Under supervision of Machida Seisakusho Company and Toshiba Medical Company, an improvement of endoscopic ultrasonography was achieved and its usefulness in the esophageal diseases was also assessed. In fundamental studies, seven layers in the esophageal wall were visualized in the surgical specimen placed in air-free water. A clear correspondence was observed among the seven layers and the layers of the esophageal wall, as follows : mucosa-first and second layers ; submucosa- third layer ; muscularis propria-from the fourth to the sixth layer and, adventitia-seventh layer. Besides, the visualization of lymphnodes about 5 mm in the largest diameter became also possible : However, it was difficult to identify whether lymphnodes were metastatic or not. In the clinical cases a diagnostic rate of the depth of invasion of esophageal cancer was 83.3%. An improvement of the visualization rate of lymphnode over 5 mm in the largest diameter was made from 27.6% in the early period to 57.9% in the late period. Moreover, the diagnostic rate of existence of lymphnodes over 5 mm in the largest diameter was improved from 52.6% in the early period to 79.1% in the late period. Furthermore, this performance was extremely useful in the differential diagnosis among the submucosal tumors as well as the external compressions of the esophagus. It is concluded that endoscopic ultrasonography would become a helpful and inevitable diagnostic method in the near future.

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Histopathological studies of esophageal varices were made with 9 autopsy cases withesophageal varices and 3 cases without esophagogastric varix, using transparent specimensof their esophagus. Endoscopic findings of esophageal varices were re-examined in comparison with these histopathological findings . The results obtained were as follows : 1) Both the vessel named "teleangiectasia" and the one named "Red wale marking" seemed to be derived from subepithelial veins and seemed to transform reciprocally . 2) There were three different mechanisms at least, concerning the development of the vessels named "Red-Color signs", especially "Red wale markings" (and some "Cherry red spots"). The first : partial dilatation of "palisade-like" veins ; the second : dilatation of "short-circuit" branches on the transitional area between the "palisade -like" vein and thevariceal one ; and the third : dilatation of "anastomosing" branches . 3) There were two mechanisms in the development of vessels named "teleangiectasia", that is the vessels connected to "palisade-like" veins (derived from "shortcircuit" branches) and subepithelial veins connected to submucosal varices via "penetrating" branches. 4) The findings of "teleangiectasia" were as important as the findings of "Red-Color signs" with respect to foresight of esophageal variceal bleeding .

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The complexity of cholangioscopic lithotomy arises from the arduousness to crush large or incarcerated stones, as well as from the insertion of the cholangioscope into the stenosed bile ducts. Fundamental and clinical investigation on crushing stones with Nd : YAG laser and widening stenosed bile ducts with Nd : YAG laser and high freguency wave scalpel were carried out. The effectiveness of lithotomy by Nd : YAG laser was assessed by irradiating human calcium bilirubinate and cholesterol stones perfused continuously with saline solution at a distance of 5 mm using 50 watts, 70 watts and 90 watts for 0.2, 0.5, 0.8 and 1.0 second. Injuries caused by Nd : YAG laser irradiation on the bile duct wall were evaluated by experimental study on canine common bile duct with either direct or indirect irradiation on the bile duct wall or on the stone, respectively. No injury in the bile duct wall was noted with indirect irradiation. Irradiation of 70 watts, 0.5 second on calcium bilirubinate stones and 70-80 watts, 2 seconds on cholesterol stones applied repeatedly were found to be the safest and the most effective conditions for achieving complete lithotomy. The safety of the depth of incision in the stenosed bile duct was verified in 16 cases of either hepatectomy or autopsied liver by histologic study on the peripheric area of the first intrahepatic branch of the left hepatic duct. The average of the distance from the inner wail of the bile duct to the vessels was 1.2 ± 0.7 mm. This suggests that an incision of 1.0 mm into the stenosed portion was sufficiently safe. In applying these basic investigation to the clinical cases, the rate of complete lithotomy improved markedly from 66% (31 out of 47 cases) to 95.2% (40 out of 42 cases).

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The development and extension of fundal gastritis and intestinal metaplasia were investigated by the endoscopic Congo red-methylene blue test in 44 healthy subjects, 106 patients with gastric ulcer and 26 patients with gastric polyp. Follow-up chromoendoscopic examinations were made an average of 3.4 years (110 years) after the initial endoscopicassessememt. Among healthy subjects, the development and, or extension of fundal gastritis and of intestinal metaplasia were only found in 3 (6.8%) and 2 (4.5%), respectively, and the development and extension of these changes may require time. In patients with gastric ulcer and in those with gastric polyp, fundal gastritis and intestinal metaplasiadeveloped or extended significantly more frequently and more rapidly than in healthy subjects. Fundal gastritis and intestinal metaplasia extended with time mainly in an upward direction.

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Recently, endoscopic retrograde biliary drainage (ERBD) has became to be a common technique as a nonsurgical biliary drainage in our country. We have investigated on the evaluation, the indication, and the complication of this internal biliary drainage in our series and concluded as follows. ERBD has been performed successfuly to 33 out of 44 cases (75.0%) as an effective method of the biliary drainge. However, we had some unsuccessful cases of ERBD which were associased with biliary carcinoma, including gallbladder carcinoma infiltrated into the hilar region. Nowadays, the success rate of ERBD is rising up by using a new guidewire which was modified from the basket catheter. We can do ERBD in order to improve jaundice of each case with extrahepatic biliary stenosis, especialy inoperable cases of cancer of the pancreas or the biliary tree, and also preoperative cases of benign or malignant pancreatobiliary diseases whose intrahepatic bile duct has not yet been remarkably dilated. Cholangitis in 3 cases, and perforation of the choledocal wall in one as an early complication, and deviation of endoprosthesis in 3 cases, clogging in 4 and duodenal ulceration in one, as a late one were experienced in our series. Cholangitis and clogging, the most frequent complication of ERBD were improved by washing or exchanging ofendoprosthesis. It is concluded that ERBD is one of the most effective and the safety procedure among nonsurgical methods of the biliary drainage.

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Endoscopic Nd: YAG laser irradiation was applied preoperatively to eight endoscopically diagnosed depressed early carcinomata of the stomach in eight patients, and the effect of Nd: YAG laser irradiation was investigated in the resected specimens . Four lesions which were diagnosed as mucosal carcinoma were irradiated almost completely. Surgery revealed no metastasis in these four patients . Histopathologic study of the resected specimen in one minute carcinoma revealed no malignat cells, which suggests that Nd: YAG laser irradiation for such carcinoma has become the treatment of choice, instead of surgical resection. Histopathologic study of the other three resected specimens disclosed minimal mucosal carcinomatous residues in one part of the circumference of the laser-induced ulcer, which demonstrated the difficulty of accurately aiming the laser at the entire area of the depressed early carcinoma . Radical cure for such lesions, however, may be achieved by additional laser irradiation. Four lesions chould only be partially irradiated with Nd : YAG laser . Three out of them were considered to have submucosal invasion and the remaining case was diagnosed as a large mucosal carcinoma, exceeding 3 cm in diameter. All these four cases showed no evidence of any metastasis upon operation. Histopathologic study of the former three lesions showed carcinomatous residues at the deep submucosal layer of the laser-induced ulcers, and the latter showed a large mucosal carcinoma at the circumference of the laser-induced ulcer. These results demonstrated that endoscopic Nd: YAG laser irradiation as a curative method of early carcinoma is not available for either a carcinoma invading the deep submucosal layer or a large mucosal carcinoma exceeding 3 cm in diameter. Hematemesis and melena as a complication of Nd: YAG laser irradiation was encountered in one patient three days after the procedure, but it was not serious and blood transfusions were not required. Although no free perforation was encountered in these eight patients, partial disruption of the proper muscle as an effect of Nd: YAG laserirradiation was recongnized in one resected specimen . Therfore, excessive laser irradiation onto the depressed type of early carcinoma should be avoided and the power of the Nd : YAG laser should be limeted to under 50W with the pulse setting at 0.51.0s.

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Ultra-high magnifying fibergastroscopes were developed for the purpose to observe the cells and nuclei of stomach endoscopically. At first, rat's gastric mucosa was observed under 170× magnifications (Figure 2, 3) using rigid ultra-high magnifying fiberoptics(Figure 1). For clinical application, mother and child type ultra-high magnifying fibergastroscopes were developed (Figure 4). Epitherial cells which absorbed methylene blue were observed clearly using this instrument (Figure 5, 6).

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In order to compare endoscopic findings with macroscopic and microscopic findings in the resected stomach, an improved endoscopic China ink injection method, "mucosal injection method", was studied. The materials were ninety-three resected cases of gastric carcinoma and a following-up case of gastric erosion. The plastic-made and disposable syringe (Figure 2-C, the capacity of 1ml) was better than the other syringes. An undiluted China ink was best in four kinds of coloring materials (Table 1). 1.5 mm long fiberscope injector's needle (Figure 3-B) was better than the other length needles in jnjecting China ink into the mucosa alone (Table 2). Comparing 0.01 ml with 0.005 ml volume at one injection, the remaining rate of black spots was the same (Table 3) but the spots of 0.01 ml were clearer (Figure 4, 5). The mucosal spots made with China ink were seen black in color on the endoscopy (Figure 9) and the macroscopy (Figure 10), and many black granules of China ink were seen to be localized in the gastric mucosal stroma on the microscopy (Figure 11). A clear black spot remained black one year and nine months after China ink injection near the gastric erosion in the antrum (Figure 6, 7, 8). With the improved China ink injection method, we can obtain a very small clear mark remaining for a long time. Therefore, this method seems very useful for the studies of comparing endoscopic findings with macroscopic and microscopic findings and examining the course of gastric lesions.

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Endoscopic sphincterotomy of the pancreatic duct, EST-PD has been performed in 9 cases of diffuse chronic pancreatitis for non-operative treatment, and in 2 cases of pancreatic carcinoma for transpapillary biopsy. Widening of pancreatic orifice by EST-PD was done, followed regular endoscopic sphincterotomy (EST), in the same way of EPT. We have succeeded in it in 10 of 11 without severe complications. In 6 cases of chronic pancreatitis, clinical symptoms were improved by EST-PD, and in 2 of these cases, pancreatic stones were extracted by basket catheter. However, endoscopic biopsy of pancreatic carcinoma has not yet been successful by this new procedure. It is concluded that EST-PD is a safe procedure in cases with diffuse chronic pancreatitis associated with fibrosis at the pancreatic head. This procedure will be expected as a new endoscopic treatment of chronic pancreatitis in the near future.

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Intra-abdominal bleeding and bile peritonitis are major complications of liver biopsy through laparoscopy. In this study, a gelfoam embolization method was applied for prevention of bleeding or bile leakage from biopsy wounds of the liver. Liver biopsy through laparoscopy has been performed in 69 cases from Oct, 1982 to Jun, 1983. In 49 out of 69 cases, the gelfoam embolization method was used for hemostasis of biopsy wounds, and in 20 cases the conventional method was used. These two methods were compared in regard to hemostatic effect, influence on liver function tests, ultrasonography and CT of the liver. The gelfoam embolization method was considered to be superior to the conventional method from the standpoint of hemostatic effect. But, some side-effects were seen such as right hypochondralgia, fever, leucocytosis, positive CRP, and development of space occupying lesions. Since these side-effects were considered to occur due to portal thrombosis or hematoma in the liver, which were formed by over-dose injection of the gelf oam, they would be prevented by reducing the dose of gelf oam as small as possible. Hemostasis using gelfoam is easy and secure even in a patient with advanced liver cirrhosis, and it would be possible to extend the application of laparoscopic liver biopsy by this hemostatic method.

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Out of 841 cases observed the liver with laparoscope in our department during 12 years from 1970 to 1981, forty eight cases had a history of laparotomy excluding appendectomy and repair of inguinal hernia. They had histories of upper abdominal surgery in 9 cases (group 1) and lower abdominal surgery in 39 cases (group 2). Laparoscopy failed to demonstrate the liver in one case in each group (11.1% in group 1, 2.6% in group 2, and 4.2% as a total). On the other hand, out of 793 cases without history of laparotomy, we failed to observe the liver in 5 cases (0.63%). Adhesion between abdominal organs and wall was observed in all cases with laparotomy and also found in 3 cases without laparotomy. There was no significant difference in occurrence of unobservable cases between operative and non-operative patients. Determining the proper location of trocar insertion (ie. far enough from the scar of laparotomy) after making adequate pneumoperitoneum, laparoscopy to the patients with a history of abdominal surgery will be performed safely.

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Lower esophageal web, which was a relatively rare esophageal anomaly, was successfully treated by the endoscopic diathermic incision. A 47 year-old businessman had complained of occasional dysphagia for the last ten years. Lower esophageal web was confirmed by the esophagogram, endoscopy and biopsied specimens at the age of 42, and he had been observed for the following 4 years without an effective treatment. Because of his exacerbating troubles and findings on examinations, the diathermic incision with the spatulate knife (Olympus Co.) was performed. Four directions of the web were cut with no complication, and the narrow segment was widely opened after the procedure. Post-operative ulcerations were favourably healed, and the size of the lesion was extended twice as large as the square measure in the pre-operative condition. Although various therapeutic techniques was applied to the esophageal web, these have been reported to have some undesirable problems, such as bleeding, perforation, restricture and others. On histological basis of the web, which is characterized by a thickness of the lamina propria, the present method could have safety and reliability for relief of the patient's complaints.

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Diffuse eosinophilic gastroenteritis is a rare disease on which only 120 cases in Western countries and 21 cases in Japan have been reported until 1983. This report describes a case of this disease, who was 50-year-old male with a chief complaint of abdominal fullness. Eosinophilia was not observed in the peripheral blood but a high level of IgE, iron deficient anemia and hypoproteinemia were detected. Upper GI series revealed circumferential irregularity and stiffness of the gastric wall from the fornix to the lower portion of the gastric body. Endoscopic study showed hyperplasia, tortuosity of mucosal fold and irregularly shaped ulcerations. Pathological diagnosis was not obtained by the histological examination of biopsied specimen and the total gastrectomy was performed. Perigastric adhesion to the left-diaphragma, pancreas, transverse colon and swelling of the regional lymphnodes were observed. Histological study showed diffuse infiltration of eosinophils in all layers especially in the submucosal layer, edema in the submucosa and partial granulomatous change. Cases like this involving almost the whole stomach and marked granulomatous change, are very rare and the present case was regarded to correspond with allergic granulomatosis proposed by Churg and Strauss.

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In this paper, we presented a case of congenital biliary dilatation with carcinoma of the gallbladder. A 67-year-old woman visited our hospital with a complaint of epigastralic pain. By means of abdominal ultrasonography, abdominal CT scan and endoscopic retrograde cholangiopancreatography, we diagnosed as congenital biliary dilatation with tumor of the gallbladder and she was operated on. Amylase in the bile from the dilated common bile duct was very high, which was taken in the operation. A histopathological finding of the gallbladder tumor showed adenosquamous carcinoma. Only chronic inflammatory cell infiltration was observed in the wall of the dilated common bile duct and malignant finding was not recognized. In recent 8 years, 40 cases of congenital biliary dilatation with carcinoma of the gallbladder were reported. It has been known that there is close relationship between carcinogenesis of the gallbladder and existence of gallbladder stone, but gallbladder stone was not recognized except 5 of 41 cases and abnormal pancreatico-cholangio connectionwas recognized in 37 of 41 cases. In our case, we suggest that there is close relationship between carcinogenesis of the gallbladder and reflux of pancreatic juice into the biliary tract from the pancreatico-cholangio connection.

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Most intraluminal diverticula are located in the duodenum, other sites are extremelyrare. To our knowledge, this is the second reported case of cecal intraluminal diverticulum. A 48-year-old male was admitted to Kariya General Hospital with a chief complaint of right flank pain. Barium enema revealed a pedunculated polyp-shaped tumor in the cecum. Endoscopic examination showed an elevated lesion covered with normal mucosa, which appeared a submucosal tumor. A small orifice was recognized at the top of the tumor, which was retrospectively seemed to be a typical feature of intraluminal diverticulum. The tumor was resected by endoscopic polypectomy. Resected specimen was sac-shaped with a thin wall, 2×2×3cm in size, and contained a clayey fecal mass. Microscopic examination revealed that the wall was covered on both sides with colonic mucosa with the muscularis mucosae, and no muscular layer was seen between them. We suppose that an acquired small intramural diverticulum was distended by the fecal inflow. This pulsion diverticulum, if restrained by the muscular wall of the colon, could eventually grow into lumen, carrying a layer of the mucosa before it.

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[in Japanese]

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