentricity. In addition, redical gastrectomy should be done because of the possibility of invasion to lymph vessels and the presence of microscopic tumorlets around the tumor.

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Two cases of duodenal lipoma was reported. Case 1: A 78-year-old man was admitted to our hospital with a complaint of upper abdominal pain. Upper GI series demonstrated a round shadow defect at the 3rd portion of the duodenum. Endoscopic examination revealed a yellowish tumor with smooth surface. He died of renal insufficiency. At autopsy, the tumor was pedunculated and 20×14×14 mm in size. Histologically, the tumor was a benign submucosal lipoma. Case 2: A 36-year-old man with upper abdominal discomfort was admitted to our hospital for precise examination. Hypotonic duodenography and endoscopic examination showed a semipedunculated submucosal tumor at the 3rd portion of the duodenum, and the tumor was yellowish endoscopically. Surgical excision was performed. The resected tumor was club-like formation, measuring 12×12×28 mm, and diagnosed as a benign submucosal lipoma histologically. To our knowledge, only 27 cases of duodenal lipoma have been reported in Japan including our 2 cases, and a review was made on the literature about them. We considered that the clinical tentative diagnosis of lipoma was able to made, because they were recognized yellowish submucosal tumor, endoscopically.

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We treated a 40-year-old man who suffered from pneumatosis cystoides intestinalis (PCI) of the right side colon. The patient was treated with 75 % oxygen inhalation under a oxygen tent. Oxygen inhalation was given for 6 hours per day. During therapy, we monitored the gas cysts near the ileo-cecal region with X-ray television. The treatment was repeated 6 times in the same way. Abdominal plain film, barium enema and colono-scopy demonstrated gas cysts completely disappearing after treatment. The symptom also subsided. We think that our treatment was very useful. Advantages of our treatment are as follows. 1. Technique of treatment is very easy. 2. Patient has no discomfort during treatment. Patient is restricted for only 6 hours per day. 3. Pulmonary oxygen toxicity due to high concentration oxygen inhalation was minimal and the effect was satisfactory.

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An eleven-year-old girl was admitted because of hematoemesis from esophageal varices. On admission, splenomegaly and anemia were markedly seen, but hepatomegaly, ascites and jaundice were not present. Laboratory data on admission revealed pancytopenia and occult blood of stool. Liver function tests were within normal limits (Table 1). Laparoscopic examination revealed almost normal liver and 410mm H2O of the pressure in the spleen. Angiography showed marked splenomegaly and dilatation of the portal vein. We could not check any other diagnostic findings by ERCP, CT scanning and retrograde portography from hepatic vein. Operation was done on suspicion of idiopathic portal hypertension. Portography at the operation revealed the stenosis of the portal vein as shown in Figure 5. Generally prognosis of this disease is rather good but diagnosis is thought to be difficult, even though correct diagnosis is important. We thought that percutaneous transhepatic portography might be necessary for correct diagnosis.

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Two cases of hepatic Wilson's disease in siblings were reported. Case 1. A 14-year-old girl was admitted because of icterus, ascites and secondary ammenorrhea. Slit lamp examination showed Kayser-Fleischer's ring. Hypocupremia, hypoceruloplasminemia, and panaminoaciduria were present. Urinary copper excretion was increased. Clinical stage was Deiss' IIB and Dobyns' IIBI. She died of hepatic coma and autopsy showed the liver cirrhosis. Hepatic copper concentration was 623, ug/g dry weight. Case 2. A 12-year-old younger sister of case 1 was asymptomatic but found to have the same disease in family study. Kayser-Fleischer's ring was absent, but hypertransam-inasemia, hypocupremia and hypoceruloplasminemia were seen. Urinary copper content was increased. Peritoneoscopy showed yellowish liver. Its surface was smooth but the brown reticular pattern was seen all over the liver. These areas were thought to cor-respond to the hepatic lobules. The microscopic examination of biopsy specimen disclosed fatty degeneration and fibrous expansion of Gllison's sheath but glycogen nuclei were absent. Hepatic copper concentration was 1235Icg/g dry weight. Clinical stage was Deiss' I and Dobyns' I or IIA. She was placed on D--penicillamine and diet therapy with eventual improvement of liver function tests.

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