The development of endoscopic medicine started with the development and devise of the instruments themselves. The new aspects of the diagnostics, resarch field, and thera-peutic measures followed it. This paper discussed mainly about the instruments based on the established technology as well as the near future when it is utilized. The development of the instruments has come out from the one of the surrounding-area technology in advance. But it is not until the fundamental technology has been developed commercialy as well as financially that the new technology is able to be adapted for endoscopes. Endoscopes have been developed, which started with a rigid gastroscope and followed after a gastrocamera, a fiberendoscope, and reached a videoendoscope recently. Videoendo-scopes are overwhelming fiberscopes gradually though they are coexisted so far. From the above, the near future of endoscopic medicine must be related with the one of videoendo-scopes. What were discussed in this paper were the followings ; the possibility of the development of the videoendoscope itself, the resolution of pictorial images, the application of liquid crystal, the pictorial management, the analysis of the pictorial images, the posibility of autodiagnosis, the application of infrared videoendoscope to diagnostics, the correction of color break-up in moving pictures, the development of a stereoscopic videoen-doscope and a cholangiopancreatoscope, the application of a gamma ray to an endoscope, an MRI endoscope. A capsule endoscope might take place of a videoendoscope and other micromachines might be utilized. The further development of three dimensinal display by an endoscopic ultrasonographic tomography, pictorial filing system and the development of endoscopic surgery were mentioned. Endoscopic examinations were expected to be more spread with the development and management of the facilities.

View full abstract

Chemical lymph nodes dissection was attempted with multiphasic emulsion (W/O/W) containing either epirubicin (EPI) or doxifluridine (5'DFUR) as an adjuvant chemotherapy after endoscopic therapy for early gastric cancer. The W/O/W emulsion showed good stability and an average particle size of 2.63μm. In a study using colon 26 cancer-bearing BALB/c mice, improvement of targeting tumor was confirmed. In a clinical study with the administration of the EPI W/O/W emulsion into the peripheral gastric walls of the tumor in 30 patients with gastric cancer, a concentration of 244±240 ng/g in the targeting regional lymph nodes was found for as long as 5 days after administration. Oral adminis-tration of the 5'DFUR W/O/W emulsion in 20 patients with gastric cancer revealed that the concentrations of 5-FU were approximately 30-fold in gastric cancer tissues and approximately 20-fold in the regional lymph nodes in comparison with oral admisintration of the 5'DFUR capsules. The targeting of the tumor was excellent ; lymph node targeting was greatly improved and it is also possible that it resulted in a reduction of side effects. This emulsion should be used for adjuvant chemotherapy under endoscopy in the future.

View full abstract

The healing process of gastric ulcer was examined by EUS. The subjects were classified into two groups. Group A consisted of 8 patients with 9 lesions who were treated with both H₂ recepter antagonist and mucosal protective agent. Group B consisted of 6 patients with 7 lesions who were treated with H₂ recepter antagonist only. The endoscopic and ultrasonographic findings of group A were compared with those of group B. The results were as follows; 1) Endoscopically, regeneration of gastric mucosa was accelerated in group A (Figure 4-6). 2) Ultrasonographically, contraction of gastric wall of the lesion was accelerated in group A (Figure 9, 12). 3) These results suggested a high possibility that mucosal protective agent was effective for clinical treatment of gastric ulcer. 4) EUS was very useful for examining the healing process of gastric ulcer because both endoscopic and ultrasonographic findings could be obtained.

View full abstract

We studied clinical and histological diagnosis of 22 cases of RLH in the resected stomach. It was difficult to diagnose them as RLH endoscopically. Because we diagnosed only one case as RLH suspicious and 9 cases as early gastric cansers by endoscopic examination. By biopsy findings we diagnosed 6 cases as RLH and one case as RLH suspicious and the diagnostic accuracy of RLH by biopsy was 31.8% (7/22 cases). In the remaining cases, one was diagnosed as malignant lymphoma (ML) and one as ML suspicious by biopsy. Of 5 cases diagnosed as gastric ulcers or gastritis with infiltration of lymphoid and round cells, 2 cases were diagnosed as RLH by repeated biopsy. According to the biopsy sites, we divided the biopsy specimens into 3 groups ; the center, the border and the outside of the lesions and compared them with respect to the biopsy findings. As a result of biopsy findings infiltration of lymphoid and reticular cells was found in 53% at the border, in 40% at the outside and in 38% at the center of the lesions. We concluded that it is important for the definite diagnosis of RLH of the stomach to obtain biopsy specimens from the border of a lesion.

View full abstract

Since 1983 to 1987, five hundred forty-eight patients with colorectal adenoma were diagnosed in our mass screening program for colorectal cancer. We have used flexible sigmoidoscopy and double contrast barium enema as the work-up strategy for the cases of positive fecal occult blood test (FOBT). And we have also use the same work-up examina-tion as the surveillance after endoscopic treatment for colorectal adenoma. The 1st and 2nd surveillances after initial treatment were performed in 507 and 385 cases, out of 548, respectively. The detection rate of the other adenoma in the surveillances was about 40%, and this proportion was common to twice surveillances, but detection of new cancer were rare, only 5 cancers were diagnosed in our series. From present study, the risk factors of diagnosed as carrying the other adenoma at the 1st surveillance were identified "multiple adenomas" with odds ratio of 3.0 and "male" with odds ratio of 2.2, but was not "age at the initial treatment". Using the data of three time examinations in the 385 patients, we derived the sensitiv-ity of work-up examination and the rate of newly developing adenoma. With limitation of larger than 5mm in diameter, the sensitivity of work-up examination for adenoma was 84% in entire colon, and was 92% in rectum and sigmoid colon. But with same limitation, the rate of newly developing adenoma was 0.02/person-year in entire colon and was 0.006 in rectum and sigmoid colon. With the use of both flexible sigmoidoscopy and barium enema, it was considered that undiagnosed diminutive adenomas still remained, but newly developing large adenomas were very rare. Consequentry, other less expensive follow-up programs, for example FOBT, should be applied in the patients after colorectal polypectomy, and the intervals of surveillance by work-up examination can be prolonged.

View full abstract

Sixty-one nodule-aggregating tumors and 131 non nodule-aggregating flat elevations were compared clinicopathologically. Characteristics of nodule-aggregating tumors was demonstrated as follows; 1) Tumors were predominantly found in the rectum and cecum. 2) The size of adenoma, m-cancer and sm-cancer was about twice as that of non nodule-aggregating flat elevations, although the depth of invasion was less despite of the larger size. 3) In many cases cancers were accompanied by adenoma components. Histologically, adenoma or adenoma components associated with cancer was usually characterized by tubulo-villous type. This tendency was more remarkable in larger tumors. 4) Compared to non nodule-aggregating flat elevations, the incidence of whitish tumors was higher and reddish ones lower. In particular, this tendency was more remarkable for adenoma. 5) Larger tumors contained vertically higher parts, in which cancer and sm invasion were confirmed histologically. These findings indicate that nodule-aggregating tumors essen-tially characterized by horizontal growth manifest vertical growth in accordance with malignant transformation or development of sm invasion. The lower frequency of adenoma than m cancer, among nodule-aggregating lesions, suggests the possibility of overlooking the diagnosis of adenoma. When nodule-aggregating lesions were defined as those over 20 mm in diameter, the difference in the frequency of adenoma and m-cancer became more evident. No difference in localization was noted between tumors over 20 mm in diameter and smaller ones. When lesions less than 20 mm in diameter were included, the size went in an ascending order from adenoma to m-cancer to sm-cancer. From these findings it seems appropriate to include nodule-aggregating flat elevations in nodule-aggregating lesions irrespective of their size.

View full abstract

We experienced a case of broad IIb type early gastric cancer with heterotopic gastric mucosa. The patient was a 63-year-old-man who was pointed out the abnormal lesion in barium meal exmination. As he admitted to our hospital, upper GI endoscopy revealed irregular, thick gastric mucosa at posterior wall of corpus. We suggested that he suffered from Borrmann 4 type advanced gastric cancer. Endoscopic ultrasonography showed multiple small cystic lesions in submucosal layer at posterior wall of corpus. The patholo-gical findings of endoscopic biopsy specimen from that lesion was poorly differenciated adenocarcinoma. We finally diagnosed broad IIb type early gastric cancer with heterotopic gastric mucosa. We performed total gastrectomy. The gastric gland, usually found in the lamina propria. That gland in the submucosa is raraly observed which could be called "heterotopic gastric mucosa" of the stomach. It has been noticed that the stomach with submucosal heterotopic gastric mucosa is frequent-ly associated with gastric cancer and high occurrence of multiple gastric cancers. However, it is rare that the heterotopic gastric mucosa itself turns malignant.

View full abstract

The patient was a 54-year-old male who visited our department without any symp-toms after the elevated lesion of lesser curvature of antrum was noted in a mass X-ray survey of the stomach. Gastroendoscopy revealed a flat lesion forming a white color zone on the anterior wall of the anglarnotch. In biopsies from the white color zone, lympho-plasmacytoid cells producing monoclonal IgM/λ were diffusely observed in the lamina propria mucosae, leading to diagnosis of plasmacytoma. Similar changes were also observed in the lamina propria mucosae of the resected specimen. About 100 cases of plasmacytoma of the stomach have been reported abroad, and 38 cases including ours in Japan.

View full abstract

A 83-year-old woman was admitted with a complaint of melena. Besides the early gastric cancer and the gastric ulcer, a deposition of black pigment from the bulb to the second part of duodenum was observed and it was diagnosed as melanosis duodeni by the histochemical and electromicroscopic examinations. The medical observation has been done for 18 months continuing the endoscopic therapy for the cancer and simultaneously with the ulcer healing to scar formation, the pigmentation disappeared. As she has been taking hydralazine hydrochloride, metoprorol, isosorbide dinitrate, it is suggested to be a possibility that the upper gastrointestinal hemorrhage induced the pigmentation under the effects of these drugs.

View full abstract

A 57-year-old woman with stage IIb cervical cancer of the uterus underwent extended hysterectomy combined with postoperative radio and chemotherapy in August, 1985. Subsequentry, she was hospitalized because of nausea and vomiting in September, 1990. A 5×7cm mass was palpable in the epiumbilical region of the abdomen. A radiographic smallbowel series demonstrated complete obstruction at the transverse part of the duode-num. Endoscopic studies showed an almost circular mass with a velvety appearance at the same site. However, it was difficult to establish a diagnosis of either primary or metastatic cancer, based on X-ray and endoscopic findings alone. Histological examination of biopsised tissues revealed a diagnosis of squamous cell carcinoma. By abdominal ultrasonography and computed tomography, the tumor was found to involve the aorta distal to the furcation of the superior mesenteric artery, although there was no evidence of a mass in the pelvic cavity. The tumor was confirmed by celiotomy. This seems to represent a rare case in which the metastatic tumor of the periaortic lymph nodes, originating from the uterine cancer, which had been surgically treated 5 years and 2 months before, caused obstruction of the transverse part of the duodenum.

View full abstract

A 50-year-old man was admitted to our hospital complaining of recurring right lower quadrant abdominal pain. Barium enema showed an elevated lesion with smooth surface at the orifice of the appendix, but no abnormality in the colon. Four months later, re-examination of barium enema disclosed mucosal coarseness and tiny ulcerations in the rectum and sigmoid colon, normal findings from the descending colon to the cecum, and more grown elevated lesion in the appendix. Colonoscopy showed the same findings as barium enema. Biopsy specimen showed infiltration of inflammatory cells and crypt abscess in the mucosa of elevated lesion in the appendix and the sigmoid colon. The mucosa of the ascending colon was normal. Appendectomy and partial resection of the cecum were performed. The histological diagnosis was appendicitis due to ulcerative colitis, and the mucosa of the resected cecum was normal. Our diagnosis of this case was appendicitis associated with ulcerative colitis, so-called 'ulcerative appendicitis'. This is the first case of ulcerative appendicitis in Japan, which was advocated by Cohen et al. These cases may be misdiagnosed as Crohn's disease because of their 'skip' involvement of the appendix.

View full abstract

A 18-year-old male was admitted to our hospital because of rectal bleeding. Endo-scopic examination showed a semi-pedunculated polypoid lesion (10 mm) in the rectum. Endoscopic polypectomy was performed by the snare cautery procedure and the his-tological findings showed diffuse infiltration of plasmacytes. Immunostaining (ABC method) demonstrated a monoclonal feature of the intracellular IgG-λ. No evidence of complicating multiple myeloma was observed by examinations including serum M-protein, urinary Bence-Jones protein, Ga-scintigraphy and bone marrow biopsy. From these results, we diagnosed this case as solitary extramedullary plasmacytoma.
We reported the first case of colonic plasmacytoma removed by endoscopic polypectomy and reviewed 25 cases which have been reported in the literature.

View full abstract

A 66-year-old woman was admitted to our hospital for further examination of liver dysfunction. A test for second generation HCV antibody was positive. The image of abdominal ultrasonography and CT scan showed multiple SOLs in the liver. The initial laparoscopy revealed multiple yellow-white flecks and several large yellow-white nodules, 10mm in size on the liver surface. Needle biopsy of the flecks and nodules revealed non-caseating epithelioid cell granuloma containing giant cells and prominent lymphocytic infiltration into the adjacent tissue, compatible with liver sarcoidosis complicating chronic type C hepatitis. Because of these multiple nodules, the patient was treated with pred-nisolone. Three weeks after the steroid therapy, multiple SOLs at abdominal ultrasono-graphy disappeared. The second laparoscopy 2 months after the start of therapy disclosed the decrease of yellow-white flecks and convertion of large nodules into depressed scars. Liver dysfunction due to hepatitis C remained unchanged.

View full abstract

Most of patients with complete bowel obstruction due to colorectal cancer are required emergency surgery. There are two important problems in emergency operation, one is a decompression of distended proximal colon and the other is a curability of cancer. In many cases, an emergency operation without examinations was performed. It seems to be dangerous to carry out one-stage resection and anastomosis at the same time when the proximal bowel of stenotic lesion is dilated. Because the patients are often under dehydrat-ed condition with electrolyte unbalance, and after operation they had sometimes septic complications, specifically wound infection and intraabdominal abscess, which make their operative risks poor. The traditional operative method for obstructive carcinoma was a staged procedure, namely, proximal colostomy or resection of the tumor with a colostomy. Decompression of the proximal bowel was achieved with a long tube inserted to the stenotic lesion of the left colon with the aid of a colonoscope in 9 patients. In all cases, one -stage procedure was performed after preoperative exminations and complete preparation of the colon. The method of inserting a decompression tube using a colonoscope was easy without specific material, so we recommend this method in the patients with obstructive left side colon cancer.

View full abstract