Ninety-four patients of superficial esophageal cancer without no preoperative treatment were studied. They included 22 patients with mucosal cancer (5 cases of ep cancer and 17 cases of mm cancer) and 72 with sm cancer. Mucosal cancer comprised only 21.4% of superficial cancer. The frequency of multiple superficial cancer was 18.1%, and 23.4 of the patients also had cancer of other organs, with high incidence of gastric cancer. Among the mucosal carcinomas, 90.9% were asymptomatic and 72.7% were discovered on endoscopy. Cancers macroscopically classified as ep and mml were all fundamental type, but 36.3% of mm_2-3 cancer were mixed type lesions with features of types 0-IIc. A few sm cancers were of types 0-II, but many of the sm_2-3 cancers were mixed type lesions with features of types 0-I. Lymph node metastasis was not seen in patients with ep-mm₃ cancer, but the rate was 38.9% for sm cancer. Flat and depressed mucosal cancers are usually detected endoscopically by the presence of small whitish coat and a change in thin-reddish color of the mucosa. Even when the feature of border and surface were assessed, it was difficult to diagnose the depth of invasion of mm₃ and sm₁ cancer. Overall accuracy rate in the diagnosis of the depth of invasion was 69.7% on endoscopy and 67.9% on EUS.

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The small intestinal mucosa of acute ischemic models in the dog was observed endoscopically, taking biopsy specimens and measuring tissue blood flow, in order to determine the relationship between the duration of ischemia and the severity of tissue injury. The mucosal changes observed in the early course of ischemia consisted of longitudinal redness and erosion on the opposite side of mesentery. These changes appeared 30 min after anterior mesenteric artery occlusion. Histological examination revealed that these changes were deprivation at the tip of the villi and congestion of mucosal layer. The mucosal ischemic changes became circumferential 3 to 5 hours following arterial occlusion. The mucosa had a dark red color, along with severe erosion and bleeding at 7 hours or more. Histologically the tissue injury was characterized by coagulation necrosis and infiltration of neutrophils. The rate of tissue blood flow recovery was significantly lower upon reperfusion after 7 and 10 hours of ischemia than after 3 and 5 hours. The ischemic changes were severe in many models after reperfusion. The findings suggest that reperfusion is deterious to the ischemic mucosa. Briefly, based on the pathological findings obtained at various periods after ischemia, it may be concluded that tissue injury and the recovery of tissue blood flow after reperfusion characteristically varied with the duration of ischemia.

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The therapy of gastric lesions by strip biopsy is complicated by two major problems :(1) a high residual rate of gastric cancer, and (2) difficulty in defining the oral and anal sides of the resected specimen. To overcome these difficulties, the authors have developed an improved technique for strip biopsy and assessed its clinical usefulness. In this improved procedure, four sites of the mucosa surrounding the gastric lesion are fixated by the two blades of a newly designed jumbo grasping forceps and two short clips of different colors. This allows the lesion to be reliably resected by means of a snare along the outer margin marked by the four sites. The lesion can then be removed from the stomach with the two short clips in place. Patients with early gastric cancer localized in the mucosa or gastric adenoma (total 101 cases) were divided into following three groups. Group A : A forceps designed for conventional strip biopsy was used (17 cases). Group B : A newly designed jumbo grasping forceps was used (63 cases). Group C : A newly designed jumbo grasping forceps and two short clips of different colors were used (21 cases). The complete resection rate was 66.7% in Group A, 92.1% in Group B, and 100% in Group C. The complete resection rate (which is based on the definition of Tada et al.) was significantly higher in the latter two groups than in Group A. The oral and anal sides of the resected specimen could be readily determined in all cases only in Group C. The time required for treatment was about 20 minutes in all three groups. Hazards such as excessive bleeding and perforation did not occur after resection in any patient. The results of this clinical study indicated that the technique employed in Group C (resection using a jumbo grasping forceps and two different-colored short clips) was superior to the other two procedures. The authors named refer to this technique as the "four-point fixation method".

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Various methods for endoscopic mucosal resection (EMR) of the esophagus have been developed. EMR is mainly applied for superficial mucosal carcinomas. The EMR methods with prior injection of fluid into the submucosal layer and intraluminal suction (EEMR, EMRC, np-EEM, etc.) are now most prevalent in Japan. However, the vertical or horizontal ranges of resection by these methods have not been clearly demonstrated yet. We investigated some problems on EMR of the esophagus with clinically resected esophageal carcinomas and canine experiments. In order to evaluate the resecting level in the submucosal layer, we used the esophageal glands proper (EGP) in it. We think that the EGP and their ducts must be removed thoroughly by EMR, for the intraductal spreads of mucosal carcinomas of the esophagus are not so rare (40.5% in our institute). Not only in case of one-piece resections but also in piecemeal resections, the EGP in the submucosal layer are always resected by EMR of the esophagus. The artificial ulcer after EMR shows saucer shape ; the center of the ulcer floor is deeper than the margin. The submucosal layer becomes markedly edematous after the injection of fluid, the EGP are elevated together with the mucosal layer, and consequently, the mucosal layer is detached from the muscularis propria. Not only the mucosal layer but also the muscularis propria protrude into the lumen by the maneuver of intraluminal suction. But after the injection of fluid into the submucosal layer, only the mucosal layer and the EGP can be sucked and snared, and the muscularis propria remains. Therefore, in these methods of EMR of the esophagus, the injection of fluid into the submucosal layer is useful and essential to keep the depth of the resecting layer constant and to avoid perforations. There results suggest that the primary lesions of carcinomas invading the muscularis mucosa or slightly involving the submucosal layer would be resected completely by EMR of the esophagus. So these carcinomas may be resected by EMR in the near future. Piecemeal resections for rather widely spreading carcinomas are expected to be as effective as one-piece resections.

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An attempt was made to clarify the existing morphology of the submucosal arterial system that may be injured by endoscopic mucosal resection (EMR) and, further, to investigate the post-EMR effect on those arteries. Cleared tissue preparations of stomach wall from fifteen adult dogs were made by injection of barium-gelatin.1) The mean inner diameter of submucosal arteries was 519.8±154.8 μm in C area, 466.4±128.7 μm in M area and 354.4±47.8 μm in A area, thus, being significantly wider diameter in C and M areas as compared to those of A area.2) When the blood vascular supply of the gastric mucosa was examined microscopically in cross-sections of stomach walls, it became clear that arteries passing to the stomach, after transversing the muscular layer, course linearly or along the curvatures of the mucosa in the middle of the submucosa. 3) Microscopic examination of the arterial system in a plane passing parallel to the mucosal surface, revealed that the arteries run transversely in a tree-like pattern in the submucosa. 4) Inspection of submucosal arteries at sites of mucosal defects caused by EMR disclosed that submucosal arteries might or might not be damaged concomitantly according to the circumstances. Thus the submucosal arteries underlying a mucosal defect caused by EMR were found virtually intact in some instances, while, in others, cut ends of the submucosal arteries were found at the margins of a mucosal defects.

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We analyzed the accumulated data on patients who underwent emergency endoscopy at our department during the 12-year-period from 1980 to 1991 in order to determine the benefits and limitations of endoscopic hemostasis for upper gastrointestinal bleeding, especially that due to gastroduodenal ulcer. During this period, emergency upper GI endoscopy was performed on 378 occasions in 279 patients with gastrointestinal bleeding, representing about 1% of all the endoscopic examinations performed at our department. While the total number of examinations continued to increase annually, the number of emergency endoscopies decreased annually after the pear year of 1985. Most of the patients had gastroduodenal ulcers, and endoscopic hemostasis was successful at a high rate of 93.2% in this group. Uncontrollable bleeding only occurred in severely ill patients, and all but one patient had multiple organ failure or other severe complications. Local injection of 100% ethanol and other endoscopic hemostasic techniques proved very usuful for the control of bleeding from gastroduodenal ulcers, but there was no further increase in the rate of adequate hemostasis after 4 or more treatments. Thus, if adequate hemostasis is not achieved after 3 endoscopic treatments, patients with operable gastroduodenal ulcers should undergo surgery.

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We reported 10 cases of esophageal melanosis. Seven cases were male, and the other three were female. The mean age of the patients was 58.5 y/o. All cases had no symptom related to esophageal lesions and the diagnosis of esophageal melanosis was made by endoscopic examination which was performed for screening or suspected gastric disorders. Endoscopic examination showed the flat lesions characterized by spotty, linear, band like, or patchy pigmentation with color of brown or black. The size of lesions ranged from 2 to 20mm. All the lesions were located in the middle or lower third of the esophagus. Histological examination of the biopsy specimen showed many brown granules in cells of the basal layer of the esophageal epithelium on H-E stein. Masson-Fontana stain and electron microscopic findings confirmed that these cells were melanocytes. The prognosis of esophageal melanosis and its association with malignant melanoma are still unknown, since there have been few reports of this lesion. Recent progress of esophageal endoscopy, including electronic endoscopy, will increase the chance to find esophageal melanosis, and prospective follow-up of many cases with this lesion will clarify the natural history of esophageal melanosis.

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Carcinoid tumors arising in the duodenum are uncommon. We reported a case ofduodenal carcinoid evaluated by endoscopic ultrasonography with intraductal catheter probe. A 68-year-old man was admitted to our hospital in May 1993 with nausea. Endoscopic finding showed a small elevated lesion with slight depression on the anterior wall of the duodenal bulb. Biopsy specimen taken from the lesion revealed carcinoid tumor. Endoscopic ultrasonography (EUS) with intraductal catheter probe (20MHz) revealed a hypoechoic tumor with regular margin in the second-third layer of the duodenal wall. The tumor, measuring 6. 4mm in size, was removed by surgical operation. The tumor was located in the duodenal submucosa. EUS with intraductal catheter probe was thought to be useful for the diagnosis of the extent and depth of invasion of a small duodenal carcinoid tumor.

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A 60-year-old man was pointed out to have an early gastric carcinoma of ha + IIc in the prepyloric region by endoscopic examination. The histological findings at the lesion removed by strip biopsy were moderately differentiated adenocarcinoma, in which the depth of the cancerous invasion remained within the mucosal layer of the stomach. The edge was free of carcinoma. After 5 months, at the same site of strip biopsy, a new elevated lesion of Yamada's classification type III with diameter of 2cm was recognized. He had taken an H₂ receptor antagonist for 5 months after strip biopsy. The biopsy specimen of the polyp showed no malignancy. However, polypectomy was performed to do complete examination for the excised specimen. The histological findings were compatible with hyperplastic polyp with no malignancy. The mechanism of growth of the polyp was considered that the epithelium regenerated excessively at the site of mucosal defect after strip biopsy. This was a very interesting case to concern the mechanism of development of hyperplastic polyp.

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We have used sonoprobe system for the diagnosis of not only the depth of gastric cancer but also submucosal lesions. Recently heterotopic submucosal cysts of stomach have been noted to be combined with gastric cancer. However, the diagnosis of heterotopic submucosal tumor is difficult by conventional endoscopy preoperatively. It was confirmed by pathology of resected specimens. We examined four cases of heterotopic submucosal cysts by 20MHz sonoprobe system and these echograms demonstrated low circle echoic areas in the third layer of uneven and rough gastric wall. These findings of echograms correspond to the pathological finding. Heterotopic submucosal cysts with dilated gland in submucosal layer and gastric cancer was pathologically found near the cystic lesion in 2 cases. Conclusively, endoscopic ultrasonography (EUS) with 20MHz sonoprobe system is useful for diagnosis of cystic lesions of the stomach.

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A case of Mirizzi syndrome diagnosed by Endoscopic Ultrasonography (EUS) is reported. A 70-year-old man suspected to have Mirizzi syndrome by ERCP, CT, MRI, US and angiography, was referred to our hospital. PTC showed a tumourous shadow in the common hepatic duct, which was most likely a malignant tumor. But EUS revealed a stone shadow outside of the common hepatic duct and the diagnosis of Mirizzi syndrome was made. Thus, EUS is helpful for diagnosis of Mirizzi syndrome.

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The authors experienced 3 cases of enterobiasis of the large bowel. In all, Enterobius worms were detected during sigmoidoscopy for colorectal cancer screening in a health care examination. One patient had perianal itching without abdominal symptoms and the other two patients had no symptoms. In one patient worm was found in the rectum and in two, worms in the sigmoid colon. Colonoscopy showed no mucosal lesions in the lumen. It is considered to be rare that Enterobius is found during colonoscopy. Recently in Japan, however, some reports of endoscopically diagnosed Enterobius have been appearing, particularly with the spread of colonoscopy. Enterobiasis is not rare and not stamped out disease. Therefore, enterobiasis should be taken into consideration when colonoscopy detected a semitransparent white worm like but smaller than Anisakis.

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We experienced 2 cases of F₀ recurrent gastric varices after endoscopic therapy. Case 1 was a 68-year old man. Endoscopic finding was Lg-f. We performed endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). Gastric varices disappeared after endoscopic therapy. F₀ recurrent gastric varices (red vein) were recognized near by ulcer scar 3 months later. Case 2 was a 64-year old man. Endoscopic finding was Lg-cf. We performed EVL and EIS for this patient. F₀ recurrent gastric varices were recognized near by ulcer scar 5 months later. The findings of F₀ recurrent gastric varices are similar to those of F₀ recurrent esophageal varices. We should pay attention to these findings.

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As a biliary drainage method mainly for inoperable cases of malignant biliary obstruction, percutaneous transhepatic biliary endprosthesis has greatly contributed to prolongation of life and improvements in the quality of life. However, the drainage treatment with the tube stent normally employed is still complicated by obstruction or defluxion of the stent, despite of the improvements in its material of construction and a widening of its caliber. There are no effective methods to prevent these complications. In order to reduce the drawbacks of a tube stent, we introduced an expandable metallic stent (EMS), such as a Gianturco Z stent or a Strecker stent, for biliary endoprosthesis (EMBE) operations. For 6 cases of malignant biliary obstruction, we performed biliary endoprosthesis using a self -expandable metallic stent (Wallstent), which is already commercialized in Western countries and became available in Japan in May, 1993. The present report provides detailed information on the procedures involved in using the stent.

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