Familial adenomatous polyposis (FAP) is an inheritable disease which characterize by the development of numerous polyps in the colon and rectum. This usually occurs at about the second decade of life and the polyps are likely to develope to cancer with 100% incidence unless treated. Among the several surgical options available, one of the most difficult decisions is determing whether the anal transitional mucosa (ATM) should be retained or completely removed. The risk of developing cancer is less when the mucosa is completely removed, however post-operative anal functionality seems to be better in ATM retaining operations. This is especially noted when operating on early-detection cases in which the polyp had not fully developed. This presents a dilemma in which it is difficult to determine the operative procedures. In an attempt to classify the cancer risk of the background rectal mucosa, we observed the microadenoma in the resected specimens by the utilizing the stereomacroscope, magnifying endoscope, and finally, the videomacroscope which was developed by this research team. Microadenomas, and even single gland adenomas can be observed by these instruments. Microadenomas were histologically corroborated after observation with the stereomacroscope. FAP is characterised by density of polypes as follows. 1. carpet type 2. scattered type. In the latter type, microadenoma are scarcely present in the ATM. Cancer risk seems to be lower in this type of FAP. Therefore, an operative procedure for FAP should be chosen by taking into account the reduced cancer risk with a complete removal of high risk mucosa and the patient's quality of life (QOL) with the resulting post operative anal function by an ATM retaining prosedure. A videomacroscope is very useful instrument for this diagnostic purpose.

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The relationship between the pattern of ulceration in cancerous foci and cancer invasion were investigated in 90 patients with depressed type of early gastric cancer. Of all, cases with ulcerative change were 83.3%, of which cases with ul-II occupied 77.3%. Classification of fibrosis patterns was suggested as follows : (1) F-I, fibrosis was visible only in some parts of the submucosa (sm) ; (2) F-II, fibrosis occurred in the full depth of sm ; and (3) F-III, masslike fibrosis. We also proposed sub-classification for F-II, fan-shaped fibrosis was sub-divided into F-II₁ and F-II₂, according to whether it was ulcer scar or open ulceration ; Diffuse fibrosis type was classified into F-II₃. F-I, F-II₁ and F-II₂ developed primarily in mucosal cancer, while F-II₃ and F-III mainly occurred in sm cancer. From the viewpoint of the relationship between patterns of cancer invasion and the fibrosis, diffuse invasion was chiefly seen in F-III, while marginal invasion was found primarily in F-II. As to the relationship between the pattern and depth of invasion, marginal invasion principally involved superficial layer of sm and diffuse invasion frequently reached the deep leyer of sm. These results contribute significantly to the analysis of ultrosonographic endoscopy.

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Endoscopic ultrasonography (EUS) was performed on 19 cases with gastric leiomyoma and on 8 cases with gastric leiomyosarcoma. We tried to determine whether EUS images could serve to distinguish leiomyosarcoma from leiomyoma. Ultrasonographic equipments used were OLYMPUS GF-UM1, GF-UM2 and GF-UM3 at the frequencies of 7.5 or 10 or 12MHz, with water fill-up method. The mean of the maximum diameter of leiomyoma was 3.9±1.9 cm (mean ± SD) and that of leiomyosarcoma was 9.9 ± 5.9 cm, the difference being significant (p <0.0005). We classified the tumors into three groups based on the tumor sizes : less than 3cm, 3-8.9 cm and more than 9cm in diameter and compared each other to determine whether leiomyoma or leiomyosarcoma has characteristic EUS images. In 7 tumors less than 3cm in diameter, 6 tumors were leiomyomas whose EUS images were characterised by smooth marginal echoes and homogeneous internal echo textures without cystic formation more than lcm in diameter. Four tumors were more than 9cm in diameter and all of them were leiomyosarcomas with cystic formation more than lcm in diameter. Sixteen tumors in the range of 3 to 8.9 cm in diameter were often difficult to distinguish malignant from benign tumors and the accuracy remained arround 60% level based on EUS images. For this reason, histologic examinations of biopsy specimens are required for this group of tumors. In conclusion, the tumors smaller than 3cm or larger than 9cm in diamer are rather accurately differentiated as benign or malignant based on EUS images, but the tumors with intermediate in size, from 3 to 8.9 cm, are often difficult to distinguish malignant from benign fumors based on the sonographic characteristics alone.

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In our prospective study, we found endoscopically small esophageal red spots in 61 (11%) of 564 cases which were not associated with reflux esophagitis, carcinoma, varices and stricture in the esophagus. The incidence of the red spots increased with age. With Lugol staining, 35 lesions (57%) of them were deeply stained, 4 (7%) were normally, 10 (16%) were slightly and 12 (20%) were not stained. Biopsy was performed in 25 of 61 cases during endoscopy. In 20 cases (80%) of them, histological examination of the biopsy specimens revealed infiltration of inflammatory cells, thickening of basal cell layer or/and extension of papillae. These results suggested that many persons had solitary esophagitis. Out of 9 cases which was not stained with Lugol's solution, one was histologically diagnosed as squamous cell carcinoma on biopsy specimen and one was diagnosed as moderately dysplastic lesion. This study showed small superficial esophageal carcinoma could be found by means of biopsy of red spots which were not at all stained or deepstained partially with nap-like shape at its margin with Lugol's solution.

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In 49 patients who were diagnosed as suspicion of submucosal tumor in digestive tract, the usefulness of endoscopic ultrasonography (EUS) in diagnosis of submucosal tumors was evaluated from three viewpoints, that is, differential diagnosis from extramural compression by the proximal organs and submucosal tumor, qualitative diagnosis of submucosal tumor and differential diagnosis between benignancy and malignancy. EUS equipped with the radial scanning type of Olympus make was used. It was possible to make differential diagnosis for extramural in all cases. Qualitative diagnosis among submucosal myogenic tumor, hemangioma, lipoma and cyst was possible to assess internal echo level and wall site of occurrence. Differential diagnosis of myogenic tuomr between benignancy and malignancy was impossible. Based on summarised data EUS and histopathological findings obtained from 18 surgical cases of myogenic tumor, it was recommended that surgical treatment should be considered by suspecting sarcoma if three of four findings such as more than 30mm of tumor diameter, asymmetrical margin, uneven internal echo and/or echo free area were obtained.

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We have established PTCCSL, one of the non-surgical treatment modalities for gallstones, as a safe, reliable and technically easy therapeutic procedure through improvements in PTCCSL manipulation and the developement of new devices for this technique. To date, we have performed PTCCSL in 37 cases of cholecystolithiasis and have succeeded in the removal of the stones in all cases without any serious complications. These patients required PTCCSL an average of 2.1 times, with a mean of 11.8 days being required from initial puncture of the gallbladder until stone removal. The post-treatment follow-up observation period in these cases ranged from 1 to 60 months, averaging 24.7 months. Gallbladder function returned to the pretreatment level and has continued to be good in all cases. Unfortunately, gallstones recurred in 7 cases (18.9%), although neither cancer nor polyp has been noted to occur during the post-treatment observation period. PTCCSL is less invasive than cholecystectomy, whether performed by laparotomy or under peritoneoscopic visualization, and can be performed repeatedly without much inconvenience or ill effects. However, PTCCSL is followed by relatively early recurrence in a significant proportion of cases, against which there currently are no reliable prophylactic measures available. PTCCSL is best served on those high-risk patients in whom general anesthesia is contraindicated.

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Thirty one cases (male: 15, female: 16) of the upper and middle third esophageal ulcers were investigated. The average age was 42.1 years, which was younger than that of the lower esophageal ulcers (58.5 years). The causes of the ulcers were drug administration (12 cases), foreign bodies (2 cases), radiation (1 case), food (1 case), lichen planus (1 case) and unknown (14 cases). A majority of initial symptoms were retrosternal pain, disturbance of passage and odynophagia. Endoscopic findings of the disease were divided into 3 types : the irregular type, round type and exfoliation type. Most of the ulcers were the irregular or the round type. There were only 4 cases of the exfoliation type. The exfoliation type improved earlier than the other two types on the endoscopic findings and symptoms. This is because the ulcer lesions of the exfoliation type were superficial. The literatures on exfoliative esophagitis were also reviewed.

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We have experienced sixteen cases of drug-induced esophageal ulcer. The causative drugs were thought to be antibiotics in 11 cases (doxycycline in five cases, bacampicillin in two cases, cef otiam in two cases, clindamycine in one case and minocycline in one case), analgesic in 3 cases (dicrof enac natrium in two cases and indomethacin in one case), KCl in one case and ferrous sulfate in one case. The forms of causative drugs were tablet in ten cases and capsule in six cases. All cases complained of heartburn and retrosternal pain. Two cases complained of hematemesis. Five cases took a drug without water and two cases did on supine position. Nine cases of drug-induced ulcers were observed in the middle esophagus, and seven cases were in the lower esophagus. The ulcers were single in eleven cases and multiple in five cases in number. Most of cases healed rapidly with medical treatment. But, the cases with hiatus herniation healed more slowly than those without it. We experienced the intractable cases which had been caused partly by esophageal dysfunction, such as lowering of LES (lower esophageal sphincter) and primary peristalsis.

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Endoscopic observation of the cystic duct was performed in 18 cases since January 1990. All cases had recieved endoscopic lithotomy for the stones in the common bile duct transpapillary. After complete removal of stones, peroral cholangioscopy was perfoemed using the baby scope. As the results, the insertion of the baby scope into the cystic duct was successful in 15 cases ; in 3 cases into the neck of gallbladder, in 13 cases upto the valvular portion and in all cases upto the smooth portion. It was failed in 3 cases. Endoscopic findings could be evaluated in 12 cases. All cases had fine branching vessel and in 4 cases, the valvular portion showed dilated vessles. The rough mucosa was shown in 2 cases in the valvular portion. Methylene blue staining was perfonrmed in 4 cases. It was effective to show the surface structure of the mucosa clearly in the cystic duct. Histological findings of the rough mucosa showed the chronic inflammatory changes. In conclusion, endoscopic observation, the dyeing method and the histological examination are useful for the diagnosis of the mucosal structure of the cystic duct.

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We studied the efficacy of new topical treatment with lidocaine gel, that was reported by Björk, et. al.(1989) for ulcerative proctitis. In our 6 cases with active proctitis, symptoms and endoscopic features were markedly improved after two-weeks intrarectal administrations of 2% lidocaine gel (40ml/day). Pathological findings of rectal inflammation were improved in 4 of 6 cases. No side effects were observed, and the serum concentrations of lidocaine during therapeutic periods did not exceed the minimum concentration to exhibit antiarrhythmic effects. These results suggest that the topical lidocaine treatment may be useful in the patients with long-standing proctitis that have hardly responded with the conventional steroid therapy.

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Two cases of portal and mesenteric venous thrombosis with bowel infarction occurring after endoscopic injection sclerotherapy (EIS) for esophageal varices are reported. Case 1 was a 62-year-old female. She was undergone prophylactic EIS in August, 1985. Six months later, a small thrombosis attached to the portal vein wall was detected by abdominal computed tomography and ultrasonography. Second EIS for reccurent esophageal varices was performed in April, 1988. One week later, she complained of colicky abdominal pain. A plain roentogenography of abdomen revealed a dilated and edematous small bowel consistent with ischemic colitis. Her condition became worse and died three weeks after second EIS. A case with autopsy findings demonstrated old and fresh thrombosis in the portal vein and superior mesenteric vein with hemorrhagic infarct of the small intestine. Case 2 was a 60-year-old male. He was carried out elective EIS in December, 1987. One year and six months after, he complained severe abdominal pain followed diarrhea and fever. A plain roentogenography of abdomen revealed areas of dilated small bowel consistent with ileus. He died two weeks after he was treated for his intestinal obstruction. Autopsy findings showed fresh thrombosis of portal and mesenteric vein, and secondary infarction of small bowel was noted. It was suggested that both cases of portal and mesenteric venous thrombosis were referred to the change of blood flow after EIS.

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We have experienced a case of heterochronous multiple minute esophageal cancers occurring in an interval of one year and six months during the periodical observation following endoscopic injection sclerotherapy for esophageal varices (EIS). In a case of a 52-year-old man, approximately 2mm sized esophageal cancer was detected at 28cm from the incisors and toward 4° direction one year and six months after EIS. Sufficient laser treatment was made. One year and six months thereafter, another approximately 2mm sized esophageal cancer was noted 3cm oral to the previous lesion toward the 3° direction. The new lesion which could not be visualized after biopsy at that time, became observable four months thereafter and received hot biopsy during hospitalization. Histologically, it was squamous cell carcinoma. Although the causal relationship between EIS and pathogenesis of esophageal cancer is still unknown, periodical detailed observation of the course of disease are necessary in view of further increase in the number of such cases.

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A 74-year-old female farmer was admitted to our hospital with dizziness. Laboratory examination showed severe iron deficiency anemia and eosinophilia. The second examination of feces revealed many hookworm eggs. Endoscopy showed the presence of many red worms, 1 cm in length, from the angulus of the stomach to the second portion of the duodenum. Some worms were removed with biopsy forceps, and confirmed to be the Necator americanus from their morphological features. The patient was treated with 800 mg of pyrantel pamoate three times. Subsequently worm eggs in the feces and worms in the stomach and duodenum were found to have completely disappeared. Examination of worms removed by endoscopy proved useful for differential diagnosis in addition to fecal worm egg culture. Hookworms usually inhabit the duodenum and upper jejunum, and it is very rare for such parasites to migrate to the stomach. To our knowledge, there have been no case reports concerning Necator americanus involving the stomach in Japan.

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A 65-year-old man was admitted to our hospital because of endoscopic abnormal finding of the esophagus. Operation was done for type 0-IIc mucosal cancer of the middle intra-thoracic esophagus. During operation, a localized wall thickening of the fornix of the stomach and an elevated submucosal tumor of the transverse colon were found out. Intra-thoracic esophagectomy without thoracotomy, partial proximal gastrectomy and partial transverse colectomy were carried out. Histologically, the esophageal cancer was moderately differentiated squamous cell carcinoma with invasion to the muscularis mucosae. The lesions of the stomach and colon were medium cell type of follicular lymphoma which invaded to the subserosa and metastasized to the regional lymph nodes. Another submucosal lesion like IIa type of the transverse colon was also disclosed. The lesions of the stomach and colon were consistent with Dawson's criteria and there were no lymph nodes swelling around the abdominal aorta. Therefore, the lesions of the stomach and colon were considered to be double primary malignant lymphoma of the digestive tract.

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A 8 year-old-girl with Peutz-Jeghers syndrome has been followed for 8 years through X-ray study. A polyp was recognized at 8 years of age. At 11 years of age. 27 or more polyps were found in her stomach, which were not recognized by double contrast X-ray study done 6 months previously. The first polyp disappeared at her 15 years of age. One of the polps in the stomach increased in diameter from 8mm to 34mm during 4 years, which showed a difference in growth in two portions of the lobulated polyp. In the large intestine, two polyps were recognized. We removed three gastric polyps and two colonic polyps by means of endoscopic polypectomy in 1989. One of the gastric polyps was hamartomatous polyp and the other two were hyperplastic polyps. One of the colonic polyps was tubular adenoma and the other was hyperplastic polyp.

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Two cases with angiodysplasia of the colon treated by superselective embolization was reported. In the case 1, a 74-year-old man was admitted for the evaluation of chronic lower gastrointestinal bleeding. In the case 2, a 60-year-old man was admitted for the evaluation of several episodes of small amounts of bright red blood per rectum. After admission, visceral angiography was performed in the both cases. Angiodysplasia was recognized at the right colic artery in the case 1 and at the superior rectal artery in the case 2. Because two patients weren't surgical candidates, a Tracker-18 catheter was used to embolize the artery with a microcoil superselectively. After embolization, there had been no recurrence of rectal bleeding in both cases for 7 and 9 months, respectively.

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A 30-year-old woman at 12 weeks' gestation was referred to the outpatient department of Shinshu University Hospital with the complaint of bloody stool. Colonoscopy was performed at 16 weeks' gestation, and a semipedunculated polyp was revealed in the sigmoid colon. Histological diagnosis was a Group 5 lesion of well differentiated adenocarcinoma. Endoscopic polypectomy was performed at 22 weeks' gestation, as the lesion was suspected to be an early cancer by endoscopic evaluation and also due to pregnancy. The resected tumor was 22 × 15 × 15mm in size and histologically confirmed to be a well differentiated adenocarcinoma. As cancer cells limited to the submucosal layer (micro invasion) without any vascular invasion, so colectomy was not performed during pregnancy. At 38 weeks' gestation the patient was delivered of a healthy female infant with no complication. Subsequently colectomy was performed after the delivery. Neither residual tumor nor lymphatic invasion was found in the resected tissues.

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A 69-year-old woman with a bile duct carcinoma associated with anomalous pancreaticobiliary ductal junction is described. The patient underwent cholecystectomy at a local hospital for acalculous cholecystitis 4 years previously. The anomalous junction was demonstrated by ERCP performed as a preoperative examination at that time, but the dilatation of the common bile duct was considered innocent. Right upper abdominal pain and general malaise brought the patient to our hospital, and thorough examinations revealed the carcinoma in the mid-portion of the common bile duct. Biopsy at percutaneous transhepatic choledochoscopy showed well-differentiated adenocarcinoma, and then bile duct resection and lymph node dissection were performed. This case seems note worthy to show a chronological factor of the development of bile duct cancer in patients with the anomalous pancreaticobiliary ductal junction.

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A 62-year-old man was referred and admitted to our hospital after colonoscopy for further examination of occult bloody stool demonstrated a tumor in the descending colon. Colonoscopic findings showed a protruding, ralatively soft and smooth surfaced tumor occupying the lumen, with no ulceration (Figure 2). It looked like submucosal tumor and a diagnosis of malignant lymphoma was made from biopsy specimens (Figure 3). We performed a left hemicolectomy with R₂ lymph node dissection and resected pancreatic tail and spleen because there was an invasion in the adipose tissue adjacent to the pancreatic tail. The resected tumor was 13.5 × 10.5 × 5.0 cm in size macroscopically and presented the same appearance as the colonoscopic findings (Figure 5). Histopathological finding showed a non-Hodgkin lymphoma, follicular, medium-sized cell type according to LSG classification (Figure 6) ; immunohistochemical staining demonstrated a monoclonal B-cell lymphoma producing IgM composed of only λ-chain (Figure 7). Following operation, chemotherapy was administered with VENP (Vincristine, Endoxan, Naturan, Predonine). The patient has presently (July, 1991) survived for 35 months. Primary colorectal malignant lymphomas are rare, comprising only 0.65% of colorectal cancers, They are generally found in the cecum and rectum, with the descending colon being an unusual site for their occurrence. To our knowledge, this case is only the sixth report concerning a malignant lymphoma of the descending colon in Japan.

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A 58-year-old man was referred to our hospital with a chief complaint of abdominal fullness. He was found to have ascites with imaging diagnosis (ultrasonography, abdominal computed tomography). On laparoscopy, yellow-whitish nodules and tumors were seen on parieto-visceral peritoneum. He was laparoscopically diagnosed to have malignant peritoneal mesothelioma by biopsy from these tumors.

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We occasionally find grayish white miliary nodules on the diaphragmatic liver surface in patients with primary biliary cirrhosis (PBC) by peritoneoscopy. It is reported that the pathologic feature of granuloma and chronic non-suppurative destructive cholangitis (CNSDC) are frequently recognized in the needle biopsy. But the findings of aimed biopsy of this nodule has not been reported. To clarify that the nodule is not lymphoid vesicle but granuloma histopathologically, we enforced aimed-biopsy of these grayish white nodules with bioptic forceps in two patients with PBC. A needle biopsy of the other site in the liver was also taken for comparison. The histopathologic findings were: 1) grayish white miliary nodules were evidently large granuloma with severe CNSDC. 2) on the other hand, neither granuloma nor CNSDC was recognized in the needle biopsy. Two cases were diagnosed as stage I of Scheuer's concept by means of the aimed-biopsy. It is suggested that the grayish white miliary nodule on the liver surface is one of the characteristic findings in early stage of PBC.

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