In order to clarify the growth process of nodule-aggregating lesions of the colorectum, we analized the clinicopathological features in 39 of our cases larger than 2cm in size. The pathological diagnosis were tubulovillous (TV) adenoma in 25 cases, mucosal (m) cancer in TV adenoma in 5 cases, submucosal (sm) cancer in TV adenoma in 3 cases, muscularis propria (mp) cancer in TV adenoma in 2 cases and subserosal (ss) cancer in TV adenoma in 4 cases. Eighteen lesions were located in the rectum, 12 in the ascending colon and the cecum and 5 in the sigmoid colon and 4 in the transverse colon, respectively. The average size was 33.6mm in TV adenomas, 41.8mm in m cancers, 50.3mm in sm cancers, 45.5mm in mp cancers and 82.0mm in ss cancers, respectively. In cases of mp and ss cancers, there were distinct depressed areas surrounded by nodule-aggregating lesions, and in these cases cancer cells invaded mp and/or ss layer. The sizes of the entire lesion and depressed area became larger with the growth of cancerous invasion. In cases with submucosal and further invasive cancer, ly(+) was detected in all cases, v(+) in 4 and n(+) in 5.The prognosis of cases of mp and further invasive cancers were poor unexpectedly. Three of 6 cases of mp and further invasive cancers died of cancerous metastasis to the distant organs, such as the liver, lung and bone.

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We have performed 12 cases of colectomy under laparoscopic control from December, 1993 to March, 1995. In order to estimate the location and the spreading of the polypoid lesions and to make a definite diagnosis of cystic tumor, laparoscopic ultrasonography(Lapa-US)was performed in 8 cases as follows;(1) 1 case of appendiceal mucinous cystadenoma(AMC), (2)1 case of submucosal tumor(SMT), (3)6 cases of adenocarcinoma(m;1, sm;3, mp;2). Using the Lapa-US, it was easy to find the images of metal clips and the polypoid lesions. Then, we were able to diagnose the cystic tumor as AMC, and know the location of polypoid lesionsand the depth of invasion of the cancer. In conclusion, it was considered that the Lapa-US was very useful to get the informa-tion of the location and the spreading of the polypoid lesions, and the understanding of the vasculature.

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We underwent computed tomography under endoscopic retrograde pancreatography inorder to understand the three dimensional divergent morphology of the pancreatic duct, and to evacuate the area how inferior branch of the pancreatic head occupies. After leaving balloon catheter in the main pancreatic duct and injecting the diluted contrast media, we took endoscopic retrograde pancreatography and computed tomography. By comparing the computed tomography reconstructed in 1mm slice interval With the endoscopic retrograde pancreatography, we tried to reconstruct the three dimensional image of pancreatic duct and evaluated the occupying area of the inferior branch of the pancreatic head. In 9 cases of 12 cases, we had satisfactory images to understand the three dimensional divergentmorphology of the pancreatic duct. In failed 3 cases it caused that the contrast mediaflowed out through Santorini duct excessively. As a result of study of the area occupiedby inferior branch of pancreatic head, in normal individuals all of 6 the inferior barnchesfrom Santorini duet occupying ventral inferior, 16 inferior branches from Wirsung duct were divided into 4 branches occupying dorsal inferior and 12 branches occupying uncus. In ANSA type 10 inferior branches from Santorini duct were divided into 4 branches occupying ventral inferior and 6 branches occupying uncus, 3 inferior branches from Wirsung duct were divided into 1 branch occupying dorsal inferior and 2 branches occupying uncus.

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Endoscopic pancreatic sphincterotomy(EPST)has been performed in twenty cases (chronic pancreatitis:15 cases, tumor: 4 cases, pancreatic cysts: 1 case)which needed pancreatic ductal drainage at the pancreatic head. In ten cases of calcified chronic pancreatltls, extracorporeal shock-wave lithotripsy(ESWL)has been added to disintegrated pancreatic stones located in the main pancreatic duct for 7 patients. Stone disintegration was achieved in 5 patients. Imprflvement of the pancreatic enzymes and/or pain relief was observed in all 15 cases of severe chronic pancreatitis without major complicationsafter EPST. We also performed pancreatic biopsy following EPST in 5 cases. EPST for the patients with ductal stenosis of the pancreatic head, combined with endoscopic duct-drainage procedures(endoprosthesis, ESWL etc), may provide restoring the physiological secretion of the pancreatic flow and inhibitive from postponing the degradation of exocrineand endocrine functions.

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A 75-year-old woman with a chief complaint of general malaise was examined by alocal physician. Microcytic hypochromic anemia and a positive fecal occult blood testwere evident, but their cause remained unidentified. The patient was referred to thishospital to undergo further tests to define the cause of anemia. Upper endoscopic examination resealed telangiectasia localized in the antrum of the stomach. gastric antral vascularectasia(GAVE)was suspected, and endoscopic mucosectomy was performed to confirm thediagnosis. Histopathological examination of the resected specimen revealed hyperplasia ofmangy dilated capillaries in the mucosa. The diagnosis of GAVE was confirmed, andcauterization therapy v as performed using a heater probe. After the therapy, the capillarydilatation disappeared, and there was remarkable improvement in anemia. The patient'scou.rse was good..Heater probe treatment was a safe and.effective procedure in thisdisease. As, GAVE is essentially a benign disease, endoscopic therapy should he thetreatment of first choice for this disease.

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A 62-year-old woman was admitted to a local hospital with complaints of nausea, vomiting, anorexia, dysgeusia and watery diarrhea. After that, hypoproteinemia, alopeciaand onychoptosis developed and she then was referred to our hospita1. X-ray arld endoscopic examinations showed polyposis in the stomach. However, polyposis was not seen inthe small and large intestine. This case vvas diagnosed as Cronkhite-Canada syndrome.Clinical symptoms, ectodermal abnormalities and polyposis improved markedly with bothprednisolone and antiplasmin agent;tranexamic acid.

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A 49-year-old man was referred to our hospital because of fever.On admission, superficial lymph nodes were palpable in the neck, axilla and inguinal regions. Histological study of the biopsy specimens taken from the inguinal lymph nodes demonstrated a typical feature of IBL Iike T-cell lymphoma. Colonscopic examination at the same time revealed multiple polypoid lesions in the transverse, descending and sigmoid colon. The biopsy specimens taken from the polypoid lesions also revealed lymphoid cell infiltration in the submucosal layer of colonic mucosa. The colonic lesions were diagnosed as multiple lymphomatous po1yposis(MLP)on the basis of the above clinical findings.The patient was treated by chemotherapy with CAMBO-VIP, which improved lymph node swellings and the calonic lesions far a short peried. However, he died from recurrence g months after the definite diagnosis. In the literature, there has been no report an MLP complicated with systemic lBL Iike T-cell lymphoma. This case seem very interesting to consider about the relationship between systemic lymphoma and MLP.

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Granular cell tumor (GCT) of the colon is a rare disease. In Japan 19 cases including our cases have been reported.
Two cases of granular cell tumor of the cecum are described. Case I was a 59-year-old-male who was admitted to our hospital because of an abdominal pain and diarrhea and Case 2 was a 64-year-old-male who visited our hospital for closer examination of fecal occult blood. Endoscopic examination revealed semipedunculated submucosal tumor about 10mm in diameter and yellowish-red in color in the cecum of case 1. These findings were similar to endoscopical features of carcinoid. The lesion in case 2 was covered with intact mueosa and was about 5mm in diameter.
These tumors were removed by endoscopic polypectorny, and histologically, showed GCT, which were situated from the colonic mucosa to submucosa, composed of closely packed palyganal cells, containing delicate acidophilic granules and were strongly positive for S-100 protein. On histological section, the tumor nodule of case 2 measures 2.5mm in diameter, which is the smallest colon GCT in reported cases in Japanese literature. Basedon the above described endoscopical findings and microscopic features of these lesions, wecan deduce following conclusions about clinicopathological features of colon GCT. A larger colon GCT such as the lesion seen in case l seems to have carcinoid-like endoscopical findings because of GCT exists in mucosa and submucosa. It is feasible to surmise that colon GCT arise from the vicinity of muscuiaris mucosa and spreads into the mucosa and subxnucasa.

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A 23-year old woman was admitted to our hospital for examination of anemia and melena. Barium enema study and colonoscopy showed multiple polipoid lesions and loss of normal network pattern on surface of colonic rnucosa. The endoscopic retrograde cholangiography revealed irregular stenosis of the common bile duct and stricture and dilatation of the intrahepatic file duct. Her liver function was deteriorated, 10 days after 30mg/day of predonizolone was started. The reduction of predonizolone improved the deterioration of liver function. We summerized and discussed the reported cases of ulcerative colitis associated with primary sclerosing cholangitis in Japan.

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A 69-year old male was admitted to our hospital. He had already performed extended bi-segmentectomy of the liver, because of hepatocelullar carcinoma(HCC;S₄, 6cm diameter). But reccurence has occured from residual liver(S_{5, 6})and extrahepatic growth was observed. Subsequently he was treated by chemolipiodolization and TAE. Upper gastrointestinal endoseopy for the examination of melena and progressive anemia revealed a hemorrhagic ulcerated tumor like Borrmann 2 type in the duodenal bulb. Biopsy specimen, barium meal examination and abdominal CT showed direct invasion of the HCC to the duodenal bulb. Recently the prognosis of HCC patient has been getting better. We must be alert to gastrointestinal lesions during the follow up of HCC patients.

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A 40-year-old woman underwent laparoscopic cholecystectomy(LC)with a preopertive diagnosis of cholelithiasis and chronic cholecystitis. We did not suspect gallbladder carcinoma during the operation. Macroscopic finding of the resected gailyladder was chronic cholecystitis with marked fibrosis of the wa1l. Histological examination revealed transmural poorly differentiated adenocarcinoma spreading the whole gallbladder.Relaparotomy, 54 days after LC, disclosed diffuse peritonitis carcinomatosa. Because peritonitis carcinomatosa or local recurrence arround the torocar sites may occur shortly after LC for unsuspected galibiadder carcinoma, an early radical operation should be performed as soon as the final diagnosis was obtained.

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A-61-year old female was admitted to our hospital because of the elevated liver and bile ductal enzymes and a dilatation of the xntrahepatic bile duct. Endoscopical examination revealed severe stenosis at the superior duodenal angle (USDA). Endoscopicretrograde cholangiographic(ERC)examination revealed a severe stricture in the common hepatic duct and bilateral hepatic ducts, and then we diagnosed this case as cholangiocarcinoma of the hepatic hilus. After perforrning percutaneous transhepatic cholangial drainage(PTCD), a wallstent was placed in this narrowing space. Because of the doudenal stenosis due to the growth of cholangiocarcinorna, an expandable metallic stent(Z-stent)was placed at the stenotic site. Thereafter, the patient was free from the symptom and was able to take a diet for about 3 weeks. Clinical application of a Z-stem on doudenal stenosis is useful in respect to the improvement of QOL.

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A 66-year-old woman, who had been performed extended cholecystectorny for advanced gallbladder carcinoma in pct.1983, was admitted to Iwakuni Medical Center Hospital with complaints of epigastralgia and vomiting on pct.1, 1994. The elevated lesion in, middle bile duct was pointed out by endoscopic retrograde cholangiogram(ERC)and, subsequently, she was referred to our hospital. Peroral cholangioscopy(POCS)proved the presence of papillary tumor with microgranular surface and its cytology discloscd class V. A bile duct carcinoma was diagnosed, because ARC demonstrated normal residual cystic duct and the tumor was demonstrated within the wall of the bile duct by U5, CT, MRI and EUS. Resected specimen revealed early bile duct carcinoma limited to the fibro-muscular layer without lymphnode metastasis. There is an interval of ll years between the first gallbllader carcinoma and the second bide duct carcinoma.This is the sixth case of metachronous multiple primary biliary cancer reported in Japan.

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We applied the new endoscopic ultrasound probe combining radial and linear scanningfacilities (FUJINON, SONOPROBE SYSTEM SP-501) for endoscopic ultrasonography (EUS) of various lesions of the esophagus and stomach, during the 11-month period fromFebruary through December 1993. The subjects of this study comprised ten lesions ofesophageal cancer, two esophageal dysplasia, three esophageal leiomyoma, one benignesophageal stenosis and five early gastric cancer.
A20-MHz ultrasoud transducer combining radial and linear scanning is mounted onthe tip of the probe. A translator is attached to the opening of biopsy channel of ordinaryendviewing endascape, and the mode of radial and linear scanning is able to easily changedusing lever on it. Under direct control of endoscopy, we scanned lesions with real time radial method totake tomographic overview and confirm the area of interest of it, and we then addedmanual linear scan to take mare detailed infarmatian of the area. Some of subjects were small (less than 1 cm in diameter), although there was no undetectable lesion. In this study, the results of tumor invasion depth diagnosis was not improved comparedwith those of current reports. However, these two scanning modes combining a probe haveovercome a weak point of conventional EU5 instruments which were hard to visualizesuperficial or small lesions.

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