The word of "laterally spreading tumor (LST)" proposed by Kudo is getting familiar, but the concept of non-granular type among LST has not reached an established theory compared with granular type among LST. The problems especially in the differences with ha or nodular-aggregating tumor, regulations of sizes and handling when it shows partial depression still remain to be solved. The author proposed "Pseudopodia-like appearance" of the superficial tumor as the marker of the potential to grow to lateral side ; such tumor is supposed to be equivalent to non-granular type. "Pseudopodia-like appearance" is a general term indicating the edge shape of the tumor which protrudes outside like amoebase's pseudopodia. To examine the significance of "Pseudopodia-like appearance", they were compared with other superficial tumors (ha, IIa+IIc and IIc) and granular type among LST in the aspects of clinicopathological and genetic findings. The characteristics of non-granular type were as follows ; In those more than 10mm in size, non-granular type showed 11% of sm involvement, which were all more than 25mm, and they all showed polypoid growth histologically by Shimoda and Ikgami's classification. In the gross shape, most of them showed flat elevation. The rate including partial slight depression increased in the tumors more than 20mm in size, which did not correspond to sm involvement. On the other hand, the tumor with absolute depression which was shown in only 1 case was sm involvement. In genetic findings, there were no K-ras point mutations in non-granular type and overexpressions of p53 were diffusely observed all over the tumor in spite of diversity of histological atypism. Even in those less than 10mm in size, superficial tumor with "Pseudopodia" also showed the same characteristics as those more than 10mm i size and moreover showed the differences from ha which showed the same shape of flat elevation and were commonly seen in those less than l0mm in size. Therefore, it was suggested that superficial tumors with "Pseudopodia" should be dealt with as the specific tumor which has the same genetic backgrounds with ha + IIc or IIc and nevertheless does not invade until it grows in a larger size. That is equivalent to the concept of non-granular type of laterally spreading tumor.

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Endoscopic mucosal resection (EMR) is useful as a radical treatment for early gastric cancer. However, a difficulty of this technique depends on the sites of lesions. If the lesions are in the lesser curvature or the posterior wall of the M- or C-region, it is very difficult or even impossible to resect them. We carried out a clinical study to compare the results of EMR using a 2 channel scope (EMR-2CS, conventional method) with those of EMR using a cap-fitted panendoscope (EMRC, newly introduced method) for lesions at the abovementioned sites. Thirty-four patients with 35 lesions (17 lesions resected by EMR-2CS, 18 lesions resected by EMRC) located in the lesser curvature or the posterior wall of the Mor C-region were included in this study, and the results were as follows : 1) Rate of complete resection with EMR-2CS was 64.7% and that with EMRC was 77.8%. 2) Especially, for the lesions located in the lesser curvature or the posterior wall of the M-region, EMRC was very effective and the rate of complete resection reached 90%. On the other hand, the lesions in the lesser curvature or posterior wall of C-region were still difficult to resect even by EMRC, the rate of complete resection being 63%. 3) There were no major complications in EMR-2CS, but there were two patients with massive bleeding and two who suffered from perforation by EMRC. Specimens obtained by EMRC tended to be resected more deeply. Thus we conclude that EMRC is a useful treatment for early gastric cancer located in the lesser curvature or the posterior wall of the M-region.

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In 85 cases of "early" gastric carcinoma including 30 cases of intramucosal carcinoma (m) and 55 cases of carcinoma with submucosal invasion (sm), the relation between Helicobacter pylori (Hp) infection and ulceration in cancerous lesion was studied clinicopathologically. All 85 cases of "early" gastric cancer could be divided into two broad categories of histology : differentiated type (dif f : intestinal-type adenocarcinoma) and undifferentiated type (undiff : diffuse-type adenocarcinoma). The overall Hp positive rates were 54.1% (46/85). In "early" gastric cancer with ulceration (UL (+)), rates of Hp infection were 93.4% (15/16), and "early" gastric cancer without ulceration (UL (-)) was 48.4% (31/ 69). The rates of Hp infection in UL (+) were significantly higher than that in UL (-). There was no significant difference in Hp positive rates between two histologic types, dif f type : 47.4% (18/38), undiff type : 54.9% (28/47). The positive rates of Hp infection in "early" canoe of gastric body were (69.0%, 29/42) higher than that of "early" cancer of antrum (38.9%, 14/36) and "early" cancer of cardia (42.9%, 3/7). In addition, Hp infection in UL (+) was similar to that gastric peptic ulcers. And nonmetaplastic area around cancer was higher positive-rates of Hp infection than that in cancer and metaDlatic area. These results suggest that Hp infection may be associated with the development and ulcer-formation of "early" gastric cancer but may not be implicated in its morphology and evolution. The combining staining method (Steiner, hematoxyli-eosin, and alcian blue) was useful for the detection of Hp and for the evaluation of morphology and, therefore, can be advocated for the routine diagnosis of Hp infection.

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We experimented basic examination in 5 mongrel dogs to establish reliable multi-EMRL procedure and useful reconstruction procedure of the resected specimens. It is most effective and reliable technique that, at first EMRL, we applied the cap (EVL device) to both front and one side markes and resect mucosa about ×20 mm in size by 3 times EMRL. The depth of the ulcer base induced by multi-EMRL, even at the borderline between the two resected mucosa, reached submucosal layer (sm3). And it is very effective reconstructed procedure of the specimens by piecemeal resection that clip as mark is punched on the ligated mucosa. These results indicated that multi-EMRL procedure using clip may play a effective and reliable role in the division of mucosal resection.

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We performed peroral transpapillary pancreatoscopy for 33 patients who were suspected pancreatic cancer after medical sphincter dilation using sub-lingual nitroglycerin. By administration of 0.3-0.6 mg nitroglycerin pancreatoscope which has an outer diameter of 2.2 mm, could be easily inserted into a normal papilla of Vater in 29 of 33 patients (87.9%). Four patients could not keep the guide wire into the distal portion of pancreas because of obstruction of main pancreatic duct due to the cancer of head of the pancreas. The success rate of total pancreatoscopy or observation of obstructive lesion after the insertion was 79.3%. For general influence of nitroglycerin we analyzed changes of systolic blood pressure during peroral pancreatoscopic examination. Systolic blood pressure during examination was significantly decreased in the case with and without treatment of nitroglycerin. (p < 0.0001) No difference of decrease of systolic blood pressure between nitroglycerin and control group was existed. (p = 0.7127) In our study, this examination with sub-lingual administration of nitroglycerin is extremely effective for peroral transpapillary pancreatoscopy in patients with an intact papilla without any side effects.

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We report a patient with giant Yamada (Y)-3 type gastric hyperplastic polyp developing after endoscopic mucosectomy for early gastric cancer. Sixty two year old man wasadmitted to our hospital due to endoscopic mucosectomy for early gastric cancer (typeIlc+Ila) in the antrum. The removed lesion revealed histologically as well differentiatedtubullar adenocarcinoma confined to the mucosa. Follow-up endoscopy about 10 monthsafter mucosectomy showed a polypoid lesion in the resected site, which was identifiedhistologically hyperplastic polyp. The polyp had grown up to Y-3 type, sized about 25mmin diameter, so it was resected by endoscopic polypectomy. A case of gastric hyperplasticpolyp developing after endoscopic mucosectomy for early gastric cancer has been rarelyreported in Japan. The mechanism was still unknown, but was thought that excessiveregeneration of epithelium was promoted by formation of ulcer after endoscopicmucosectomy, administration of H₂-receptor antagonist and mechanical stimulation byincreased peristalsis.

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We reported 4 cases of bleeding colonic angiodysplasia (AD) diagnosed by urgentcolonoscopy. Case 1:a 82-year-old female patient was admitted with hematochezia andsevere anemia (Hb 5.1). She was treated chronic heart failure due to longstanding mitralvalve regurgitation. Bleeding ADs were scattered through the ascending to descendingcolon and treated by hot biopsy and epinephrine injection. Histology proved dialatedvessels in the mucosa. Case 2:a 52-year-old female was admitted with massive freshbloody stools after hemodyalysis. She had chronic renal failure and had receivedhemodyalysis 3 times a week. Urgent colonoscopy revealed a bleeding AD in the sigmoidcolon and was also treated by hot biopsy and ethanol injection. Histology proved severaldialated vessels in the mucosa. Case 3:a 43-year-old male passed massive fresh bloodystools during treatment of liver cirrhosis. A bleeding AD was observed in the ascendingcolon by colonoscopy. Hot biopsy stopped bleeding. Histology proved multiple dialatedvessels in the mucosa. Case 4:a 54-year-old male was admitted with hematochezia. Hehad a long history of liver cirrhosis and esophageal varices. Urgent colonoscopy revealeda bleeding AD located in the sigmoid colon. Hemostasis was successful by epinephrineinjection. Bleeding AD is relatively easy to make the diagnosis on urgent colonoscopy. Wewould stress on the efficacy of emergency colonoscopy for the diagnosis and treatment ofhematochezia.

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A 49-year-old female, who had a history of radical mastectomy for right breast canceron July 1990, visited to our hospital because of epigastralgia on March 1995. Endoscopyand barium meal suggested scirrhous carcinoma of the stomach with antral stenosis, butrepeated biopsies failed to demonstrate malignant cells. After admission, bilateral pleuraleffusion became apparent. Aspiration cytology showed breast cancer cells, thereby suggesting a gastric metastasis which formed Borrmann type 4 carcinomalike appearance.Gastric metastasis of breast cancer was confirmed by the autopsy, which demonstrateddiffusely infiltrating breast cancer cells (invasive lobular carcinoma) in the gastric wall.

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A 75-year-old female was admitted to our hospital with complaints of dysphagia andtachycardia. Gastroscopy revealed a submucosal tumor on the posterior of the upper body.The tumor has erosion on its surface, and 8cm in its size. The tumor was diagnosed as aleiomyosarcoma with endoscopic findings. On April 5, 1995, total gastrectomy was performed. Histological finding of theresected specimen showed leiomyoma associated with hyperplastic polyp. Peculiar forming leiomyoma as is shown in this case was rarely reported especially that with hyperplastic polyp.

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A 47-year-old male with upper abdominal pain was admitted to our hospital forfurther examination for leukemia. The patient was diagnosed as having acute lymphocyticleukemia of L3 (Burkitt type). An upper gastrointestinal endoscopic examination revealeddiffuse gastric and duodenal invasion of leukemic cells. After chemotherapy, however, these findings almost disappeared. ALL of L3 type is a ralatively rare disorder and has apoor prognosls. We here reported a case of ALL (L3) with marked invasion to the stomach and theduodenum, who improved remarkably after chemotherapy.

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Three cases of sessile protruded lesion in the second portion of the duodenum perfomedendoscopic mucosal resection (EMR) are reported. ln each case, the lesion was completelyresected by‘strip biopsy’ using 2 channel endoscope (2 cases w/ith the Olimpus GIF-2T200, 1 case with the Olimpus XGIF-2TK200) . Histologically they vvTere diagnosed as duodenaltubular adenoma, carcinoid tumor, and atypical hyperplasia of Brunner's gland, respectively. Resected margins were free of lesion in all cases. Hemorrhage occurred in 2 cases, butboth cases recovered byendoscopic and conservative treatment.
It is possible to perform EMR in the second potion of the duodenum as well as in thestomach and colon, but the choice of endoscope depending on the region of lesion and thepreparation for avoiding complication were thought to be necessary.

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A 76-year-old woman was presented with positive fecal occult blood test. Upper GIendoscopy showed a Ila-like elevated lesion in the antrum with an invasion to bulbus andthe'biopsy revealed well-differentiated adenocarcinoma. The lesion of invading into thebulbus demonstrated a white villi-like appearance. She was admitted for subtotal gastrectomy and histological finding of excised specimen was tubular adenocarcinoma in lamina propria with infiltration to submucosa only inpyloric ring. The bulbus side of the lesion showed the histological findings of papillaryadenocarcinoma. Along with bulbus, the invasion of mucosal papillary adenocarcinomabecame gradually thin, and was extremely thin in the white villi-like lesion. Total length of bulbar invasion from pyloric ring reached 2.5 cm which appeared to bethe maximum duodenal extension among the previous reports of early gastric carcinoma.

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We experienced a rare case of double primary malignancies of the large bowel and stomach. A 61-year-old male presenting the symptoms of diarrea, soft and bloody stools visited our hospital. Colonoscopy and barium enema revealed a creeping tumor coexisting with a type 2 advanced cancer in the rectum. Screening UGI endoscopy showed a IIc lesion in the stomach. A pancreas tumor was also detected in the body of the pancreas by US and CT. As the result of these diagnosis surgical operation was performed. The pancreatic tumor was a solid cystic tumor, 1.5 cm in size. The lesion of the rectum was a tubulovillous adenoma partly with moderately differenciated adenocarcinoma of the depth ss. The lesion of the stomach was a IIc type moderately differenciated adenocarcinoma of the depth sm. As the colon creeping tumor has a tendency to coexist with the colon cancer of other portion or the cancer of other organ, the neccesarity of examination before operation keeping the disease of other organ into mind is suggested.

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From January in 1984 to May in 1995, we performed laparoscopy for 1342 patients and were able to observe gallbladders in 1278 cases. Among them, 11 patients (0.86%) were found to have ectopic liver tissue on serosal surface of the gallbladder. These cases were composed of 3 male and 8 female with age of 18 to 62 years. There were no symptoms relevant to the ectopic liver tissues. They were less than 15 mm in diameter, and were stained greenish by intravenous ICG injections similarly as the liver. Ten of 11 cases had single ectopic tissue and 1 case with two tissues.

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A 64-year-old man was found to have a filling defect of 10 mm diameter with slight movability in the dilated main pancreatic duct on endoscopic retrograde cholangiopan creatography (ERCP) performed as part of further examinations on the diagnosis of acute pancreatitis. Peroral transpapillary pancreatoscopy (POPS) demonstrated a papillary tumor without mucin production in the main pancreatic duct and intraductal ultrasonography (IDUS) gave images of a pedunculated polyp without involment of the pancreatic parenchema. It was, therefore, diagnosed as an adenoma or carcinoma in situ, presenting as a intraductal papillary tumor with scant mucin production of the pancreas. Histological diagnosis of the resected specimen was a papillary adenoma with a background of chronic pancreatitis. Intraductal papillary tumor with scant mucin production is very rare in the pancreas, and in case with a filling defect in the main pancreatic duct, POPS and IDUS were established to be useful methods for making a differential diagnosis.

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A 64-year-old female with liver cirrhosis was admitted with complaint of hematemesis and melena. Altough S-B tube was introduced, hemostasis was unsuccessful. Endoscopic examination revealed varices like a submucosal tumor in the second portion of duodenum. There was a bleeding point on the varices, and we performed EVL for it. After that, bleeding just stopped and general status improved. We perf omed TIO additionaly one day after EVL for fear of rebleeding. Portography on TIO showed a dilated inferior pancreaticoduodenal vein and blood flow was completely blocked at EVL sites. After EVL and TIO, duodenoscopy revealed the varices disappeared and scar formation occuured. Combination therapy of EVL and TIO was considered to be effective to rapture of the duodenal varices.

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