In this paper, author studied on the diagnostic ability of lymph nodes metastases in the gastric cancer by endoscopic ultrasonography combined with the method of the oral administration of the emulsion (the enhanced EUS). At first, by using rats and dogs which were made artificial gastric erosions or ulcers, author clarified that the emulsion was absorbed at the part of erosions or ulcers and flowed to lymph nodes surrounding the gastric wall. Next, by the method of the acoustic investigation, author made clear that the enhancement effect by the olive-oil-emulsion, which was newly developed, was stronger in comparison to the sesame-oil-emulsion. In clinical studies, 20% sesame-oil-emusion, 20% olive-oli-emusion and 40% olive-oil-emulsion were employed. As the result, 20% olive-oil-emulsion showed the highest ratio in the visualization of lymph nodes surrounding the gastric wall. No significant differences in the diagnostic ability of lymph nodes metastases were recognized among three emulsions, although each emulsion showed the high accuracy rate in the diagnosis of the lymph nodes metastases. In conclusion, author considered 20% olive-oil-emulsion to be the most suitable emulsion in the enhanced EUS, but more clinical studies should be performed in order to clarify the usefullness of this emulsion in the diagnosis of lymph nodes metasteses in gastric cancer.

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Nine patients of unresectable gastric cancer were treated by both endoscopic and intradermal injections of OK-432. Roentgenographic and endoscopic examinations revealed morphological improvement in two of them. One case was Borrmann 1 type advanced cancer and another case was IIa +IIc type early gastric cancer. In these cases the tumor masses disappeared completely, and in the latter case no cancerous tissue was detected by biopsy examination. Fever (38 to 39°C) was noted four to five hours after the endoscopic injection of OK-432 in all cases. But there was no serious side effect of this therapy except fever. Local administration of OK-432 by endoscopic injection is effective and recommended for the treatment of unresectable gastric cancer.

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As an adjunct procedure on choledocholithiasis, we have been performing side-to-side choledochoduodenostomy (C-D) since 14 years ago, and have got good results. However, little has been reported on postoperative endoscopic findings on the stoma and bile duct mucosa. So this study was made to tell us the real mucosal condition of C-D stoma, proxymal bile duct, and distal bile duct in 28 patients, including 23 of common bile duct stones, 4 of intrahepatic gall stones, one chronic pancreatitis. Endoscopic examination was done from 1 month to 12 years after C-D operation. Stomas were placed on the supraduodenal angle. All of them were round, patent, and showed no narrowing. So it looked as if supraduodenal angle had been occupied by biliary mucosa. Endoscope passed easily through the proxymal and distal bile ducts. We found only a mild inflammatory changes in the proxymal bile duct and stoma (4 patients), but no cholangitis were noted clinically. On the other hand, in the distal bile duct, we found food debris (5 patients), mild inflammatory mucosa (11 patients) and severe inflammatory mucosa (4 patients). But those patients did not show the clinical sign of cholangitis nor "Sump Syndrome". According to our results, we believe that C-D is safety and useful procedure if the stoma size is provided larger than 3cm.

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Following the discovery of atypical mycobacterial contamination of endoscopes and of automatic endoscope washers, we report the results of our further investigation. Such contamination had been prevalent when 1% glutaraldehyde solution was used as disinfectant solution, and despite standard use 2% glutaraldehyde solution for the washers when used without exchange of the solution in the washer-reservoir tank for more than two weeks. It is interesting to note that recorded glutaraldehyde concentrations contained in the washer were found to marginally decrease in each washing cycle with a total eventual decrease of 20%-40% by 25 cycles, due to introduction of rinsing water into the disinfect ant reservoir. Optimal concentration of glutaraldehyde (2%) was found to be maintainable using a 3% solution of glutaraldehyde to prevent the washing solution falling below effective concentration levels and by replacing this with a complete exhange twice a week (every 3-4 days). Vigorous brushing of the biopsy channel and overnight immersion of the endoscope, both using concentrated disinfectant solution (3%), effectively prevented atypical mycobacterial contamination. All bacteriological examinations showed that these prevention techniques have been effective for a continuous period of over 18 months to date. We have accordingly undertaken routine examinations of the employed bronchoscopes, following bronchoscopy in 12 cases of active pulmonary tuberculosis where bronchial secretes carried M. tuberculosis, and no contamination of either endoscope or washer by M. tuberculosis was found since introduction of our new techniques. The acid fast bacilli which had contaminated the endoscopes and the washers were confirmed to be M, chelonae subsp. chelonae, M, chelonae subsp. abscessus and M. gordonae. The M. gordonae was also confirmed in the local water delivery systems. The source(s) of other acid fast bacilli are being still actively investigated.

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Pathomorphological studies were performed in seven cases which achieved perfect eradication of varices comfirmed endoscopically and survived more than one year after endoscopic injection sclerotherapy. Three of them which showed perfect eradication of varices at autopsy had four occluded variceal veins by extensively organized thrombi with occasional recanalization. The other three cases had moderately dilated recanalized small vessels in the organized thrombus in the varices in the submucosa, and dilated variceal veins in the mucosa. These pathological findings were considered to be consistent with endoscopic findings of atypical red-color sign and telangiectasia. The remaining one case which developed reccurence of varices and died of bleeding from ruptured varices showed obvious varices at autopsy. These varices consisted of markedly dilated small vessels in the organized thrombi and dilated vessels around the varices. The description of this finding has never reported so far. Through the investigations on these cases, it was suggested that excessive intake of alcohol and deterioration of hepatocellular carcinoma found in 6 cases were important factors to promote the reccurence of esophageal varices.

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The usefulness of ECG unit in functional endoscopy is discussed. ECG unit is an apparatus for getting good still images of electronic endoscope with decreasing the affecting of cardiac movement originally. Since it superimposes electrocardiogram upon TV monitor, we applied ECG unit to superimpose the recording of mucosal blood flow, pH and potential difference in addition to ECG. This application resulted in stable and effective measurements. The superimposing display of ECG also made the endoscopic surgery more safely in patient with cardiovascular diseases.

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Endoscopic polypectomy has been performed for 581 lesions in 413 patients at our center during the past seven years. Among these patients there were ten gastric IFPs in nine patients, which is equivalent to 1.7%. We studied the endoscopic appearance and histopathological finding of the IFP cases. The results were as follows: 1) Gastric IFPs were frequently found at A-site (Table 2). The mucosal surface in these cases was smooth and appeared to be normal in color (Table 2, Figure 1). The features of the majority of gastric IFPs corresponded to Yamada's type III, few of them had local redness or white coating and none showed bleeding or bridging fold (Table 2, Figure 1). 2) Endoscopic polypectomy of gastric IFPs is very useful as a method of total biopsy, because it is difficult to diagnose gastric IFP based on specimens obtained by biopsy forceps. 3) It is suggested that gastric IFPs are mainly located at the deep portion of the mucosal layer or at the shallow portion of the submucosal layer and that they grow vertically in both directions (Figure 3-6).

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Peritoneoscopy and liver biopsy were perforemed in six survived patients with fulminant hepatitis. The results of peritoneoscopic examination were grouped into two categories. The first category was characterized by almost normal liver shape or small depressions on the liver surface. The second category showed the caracteristics of so-called "potato-liver" or "scar-liver". No clinical difference were found between the two categories. However, the latter showed fluctuating aminotransferase levels. For the latter, a series of follow-up biopsy during the period from 18 to 24 months was performed on two patients, which results showed CAH ha and LC. It is suggested that the results may indicate development of chronic liver disease associated with NANB hepatitis.

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In a period of the recent 5 years and 6 months, 89 lesions in 87 cases have been removed in a piecemeal fashion endoscopically. From the pathological point of view, 100 specimens taken in a piecemeal fashion were examined for the adequacy of orientation and margin of excision. The results were as follows; 1) Microscopic orientation of the tissues was excellent in 5.3% (5 mm or less than 5 mm in diameter), in 62.2% (69 mm), in 80.8% (1014 mm) and in 100% (more than 15 mm in diameter). Larger specimens more than 10mm in diameter were considered easier to make an accurate diagnosis pathologically. 2) However, tissues including the mucosal muscle were present in all, 6 mm or more in maximal diameter. In these groups, it was sufficient to diagnose adenomas and focal carcinomas. 3) The colonoscopist has to cut the specimens from the base to the head of the polyp and divide them into two fragments (proportion ratio 7 : 3) in order to show the submucosa and excisional margin accurately. Therefore, well oriented fragments, which give much detailed information pathologically, can be obtained even in piecemeal speci mens.

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A 73-year-old woman suddenly developed an abdominal pain and distension in January 1985, and visited a hospital where her condition was diagnosed as essential thrombocytosis and cholecystic polyp, however, the cause of the abdominal pain remained unknown. In April 1986, she was admitted to our department with a recurrent abdominal pain. Since detailed examinations revealed portal vein thrombosis and cavernous transformation, i. e., the collateral circulatory pathway toward the liver in the hepatic hilum, the patient was diagnosed as having the old stage of portal vein thrombosis associated with essential thrombocytosis. However, since a protuberant lesion of the neck of the gallbladder could not be definitely identified as the collateral circulatory vein, laparotomy was carried out as a trial in November 1986. As a result, the protuberant lesion of the neck of the gallbladder was revealed as a cholecystic varix, i. e., the collateral circulatory pathway toward the liver. This finding was supported by portgraphic findings during the operation. The patient's postoperative course is at present uneventful owing to administration of an inhibitor of thrombocyte function.

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A 82-year-old female was admitted because of right hypochondric pain and fever. Abdominal ultrasonography showed a thickened wall of swollen gallbladder and an incar-cerated stone of the neck. Percutaneous transhepatic cholecystgraphy and drainage (PTCCD) was performed because of severe inflammation in the gallbladder. Abdominal pain and fever was alleviated by PTCCD and antibiotics. At first the contrast medium could not pass from the gallbladder to the cystic duct. Seven days later the gallbladder contracted and the stone disappeared. Because the bilio-enteric fistula developed after the gallbladder drainage, it seemed that contraction of the gallbladder caused the fistula.

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A case of pedunculated lipoma of the duodenum is reported. A 58-year-old man was admitted to our hospital complaining of fatigue and a loss of appetite. Barium X-rays (hypotonic duodenography) and endoscopy revealed a pedunculated tumor with erosion at the tumor head in the 2nd portion of the duodenum. The head of the tumor was covered with intact duodenal mucosa except for the part involved with erosion, and the erosion was attached with whitish coat. The tumor was diagnosed as a submucosal tumor of the duodenum. The surgically resected tumor was 2.7×2.1×1.9 cm in size and diagnosed his-tologically as benign lipoma derived from the submucosal layer of the duodenum. Fifty-six cases of duodenal lipoma including ours are reported in the literature up to 1987 in Japan. The clinical features of these cases are also discussed.

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Case 1. A 68-year-old male patient visited our clinic for high fever. On the chest roentogenogram, miliary shadows were shown throughout the lung field at 47 days after the onset. On peritoneoscopy, numerous small white spots (about 0.5 mm) were scattered on the liver surface and on histology we could find many epithelioid granuromas containing giant cells of the Langhans type in the liver biopsy. On peritoneoscopic follow-up we could find that small white spots had disapeared completely after the administration of antituber-culous drugs for one year. Case 2. A 56-year-old female patient visited our clinic for ascites. Peritoneoscopically there were numerous nodules on the thickened parietal peritoneum with adhesion to the liver surface, and on histology we could find epithelioid granulomas containing giant cells of the Langhans type in the biopsy of the nodule on the parietal peritoneum. At 2.5 months after the initial administration of antituberculous drugs, the number of nodules on the adhesions was decreased but nodules on the parietal peritoneum showed a tendency to swell and fuse. The number of nodules markedly decreased at 6 months, and completely disappeared at 11 months. We concluded that these two cases showed typial peritoneoscopic findings of the healing process of hepatic tuberculosis, acompanying miliary tuberculosis, and peritoneal tuberculosis.

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A 60 year-old-female was admitted to Yamaguchi Rosai Hospital in order to remove gall bladder for cholecystolithiasis. Endoscopic examination of the duodenum showed an extremely elongated lesion covered with normal mucosa, of which base was attached on the margin of the juxta-papillary diverticulum, and the top of which was located in the duodenal bulb as if a snake lying in a coil. A long mucosal sac was suspected, for example, a subtype of Intraluminal duodenal diverticulum (IDD). Resected specimen was 0.5 x 8 cm in size, a narrow and long sac, having large and long blood vessels from the base to the top through the submucosal layer. Moreover, microscopic examination revealed that the outer side was covered with duodenal mucosa and the inner side was consisted of loose connec-tive tissue and large blood vessels. These findings proved that our finding was completely different from IDD. To our knowledge, such a case has not been reported, therefore, we named it Intraluminal duodenal protrusion (IDP) based upon the impression of an extremely long mucosal protrusion like a snake.

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A 53-year-old female was admitted to our hospital, complaining of melena (tarry stool). Upper GI series demonstrated an elevated lesion at the 2nd portion of the duodenum. Endoscopic examination revealed a submucosal tumor. Histology of biopsy specimen obtained from the central ulceration showed leiomyoma. Surgical excision was performed. Two tumors (3×3mm, 10×10mm) were seen at the jejunum except the tumor of the duodenum (32×20mm). Histopathologically, the tumors were benign leiomyomas. To our knowledge, only 11 cases of multiple leiomyomas of the small intestine have been reported in Japan, and a review of literature was made. This case, leiomyaoma of the duodenum is considered to be the first case which is associated with multiple leiomyomas of small intestine in Japan.

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The combined method of direct-coating with sucralfate-thrombin mixture and H2 blocker administration was performed to 87 cases showing upper gastrointestinal hemorrhage. Patients ranged from 20 to 93 of age. The mean age in males (62 cases) and females (25 cases) was 59 and 65 years of age, respectively. There were 31 cases (36%) of gastric ulcer, 22 (25%) of duodenal ulcer, 6 (7%) of stomal ulcer, 13 (15%) of acute gastric mucosal lesion, 8 (9%) of gastric cancer and 7 (8%) of other diseases (Mallory-Weiss syndrome 2, submucosal tumor 1, post-polypectomy 4). Forty three cases (49%) had severe primary diseases and 8 cases (9%) died from other causes. In twenty four cases (28%), severe epigastralgia was shown at emergency endoscopy. Endoscopic findings on an ulcer base were as follows : without blood clots, 12 cases (14%) ; with fresh blood clots, 40 cases (46%); oozing, 17 cases (20%); capillary blood vessels, 14 cases (16%) ; exposed vessels, 4 cases (5%). Hemostatic rates in this method was 100%. Complete and temporary hemostatic effect was obtained in 85 cases (98%) and 2 cases (2%), respectively. Furthermore, severe epigastralgia in 24 cases (28%) was disappeared immediately after direct-coating therapy. The results indicate that drug direct-coating method using endoscopic hemostasis are valuable for upper gastrointestinal hemorrhage and also effective to alleviate symptoms (epigastralgia and so on).

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Successful treatment of renal stones have been recently reported with an extracorpor-eal shock-wave lithotriptor. The authors attempted to apply the lithotriptor to the treatment of big stones in the common bile duct which are not amenable to the extraction with a basket catheter. The first step was started with an in vitro experiment : a gall stone obtained during a surgical operation was exposed to the shock-wave in vitro. The stone was fragmented after 750 shock-wave exporuses. Consequently, the next step was taken to apply the lithotripter to two patients with big stones which had been found in the common bile duct some years after cholecystectomy, because the endoscopic papillotomy and extraction of the stones with a basket catheter was unsuccessful. The two patients were exposed to the extracorporeal shock-wave under epidural anesthesia and under the guidance of radiogra-phy after injecting contrast material through the endoscopic nasobiliary tube which had been detained following the endoscopic papillotomy. The fragmented stones were easily removed with an endoscopic basked catheter 2 days after in one case ; and the stones were found to have disappeared 4 days later in the other case. The results suggest that the extracorporeal shock-wave lithotripsy will prove to be useful for the treatment of big stones in the common bile duct. Further clinical studies are now in progress.

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