In making the diagnosis of gastric lymphoma, a possibility of carcinoma is occasionally retained until proven by biopsy; direct vision biopsy, however, is not always reliable: Lymphomatous tissue contained in the specimen may be too insufficient to recognize as such, or being fragile, lymphomatous tissue may be seen as a crushed tissue not allowing to make a diagnosis. Lymphoma, in addition, may be mistaken for undifferentiated carcinoma on routine sections. The accuracy of endoscopic diagnosis should be improved for gastric lymphoma. In lymphoma (29 cases summarized in Table 2) and carcinoma (378 cases) the mucosal aspect of the stomach was scrutinized mainly by using the macroscopic photographs of the materials resected surgically or obtained at autopsy. The findings were compared between lymphoma and carcinoma with special reference to those of ulcerations and the results were statistically analysed : The neoplastic lesions were most frequent on the lesser curvature aspect in carcinoma (Figure 7), while in lymphoma (Figure 1) they were more evenly distributed (p <0.001). As for the gross morphologic classification (Tables 1 and 8), the cases forming prominent ulceration were most frequent (>80%) in both groups (no significant difference). Though being non-epithelial, a typical submucosal tumour (Figure 3) was rare in lymphoma. Distribution of the depth of involvement (Tables 3 and 7) showed a higher frequency of early carcinoma (p<0.05) than of the corresponding lymphoma infiltrating the submucosa at the deepest (Figure 5). The size of ulcerations showed no significant difference between lymphoma and carcinoma (Tables 4, 9 and 10). As to the other findings listed in Tables 6 and 11, the followings were significantly more frequent in lymphoma : Ulcerations that were shallow (p < 0.001), those of round shape (Figure 6, above) (p <0.001), those having flat ulcer base (p<0.001) and, if marginal elevation was formed, those with thin-walled elevation (p<0.001), the cases with multiple ulcerations (Tables 5 and 12) (p<0.01), and those forming giant rugae (Figure 2) (p<0.001). Ulcerations that were irregular-shaped (p<0.001), those forming marginal elevation (p<0.05), especially thick-walled elevation (p<0.001), those associated with radiating folds (p<0.001), and rugal thickening around ulceration (p<0.01) were more frequent in carcinoma. Undermining of the ulcer edge (Figure 9), abrupt obliteration or thinning of the radiating folds (Figure 8), and clustered tumours (Figure 4 and 10) showed no significant difference between the two groups. Those gross findings with a significant difference were individually no absolute criteria, but the differential diagnosis between gastric lymphoma and carcinoma is thought to be made possible by the degree of conformity of their combination to either of the patterns given in Table 13. Based on the present investigation an attempt is being made to establish a system for the quantitative differential diagnosis.

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The purpose of this study is to evaluate the utility of laparoscopic findings of the liver in predicting the prognosis of patients with liver cirrhosis. 353 patients with liver cirrhosis (234 survivors and 119 fatals) were studied in order to clarify the clinical course of cirrhotic patients on the basis of survival curves. Furtheremore, the relation of laparoscopic findings to the etiology, physical findings and laboratory findings was discussed. Reddish marking was observed more frequently in HB virus associated liver cirrhosis. Hepatomegaly and lymphatic cyst was more common in alcoholic liver cirrhosis and macronodular formation was in non-B liver cirrhosis. Incidence of vascular spider in creased as regenerative nodule developed. The ratio of GOT/GPT, ZTT, serum gamma globlin and R15-ICG showed higher levels in cases with well developed regenerative nodule and lymphatic cyst. By contrast, serum albumin, cholinesterase and K-ICG decreased. Development of regenerative nodule and existence of lymphatic cyst reflected a poor prognosis of patients with liver cirrhosis according to the cumulative survival curves. However, degree of hepatomegaly and liver atrophy, existence of reddish marking and splenomegaly did not reflect the prognosis. These results led to conclude that laparoscopic findings of the liver was a useful tool in predicting the prognosis of liver cirrhosis and in management of this desease.

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We experienced 21 patients with goose flesh-like mucosa of the stomach and conducted clinical, histological and immunohistological studies. Females comprised 57.1% of all patients; 81% aged from 10 to 29. Concerning the clinical symptoms, 52.4% of the patients had epigastralic pain and some had nausea and vomiting. Numerous granular small elevations were observed in the pyloric gland region by roentgenological examination. Uncountable small elevations appearing goose flesh were seen by endoscopic examination. Dye spraying endoscopy with Indigocarmine revealed more elevated lesions, compared with normal area gastrica of pyloric gland and made the surface clear. C0 and C1 types of the mucosal border of the stomach comprised 90%. Histological findings showed hyperplasia of the foveolar epithelium, but atrophy of pyloric glands was rarely seen. Lymph follicle formation was frequently seen in the propria mucosae. This lesion could be differentiated from follicular gastritis of the atrophic type as defined by Yoshii or Morson. Goose flesh-like mucosa of the stomach was thought to be follicular gastritis of the hyperplastic type. Some cases showed a strong stain of IgA and positive tendency of SC in the lumen of pyloric glands by immunohistological study.

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Comparative study was carried out on galactose tolerance test and laparoscopic findings in chronic liver diseases. Eighty-seven patients with chronic liver diseases were classified according to laparoscopic findings as reported by Shimada and coeditors. Galactose tolerance test, known as a test for functional reserve mass of the liver, correlated with laparoscopic findings and histological findings. Fatty changes and cholestasis in biological data and histological findings, known as an interferential factor for the test of ICG, had no interference in the estimation of galactose tolerance test. Laparoscopic findings and galactose tolerance test were correlated with clinical course and histological changes, suggesting that galactose tolerance test was significant as well as laparoscopic findings for the estimation of the prognosis and histological changes in patients with chronic liver diseases.

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Twenty cases of pancreas divisum were diagnosed by Endoscopic Retrograde Cholangio-Pancreatography (FRCP) and other imaging techniques at our institute. The clinical features, labolatory examinations (serum amylase, urine amylase, pancreozymine-secretin test, provocation test, fast blood sugar and glucose tolerance test) and pancreatograms of these 20 cases of pancreas divisum were discussed. The results were follows. 1. Tewnty cases of pancreas divisum were clssified into two groups from the clinical features. Ten cases were found unexpectedly when the patients were examined of the billiary tract or liver by ERCP or other imaging techniques. Another ten cases were diagnosed as pancreas divisum when the patients, complaining of upper abdominal discomfort or pain, back pain and nausea in long duration like psychogenic symptom, were examined finally in pancreas. 2. In labolatory examination, serum amylase showed abnormalities at the rate of 35.5%, pancreozymine-secretin test in 42.8%, provocation test in 80% and oral glucose tolerance test in 89.9%, respectively. 3. Ventral pancreatogram was obtained by ERCP in 19 cases and dorsal pancreatogram in 6 cases. Two cases (10.5%) of the ventral ducts showed chronic pancreatitis and the dorsal ducts in 2 cases (33.3%), respectively. The obstruction of the dorsal pancreaticduct was seen in one case which was diagnosed as pancreatic cancer by surgery. These results suggest the necessity of the minute clinical examination of the pancreas on the patient complaining of vague abdominal symptom.

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Since 1980, 119 cases of digestive tract cancers which included 10 esophageal cancers, 100 gastric cancers and 9 colonic cancers, have been treated by YAG laser in our institutions. The endoscopic laser therapy was successful in 92 of 119 cases (77.3%). The effectiveness of the therapy was judged by alleviation of stenosis in advanced cancers and by negative biopsy under endoscopic direct vision in early cancers. Sixty six early cancers out of 80 cases (82.5%) were treated successfully and in 26 advanced cancers out of 39 cases (66.7%) was effective YAG laser. The laser treatment was successfully accomplished in all of the esophageal and colonic cancers, but the effective rate in the advanced gastric cancers was 51.9% and that of early gastric cancers was 80.8%. Regarding to the advanced gastric cancers, the cases with pyloric stenosis were more difficult to obtain the laser effect than the ones with cardiac stenosis. Complete treatment of early gastric cancer was possible by enough energyed laser radiation and the early gastric cancer which was prominent type and/or less than 2 cm in diameter, was the best indication for this treatment. The combined treatment of Co⁶⁰ -radiation therapy and YAG laser therapy was more effective in advanced esophageal cancer. YAG laser treatment also proved to be effective in colonic cancers, especially those located at the lower colon, because of its easier manipulation. Endoscopic YAG laser photocoagulation has become a safe and effective procedure in the treatment of digestive tract cancers. The accurate diagnosis of the extent and depth of the lesions should be requied for its indication. Dye spray endoscopy and endoscopic ultrasonography are very useful for this purpose.

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We attempted to select a super-high risk group of hepatocellular carcinoma (HCC) from liver cirrhosis (LC) patients, a high risk group of HCC, by peritoneoscopic findings. LC patients diagnosed by peritoneoscopy and biopsy were followed. 138 LC patients died of chronic liver diseases 1 to 18 years after diagnosis of LC. 43 patients of them died of HCC (HCC group) and 95 died of hepatic failure or gastrointestinal bleeding (Non-HCC group). Median survival time was 7.0 in HCC group and 3.8 years in Non-HCC group by the empirical life table method. Patients with reddish markings on the liver surface had a higher relative risk rate of HCC development than those without. The theory of quantification II of Hayashi demonstrated that reddish markings, no splenomegaly and nodules about 5 mm in diameter, arranged in order of importance, were markers predicting HCC development in LC patients. The correct rate of the retrospective prediction was 75% in all cases.

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Colonoscopic examination for the aged subjects poses various clinical problems, because they have generalized degenerative changes. We experienced 826 colonoscopic examinations in 636 subjects over 70 years during the last 11 years. Colonoscopy desirable for the aged is discussed based on the data of this series. Colonoscopy using a small caliber fiberscope proved to be less painful and less time-consuming compared with that using middle or large caliber scope. Accordingly, it is concluded that small caliber fiberscopes, type PCF and PCF-10, promise safer and reliable practice in the aged as well as in children. Attitude toward colonoscopy for the aged and selection of bowel preparation and/or premedication are also considered.

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The endoscopic resection method, which we developed for resection of early gastric cancer with local injection of Hypertonic Saline-Epinephrine (HS-E), was applied to esophageal leiomyoma and the tumor was safely resected. The suspected case was a 68 years old male who had a raised focus in the lower part of the esophagus, and was referred our hospital for endoscopic resection. On the basis of X-ray, endoscope and CT findings, was revealed that the disease was submucosal tumor of Yamada I type, which was an indication for endoscopic resection. The features of the method practiced this time were the use of scalpel for endoscope was facilitated due to sufficient submucosal infusion of HS-E solution so that bleeding during/post-resection can be minimized, and (2) the mobilization of the tumor onto the mucous membrane with resultant easy snaring and easy resection of Yamada I type. The size of the resected sample was 10 × 8 × 6 mm, and the pathological diagnosis was esophageal leiomyoma. The patient scarcely showed bleeding during/post-resection, the no side effect of epinephrine was noted. Hence, this method is widely applicable to endoscopic resection and patho-histological diagnosis of submucosal tumor.

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This case report describes two patients of fibrovascular polyp of the esophagus. Case 1: A 35-year-old male was admitted to our hospital with a complaint of epigastric pain on March 11th, 1983. On upper gastrointestinal roentgenogram, a small protruded lesion was recognized in the lower esophagus (Figure 1). Endoscopical examination showed it to be a lobulated polyp (Figure 2) and it was removed by polypectomy. The collected polyp measured 6×5×6 mm (Figure 3) and the histological finding disclosed fibrovascular polyp (Figure 4). Case 2 : A 56-year-old male was admitted to our hospital with epigastric discomfort on April 11th, 1983. On upper gastrointestinal roentgenogram, a small protruded lesion was recognized in the lower esophagus (Figure 5). Endoscopical examination showed it to be a emipedunculated polyp (Figure 6) which was removed by polypectomy. The collected polyp measured 3×3×4 mm (Figure 7) and the histological finding disclosed fibrovascular polyp (Figure 8). 16 cases of esophageal polyp have been reported so far in Japan. Endoscopic polypectomy is useful for the diagnosis and treatment of esophageal polyp.

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A 68-year-old female with diabetes mellitus was admitted because of general fatigue and loss of appetite. On admission hepatomegaly and splenomegaly were not present. X-ray and endoscopic examination of the esophagus showed a localized dome-shaped, dark-bluish soft lesion, 13×5 mm in size, in the lower part of the esophagus. Angiography showed neither sign of arterio-venous malformation nor haemangioma and then endoscopic varicography was performed. 76% urographin with antibiotics was injected into the lesion under the direct vision of endoscope to demonstrate whether it was varices or cyst. Varicography revealed it to be localized esophageal varices with efferent and afferentveins. Further examination using CT, US, scintigraphy, peritoneoscopy and liver biopsy showed no signs of portal hypertension. No abnormalities were found in the chest and the cervical region. This localized esophageal varices has neither association with so-called uphill varices nor downhill varices. Endoscopic embolization of the localized esophageal varices using 5% ethanolamine oleate was done. Two weeks after the treatment, the varices completely disappeared and slight linear scarring was observed at the same place.

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Gastric lipoma is comparatively rare disease and lipoma with bleeding is further rare in Japan. We encountered a case of gastric lipoma with bleeding and removed it by endoscopic polypectomy. The patient is a 73-year-old female who admitted to Ozuchi Hospital with the chief complaint of dizziness. On the second hospital day, endoscopy revealed a pedunculated submucosal tumor with ulcers on its top and neck on the greater curvature of the lower gastric body. On the 4th hospital day, the patient complained of tarry stool, so endoscopic polypectomy was performed. The resected tumor was 2.0×2.0×3.5 cm in size and was diagnosed as gastric lipoma by histolosical examination. Endoscopic polypectomy is considered to be an effective treatment of hemorrhagic pedunculated polyp of the stomach.

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A 34-year-old man visited to our hospital with a complaint of stubborn epigastric pain. He had a laparotomy 1 year ago for pancreatic hematoma due to traffic accident. But the pain occurred occasionally two years ago. There was no significant change in the laboratory data except for elevation of amylase in the urine. A plain film of the abdomen revealed a small calcified shadow in the right upper quadrant of the abdomen. ERCP showed that the calcification was located in the main pancreatic duct. As the patient did not want a repeat laparotomy, EST was attemped for removal of the pancreatic stones. The procedure was accomplished with successful incision of the orf ice of the pancreatic duct. Basket retrieval of the pancreatic stones was then completed under duodenoscopic guidance. No complication occurred during or after the procedure. Ten month later the patient was still asymptomatic. EST has now become an acceptable alternative to transabdominal surgery for removal of biliary tract stones. The wide-spread availability of the technique will lead to open a new indication for EST in the treatment of pancreatic disease.

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A 22-year-old-female visited the gastroenterological division of Sapporo National Hospital on April 9, 1980, complaining of pain in the upper part of the abdomen and back. Upper GI series revealed a pouchy shadow surrounded by a translucent halo in the lumen of the second portion of the duodenum, which appeared characteristics of IDD. Endoscopic excision for the most part of the IDD was done on July 23, 1980. But because abdominal pain sometimes occured during the following 6 months, subsequent surgical excision for the residual IDD was done on January 27, 1981. IDD is rare. Only 23 cases of IDD including the authers' case have been reported in Japan. The pathogenesis of IDD suggests that the residual incomplete duodenal diaphragm gradually trasform due to peristalsis and passage of the duodenal content. A few cases treated by endoscopic excision have been reported so far. It is concluded that endoscopic excision is useful in some cases of IDD and, therefore, should be performed carefully and positively before surgical treatment.

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A case of small liver cell carcinoma recurred 8 months after resection is presented. The patient was a 63-year-old female. Laparoscopically a small highly-vasculized tumor was seen at the middle of the left hepatic lobe surface. Left partial lobectomy was performed. The size of the tumor was 2.0 × 1.9 × 1.2 cm. Histology of the specimen showed hepatocellular carcinoma (Edmondson's type III, trabecular pattern) with hepatic cirrhosis. Serum a-fetoprotein (AFP) was preoperatively 368 ng/ml and once decreased to 25 ng/ml after resection. It seemed that the operation had been curative. But the serum AFP increased slowly to the preoperative level, and a mass lesion was found in the right hepatic lobe by computed tomography. It seemed to be hepatoma newly originating in the right posterior segment. In spite of several transcatheter arterial embolizations, the AFP level increased steadily over 10, 000 ng/ml.

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