The First Department of Internal Medicine, Yamaguchi University school of Medicine, Ube, Japan. We have reported that an ordinary laparoscopy has limitation in observing the entire liver surface in spite of its benefit to directly diagnose a localized lesion, particularly hepatocellular carcinoma (HCC). We have developed four types of ultrasonic laparoscope in cooperation with Machida Co. and Toshiba Medical Co. since 1981, as reported previous-ly. We here-in reported diagnostic usefulness of a new type ultrasonic laparoscope (model V), inserted linear electronic real-time scanner of 5.0 MHz. Tte characteristics are as follow. 1) linear scanner type of ultrasonography. 2) forward-oblique type of optical system. 3) flexible fiberscope system. 4) panning system. We have applied these equipments to 30 cases of miscellaneous disease. It is concluded that the ultrasonic laparoscope can increase the diagnostic ability of localized lesions on and inside of the liver, gall bladder and pancreas.

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Fifty three patients with ischemic colitis were studied clinically. In order to investi-gate the clinical features and the indication for operation, stricturing rate (s. r.: the diameter of the narrowed lumen/the diameter of the normal lumen × 100 %) should be established objectively in barium enema examination. Referring to the writings of Marston, the new original description of ischemic colitis was graded four forms by s. r.. These were as follows : (1) gangrenous form : 2 cases (2) stricturing form. severe (s. r. ≤ 50%) : 7 cases (3) stricturing form, mild (s. r.>50%): 11 cases (4) transient form : 32 cases ((a) longitudinal ulcer or erosion: 17 cases (b) irregular ulcer or erosion: 15 cases) The three forms except gangrenous form was analysed in age distribution, associated disease, main symptoms (initial symptoms), duration of symptoms, locative distribution, X-ray findings, endoscopic features, laboratory data and etc. in detail. Colonoscopically, the longitudinal ulcer was observed from one to three lines. Most of the longitudinal ulcer were seen in the left side of colon, especially sigmoid and descending colon. Operation should be performed only in the cases in whom following all items are satisfied.: (1) symptoms over about two months after onset (2) s. r. ≤ 50% (3) relatively younger cases in whom no severe complications are not seen.

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Factors leading to ischemic colitis are considered the vessel (artero-sclerosis, artero-spasm, ---), the intestine (high-intraluminal pressure, hyperactive peristalsis, ---) and etc.. Characteristic features of this disease are either longitudinal ulcer or erosion at the site of taenia coli. Therefore, using rabbit, an association between the high-intraluminal pres-sure & hyperactive peristalsis and the colonic mucosal blood flow in both sites of taenia and non-taenia coli was investigated experimentally. As the results, with the pressure of 30 mmHg, the blood flow in both sites was reduced, however, marked reduction at the site of taenia coli was observed. On the state of hyperactive peristalsis after intravenous administration of neostigmin and dinoprost, the average of blood flow in total cases was reduced temporarily, despite that the blood flow in each case was variable. Colonic mucosal blood flow was clearly influenced by the change of intraluminal pressure, showing that particularly the blood flow of the site of taenia coli decreased much more by the high pressure. This may be one of the reasons why longitudinal ulcer is seen frequently at the site of taenia coli. In conclusion, it is strongly considered that the intraluminal pressure might be involved into the etiological factor of ischemic colitis.

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We investigated a visualization method of the pancreas in endoscopic ultrasonography (EUS) and its usefulness as a diagnostic measure for the pancreatic diseases. Subjects were 3 autopsy cases and 50 clinical cases including 19 patients with pancreatic diseases. It was proved by EUS and the anatomical investigation in the autopsy cases that the portal vein system, the left kidney, the gastroduodenal artery and the common bile duct were very important as landmarkers to visualize the pancreas in EUS. In clinical study, those landmarkers were also very effective to do the pancreas. The instrument used in clinical study was the third prototype (Olympus GF-UMI), ultrasonic endoscope with 7.5 MHz rotating transducer. Compared with the visualization rates of the pancreatic regions by conventional ultrasonography (US), those rates with this instrument were very high. Moreover, the better resolution of ultrasonic image could be definitely obtained with this instrument than that of US because its ultrasonography was intraluminally performed with high frequency and that the image was never disturbed by the gastroduodenal gas nor the abdominal wall tissues. Both the sensitivity and specificity of this method were much higher than those of US in the diagnosis of 3 pancreatic cysts, 7 chronic pancreatitis, and 10 pancreatic cancers. Especially, this method was more effective in the diagnosis of chronic pancreatitis and small pancreatic cancer, and in the differencial diagnosis between them, compared with the other examinations. It is concluded that the endoscopic ultasonography is a new diagnostic method of great value for the pancreatic diseases.

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We have studied on ultrasonographic figures of colonic wall, cancer and polypoid lesion of the colon by means of a ultrasonic endoscope equipped with a mechanical radial or a electronic linear array. Ultrasonographically, the wall of normal colon was formed with 7 layers, and in the first and second layer from the side of mucous membrane the musclaris mucosae was held. The third layer represented submucosae, the fourth propria muscularis, the fifth intra-musclar tissue, the sixth traverse muscle and the seventh subserosa, respectively. High echoic border was shown the surface side of each layer. Colon cancer was detected to be low echoic shadow and its invasion was caught as interruption or tear of each layer. Regarding ultrasonographic view of polypoid lesion, low echoic region was observed in the center of this lesion as if ghoast echo, in the similarity of cancer.

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In order to elucidate the morphological features and the course of non-A, non-B chronic hepatitis, we have studied the laparoscopic and histological findings comparing with type B chronic hepatitis. The subjects were 34 cases of non-A, non-B chronic hepatitis and 39 cases of type B chronic hepatitis which were diagnosed in our department. In non-A, non-B chronic hepatitis, the frequency of typical pen-portal reddish mark-ings and dark-reddish patches were lower than those of type-B chronic hepatitis. Further detailed observations revealed the high frequency of partial and irregular "atypical re-dness". This finding would be due probably to wide hepatocellular damage and later develop a partial depression on the liver surface. Therefore, the liver surface would become uneven. These findings were more and stronger in liver cirrhosis than in chronic hepatitis. The liver function in cases with "atypical redness" were unstable. So these findings were thought to be important in progression of non-A, non-B hepatitis to liver cirrhosis. Histologically, follicular infiltration of lymphocytes, changes in the hepatic parenchyma and hepatocellular damages around the central veins were seen more fre-quently in non-A, non-B chronic hepatitis than in type B chronic hepatitis. It is concluded that the course of non-A, non-B hepatitis would be fairly different from that of type B hepatitis.

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A new approach of dye peritoneoscopy using intravenous injection method of Indo-cyanine Green (ICG) was peritoneoscopically evaluated. Method : ICG was intravenously tolerated as 2 mg/kg or 4 mg/kg. Liver surface was peritoneoscopically observed from 0 to 40 minutes and photographies were taken at 5, 10 and 15 minutes after injection. Results: 1. Acinar markings of the liver surface were contrasted by ICG-dyed pare-nchyma. Optimal time of peritoneoscopic observation was from 5 to 40 minutes. Both tolerance dose gained almost same peritoneoscopic findings. 2. Dark reddish patchy marking (Shimada's code No. 7) representing regenerative hepatic cells was well stained and clearly contrasted, although periportal reddish marking (Shimada's code No. 4 ) representing piecemeal or bridging hepatic cell necrosis was not stained. 3. Hepatoma tissue remained to be unstained, of which discovery being made easily. Differentiation of hepatoma tissue with adipose tissue was, however, difficult because localized deposition of fat also remained to be unstained. Further clinical evaluation of this method is, thereafter, thought to be necessary to improve the accuracy in diagnosis of hepatoma. 4. No untoward effects was observed in this new method.

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Peritoneoscopy has been a measure to assess the progress and activity of liver disease, judged from the structual changes of the liver surface. In the present study, Indocyanine Green (ICG) was applied with the assumption it might help to see much clearer the pathology of liver acini. 100 mg of ICG was given intravenously followed by the admini-stration of another 100 mg of ICG 15 minutes later and photography was taken each 15 minute. Since liver acini became green, it became easy to identify acinous markings, while white markings became much clearer as well. It seems likely that it is able to assess the status of liver function since nodules in nodular liver took moreICG compared to the rest of them. The uptake of ICG was poor at the site of severe fatty infiltration. These results suggest that peritoneoscopic examination after ICG administration is usuful to assess the severity of the liver disease.

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We investigated clinical application of the laser treatment in 17 lesions of gastric cancer and 7 lesions of atypical epithelium. Twenty lesions were attempted to treat curatively and ten lesions of them disappeared successfully with this method. All the lesions were less than 1.5 cm in size and cancerous infiltration was limited to the mucosal layer. Histologically, in nine lesions which were irradiated before operation, the mucosal layer and the lamina muscularis mucosae disappeared and the submucosal layer was changed into the necrotic tissue in various degrees. A part of the proper muscular layer was destroyed in three cases. Thirty cases (8.5%) in 351 cases of solitaly early gastric cancer accompanied the lymph node metastasis in our institute. In two cases out of them cancerous tissue was located in the mucosal layer and these lesions were diagnosed as a IIc type early cancer with ulcer scar, respectively. The lesions which are feasible to be cured completely by the laser irradiation are thought to be those less than 2 cm in diameter, limited to the mucosal layer and of the protruded type or the depressed type without ulceration or ulcer scar. In two cases lesions increased the volume within a half year of irradiation. In one case the lesion grew up to the same size as seen before the irradiation one year and nine months later.

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The histological effects of Nd-YAG laser radiation on the canine stomach with the contact type of the optical fiber (laser rod) were studied comparing to those with the non -contact type of the optical fiber. Experimental studies were also performed during laparotomy in a mongrel dog weighing 15 kg under general intravenous anethesia. It was examined two methods of the contact radiation with the laser rod. One was the single radiation from 20W, 30W, 40W and 50W (actual power; 17W, 25W, 34W and 42W at the tip of the laser rod) with exposure durations of 1.0, 1.5 and 2.0 seconds. The other was the continuous radiation about 3.0 to 5.0cm in length from 30W and 40W (actual power ; 25W and 34W). Mucosal changes after the contact radiation were minimal and localized at the contact area by the laser rod than those of the non-contact radiations. The depth of histological changes by the laser rod both the single and continuous linear radiation revealed a peculiar patterns. The photocoagulated area increased in the mucosal layer and decreased in the submucosal layer (diamond shaped coagulation, Figure 6). Conclusions were as follows ; 1) The YAG laser rod was not destroyed by heat of the photocoagulation or in tissue contact, and was trasmitted about 85% of the YAG laser beam. 2) The penetration depth with the contact radiation by the laser rod was deeper than those with the non-contact radiation by the quartz fiber. 3) It was suggested in this study that the YAG laser rod may be possible endo-scopically for acculate radiations and effects to the bleeding vessels and tumorous lesions in the gastrointestinal tract.

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Liver scintigraphy, computed tomography (CT) and ultrasonography were performed in 70 patients with acute hepatitis of acute phase, and these findings were compared with the clinical severity and laparoscopic findings in recovered stage. Cases with severe necrotic lesions of the liver on laparoscopy showed severe clinical courses, however, not vice versa. The low-uptake of the liver on scintigraphy were seen in 3 cases and was related to clinical severity and massive hepatic necrosis . The heterogenous RI distribution of the liver and splenomegaly were showen in most cases of A-type and were related to rapid clinical deterioration. Two cases with the finding of a localized low density area of the liver in CT and irregular echo pattern in sonography showed severe massive necrotic lesions on laparoscopy. Scintigraphy, computed tomography and sonography are valuable in the evaluation of acute hepatic failure in patients with acute hepatitis.

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A 70-year old male was admitted to our hospital because of pedal edema. He was well until 3 years ago, when pedal edema developed. But edema subsided soon and occurred again 3 months before entry. Laboratory findings on admission revealed as follows ; T. P. 4.0 g/dl, Alb. 2.0 g/dl, absolute lymphocyte count 496/mm³, ¹²⁵I-PVP test 6.4%, ¹³¹I-RISA (T 1/2) 6.2 days. Jejunal biopsy showed markedly dilated lymphatics in the lamina propria of the mucosa. ymphangiography revealed reflux of contrast material to the mesenteric lymphatics and extravasation into the proximal small intestine. Thoracic duct above the vertebral level of T 11 was opacified normally. Chest X-ray film demonstrated lung cancer in the right upper lobe and lobectomy was performed. The lesion was localized and could not be considered to be a cause of intestinal lymphangiectasia in this patient. Four months after operation, he died of acute hepatitis (B type). At autopsy lower thoracic duct not opacified well following lymphangiography was examined in detail. No abnormal findings such as stenosis or anomaly were obtained and the etiology of intestinal lymphangiectasia in this patient remains unknown.

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A 39-year-old-female patient was admitted to our hospital ten hours after swallowing an large quantities of paraquat (28.8 g). During the clinical course, the patient showed renal failure, moderate liver damage and lung impairment, but could return to the ordinary life after the success of the treatment. For the effective treatment against paraquat poisoning, there are gastric lavage, hemodialysis, hemoperfusion and plasmapheresis. We performed intensive intestinal lavage using a special (double lumen) intestinal tube, leading to the descending portion of duodenum for certain period. We firmly believe the importance of gut lavage for the treatment of acute paraquat poisoning.

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