One hundred and six patients with gastric cancer (49 cases of early cancer, and 57 cases of advanced cancer) were examined by endoscopic ultrasonography (EUS) to determine the depth of the cancer invasion. In normal cases, the gastric wall appeared as a five-layered structure. In cancer patients, however, this structure exhibited thickening, defect, and interruption. These features were measured and employed as the EUS criteria for the classification of cancer invasion. According to this classification, cancer invasion was divided into mucosal, submucosal, proper muscular, and subserosal-serosal types. EUS diagnostic accuracy rate of early cancer was 79.6% (39/49 cases). The accuracy rate for ulcerated lesions was low (76.2%) as compared to non-ulcerated ones (100%). The causes of EUS misdiagnosis of the lesion were fibrosis (7 cases), incomplete detection (2 cases), and microinvasion of the submucosal layer (1 case). However, the wsm/wm ratio (the width of irregularities in the 3rd layer/the width of irregularities in the 1st and 2nd layer) which increased in proportion to the extent of fibrosis, proved useful in reducing the EUS misdiagnosis due to fibrosis. Although solitary cases of fibrosis and microinvasion of the submucosal layer were misinterpreted by EUS, when they existed simultaneously, the diagnosis was paradoxically correct, because fibrosis was misinterpreted by EUS as the invasion of the submucosal layer and histologic cancer invasion was at the same depth due to the microinvasion. The EUS diagnostic accuracy rate of advanced cancer was 93.0% (53/57 cases). The width of irregularities in the 4th layer by EUS (wpm) in advanced cancer increased in proportion to the depth of the lesions, and proved useful in specifying the depth of invasion into the subserosa (ssα-ssγ) and serosa. The diagnostic accuracy rate of the prognostic serosal factor (ps) was as high as 89.5% (51/57 cases), when the ps was determined as follows: wpm>40mm=ps(+) (as deep as ssγ or deeper); wpm<40mm=ps(-) (as deep as ssβ or not as deep).

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One of the marked important peritoneoscopic findings in the developing process from viral hepatitis to liver cirrhosis is the "depression" observed on the liver surface. The type of this depression is classified into 4 groups ; (1) broad depression, (2) gutter-or-trench shaped depression, (3) small depression, and (4) pen-portal reddish markings (RM). Upon the reddish markings seen in type C chronic hepatitis we have already reported as being more sparse and irregularly localized (irregular RM) than those seen in type B chronic hepatitis. This time we made a study on the other 3 groups of the depression through peritoneo-scopy on 249 cases of chronic viral hepatitis and 162 cases of acute viral hepatitis, and we have obtained the findings that broad depressions were seen only in the cases of acute hepatitis, showing its seriousness, and small depressions in most of acute hepatitis, whereas, gutter-or-trench shaped depressions were observed only in the cases of type C and B + C chronic hepatitis, which was thought to be one of characteristic findings for type C chronic hepatitis. As for the occurrence of gutter-or-trench shaped depression, investigating the relation between the localization of irregular RM and the mean age of the patients showing them, we came to a conclusion that most of irregular RM are considered to progress from irregular 1RM to irregular 2RM, and then develop to gutter-or-trench shaped depressions in the area of lobular boundary such as Cantlie line.

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We studied the effect of injection sclerotherapy (IS) on 11 patients of esophageal varices associated with gastrophrenic shunt by comparing the endoscopic varicography (EV) and the percutaneous transhepatic portography (PTP) carried out 2 weeks before and after IS. EV was carried out with a mixture of sclerosant and contrast medium while performing the IS. The rate of visualization of the portal collateral pathway by EV was evaluated by comparing the PTP before IS. The rate of embolization of portal collateral pathway by IS was evaluated by comparing the PTPs before and after IS. The rate of visualization observed by EV for each collateral pathway was 100% for the esophageal varices, 89% for the fundic venous plexus, 45% for the left gastric vein, 22% for the short gastric vein, 44% for the paraesophageal vein, 18% for the phrenic vein, 0% for the pericardiac vein and 0% for the intercostal vein. The rate of embolization by IS for each collateral pathway was 100% for the eso-phageal varices, 89% for the f undic venous plexus, 9 % for the left gastric vein, 11% for the short gastric vein, 22% for the paraesophageal vein, 0% for the phrenic vein, 0 % for the pericardiac vein and 0 % for the intercostal vein. We conclude that the IS, for esophageal varices associated with gastrophrenic shunt, embolize the esophageal varices successfully and embolize the fundic venous plexus considerably, but it not embolize the gastrophrenic shunt at all.

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Hemodynamics of the varices of the gastric fundus (FV) were evaluated by means of transesophageal doppler echography in five patients. Three out of five patients showed tumorous FV and 2 patients showed flat elevated FV endoscopically. All of the five patients had a large gastro-renal shunt. In 3 patients with tumorous FV, the mean blood flow rate was 478 ml/min., 345 ml/min., and 464 ml/min. in the inflow blood vessel, varicose vein at the FV, and the outflow blood vessel, respectively. These values were similer to those of the splenic or superior mesenteric veins, which were obtained by external echo-doppler examination. From these results, tumorous FV demonstrated a hyperdynamic state. In another 2 patients with flat elevated FV, the blood flow rate in the varicose vein at the FV could not be measured. However, the blood flow rate in the extragastric collateral vein, which drained into the left renal vein via a gastro-renal shunt, was similer to that of tumorous FV. From these results, we consider transesophageal doppler echogra-phy is to be a very useful technique in assessing the hemodynamics of FV and its surround-ing collateral veins.

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Fujinon electronic endoscope (EVG-HR, superimage series) with a CCD of about 180, 000 pixels gives us clear and high quality images. We manufactured a magnifying electronic endoscope for trial, the visual field of which was narrowed to 90 degree from 120 degree of original electronic endoscope (EVG-HR). This endoscopic images recorded on 35 mm films are magnified 4 times, then, we can easily observe pits approximately 0.1 mm in diameter of the gastric mucosa and fine capillary network around each gastric pit with the endoscope. We studied fine structures of the surface of gastroduodenal lesions by using the magnifying electronic endoscope. This endoscopy revealed fine capillary networks within the membranous regenerated epithelia at the margin of gastric ulcer, which had been reported as flat and non-structural epithelia by magnifying fiberoptic endoscopes. An early well-differentiated adenocarcinoma of the stomach had irregular shaped sulculi of various sizes on its surface, which were different from those at the adjacent normal mucosal surface. We could also clearly observe each villus and capillary within it in the duodenal bulb. This magnifying electronic endoscope is useful to study fine structure of the surface in various gastroduodenal lesions.

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The effect of abdominal insufflation (10mmHg) with carbon dioxide during laparo-scopic cholecystectomy (done under general anesthesia) on the circulatory and respiratory systems was investigated. Circulatory and respiratory parameters (Heart Rate, Arterial Blood pressure, etc) were serially measured in patients under the same respiratory, anesthetic and abdominal insufflation conditions. Out of the circulatory parameters, only central venous pressure significantly increased (p <0.01). Arterial blood pressure, heart rate, and cardiac output changed slightly. In terms of respiratory parameters, increases in endotracheal pressure and significant increase (p <0.01) in blood carbon dioxide concentra-tion occured. Values of these parameters tended to return to their pre-operative level following surgery. Central venous pressure and arterial carbon dioxide concentration tended to decrease after abdominal deflation ; however, they remained at significantly higher levels even after surgery. Such information on the changes that occur during anesthesia may allow this procedure to be conducted with greater safety.

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During laparoscopic cholecystectomy, the resected gallbladder (GB) containing a large stone can not be pulled out through the trocher-punctured opening. To overcome this difficulty, we have employed the utility of the ultrasonic lithotriptor to fragment such a stone. 1) The neck of the GB was pulled up through the trocher-punctured opening and the nephroscope was inserted into the GB through an incision made at the neck. Then, ultrasonic lithotripsy of the incarcerated stone in the detached GB was perf omed under TV monitoring. 2) As the lithotriptor and suction pump were powerful, even a hard cholesterol stone was easily fragmented and rapidly aspirated out of the GB. The nephroscope gave a clean visual field because of its irrigation system. 3) Four cases of cholesterol stone (diameter : 25-36mm) and three cases of mixed stone (diameter: 19-22mm) were successfully managed by this method and the removal of the GB was completed without widening the opening by an additional incision. The time required for this procedure in the four patients with cholesterol stone and in the three patients with mixed stone were 18-50minutes (mean : 35minutes) and 13-30minutes (mean 2lminutes), respectively. In coclusion, we believe that this method is easy and holds less tissue trauma and more potential of reducing recovery time compaired with other means of fragmentation or incision enlargement.

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Recently we treated a patient with acute gastric mucosal bleeding and early gastric cancer in the reconstructed stomach tube, who received esophagectomy and reconstruction using stomach tube for esophageal cancer 3 years and 2 months ago. Acute gastric mucosal bleeding was successfully controlled by conservative therapy, and early gastric cancer was managed by endoscopic resection using electric knife. Twenty four hours PH measurement, mucosal blood flow measurement and internal pressure measurement for the reconstructed stomach tube was done, which showed resid-ual acid secretion and destruction of mucosal barrier seemed to play an important role in the development of acute gastric mucosal bleeding.

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In a 72-year-old man synchronously developed cancers were found in the middle esophagus and in the lower corpus. The esophageal and gastric lesions were diagnosed as to be Ia and IIc types of early cancer, respectively, on X-ray and endoscopic pictures. Histological study revealed squamous cell carcinoma and adenocarcinoma, respectively, on biopsy specimens. Because of associated severe lung emphysema, endoscopic laser irradia-tion to the lesions was performed twice for eight day-interval. With total laser irradiation to the esophageal cancer of 300 and 762 joule (J) using a contact and non-contact laser probe and to the gastric cancer of 550 J and 3144 J using a contact and non-contact probes, respectively, cancer cells disappeared completely on biopsy study. Throughout the follow-up period for about one and a half years until he died of heart failure due to the lung disease, no cancer cells were found on repeated biopsy studies of both lesions. Cancer cells were also not found in esophageal and gastric tissue specimens obtained by autopsy. The cases of synchronously developed early esophageal and gastric cancers had been rarely reported. In addition, our case suggests the effectiveness of laser therapy to such lesions in patients who have no surgical indication due to severe complications.

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We reported a successful case of endoscopic injection screlotherapy (EIS) for eso-phageal varices complicated with adult polycystic liver. A 43-year-old woman was admitted to our clinic for treatment of esophageal varices with EIS after surgical treatment for polycystic liver through fenestration and partial resection. Compression of the portal veins by liver cysts was considered to form eso-phageal varices based on the histologic findings of the biopsied liver. The esophageal varices disappeared by a combination method of EIS with EO-AS. After EIS, a heart/liver ratio on the scintigraphy of 201-T1 administrated perrectaly was higher than that of liver cirrhosis. This result suggested that collateral routes of portal veins were developed sufficiently. She has been free from recurrence of esophageal varices for 30 months.

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A 41-year-old man was admitted to our hospital because of gastric cancer. X-ray and endoscopic examination revealed a protruded lesion with irregular surface and central depression on the lesser curvature of the upper body (Figure 1, 2). Except for a slightly high 23ng/ml serum AFP, no abnormal findings were noted on blood biochemistry, abdominal ultrasonography and computed tomography. Total gastrectomy was carried out and no liver metastasis were found. AFP level became to normal range (5ng/ml) after operation. On the resected specimen, a Borrmann type 2 like protruded lesion measuring 2.8×2.8cm was noted on the anterior aspect of the lesser curvature of the upper body (Figure 3). Histological findings in the gastric cancer showed papillary clear adenocarcinoma mixed with hepatoid carcinoma and massive invasion to the submucosal layer (Figure 4, 5). Lymphnodes metastasis were noted. Eosinophilic granuloma which was formed by the infestation of a laval anisakis was found in the gastric mucosa of the posterior wall (Figure 6). The localization of AFP with ABC method was immunohistochemically demonstrated in the cytoplasm of the primary lesion and the metastatic lesions of the regional lymphnodes (Figure 7). Early gastric cancer producing AFP is rare. Only 6 reported cases of early gastric cancer with immunohistochemical localization of AFP in which a preoperative serum AFP level of more than 20ng/ml became normal after gastrectomy were reviewed in Japan (Table 1).

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A 56-year-old male was admitted to our hospital for the further examination of an elevated lesion in the gastric body which had been detected by X-ray. Endoscopic examination showed a small elevated lesion on the posterior wall near the greater curva-ture of the body of the stomach. The endoscopic biopsy from the depressed area led to the histological diagnosis of carcinoid tumor. The endoscopic ultrasonography (EUS) revealed a hypoechoic tumor extending from the 2nd layer to mainly (the 3rd layer) of the gastric wall without change below the 4th layer. Gastric resection was performed. The tumorous invasion was limited to the submucosal-layer of the gastric wall. This finding corresponded to the preoperative diagnosis by EUS. Application of EUS for gastric carcinoid has not been so far reported. EUS was expected to be useful to diagnose the degree of the extent of carcinoid tumor, contributing to the determination of operative procedure.

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A 65-year-old male patient complained of fresh melena. He became completely blind because of bilateral cataract at 33 years old. On May 25, 1989, the patient had a cup of melena. Hemorrhage recurred twice after initial evidence and he was hospitalized. Hematological examination revealed anemia, showing Hb value 10.3 g/dl. Colonoscopy disclosed two irregular ulcers with visible blood vessels at 5 cm from the anal ring. Longitudinal ulcer was formed on the oral side in one lesion. Hemorrhage was stopped with conservative treatment. Ulcer developed scar formation on the 14th hospital day. This case is not acute hemorrhagic rectal ulcer proposed by Kohno et al. since there were no severe basic diseases or inducements in the background. However, elucidation of the mechanism of these acutery developing rectal ulcer lesions is expected, and we would like to propose to deal with such lesions collectively as acute rectal mucosal lesions.

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A 80-year-old man was admitted to our hospital complaining of general fatigue due to liver cirrhosis. Routine upper endoscopic examination showed a flat elevated lesion on the anal edge of papilla of Vater. The lesion was 15 mm in diameter and whitish. It was consisted of conglomerated small nodules. Biopsy specimen revealed tubular adenoma. Endoscopic ultrasonography (EUS) showed the lesion as a slightly hyperechoic area. EUS also revealed the duonenal muscular layer and papillary bile and pancreatic duct to maintain the normal structere. We performed endoscopic polypectomy and succeeded. EUS was very useful for judging the indication of polypectomy in our case.

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We reported an interesting case of Crohn's disease with acute development of marked colonic stenosis. A 21-year-old man was admitted to our hospital on 11th of August 1989, with com-plaints of bloody diarrhea, abdominal pain and fever after travelling abroad. Colonoscopic examination showed multiple irregular ulcers with mucosal inflammation in the sigmoid colon, descending colon, transverse colon segmentally, and circumf erential ulcers seen in the ascending colon and cecum. Symptoms and inflammatory reactions were improved gradually but bloody diarrhea continued under medical treatment with intravenous hyper-alimentation and antibiotics. Four weeks later, barium enema study revealed longitudinal ulcers and cobblestone appearance with marked tubualr narrowings in the colon. Total colectomy was done on 27th of September 1989, because of abdominal pain due to stenosis and continuous bloody stool. Hitological findings of the resected specimen disclosed that multiple longitudinal and irregular ulcers (ul-II) were seen. Dilatation of small vessels with congestion in the mucosal layar, marked submucosal fibrosis and sarcoid-like granulomas were observed. Crohn's disease was confirmed with those findings.

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A 8-year-old-man was admitted to our hospital because of fresh anal bleeding with a sudden onset without abdominal pain. Emergency colonoscopy revealed dilatated abnormal vessel with bleeding in the rectum. Endoscopic hemostasis with a local injection of Aethoxysclerol was performed without a recurrent bleeding. Angiography is a useful method in the diagnosis of the arteriovenous malformation (AVM), but there are some asymptomatic cases of AVM. Therefore, emergency colonoscopy was considered to be an important initial examina-tion for the diagnosis of the AVM. Furthermore, we concluded that endoscopic hemostasis with a local injection of Aethoxysclerol and coagulation therapy including "Hot biopsy" were an adequate initial treatment, considering that the AVM was usually occured in an elder age.

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We report a case of rectal ulcer with vascular injury due to indomethacin suppository, demonstrating extremely interesting pictures of endoscopy and angiography. A 38-year-old woman visited to family doctor with a complaint of lumbago, and she was treated with indometachin suppository in January 1989. On next day, she noticed fresh anal bleeding. Endoscopic examination revealed geographic ulcers with a protruding lesion like a dilated vessel in the lower rectum (Figure 1). She was referred to our hospital. Laboratory data showed the normal range except for hemoglobin 8.8 g/dl. After discontinuing of the suppository, the protruding lesion disappeared, and the ulcer healed endoscopically 8 weeks later after admission (Figure 3). The angiography showed the abnormal coiling vessel in the peripheral branch of the right middle rectal artery (Figure 2), and that still remained in August 1989. It's supposed that a kind of arterio-venous fistula (pseudoaneurysm) was developed from the rectal ulcer due to suppository administration.

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Endoscopic sphincterotomy of the pancreatic orifice (EPST) is useful for preserving the function of the pancreas and decreasing pain in the cases of chronic pancreatitis accompanying pancreatolithiasis. On the other hand, for cases with pancreatic pseudocyst, surgery has been the only therapy of choice. We successfully treated endoscopically one case of 27-year-old male with chronic alcoholic pancreatitis associated with pseudocyst and lithiasis. The patient was operated on previously, because of an intra-abdominal abscess caused by rupture of a cyst. There were two procedures ; firstly, stone extraction following pancreatic sphincterotomy and secondly, cystoduodenostomy aiming at decompression of the pseudocyst located in the head of the pancreas. The pseudocyst infected with Klebsiella, Serratia and Pseudomonas bacilli caused compression to the duodenum and finally required cystoduodenostomy. A needle papillotome was applied to make a small fistel, when pus overflowed immediately. A standard papillotome was then introduced and completed cystoduodenostomy without complication. According to Sahel, mortality depends upon endoscopic skill, but was 2.1%. Endoscopic cystoduodenostomy or cystgastrostomy offers non-surgical treatment for pseudocyst of the pancreas.

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A 76-year-old male was admitted complaining of epigastralgia. ERCP showed a short segmental stenosis in the main pancreatic duct, however no tumor was detected by abdominal US or CT. Peroral Pancreaticoscopy (POPS) demonstrated the protruding lesion like submucosal tumor of which surface showed redness, increase of neovascularization and easily contact bleeding. Since the findings suggested a cancer of the pancreatic body, distal pancreatectomy was performed. Histological finding revealed a small pancreatic ductal cell carcinoma which size was 17 mm in diameter and was covered by a single-layer of epithelium in the main stenotic pancreatic duct, therefore these histological finding sugested POPS findings.

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