Scirrhous carcinoma of the stomach was macroscopically classified into 4 types: giant rugal type, giant rugal and erosive type, erosive type and nodular type. Giant rugal types were most frequent in young females (Figure 5). Accuracy of endoscopic diagnosis was worst in giant rugal type (68.8%) (Figure 8), especially biopsy specimens obtained from giant folds with acid-secreting function failed to reveal any tumor cells (Figure 13). In order to diagnose giant rugal type of scirrhous carcinoma, we devised the endoscopic aspiration cytology. By this method good results have been obtained (Figure 9 &10). Retrospective studies showed that scirrhous carcinoma of the stomach might develop from early cancer of type IIc without converging folds. Scirrhous carcinoma developed not only in the normal oxyntic gland mucosa, but also in the areas of fundal gastritis (Figure 11). Tumors in the normal oxyntic gland mucosa developed into scirrhous carcinoma with giant folds. On the other hand tumors in the areas of fundal gastritis developed into that with marked erosions (Figure 12). The former developed faster than the latter. For early diagnosis of scirrhous carcinoma of the stomach, it is necessary to find and subsequently biopsy small erosions without converging folds. With the endoscopic Congo red-methylene blue test developed in our clnic, gastric cancers can be observed as areas where both dyes are bleached to white, or as non-discolorated areas surrounded with discolorated areas. We conclude that the endoscopic Congo red-methylene blue test is very useful in early diagnosis of scirrhous carcinoma of the stomach.

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The usefulness of X-ray and endoscopic examination was analysed comparatively concerning the discovery of minute cancer of the stomach less than 5mm in diameter. Out of 141 lesions in the authers' 130 cases of early gastric cancer, 13 lesions in 13 individuals were such minute ones as above mentioned, and it was in 9 of them that this diagnosis was established preoperatively. They were IIc type of early gastric cancer larger than 3mm in diameter, all of which were histologically differentiated adenocarcinoma and showed intramucosal invasion. Endoscopically, 2 cases belonged to ha + IIc, 5 to IIc, and one looked like ulcer scar with bleeding tendency, and remaining one showed irregular red spot. Then all of these losions exibited more or less some sign of malignancy. All of the 4 cases, discovered by pathohistological examination of the resected materials, were less than 3mm in diameter and consequently were hard to discern macroscopically. In 6 (66.7%) of the 9 cases, preoperatively diagnosed as having cancer, other co-existing lesions of the stomach played the important role of a trigger in the discovery of the minute cancer. The diagnostic capability of X-ray for the minute cancer was 15.4% (2/13) in the first attempt, and 30.8% (4/13) in the final. The endoscopic result was 69.2% (9/13) both initially and finally. In the cases of small gastric cancer, measuring 5 to 10mm in diameter, the capability of X-ray examination was 30.8% (5/13) initially, and 53.8% (7/13) finally, while that of endoscopy was 84.6% (11/13) initially and 92.3% (12/13) finally. From the above results, the following coclusions were drawn: (1) The size of minute gastric cancer that permits clinical diagnoses is larger than 3mm, and it has some signs of malignancy. In many cases, it belongs to IIc category with intramucosal invasion. Most of them are histologically differentiated adenocarcinoma. (2) Associated gastric lesion other than cancer plays an significant role of a trigger in the discovery of a minute cancer. (3) Endoscope is far superior to X-ray in the detection of a minute cancer. The decision of whether malignant or benign must await the result of biopsy.

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Forty eight cases of the fatty liver in obesity were classified into three groups according to the grade of fatty changes and were investigated about liver fibrosis. Peritoneoscopic findings of the liver surface of fatty liver shows characteristically almost smooth and diffuse yellowish brown surface or cobblestone-like yellowish markings. Moreover, we often observed small depressions and dilatation of small portal vessels on the liver surface. In this study small depressions were seen in 17 cases (35.4%) and dilatation of small portal vessels were seen in 9 cases (18.8%). These findings were observed in severe fatty liver more frequently than mild and slight fatty liver, ; Histological findings of the liver biopsy specimen in severe fatty liver showed frequently hepatic cell necrosis and fibrosis around the central veins. In severe fatty liver the incidence of PP bridging fibrosis was 25% and the incidence of P-C bridging fibrosis was 30%. However, we did not experience that fatty liver showed lobular distortion all over the liver. Our findings suggest that the sinusoidal block according to fatty cysts caused hepatic cell necrosis and fibrosis around the central veins when the fatty liver in obesity became severe.

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In an attempt to obtain basic data for endoscopical photoactivation therapy for cancer, photoactivation effect of various porphyrins have been studied using a human hepatoceller carcinoma cell line (PLC/PRF/5) and its transplanted tumors. Porphyrins tested were hematoporphyrin derivative (HpD), protoporphyrin disodium (PPNa), hematoporphyrin (Hp), coproporphyrin, and cobalt-protoporphyrin (COPP). To investigate cytocidal effects by laser irradiation with these drugs, the ⁵¹Cr release assay was used. The results indicate that laser irradiation only has no cytocidal effect, while PPNa has more intense cytocidal effect than that of HpD. To investigate anti-tumor effect by PRT further, 2mg of HpD, 2mg of PPNa or 0.9% NaCI were injected into human hepatocellar cartinomas transplanted to the flanks of BALB/c nu nu mice 48 hours before laser irradiation (514.5nm, 0.1 W, 30 min). The results were analized with respect to effects on tumor regression curve and their histology. The results suggest that laser irradiation alone has no antitumor effect, while PRT with PPN a has stronger anti-tumor effect than PRT with HpD. Therefore, PPNa may be used as a new photosensitizer for photoradiation therapy for cancer.

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We have examined 196 patients (234 diseases) employing an ultrasonic laparoscope (US-laparoscope), which was designed and developed by Aloca Co. and Olympus Optical Co.. The results were compared with those of ordinary ultrasonography (US). US-laparoscopy was proved to be superior to US in the following points. With regard to the liver 1) subphrenic potion and subcostal portion were scanned without any obstacle, 2) even the smallest tumor in the liver was scanned, 3) detailed structure of the liver was visualized and 4) the portal vein, hepatic vein and bile duct were pursued to the full-end. With regard to the biliary tract 1) the gall bladder was scanned in every direction, 2) structure of the gall bladder wall depicted cleary, 3) small stones in the gall bladder, stones localized in the gall bladder wall and gall bladder polyps were visualized with detailed information, and 4) scanning rate of the neck of gall bladder and end of the cystic duct was higher. With regard to the pancreas 1) direct scanning was possible on pancreas, 2) the inner structure of pancreas was scanned, 3) the outline of pancreas was clearly depicted, 5) longitudinal as well as latitudinal scanning of pancreas was possible, 6) scanning rate of the tail of the pancreas was higher than US and 7) US-laparoscopy was more efficient for small abnormality and calcification than US.

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In the recent progress of roentogenologic and endoscopic techniques, detection of digestive tract malignancies has not been a difficult problem. However, diagnosis of metastatic lymph nodes in patients with these conditions can only be achieved on pathological assesments at the time of operation or autopsy. The authors have been able to demonstrate the pen-gastric lymphatics on X-ray in gastric cancer patients with our newly developed Endoscopic Lymphography (ELG). The procedure is the indirect method by use of endoscopy in which the contrast medium is given by the injector under endoscopic visualization into the sub-mucosa or muscle layer of the surrounding area of gastric lesion. The regional lymphatic vessels, the fine and afferant ducts, were clearly observed on X-ray immediately after the injection. The nodes were also seen on X-ray after an interval, between a few hours and twenty-four hours later. The pen-gastric lymphatics were detected on ELG in 2 of 4 cases with early gastric cancer and in 8 of 10 cases with advanced cancer. In comparison of pathological diagnosis, nonmetastatic lymph nodes revealed were less than 5 mm in size, and these usually showed fine nodular patterns. On the other hand, metastatic ones demonstrated filling defects, swelling, marginal irregularity and other abnormalities. The ELG could be a good indicator for the local treatment of early gastric cancer and the complete regional lymph node dissection at the operation. However, a further improvement in the techniques, X-ray demonstration and contrast medium is necessary for constant visualization of the lymphatics.

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It has been known that percutaneous transhepatic cholangiodrainage (PTCD) is an effective way of biliary drainage on obstructive jaundice. In recent papers, it has been shown that endoscopic nasobiliary drainage (ENBD) is an effective way of drainage on not only benign but also malignant obstructive jaundice. The purpose of this study is to clarify the effect of ENBD comparing with that of PTCD on malignant obstructive jaundice. ENBD were performed in 5 cases of cancer of the papilla of Vater and PTCD were performed in 35 cases of malignant obstructive jaundice (bile duct cancer: 16 cases, cancer in the head of pancreas: 12 cases, cancer of the papilla of Vater: 7 cases). Results were as followed, Daily mean bile volume discharged from drainage tube were 439±117.8 ml in ENBD and 433.6 + 40.1 ml in PTCD. Durations of drainage were 9 to 23 days (mean 14.2 days) in EN BD and 2 to 69 days (mean 24.7 days) in PTCD. Effects of drainage were estimated by decreases of serum total bilirubin. In ENBD, serum total bilirubin were 9.78±3.0 mg/dl (M±SE) at drainage, 7.09±2.2 mg/dl at 3days after drainage and 5.17±1.6 mg/dl at 7 days after drainage. In PTCD, serum total bilirubin were 13.7±1.9 mg/dl at drainage, 11.06±1.1 mg/dl at 3 days after drainage and 8.44±1.09 mg/dl at 7 days after drainage. Decrease of serum total bilirubin were satisfactory in both ENBD and PTCD. Complication of ENBD was obstruction of the drainage tube in one case, while complications of PTCD were hemobilia in 3 cases and one of them developed renal failure. In ENBD restriction of body movement of patients was not necessary during drainage, though restricted for several days in PTCD. We could shorten the durations of drainage and proceed to other examinations necessary for the operation immediately after drainage by ENBD. We think EN BD is an effective treatment of biliary drainage on malignant obstructive jaundice, especially on cancer of the papilla of Vater.

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Hemostatic effect of pure ethanol injection under direct vision through an endoscope devised by Asaki et a1 on bleeding after colonoscopic polypectomy was evaluated. In two cases, prophylactic ethanol injection into a cut surface of the stalk was performed. In eight cases with oozy bleeding and one case with pulsatile bleeding, ethanol injection into the bleeding site achieved a satisfactory hemostasis without any complications. In one case with oozy bleeding, recurrent bleeding occured on the 10th and 14th days after initial ethanol injection at polypectomy. Emergency colonoscopic examination revealed the presence of oozy bleeding from the cut-site of the stalk. Prompt hemostasis was obtained after local injection of pure ethanol. Even in this case and another case of pulsatile bleeding, we could avoid blood transfusion or laparotomy owing to this hemostatic method. From the standpoint of simple maneuver, safety, reasonable cost and satisfactory efficacy, it was considered that this method was effective to stop bleeding from the cut surface of the stalk after colonoscopic polypectomy.

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We herein presented two patients developing acute esophageal erosions and gastric ulcerations which were possibly induced by Lugol's solution spray at esophagoscopy for evaluation of the extent of esophageal carcinoma. Both patients developed severe epigastric pain immediately after Lugol's solution was sprayed in the esophagus. Endoscopy showed erosions in the esophagus and ulcerations just below the cardia of the stomach, 3 days later in the first patient and next day on the second patient. The first patient improved with cimetidine and other antiulcer drugs. The bleeding ulcers in the second patient were managed to stop bleeding by laser coagulation. To our knowledge, there have been few reports regarding complication in dye scatter ing endoscopy. The authors would like to stress that more attention should be paid to such complication in Lugol's solution spray at dye scattering esophagoscopy.

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A 74 years old female has had a plaque and a erosive lesion on the left ring finger and right leg respectively for over 2 years, which has increased in the size gradually. As a diagnosis of Bowen's diseases was made by biopsy from the lesion of left finger, the lesions was excised. Patient was then referred to us for examination of internal malignancies. By endoscopic examination of the stomack, an irregular shallow mucosal depression was found on the lesser curvature of the lower body, which was comf irmed as cancer by biopsy and made a diagnosis of IIc type gastric cancer. Subtotal gastrectomy was done and pathological examination revealed early gastric cancer type IIc, moderately differentiated adenocarcinoma, with no lymph nodes metastasis. Among fourteen cases of gastric cancer with Bowen's disease reported in Japan, three were of early gastric cancer. Necessity of endoscopic examination in patient with Bowen's disease is emphasized. A 74 years old female has had a plaque and a erosive lesion on the left ring finger and right leg respectively for over 2 years, which has increased in the size gradually. As a diagnosis of Bowen's diseases was made by biopsy from the lesion of left finger, the lesions was excised. Patient was then referred to us for examination of internal malignancies. By endoscopic examination of the stomack, an irregular shallow mucosal depression was found on the lesser curvature of the lower body, which was comf irmed as cancer by biopsy and made a diagnosis of IIc type gastric cancer. Subtotal gastrectomy was done and pathological examination revealed early gastric cancer type IIc, moderately differentiated adenocarcinoma, with no lymph nodes metastasis. Among fourteen cases of gastric cancer with Bowen's disease reported in Japan, three were of early gastric cancer. Necessity of endoscopic examination in patient with Bowen's disease is emphasized.

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This is a case of Menetrier's disease accompanied by Buerger's disease and multiple lipomatosis. Patient was 34-year-old male and referred to the Osaka Medical College for further evaluation of hypoproteinemia detected during the treatment of Buerger's disease. Physical examination revealed numerous lipomas on the trunk and upper and lower extremities. Laboratory findings showed hypoproteinemia and hypoalbuminemia. Loss of protein from the gastrointestinal tract was confirmed by the result of ¹³¹I-RISA and ¹²⁵I-PVP test . Electrophoretic pattern of the gastric juice was similar to that of serum protein. Huge, convoluted gastric rugae were found throughout the entire fundus and body of the stomach by both x-ray and endoscopic examinations. Histology of gastric biopsy showed mucosal hyperplasia. Gastrectomy was performed under a diagnosis of Menetrier's disease. Serum protein, albumin, ¹³¹I-RISA and ¹²⁵I-PVP improved one month following the operation.

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A 50-years-old female was admitted in November, 1982, complaining of edema over her lower limbs and tarry stools. She had suffered from dermatomyositis since 1980. On admission, fluctuation was palpable in the abdominal region, chest X-ray showed massive pleural effusion bilaterally, and laboratory finding showed anemia. On endoscopic exami nation of the esophagus, varices were seen in the lower part. The findings of abdominal CT scan and liver scintigram (^99mTc phytate) suggested marked liver cirrhosis. As there was no evidence of malignancy in any examinations and tests, we concluded that her episodes were induced by the late stage of liver cirrhosis. This case suggests the impor tance of active investigation on the liver in patients with dermatomyositis, although it is extremely rare.

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Between the anomalies of shape of the gallbladder an hourglass deformity is relatively often encountered on cholecystography. The cause is considered as congenital or acquired. In the latter benign lesions such as inflammation and adenomyomatosis are much more common as the genesis than malignancy. In this paper we reported two cases of gallbladder cancer showing an hourglass deformity on cholecystography. To avoid misdiagnosis in this condition, the followings are considered to be important cholecystographically: 1) to get clear opacification of the gallbladder by direct visualization method, 2) to observe the shift of the axis, extent and margin of the stenotic segment from many directions, 3) the additional use of compression method. It may improve the resectability of gallbladder cancer to put much care on such condition.

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