Endoscopic sphincterotomy (EST) has now gained wide acceptance as a safe and useful procedure and its indications continue to grow. However, we should always be on guard against its complications. We have used a long-tipped sphincterotome since January of 1975 and treated 368 patients with bile duct stones. Based on an analysis of our experience, this article focuses on prevention and management for complications of the procedure. EST was successful in 365 of the 368 patients (99.2%) despite that 120 patients (33%) had one or more diverticula in the periampullary region. 342 patients (93.7%) had their stones removed. Early complications in this series included bleeding (9 patients), acute obstructive suppurative cholangitis (9), acute pancreatits (7) and basket impaction (2). Duodenal perforation was not encountered in spite of the high incidence of periampullary diverticula (Table 3) ; this may represent the benefits of the long-tipped sphincterotome. Two patients died of acute obstructive suppurative cholangitis (AOSC) or suspected pancreatic abscess, thus yielding the mortality rate of 0.5%. It is of interest that 6 of the 9 bleeders had no hemorrhage on EST but occult blood in their feces was positive (Table 4). The importance of the routine check of occult blood should be stressed in consideration of possible late bleeding. AOSC is a life-threatening condition. After a distressing experience with a fatal case, we have developed the technique of endoscopic bile duct decompression by cannulation. This technique is quick, safe and effective for emergency treatment of AOSC. Hyperamylasemia occured in 72 of 186 patients (38.7%). The serum amylase level was invariably highest on the first day. This indicates that the first-day check of the amylase value is important for early detection of pancreatitis. The "precut" technique was associated with a higher incidence of hyperamylasemia (59.5% vs. 33.6%) (Table 5). Four of the 7 patients who developed acute pancreatitis had the precut procedure. These facts suggest that the technique should be avoided whenever possible.

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We investigated fundamentals of a new laparoscopic measuring system. A simple new type of grating i. e. "fiber grating" produces multiple beams of uniform intensity and has high efficency. When the fiber grating placed in front of the convex lens is projected by an argon laser of 488-nm wavelength, diffraction beams are emitted in parallel. Because each diffraction spot is uniform in intensity and the interval between the diffraction spots is 0.2mm, the length of lesions will be easily measured by counting the number of the spots. And, because the diffraction spots are viewed obliquely at an angle of 45°, the true height of the spots on the lesion will be correctly calculated by multipling the observed height by√2. The diffraction spots on the lesion is clearly observed and pictured under ordinary illumination. Then it is possible to focus the diffraction spots just on the top of the lesion of which the height should be measured. This system would be considered very significant in the clinical study of the liver diseases.

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Peritoneoscopic features important for progression of chronic hepatitis to liver cirrhosis were studied in 229 peritoneoscopy-repeated cases . The regular life table method demonstrated that 50% progression time from chronic hepatitis of code number 200 to 300 (Group 1) was 9.8 years and the time from code number 300 to liver cirrhosis of 400 or 500 (Group 2) was 5.7 years. Six peritoneoscopic findings, age and sex were used as prognostic parameters for Cox's multiregression life table method. The parameters important for the progression in Group 1 were reddish markings (risk ratio, 3.9), whitish markings (2.8/0.35) and patchy markings (2.0) in order of importance. Patients with reddish markings progressed with a risk ratio of 3.9 times of those without the markings . The 50% progression time of Group 1 cases with reddish markings was 2.9 years and the time of those with patchy and whitish markings was 3.8 and 14 years, respectively, when the influence of otherparameters were excluded. Parameters important for the progression in Group 2 were whitish markings (risk ratio, 6.6/0.15 ; estimated 50% progression time, over 15 years), reddish markings (4.2, 2.4 years) and patchy markings (2.7, 3.7 years). These findings may confirm that reddish markings and patchy markings indicate rapid progression, and whitish markings slow progression .

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During the past 10 years we have experienced 41 cases of ingested upper gastrointestinal foreign bodies. Endoscopical removal technique was applied in 28 cases and foreign bodies (89.3%) e. g. razor blade, dentures, long wires, reamers, medicine press-throughpackages, etc., were removed successfully. In the remaining 12 cases, 4 objects were removed using the Foley balloon catheter technique, 6 cases by spontaneous defecation. Malacotomy was performed in one case and laparotomy in the remaining case. We divided the upper gastrointestinal foreign bodies into three groups from the standpoint of endoscopical removal. Group I included round or cuboidal objects with a smooth margin ; Group II included needle-like shaped foreign bodies and cuboidal objects with sharp edges ; Group III included slim and long objects . We succeeded to remove unusual foreign bodies using such devices as plastic test tube and balloon catheter. In review of the literatures, we introduced some effective removal techniques using special devices, such as hood, colon stiffening tube, plastic overtube, cuff or nylon bag. It is suggested that there is the possibility of endoscopical removal of upper gastrointestinal foreign bodies which has heretofore been considered impossible to remove endoscopically.

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During a period of 13 years and 9 months from June, 1970 to March, 1984, we performed 142 upper gastrointestinal endoscopies to 103 pediatric patients under the age 15. In general, upper GI endoscopy was performed under general anesthesia in patients 9 years of age or younger, only 4 patients under the age of 9 were examined with topical pharyngeal anesthesia. As to the instrument till 1974 lateral view f iberscopes for adults, type GTF-A and JF-B₂ (Olympus) had been used in patients 6 years of age or older. Since 1975 small caliber frontal view fiberscopes, GIF-P₂ and GIF-P₃ (Olympus) hava been frequentlyused for upper GI endoscopy in pediatric patients ranging in age from 1 day to 14 years. Examined patients consisted of 55 boys and 48 girls. The age distribution was as follows : 24 patients between 0 and 2 years, 17 between 3 and 5 years, 15 between 6 and 8 years, 20 between 9 and 11 years, 27 between 12 and 14 years. Of 72 pathological cases 20 had foreignbodies, 14 had duodenal ulcers and 11 had esophageal varices. As to the correlation between endoscopic diagnoses and the age of patients, the age of 19 cases of 20 foreign body cases is 8 years or younger and the age of 12 cases of 14 duodenal ulcer cases is 9 years or older. As is mentionned above upper GI endoscopy in pediatric patients is very useful for the diagnosis and treatment of pediatric upper gastrointestinal diseases.

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With methylene blue dye spraying endoscopy with aids of biopsy study, we investigated changes of fundic-pyloric (F-P) border and the incidence and/or extension of the stained phenomenon of gastric mucosa in 176 healthy control subjects. The obtained results were as follows; 1) The F-P border shifted cephalad with age, but the unchanged F-P border remained in 35.7% of the subjects in the sixties, more frequent than in the fourties or fifties. 2) The stained mucosa with methylene blue, that is, metaplastic mucosa of the stomach spread and increased in its frequency with age, but the unstained mucosa remained in 35.7% of the subjects in the sixties. 3) By the dye spraying endoscopy fifty cases were followed for two years and 32 cases for four years. The F-P border advanced in 10 of 50 cases (20.0%) for two years, and in 9 of 32 cases (28.1%) for four years. Upward extension of the F-P border were frequent in the thirties and sixties. 4) Our endoscopic follow-up observation showed changes in the extension and degree of the stained mucosa with methylene blue in 10 of 50 cases (20.0%) for two years and in 12 of 32 cases (37.5%) for four years. In 7 cases the stained mucosa was newly diagnosed. The stained area, that is, intestinal metaplasia commonly arose on the lesser curvature of the antrum. 5) Our endoscopic follow-up study also indicated that the staining type of intestinal metaplasia developed from the depressed type to the elevated one, and the staining degree advanced from the scattered type to the diffuse one. 6) Changes in the F-P border and/or methylene blue staining were noticed in 18 of 50 cases (36.0%) for two years and in 17 of 32 cases (53.1%) for four years. In addition, our follow-up data indicate that intestinal metaplasia is likely to arise mainly from the pyloric gland area, or from the fundic gland area following pyloric metaplasia.

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Reflectance spectrophotometry Model TS-200 (Sumitomo Electric Industry Co.), newly developed for the measurement of mucosal blood flow, was tested to examine the reproducibility of the measurement of gastric mucosal blood flow in humans and dogs.Experimentally, hemoglobin volumes in the gastric mucosa in dogs were measured with high reproducibility, when the tip of optical fiber bundle was adequately contacted to the mucosal surface of the incised stomach. Hemoglobin volume measured by this method were thought to be reflecting the gastric mucosal blood flow because hemoglobin volumes were elevated in response to the administration of epinephrine. In the clinical examination performed during gastrof iberscopy, however, it was not easy to keep the fiber bundle tipcontacted adequately to the gastric mucosal surface because of peristaltic or respiratorymovement. Consequently, the rate of S. E, to the mean value of hemoglobin volumes from 5 measurments at the same mucosal point was 10 to 18%. To overcome the problem, the instrument should be equipped with the excellent contact sensor in the fiber bundle tip and the built-in computor to select approriate reflectance spectra. Illumination by gastroscopy and the air for inflation of the stomach were pointed out as factors gave an influence on the measurement of hemoglobin volume, while intramuscular injection of butropium bromide gave little influence on it.

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A 43-years-old male was admitted to our hospital for endosopical removal of esophageal submucosal tumor. Barium meal and fiberscopic study revealed a sessile tumor of the upper thoracic esophagus. For 3 years and 9 months, the tumor had enlarged 2.5 times as large as before on UGI series. After local injection of hypertonic saline epinephrin solution, endoscopic removal of the tumor was done safely. The size was 2.1×1.2×1.2cm. Histological diagnosis was esophegeal lipoma. This is the second report of endoscopical removal of esophageal lipoma in Japan.

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Gastric tuberculosis is a rare disease and only thirteen cases diagnosed by endoscopic biopsy have been reported in Japan. A 51-year-old women complaining of mild epigastric pain had an upper GI series in another institution, and was referred to our hospital because of an angle deformity. The upper GI endoscopy revealed an edematous mucosa on the angle and the antrum associated with multiple irregular small ulcers . These findings were suggestive of idiopathic inflammatory disease of the stomach or acute multiple gastric ulcers. Because epithelioid cell granulomas with Langhans giant cells were found in thebiopsy specimens, a tentative diagnosis of gastric tuberculosis was made . Chemotherapy with SM, INAH, RFP was initiated, but the follow-up study performed a month later failed to disclose any improvement. Furthermore, a definite caseous necrosis was found in a biopsy specimen taken from the lesion. Therefore, perendoscopic injection of lg SM was performed eight times, at weekly intervals, and the gastric lesions disappeared. This case is considered worth recording because of the evidence of caseous necrosis in a biopsy specimen and the therapeutic superiority of endoscopic local injection of SM over systemic therapy.

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A 74-year-old male, who was a father case, was admitted to our hospital because of hematemesis. Upper GI series and endoscopic examination showed a solitary polyp 15mm in diameter on the anterior wall of the duodenal bulb . His son was a 43-year-old male complaining of epigastric pain. Upper GI series and endoscopic examination showed multiple small elevated lesions in the duodenal bulb. In both cases, the target biopsy by endoscopy was demonstrated true gastric fundic mucosa, and a diagnosis of heterotopic gastric mucosa in the duodenum was established. They are the first familial cases of heterotopic gastric mucosa in the duodenum detected by radiologic and endoscopic exami nation.

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A 40 year-old man was admitted to our hospital complaning of acute excerbation of ulcerative colitis on June 1983. The patient had noticed bloody stool since 1976, and he was diagnosed as ulcerative colitis on 1980. After admission he had massive bloody diarrhea and showed the sign of ileus in spite of intensive drug therapy. Physical and roentgenological examination of abdomen revealed a toxic megacolon and operation was performed. Surgical findings was obserbed severe inflammation and dilatation of the total colon with marked thin intestinal walls, and the intraabdominal hematoma was recognized at the site of perforated hepatic flexure. Thirteen surgical cases of toxic megacolon were collected in japanese literature. Four perforated cases (31%) were associated with total colitis. The most frequent perforated area was transverse colon (100%), the diameter of the dilated colon ranged from 4 to 14 cm. One third of these cases died, and in the case ofperforation, mortality was up to 50%. Thus we will emphasize that it is most important to diagnose and treat in its early stage of toxic megacolon.

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A 47 year-old man was admitted to our hospital with complaints of bloody diarrhea and tenesums for 7 days. He had no history of being abroad . Barium enema study revealed irregular margin of the rectum, and erosions with surrounded defect in the sigmoid colon. Multiple erosions with central yellowish coat surrounded by slight elevation and halo in the rectum, sigmoid colon and anal side of the descending colon were revealed by an endoscopic study. Several discrete and undermining ulcers surrounded by normal mucosa were also observed on the splenic flexure, transverse colon, and ascending colon . Entamoeba histolytica was histologically found in the biopsied specimen from erosion and ulcer . Also, mobile amebas were able to be observed in fresh stool. It seems difficult to diagnose amebic dysentery of the colon only radiologically and/or endoscopically, because its features are very various, but nonspecific.

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ERCP has been applied for therapeutic as well as diagnostic purposes, especially in recent years much frequently for the former. In this paper we describe our recent experience of ERCP and therapeutic ERCP. During the last 15 months (May 1983 to July 1984) ERCP was performed 598 times in 434 patients, among which 218 times (36.5%) in 116 patients (26.7%) were for therapeutic ERCP. EPT'was done in 96 patients of them, with 68 patients (70.8%) for the procedure before ERBD or ENBD. Endoscopic biliary drainage (EBD) was attempted in 85 patients with obstructive jaundice ; 8 due to choledocholithiasis and 77 due to malignant bile duct obstruction. EBD was successfully done in all 8 patients with choledocholithiasis (5 ENBD and 3 EPT). Of 77 patients with malignant bile duct obstruction, there were no indications for EBD in 12 cases (15.6%) due to various causes, and among the remaining 65 patients EBD was successfully performed in 53 patients (81.5%, 51 ERBD-internal drainage, and 2 EN BD-external drainage). The following 5 cases of complications have been experienced ; 2 hemorrhage, 2 retroperitoneal perforations due to EPT and one post-ERCP acute pancreatitis. All patients fully recovered by conservativetreatment. This called much attention to be paid to avoid the occurrence of complications on performing ERCP or therapeutic ERCP.

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