Laparoscopic surgery has been developed rapidly in recerlt years all over the world.Its indication has been enlarged with the rapid advancement and development of opticalsystem, disposable devices and other operative instruments. It have brought the revolutionand the conceptual changes xn surgery. Recently, the indication of laparoscopxc surgery hasbeen extended to malignancy such as early gastric cancer and colorectal cancer. However, complicated procedures in laparoscopic surgery which require precise maneuver, suturingor knot tying are still difficult for surgeons, and this fact prevents its further popularizationand the further extension of its indication. In order to overcame this barrier and makelaparoscopic surgery more easier and more surgeon-friendly, we have been introducing ordeveloping several new technologies since 1994, collaborating with the Faculty of Technol-ogy and Science, Keio University and several companies. They are 3-D, head mountdisplay, tele-education system, virtual reality educational system, solo-surgery with voicecontrol robotic system and maser-slave rnanipulator. Some are still under developmentand some are already clinically applied in our institute. with these technologies, laparo-scopic surgery will become easier and safer to perform, and the indication of Iaparoscopicsurgery will extend more widely in future.

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We studied the differences in the ulcer healing and the gastric mucosal blood flow of the EMR-induced ulcer, between 34 Helicobacter pylori(HP)positive cases(41 lesions)and 13negative cases(171esions). There were no significant differences in the ulcer healing and the changes in mucosal blood flow of the ulcer margin during the time course(1 day, 1 week, 2weeks, 1month, 2months and 3 months after EMR)studies. However, at the endoscopically healing stages, rnucosal blood flow ratio(mucosal blood flow of the ulcer margin/that of the surrounding mucosa)of the SIP negative lesions was significantly higher than that of the HP positive lesions. fur results suggest that HP infection affects local factors and reduces mucosal blood flow of the ulcer margin at the healing stages.

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Endoscopic and pathologic findings of the esophagus, stomach, duodenum, and color-ectum were studied in 8 patients with AA amyloidosis involving the gastrointestinal tract.Endoscopic examinations of the stomach revealed various findings such as erosions andshallow ulcers. On the other hand, fine granular appearance especially in the secondportion of the duodenum, was observed in ail the cases. Endoscopic findings of thecolorectum showed mainly erosions and ulcer, and the degree and portion of these abnor-malities were variable, even in the same patient. The frequency of amyloid deposition inthe biopsy specimens was as follows;10Q%in the duodenum, gastric antrum, terminalileum and colorectum, 83%in the gastric body, 50%in the esophagus. The lumpydeposition of amyioid prctein in the submucosa of the duodenum, which was the highestdegree of the entire gastrointestinal tract, was considered to reflect the characteristicendoscopic findings described above. fur results indicate that for a diagnosis ofamyloidosis, it is important to examine the duodenum, which shaves the characteristicendoscopic findings and is suitable for biopsy, using endoscopy.

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A59-year-old woman visited our hospital with a complaint of general fatigue inMarch 1993. She Was diagnosed as having autoimmune hepatitis with esophageal varices(F3RC(_??_)). We performed endoscopic injection sclerotherapy(EIS)for the esophagealvarices. Two years later, esophageal varices were still visible, and repeat EIS wasperformed on March 7, 1995. After this therapy, the patient developed a fever with epigastralgia. Gastric endoscopyrevealed a giant gastric ulcer. Using endoscopic varicealography during injection scleroth-erapy, we detected a gastric arterial branch in a portion of the ulcer, which suggestedinadequate injection of ethanoiamineoieate into the gastric arterial branch. This mighthave been the cause of the giant gastric ulcer. This is a very rare but important camplica-tzon of EIS.

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We studies on nine patients with a solitary colorectal polyp which was consideredunclassified by Morson's histological criteria. Histology showed common features:almostnormal mucosa and non-specific submucosal findings such as edema, hemangiectasis and/or lymphangiectasis. No causative factors were identified for the elevated lesions. Six ofthe nine polyps had cornrnon endoscopic findings:pedunculated or subpedunculated polypscovered by normal-appearing mucosa with smooth or wrinkled surface, which can assumeviriable configuratlons i:n given conditions due to their plasticity. Therefore, we describedthese lesions as"rnucosal tongue"or"deflated balloon-shaped"polyps. These are distinctlydifferent from polyps formed by neaplasia, inflammation, malformation and dysmatura-tion, and may represent a new disease entity. The patients comprised four females and tvvomales ranging from 47 to 79 years;the polyps ranging from 3 to 1$mm in size were locatedin the rectum in twc cases and in the sigmoid cnlan in four cases. We called these polyps"mucosal tongue", because of distinctive endoscopic findings. one of the remaining threepatients showed a small spherical polyp and the other two showed lobulated polyps.Overall, the polyps in our patients shared common histological features with those reportedby Matake(colonic muco-subrnucosal elongated polyp)and those reported by Fulinuma(rnucosal polyp). It has remained, however, to be further studied whether such lesionsrepresent a continuous spectrum.

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A57 year-old male has been followed up for chronic hepatitis for 18 years. On March1987, at the age of 59, the barium enema examination showed a elevated lesion abeut 1.5cm in diameter at splenic flexure of the descending colon. The surface of the lesion wassmooth, suggesting a submucosal tumor. Endoscopic examination revealed a dark bluishelevated lesion at the splenic flexure, and calanic hemangiama vvas suspected. The size ofthe lesion did not change for 7 years. However, on June 1994, the lesion grew up to about3cm in diameter, and angiography revealed a hypervascular staining at the left branch ofmiddle colonic artery, suspecting hemangioma or arterio-venous malformation. Partialcolonic resection was performed on December 1994, and histological examination of thelesion revealed a cavernous hemangioma. This case report described the first case of the colonic hemangima whose growingprocess had been endoscopically observed for a long-term period.

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We report a case of gastro-colic fistula due to stomal ulcer reconstructed by BillrothImethod. A 68-year-old man presented to our hospital because of chronic watery diarrhea.He had been followed as rheumatoid arthritis and had medicated non-steroidal antimflam-matory drugs and steroid at the other hospital for ten years. A colonoscopic examinationrevealed a fistula between the transverse colon and the part of anastomosis. According tothe literature barium enema study has been the most popular maneuver for making adiagnosis of the gastro-colic fistula. However, the colonoscopy is also useful for earlydiagnosis of the fistula in the present ease.

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There are few case reports about recurrence of amebic colitis in Japan. We reportedacase of 60-year-old man with a recurrent amebic colitis six years after amebic proctitis.In April 1989, he complained of diarrhea and occasional bloody stool. we treated him withmetronidazole for amebic proctitis proven by rectal biopsy. In June 1996, he was referredto our clinic because of intractable colitis unresponsive to sulfasalazine, predonizolone andanti-mycobacterial agents. We reviewed his medical record, colonoscopic pictures, andbiopsy specimen, and we diagnosed as amebic colitis. He tuxned out to be homosexualthrough an interview to his wife, therfare the cause of the recurrence may he re-infectionrather than inadequate dosage of metronidazole. Increasing amebiasis among hornosex-uals has been reported in Japan as in Western countries. We should warn the patientsagainst re-irlfection and advice thern to receive follow-up examination.

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A new endoscopic polypectamy method using a ligating device far gastric polyps wasdeveloped as a preventive strategy against hemorrhage. This method was performed on 7gastric polyps in 6 patients (macroscopic classification:6 pedunculated polyps and 1 semipedunculated polyp histological finding: 6 hyperplastic polyps and 1 gastric adenoma) .Two out of 6 pedunculated lesions possessed the thick stalks more than 10 mm zn diameter.We could easily and certainly prevent bleeding after polypectomy in all the lesions and, moreover, observe no residual stalk or recurrence of the polyp in all the cases duringendoscopic follow-up examination. This method was thought to be very useful for endo-scopic polypectomy in the stomach.

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We evaluated Multi-Directional Endoscopic Varicealography during injection scleroth-erapy (IS) employing the digital angiographic (DA) system. From November 1996 to February 1997, IS utilizing the DA system vvas carried out on 8 patients with esophagealvarices. The injected sclerosant was 5% ethanolamine oleate with iopamidol(5% EOI).Endoscopic varicealography of the frontal and RAO views were obtained in all cases, butthe LAS and lateral views were obtained in only 3 cases. The cardiac venous plexus andthe cardiac branch of the left gastric vein were detected in 88% and 100% respectively, asesophageal blood supply routes. The paraesophageal and mediastinal veins were detectedin 50% and 25% respectively, as extraesophageal blood drainage routes. When weconfirmed the existence of these extraesophageal blood drainage routes, we immediatelystopped the injections. The total dose of the intravariceal injection of 5% EOI ranged from 7-33ml, which were within safety limits. In ail cases, the esophageal varices wereeradicated and the liver functions as well as the portal hemodynamics did not deteriorateafter the therapy. fur results show that Multi-directional Endoscopic Varicealographyduring IS employing the DA system can precisely control the dose of sclerosant, thereforethe effects of IS to the diver functions and the portal hemodynamics are minimized.

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A laparoscopic assisted distal gastrectomy(LADG)with Billroth I anastomosis wasperformed in 5 patients with early gastric carcinoma, 1 patient with hyperplastic polyp and 1 patient with leiomyosarcoma. The preoperative diagnosis were IIc in 4 patients and IIa+IIc in 1 patient. Pathological diagnoses of the biopsied specimen were tubl in 4 patients and tub 2 in 1 patient. Cancerous leslons in all 5 patients were examined to be localized atrnucosal layer by EUS. In a patient with gastric carcinoma, gastric adenoma and intramucosal gastric carcinoma had been endoscopically resected. LADG was performedfor cancerous lesion detected in another place of the stomach. In a patient with hyperplas-tic polyp of 3.0X2.5cm in diameter, hyperplastic polyp had been rejected endascapieally 4 times because of its recurrence and LADS was indicated, since malignancy of the polypwas not ruffed out. In a patient with leiamyosarcoma, submucosal tumor of 5.5cm indiameter showing intraluminal growth into the antrurn of the stomach was noted. As to techniques, five portal technique with 12-mm trocar was used. Lymph node of #3, #4d, #4sb, #5, #6 and #7were completely dissected with this technique. The stomachwas transected laparoscopically with endostapler, after the right and left gastroepiploicvessels and gastric vessels were clipped and dissected. The epigastric abdominal wall wasthen incised with transverse incision about 6 cm bong and duodenum was transected undervisual control. The gastroduodenostomy was then performed using automatic anastomatcircular stapler. The operation time was 4 hr 40 min in average and the mean volume ofblood loss was 140 ml. In 6 patients with malignant diseases, any recurrence was not notedduring the postoperative follow-up period ranging 5 to 13 months. LADS with Biilroth Ianastomosis is a feasible laparoscopic technique performed in patients with intramucosalgastric carcinoma or other gastric lesions whose complete resection by laparoscopic localresection or EMR cannot be expected.

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Endoscopic retrograde cholangiopancreatography(ERCP)in patients with Billroth II (B-II) gastrectomy has a number of problems such, as intubation of the afferent loop, reaching the papilla of Vater, cannulation and endoscopic sphincterotomy(EST)from areversed position. we reviewed the records of 164 ERCPs performed in 118 consecutivepatients With B-II gastrectomy at Shinshu University Hospital and its affiliated hospitalsbetween January 1989 and December 1996. Standard or therapeutic duodenascopes wereused routinely. EST Was performed using a needle-knife guided by a bitionasal drainagecatheter or biliary endoprosthesis. Cannulation of the desired duct was achieved in 124 of 164(75.6%)ERCPs;98 of 124 (79.0%) ER s and 26 of 40 (65.0%)ERPs. Reasons far failure in FRCP included;the afferent loop was too long to reach the papilla (25), thepapilla was identified but failed cannulation(10), the papilla was not identified in spite of reaching duodenal stump(3), and the afferent loop could not be entered(2). However, irlpatients whom the papilla was seen, cannulation was successful in 98 of 107(91.6%)ERCs and 26 of 27(96.3%)ERPs. Stone was extracted successfully achieved in 27 of 40(67.5%)patients with common bile duct calculi following EST (25) or endoscopic balloon papillarydilation(2), Complications occurred in 4 patients;retroperitoneal perforation(3), andbleeding(1). All complications were recovered by conservative management. Endoscopicbiliary drainage(EBD)was successful in 10 of 16(62.5%)patients with malignant biliaryobstruction. Reasons for failure in EBD included inability to reach the papilla(3)andfailure to cannulate(3). The most common reason for failure in ERCP in patients with B-II gastrectomy was inability to reach the papilla. However, tolerable results of diagnosticand therapeutic ERCP could be obtained in patients wham the papilla of Voter wasidentified. Recently, we have used an oblique-viewing endoscope in patients with B-II anastamoses who had been suspected biliary disease. This scope is superior to duadena-scope in reaching the papilla and in bile duct cannulation.

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