A diagnostic rate of the depth of invasion of gastric cancer based on endoscopic findings was 78% in the elevated lesions, 56% in the depressed lesions and 59% in the total cases. Therefore, investigation of the depth of invasion of gastric cancer through submucoso graphy was carried out. Investigation of a contrast medium as well as its association to a surfactant agent was also carried out in canine. As the result, Myodil seemed to be the most appropriate as the contrast medium. Furthermore, a tendency of spreading of the contrast medium and the relation between the radiological features of submucosography and the histological depth of invasion were also investigated in 36 clinical cases. Through the radiological features of spreading of the contrast medium, the following classification was made : type A at the frontal view-when there was no restriction of the spreading (type A' at the lateral view), type B at the frontal view-when there was a partial restriction of the spreading (type B' at the lateral view) and type C at the frontal view-when there was total restriction of the spreading (type C' at the lateral view). Histologically, the type A indicated to have the depth of invasion within m, the type B down to sm and the type C deeper than pm. The diagnostic rate of the depth of invasion by this method was 75%. Moreover, the diagnostic rate with combination of submucosography and the endoscopic findings was 81%. Consequently, submucosography is thought to be a useful method in the diagnosis of the depth of invasion of gastric cancer.

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Diminutive colonic polyps (less than 5mm in diameter) were removed endoscopically by conventional biopsy forceps or diathermy-biopsy (hot biopsy) amounting to 1, 010 specimens from April 1982 to July 1984. There were several kinds of histology recongnized among them : 660 tubular adenomas, 2 tubulo-villous adenomas, 4 focal carcinomas and one carcinoid tumor. Non-nepolasias consisted of 231 hyperplastic polyps, 63 normal, 19 lymphoid nodules, 11 hamartomas (9 Peutz-Jeghers type polyps and 2 juvenile polyps), 10 inflammatory polyps, 6 xanthomas, 2 lipomas and one leiomyoma. Neplaosias were seen in 667 out of 1, 010 (66.0%). Tubular and tubulovillous adenomas showed mild dysplasia in 55.2%, moderate dysplasia in 10.3% and severe dysplasia (focal carcinoma) in 0.4%. Malignant polyps might be found in these smaller size growths. Diminutive neoplastic polyps are evenly distributed in all sites of the colon and rectum: 10.2% in the rectum, 28.6% in the sigmoid colon, 14.1% in the descending colon, 21.7% in the transverse colon and 25.3% in the right colon. There is a large discrepancy in the distribution between diminutive neoplastic polyps and the large size polyps over 6mm in diameter. For instance, the large polyps occurred in the sigmoid colon in 53.2% compared to only 28.6% of the dimutive ones. From an endoscopic point of view, some differences of the color of diminutive polyps were noticed. These colors were classified into 4 categories, (1) orange color, (2) similar to background mucosal color, (3) bluish color, (4) micellaneous (pale gray, reddish, white spotted, etc.). Neoplasias were highly correlated with the following colors : orange in 88.5%, similar to background in 72.8% and bluish in 69.6%. There was a low incidence of neoplasia in the miscellaneous group (4.9%). In conclusion, colonic diminutive polyps should not be ignored or overlooked clinically. The majority were neoplastic polyps including a few focal carcinomas. It is suggested that diminutive polyps should be removed endoscopically if possible.

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Hematoporphyrin derivative (HpD) has an affinity to malignant tissues and show cytocidal effects when it is excited by Argon-dye laser. This method is called Photoradiation Therapy (PRT). Effects of PRT on esophgeal carcinoma were discussed. Four cases of superficial esophageal carcinoma underwent PRT. Histological studies on bite biopsy specimens from the lesions showed intraepithelial squamous cell carcinoma. Argon-dye laser was irradiated for five to fifteen minutes, with 300 to 500 mW power output at the tip of quartz fiber, under direct control of esophagofiber scope, after 48 hours following intravenous administration of HpD (3mg/kg). Esophageal lesions showed white pseudomembranous changes after irradiation in two to three days, and they formed ulcers in one to two weeks. Those ulcers healed within three months. All cases were followed periodically by endoscopy for eleven months to seventeen months. Histological studies on bite biopsy specimens from the lesions showed no malignancy. In these four cases, the results of PRT for esophageal cancer have been effective and satisfactory. Histopathological studies on resected specimen revealed the depth of PRT was mucosa and a part of submucosa. So we considered the effective depth of PRT reached to submucosa. The cases of superficial flat type and most of superficial erosive type by endoscopic diagnosis were within the depth of mucosa. Now we think the indication of PRT of esophageal carcinoma is as follows : superficial flat type and most of superficial erosive type by endoscopic diagnosis.

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Ligating marginal vessels of the descending colon, we made ischemic colitis in the rat. Using the Olympus GIF P-3, we attempted to perform colonoscopy in the rat and we could take detailed pictures of the rat colonic mucosa. In the lesion-free mucosa, submucosal vessels were clearly visualized and in the ischemic lesions, a variety of findings (mucosal edema, mucosal bleeding, erosion, ulcer) were seen. We also measured the blood flow of the colonic mucosa. The mucosal blood flow was' higher in the splenic flexure than in the rectum. Immediately after ligation of the marginal vessels, the mucosal blood flow decreased remarkably and recovered rapidly. In the study of ischemic colitis, many researchers have used a dog and not used a rat as an experimental animal, and have never followed the mucosal blood flow. This method also seemed to be useful for the studies on many other experimental colonic diseases.

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Histological findings of esophageal varices were studied in 10 subjects injected by a gelatin added barium solution into gastric coronary vein at autopsy, and its relationship to Red-Color sign as one of the endoscopical findings was discussed. Upon a histological study of the epithelium thinned by varicose vein, its frequency was noted to be nearly proportional to the grade of Red-Color sign, and it is observed more frequently in the critical area. When the part of the ruptured varices was studied in serial sections, the thinned epithelium was observed around the ruptured veins.

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Nineteen patients were treated for carcinoma of the alimentary tract by Nd : YAG laser photocoagulation for one of various reasons. Palliative treatment aiming at relief of a carcinoma-induced stenosis was performed in one patient with esophageal carcinoma and in three patients with gastric carcinoma. Although satisfactory relief of the stenosis was achieved in only one of the four patients, we would like to think that no definite conclusion can be drawn from such a small number of cases. In another patient with Borrmann I-type rectal carcinoma, curative treatment by Nd : YAG laser was deployed along with piecemeal polypectomy for tumor reduction. The laser treatment proved on autopsy-the patient having deceased due to cerebral infarction four months later-to have effected a radical cure. Endoscopic Nd : YAG laser treatment was selected rather than surgery on the grounds of the small size of one elevated early esophageal carcinoma and one ha-type early gastric carcinoma. In both these cases local cure was effected as was proven by follow-up endoscopic biopsies which showed no malignant cells at 12 and 18 months, respectively, after laser therapy. Four cases of elevated and eight of depressed early gastric carcinoma were treated by Nd : YAG laser rather than surgically for reasons of either the high operative risk involved or the patient's having refused to undergo an operation. Local cure seems to have been achieved in the four former and three of the latter cases on the evidence of biopsies taken from the sites of the healed laser-induced ulcers, which showed no carcinomatous cells at 12 to 18 months. The five remaining cases with depressed early carcinoma did, however, within six months of follow-up, reveal evidence of carcinomatous growth and required additional treatment. That carcinomatous cells appear during followup would seem to suggest their inadequate elimination by laser irradiation. Possible causes for this are 1) insufficient laser radiation of the lesion, 2) failure to determine the exact extent of the lesion during laser endoscopy, and 3) difficulty in aiming the laser at lesions on the posterior wall of the gastric body. The first cause we consider to be a merely technical error. The second is an as yet unresolved problem of Nd : YAG laser technology which is moreover not compensated by a specific anti-tumor effect as in the case of the HPD-Argon dye laser system. The third we consider to be an urgent technical problem calling for a speedy solution-namely the improvement of endoscopes used in laser treatment and/ or the development of a still finer optical fiber for introducing the laser beam into the GI-tract.

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Recently endoscopic treatment is applied to gastrointestinal bleeding, polypoid lesions and cancers. Present paper reports the results of endoscopic microwave therapy from January 1983, using Microtaze Model HS-15M (HEIWA El. CO.). It was performed in 20 cases : 8 cases of a polyp, 5 cases of gastric bleeding, 3 cases of a gastric adenoma and 4 cases of an early gastric cancer. The patients of early gastric cancer were all that refused surgical operation. The microwave tissue coagulation was performed with 30 watt for 10-v20 seconds. In a case of arterial bleeding and four cases of bleeding from the ulcer margin were successfully treated. Polyps, adenomas and cancers were disappeared completely after the therapy. The ulcer scar was observed for three to four weeks. In early cancers and adenomas, biopsy materials were taken from this scar on several occasions and no atypical cells were found until the present time, including a case which has been followed up for eighteen months. It is concluded the endoscopic microwave tissue coagulations is a new technic that can be performed easily and safely.

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The authors analysed cases of colonoscopic polypectomy at our endoscopy unit in the past ten years, which has been considerably increasing in frequency. The establishment of screening method by using fecal occult blood test at outpatient clinic and mass screening is considered to be one of the reasons. A thorough investigation was performed even in patients with positive fecal occult blood test as well as overt anal bleeding. As a result, it was frequently possible to make a diagnosis of colorectal polyp available to treatment. In our series, cancer was found in 11.5% of neoplastic polyps and in 9.3% of small polyps sized 6mm to 10mm. In 3 (20%) of 15 patients with such a small polyp, cancer cells already invaded the submucosa. The treatment by colonoscopic polypectomy was completed for a lesion with cancer limited to the mucosa. Radical operation was subsequently performed in 14 patients with cancer invading the submucosa. There were no residual cancer cells and lymph node involvement in all but one with residual cancer involving the proper muscle layer . Three such cases have been followed up without surgery for some reasons. The patients having undergone colonoscopic polypectomy were on a regular surveillance program thereafter, because such patients tend to have another neoplastic polyp later. 7.1% of all the excited polyps were detected during follow-up and again excised endoscopically. From the fact that a patient who underwent radical operation for rectal cancer with submucosal involvement after polypectomy later developed metastasis to the liver, the authors would stress that a follow-up schedule should include check-up of hepatic metastasis in patients with cancer. It is concluded that a large scale screening by fecal occult blood testing would make detection of polypoid lesions easier and colonoscopic polypectomy more valuable and popular in prevention and treatment of colorectal cancer in the future.

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We have treated early gastric cancer by endoscopical photocoagulation using MBB Medilas YAG laser, Aroka YML-801 YAG laser, Aroka LMY-1001 YAG laser and Spectra Physics model 770 Argon laser since December 1980, and evaluated the effects of laser therapy on gastric cancer. Thirty lesions in 25 patients with early gastric cancer were endoscopically photocoagulated and followed up. Cancer cells disappeared in 25 of 30 lesions, survived in two and recurred in three. We could reach a conclusion that laser photocoagulation for the protruded type of early gastric cancer is effective but is not so effective for the depressed type. We are attempting to improve the resolution of ultrasonic endoscope. Five layers of gastric wall can be visualized clinically by means of ultrasonic endoscope. The laser irradiated gastric wall was visualized as a hypersonic lesion by ultrasonic endoscope. So we can diagnose the depth of invasion of gastric cancer and identity the depth of the laser effects.

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A 37 year-old male was admitted to Akita University Hospital because of dysphagia and weight loss. An uppergastrointestinal series showed a funnel-shaped esophagus with irregular margin and the rigidity of the lesser curvature of the gastric body. Endoscopic examination disclosed a circular stenosis with irregular surface at 30 cm distal from incisor. However, GIF-P3 could be inserted into the stomach. Circumscribed mass at the cardia and multiple erosions in the gastric fundus and body were seen. Biopsy specimens from esophageal and gastric mucosa showed the signet cell carcinoma. Lower esophagectomy and total gastrectomy with Roux en Y anastomosis were performed. Histologically, signet cell carcinoma with marked hyperplasia of intestinal connective tissue were found from thoracic esophagus to gastric antrum. Carcinomatous infiltration in all layer of the esophagus was observed.

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Aortoenteric fistula is a rare complication of aortic graft insertion surgery. A 72 year old man was admitted with a complaint of melena 13 months after aortic graft insertion. Upper GI endoscopy showed an ulcer at the 3rd portion of the duodenum markedly surrounded by granulation tissue. During the course, pulsation and fresh bleeding at the same site was often observed, and finally the diagnosis of aorto duodenal fistula (ADF) was established. By operation, marked inflammatory change was observed around the aorta, and the fistula was found between the proximal anastomosis and the 3rd portion of the duodenum. Upper GI series, aortogram, and CT scan suggested the presence of the lesion, but were not helpful to make diagnosis of ADF. Awareness of this entity is the first step to lead to the correct diagnosis. Patients who present upper gastrointestinal hemorrhage of any degree following aortic graft insertion must be examined by upper GI endoscopy as soon as possible under the suspicion of ADF.

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A 68-year-old man was admitted to our hospital complaining of upper abdominal discomfort and body weight loss. Laboratory investigation revealed moderate elevation in the blood sedimentation rate and positive occult blood stool. X-ray examination of the stomach revealed a round well-difined filling defect with irregular surface on the posterior wall of the duodenal bulb. Endoscopic examination showed the tumor covered with the white coat in the bulb. Histological diagnosis of biopsy specimen was well differentiated adenocacinoma. Pancreaticoduodenectomy was performed. At surgical operation, a Borrmann II type cancer measuring 50×45 mm was seen on the posterior wall of the duodenum. There was the normal mucosa from the tumor to the pyloric ring and the tumor was distal to the ampulla of Vater by about 50 mm. At operation, one direct invasion in the liver, two hematogenous metastatic lesions and two regional lymphnode metastasis were found. Patient died of liver abscess after 3 months of the operation.

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A 45-year-old woman was admitted to our hospital with a complaint of right hypochondralgia. The echographic findings of the liver led us to suspect her to have Caroli's disease. DIC-CT also revealed multiple cystic dilatations of peripheral intrahepatic bile ducts. We there-fore could make a diagnosis Caroli's disease without performing direct cholangiography. Laparoscopically, we found moderately hard and enlarged liver, the surface of which showed dense, fibrous network patterns. Biopsy specimen taken from the liver showed typical findings of congenital hepatic fibrosis.

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A 72-year-old man visited us due to repeated episodes of passage of tarry stools associated with anemia. Examination of the upper and lower gastrointestinal tracts revealed no abnormalities. However, the findings of the superior mesenteric angiography indicated abnormal vascularization, high density areas and premature flowing out in the arterial phase of the jejunal arteries. A diagnosis of arteriovenous malformation was thus made, and surgery was performed. Endoscopy performed during the operation revealed a small eminence looking like a submucosal tumor and capillary dilation, confirming that these were the bleeding sites. The microvascular structure of the resected intestine consisted of proliferation of thick, twisting, serpiginous blood vessels and dilation of the surrounding capillaries, with growth of dilated blood vessels to near the mucosal surface. This area was considered to be the major site of bleeding.

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A case of double pylorus of a 69-year old male was reported. Following endoscopy revealed defect of so-called pyloric bridge between two pylorus due to recurrent ulcer. This patient was cured by a conservative therapy alone without pylorus stenosis.

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Recently many endoscopic hemostatic techniques against upper gastrointestinal bleeding have been devised. The endoscopic clipping technique had been devised by Dr. Hayashi, Dr. Kuramata and others about ten years ago, however, this method did not come into wide use for the reasons of complicated mechanism of the clipping apparatus and not satisfactory result. In spite of these reasons, the clipping hemostasis must be the most reliable technique, because the clip can grasp directly at the blood vessel. Therefore we had devised an improved clipping apparatus. Some advantages of this apparatus are as follows. (1) Handling of the apparatus is easier than the ordinary ones. (2) Hemostatic effect is reliable, because this clip can grasp tightly bleeding tissue by its long and narrow structure. From April 1975 to December 1983, 82 cases (92 times) were treated with endoscopic hemostasis at Sakura National Hospital, and 24 cases of them were treated with the improved clipping apparatus without serious complications, i. e. perforation, massive rebleeding and others. Hemostatic effect of the improved clipping technique were as follows : permanent 74.1%, temporary 14.8% and noneffective 11.1%.

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In recent six months, I stayed in the United States for studying the present status of digestive endoscopy in the United States. So I herein report differences in this field of medical science between Japan and the United States. In the States, as premedication of digestive endoscopy, meperidine and diazepan are given intravenously to put patients in such a somnolent state that they may be readily aroused to respond to given commands. In every case of upper gastrointestinal endoscopy, the esophagus, stomach, duodenal bulb and the second portion of duodenum are examined by a frontal view fiberscope. Colonoscopy is performed usually in the left lateral recumbent position. In many cases, the colon is telescoped for examination. No fluoroscopy, sliding tube and alpha maneuver are utilized. Like the upper gastrointestinal endoscopy, colonoscopy is therefore one of the common examination in daily practice. Personal computer is often used for patient data processing, storage and retrieval. Recently the first electronic endoscope was put on sale in the United States, and this type of endoscope is expected to rapidly come into wide use in the near future. By observing the present status of digestive endoscopy in the United States, I could catch a glimpse of the essence of American medical care system in which patients are given very human but sometimes very active treatment and care at high medical standard based on the excellent medical education system, paying full attention to the patient safety.

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