We focussed on problems of the following points in endoscopic mucosal resection (EMR) for early gastric carcinoma; techniques, indication and its extension, judgement and its criteria for complete resection (radicality), and follow-up. Curative EMR for cancer is performed with the aim of curing it. However, pretreatment evaluation of depth of the invasion is not always correct. For establishment of curative EMR as great as surgical treatment, it is inevitable to judge its curability based on definite criteria is histological examination of EMR specimen. Therefore, curative EMR is approved after the treatment. The curability should be judged based on definite criteria on the specimen of single (en bloc) EMR. The judgement of complete resection is impossible in the cases of piece meal EMR or additional EMR. Furthermore, the remnant and recurrence of cancer sometimes occur is these cases. Therefore, piece meal EMR and additional EMR are not acceptable as curative EMR. There is some doubt whether additional EMR and tissue destructive method are indicated as an additional treatment in the cases of possible remnant of cancer. Furthermore, there are problems of criteria for curability, and how to cope with noncurative cases. Regarding follow-up, there are many problems to solve including the following matters ; difficulty in performing strict follow-up, complexity of frequent endoscopies, difficulty in confirming remnant of cancer. Many efforts have been made to enlarge indication of EMR in terms of the size and depth of the lesion. So far, however, the resectable size with EMR is 3 cm in the maximum. At present, submucosal cancers are not indicated for curative EMR, taking accuracy of the diagnosis and risk for lymph node metastasis into account. Establishment of EMR as a curative treatment for cancer requires basic review of the following points from the viewpoints of radicality "as a principle of cancer treatment" : techniques, criteria for complete resection, measures against incomplete resection, and follow-up.

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We developed ICG dye enhanced diode laser photosclerotherapy as preventive treatment for bleeding esophageal varices. Submucosal injection of wave length-specific dye (ICG : indocyanine green) could provide enhanced diode laser beam absorbtion selectively in the submucosal tissues around esophageal varices. First of all, we clarified the efficacy and safety of this new technique experimentally using dog's esophagus and then applied it in 6 cases of esophageal varices. In the experimental study, thermal injuries in the mucosa and submucosa were selectively induced without surface defects during irradiation. A month follow up endoscopy showed degenerated mucosa and submucosa to be replaced with fibrosis while no changes were observed in the muscle layer. Based on these findings, we therefore, applied this technique in 6 patients of esophageal varices after EVL treatment. Complete eradication was archieved within 2 weeks in all cases. A mild stenosis was seen in 2 patients, which was easily treated by balloon dilatation. It is concluded that ICG dye enhanced diode laser photosclerotherapy would be useful as a simple, safe and effective alternative to prevent bleeding from esophageal varices.

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A 55-year-old man was admitted to our hospital for the purpose of further examination of diabetes mellitus. He presented with dysphagia on admission. An upper gastrointestinal series revealed multiple tiny outpouchings and a stricture in the upper intrathoratic esophagus. Esophagoscopy revealed multiple small depressions on the cloudy esophageal mucosa and an inlet patch in the upper part of the esophageal stricture. Endoscopic ultrasonogram and CT showed thickening of the upper esophageal wall. Therefore, the patient was diagnosed to have esophageal intramural pseudodiverticulosis with an inlet patch.

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A 64-year-old female, underwent surgical treatment for a malignant fibrous histiocytoma in the right thigh on December 10, 1996. Eight days after surgery, she developed epigastric pain and hematemesis, and was admitted to our department. UGI endoscopy and radiography revealed an ulcerated, protruding submucosal tumor about 5.3 cm in size spreading from the middle body to the posterior aspect of the lesser curvature of the upper body of the stomach. Endoscopic ultrasonography revealed the tumor existing in the submucosal layer and was not connected with the muscularis propria. A deep depression was seen on the center. The inside echo was heterogeneous and the echo level was comparatively low. Based on these findings, the patient was diagnosed to have a gastric leiomyosarcoma arising from the muscularis mucosae. She was operated on March 11, 1997. The resected tumor was 5.5.3.5.3.5 cm in size and was located in the submucosal layer. It was connected with muscularis mucosae but not with the muscularis propria. Microscopical examination showed spindle-shaped tumor cells and a high cell density. Mitosis was seen by 6/10HPF. Based on these findings, the gastric leiomyosarcoma from the muscularis mucosae was made. Gastric leiomyosarcoma arising from the muscularis mucosae has been rarely reported.

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A 63-year-old male experienced an abdominal pain and nausea 3 days after eating raw firefly squid, Watasenia scintillans, Hotaruika. A diagnosis of a paralytic ileus was made, and the ileus subsided following conservative treatment. Endoscopy revealed a fullcircumferential lesion resembling a submucosal tumor in the gastric antrum. Endoscopic ultrasonography disclosed hypertrophy extending to all layers of the gastric wall, particularly marked in the submucosal layer. He was followed without any active treatment. The lesion disappeared completely 5 months later. This case seems to involve type X larvae of the suborder spirurina.

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Eighty to 90 % of hereditary nonpolyposis colorictal cancers (HNPCC) show DNA replication errors (RER) at microsatellite loci. Meanwhile, some gastric cancers occur in a familial or hereditary manner. Then, we analyzed DNA replication errors (RER) in familial gastric cancer patients. The criteria of familial gastric cancer we used are as follows ; (A) more than 3 gastric cancer patients in the pedigree, (B) 2 gastric cancer patients in the pedigree with (1) the first gastric cancer occurs in less than 50 years old, (2) multiple gastric cancers in one patient, (3) adenocarcinoma in the other organ. By this criteria, 4 (5.1%) of 78 gastric cancers were diagnosed as familial gastric cancers. Of the 4 familial gastric cancers cases, 3 were well differentiated adenocarcinomas and the other one was a poorly differentiated adenocarcinoma, histologically. Five microsatellite loci were analyzed but no cases showed RER. The results suggest that the carcinogenetic process of familial gastric cancers may be different from that of HNPCC.

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A 71-year-old male patient visited our hospital because of vomiting coffee-ground material without abdominal pain. Upper gastrointestinal endoscopy revealed a shallow ulcer having a vissible vessel in the base with mucosal irregularity, on the lesser curvature of the upper body of the stomach. Therefore, we performed clipping treatment for the bleeding. Fourteen days after the initial endoscopic treatment, gastric biopsy obtained from the shallow ulcer revealed the histological picture of moderately differentiated tubular adenocarcinoma. About one month after his admission, he underwent total gastrectomy. Histological examination of the resected stomach showed a IIc type early cancer lesion on the lesser curvature of the upper body measuring 3.0×2.5 cm. An unusually large and f ortuous submucosal artery measuring about 2.0 mm in diameter was also observed just beneath this cancer lesion. Gastric cancer associated with Dieulaf oy's vascular malformation is extremely rare. Only 10 cases have been reported in the world literature including 8 Japanese reports (MEDLINE : Jan/1980-Oct/1997). This case suggests that the association of gastric cancer with Dieulaf oy's vascular malformation may be coincidental. It is very important that we observe as well as the complication of cancer the confirmation of hemostasis after endoscopic hemostatic treatment of Dieulaf oy's ulcer

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A 62-year-old man was admitted to our hospital with complaints of tarry stool and hypovolemic shock. This was the forth time admission for the last two years and six months. As endoscopic examination revealed an ulcerative lesion in the upper jejunum, partial resection of the jejunum was performed. Histological examination of the resected specimen disclosed angiodysplasia in the jejunum.

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A 43-year-old Japanese woman was admitted to our hospital because of an episode of massive hematemesis and melena. On admission her vital sign was unstable due to hypovolemia by bleeding. Emergency upper gastrointestinal (GI) endoscopy using a f owardviewing endoscope (Olympus Q-200, Olympus Japan Inc.) could not confirm the bleeding point from the esophagus to the second portion of the duodenum. Conservative therapy was done on her but massive melena occurred 2 days later. Total colonoscopy showed no evidence of bleeding in the colon. Angiography and scintigraphy failed also to detect bleeding points. Therefore, upper GI endoscopy was performed again. A mucosal erosion was noted within the diverticulum located in the third portion of the duodenum. Clipping was performed around the erosion because it seemed to be the bleeding point. However, she had again massive melena 4 days after the treatment. Upper GI endoscopy revealed active bleeding from the erosion in the diverticulum. 10 milliliters of Aethoxysklerol was injected into and around the erosion and hemostasis was effectively achieved. Duodenoscopy done 12 days after the injection therapy revealed red scars at the site of erosion. This is the first report of successful hemostasis achieved by Aethoxysklerol injection therapy against a bleeding duodenal diverticulum.

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Nakamura et al reported 32 cases of colorectal polyps named inflammatory myoglandular polyp in 1992. Their characteristic features were inflammatory granulation tissue in the lamina propria mucosae, proliferation of muscularis mucosae and hyperplastic glands, pathologically. We experienced a polyp identical with the report. A 71-year-old male visited Miyoshi Medical Assocoation Hospital because of the positive reaction of the stool occult test. Colonoscopy revealed a red-colored pedunculated polyp in the right-side wall of the upper rectum. The surface of the polyp was smooth and covered partially with fur. The polyp was excised endoscopically and its size was 8 × 6 × 6mm. Pathological examination showed inflammatory granulation tissue in the lamina propria mucosae, proliferation of smooth muscles in radial fashion and hyperplastic glands with cystic dilatation. Therefore, we diagnosed the polyp as inflammatory myoglandular polyp. This type of polyp of the colorectum was very rare and only 40 cases including our case have been reported in the world.

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We report a case of 4-year-old patient with Alagille syndrome (syndromatic paucity of interlobular bile duct or arteriohepatic dysplasia). He had a heart murmur at birth and had been diagnosed as pulmonary stenosis. Around the age of 1 year and a half, xanthomas in his lump and the joints of his extremities appeared outstanding, with characteristic facial appearance (hypertelorism and broad forehead), hepatomegaly, and splenomegaly. Laboratory findings on admission were as follows ; GOT 211U/l, GPT 122U/l, ALP 538U/l, γ-GTP 361U/l, T-Bil 1.9 mg/dl, T-Chol 1167 mg/dl, TG 223mg/dl, representing liver dysfunction and hypercholesterolemia. Platelet count and blood coagulation were within normal range. His karyotype was 46XY. These clinical findings were reminiscent of Alagille syndrome. Cardiac catheterization revealed increased pressure in the right ventricle and the trunk of pulmonary artery. Right ventriculogram showed a moderate bilateral pulmonary stenosis, consistent with pressure mesurement. Laparoscopic findings revealed yellow-tinted liver with fine protuberance formation, dendritic vessels, and definitely bounded white marking. Liver biopsy specimen demonstrated slight fibrosis and slight infiltration of mononuclear cells in the Glisson's sheath, and the loss of interlobular bile ducts enabled the patient to be diagnosed as Alagille syndrome.

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