Recently, endprostheses have been used for the treatment of malignant stricture in thedigestive organs. There are two kinds of prosthesis, namely plastic prosthesis and expan-dable metallic stmt (GEMS). As the results of improvement in the material and structureof EMS, which was developed to treat arterial stenosis, scenting became to be appliedwidely for stenotic lesions in the digestive organs, such as the bile duct, digestive tract, tracheobronchus and portal vein. We summarized 24 cases of rnalignant and 20f benign stricture of the bile duct, 340fmalignant esophageal stricture, 10f pyloric stricture, 90f tracheobronchial stricture, 40fmalignant stricture in the portal vein and 30f portal hypertension treated by stenting. Theresults and issues to be resolved were discussed. The scent therapy had an excellent effect tc obtain patency against malignant stricturein the digestive ergans. However, to maintain patency, ether procedures such as chemo-therapy and radiation is to be considered combined with EMS. The usefulness of the stentshould be Carefully evaluated because the results of its long-term observation is notsufficient so far.

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The patients underwent eradicative endoscopic variceal ligation(EVL)of untreatedesophageal varices employing 40 O-rings per case on the avarage. We havc conductedpercutaneous transhepatic portography(PTP)and endoscopic ultrasonography(EUS)before and after eradicative EVL therapy to evaluate hemadynamics of the venous supply-ing pathway. Pretherapeutic PTP revealed esophageal varices have run hepatofugallyfrom the left gastric vein via the cardiac venous plexus in all cases. The cases wereclassified into the following 3types:Type 1;the posterior branch of the left gastric veinvvas branched off, below the cardiac venous plexus to the paraesophageal vein, v as 130utof 20 cases(65%), Type 2;the paraesophageal vein was passed through the cardiac venousplexus, was 20ut of 20 cases(10%). Type 3;the anterior branch alone was fund, butpostelor ranch was not found was 50ut of 2D cases (25%). Hemodynamics changeaccording to the types were evaluated by posttherapeutic PTP. As for the Type 1, theportion up to below the cardiac venous plexus was visualized in g out of 13 cases(70%).The portion up to the left gastric vein base was visualized in 20ut of 2 cases (100%) and 4 out of 5 cases (80%)in the Type 2 and the Type 3, respectively. Thus, the eradicative EVL produced a favourable hemostatic effect. In the Type 1, disappearance of theposterior branch was observed in only l Cases, EUS was conducted in 10 cases of the Type1.As the results, it shoa-ed a significant posttherapeutic reduction in the intramural veinsat the cardiac part, and 5cm oral side of the esophago-gastric junction, but showed nosignificant difference in the extramural veins. Therefore, the eradicative EVL wasconsidered to produce a hemostatic effect an supplying pathway of varices and to exertlittle influence nn the paraesophageal vein.

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We examined nine cases with a small advanced colorectal cancer less than 10 mm in maximum diameter. Regarding the macroscopic type, four were like Ilc, two were like Ila, and three were like ls. As for the distribution in coloreetum of these lesions, four were in sigmoid colon, three were in transverse colon, one was in caecum, and one was in descend-ing colon. No lesions were detected in rectum. The growth pattern of tumor was 8 NPG (non-polypoid growth) and one PG (polypoid growth). No K-ras point mutation was detected by PCR method in both 7 NPG and 1 PG lesions. Histologic grade at the deepest invasive portion was 2 W (well-differentiated), 4 Mw (moderately-well differentiated), 2 Mp (moderately-poorly differentiated), 1 Por (poorly differentiated), and 1 Muc (mucinous) adenocarcinomas. Lymphnode metastasis was present in 2 of 4 Mw lesions and in 1 of 2 Mp lesions (total 33% ;3/9). This incidence is high, although the size of lesions were small. Endoscopically, all lesions accompanied with converging folds and 71esions examined by magnifying colonoscope showed VN pit pattern. From these findings, we could diagndse that the depth of invasion of these small lesions were more than submucosal invasion before surgical resection. These results indicated that the small advanced colorectal cancers less than 10 mm in maximum diameter was similar to the characteristics of superficial depressed type cancer, as reported previously, in morphologic features, its distribution and having a higher malignant potential. The findings of converging folds and pit pattern are considered to be useful indicators of the invasion depth diagnosis.

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The patient, 68-year-old male, was admitted to our hospital complaining of dysphagia.Upper endoscopic examination showed the irregular ulcerative lesion surrounded by steeptumorous protrusion at the midesophagus. Pathological examination of the biopsy speci-men revealed that the tumor cells showed hyperchromatic nuclei with scanty cytoplasmaformig focus or cord-like lesion on Hematoxylin-eosin stain. Diagnosis of small cell typecarcinoma was made, after admission, metastasis to the liver and para-aortic lymph nodesmetastasis were found. and sytemic chemotherapy were done. Though the treatment waseffective, the patient died on the 79th day after admission. Small cell carcinoma of the esophagus is considered to be very rare. ln Japan, thetumor has been reported approximately two hundred cases. We studied the endoscopicfindings including our case, It showed a tendency to take a form that from submucosal tumor like lesion toulcerative shape surrounded by steep protrusion of the tumor with increase of the size.

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A79-year-old man visited us because of retrosternal pain and dysphagia after meals.An endoscopic examination on admission revealed multiple esophageal ulcers and severelyedematous mucosa spreading aver the whole esophagus. The esophageal Iumen wasstenotic in the louver esophagus. Exfoliated esophageal mucosa was observed by thefollowing endoscopic examination performed at the eighth hospital day, and a diagnosis ofexfoliative esophagitis was made. The endoscopic ultrasonography, simultaneously conducted at the procedure, demonstrated the thickended esophageal wall and the loss of itsdefined layer structure. The esophageal ulcers and stenasis were successfully treated byaH2-blocker and a series of dilatation therapy using a esophageal balloon.

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We report a 54-years-old man with a history of high fever and cough who had aesophagathoracic fistula caused by esophageal cancer. The patient was judged inoperablefor surgery. He was treated by prompt percutaneaus drainage into the pleural cavitycoupled with a covered self-expanding metallic stent for the esophageal ffistula. The ffistulawas completely sealed. oral intake was improved soon after the procedure without anycomplications. The clinical course was satisfactory. We reviewed five cases in Japan ofthe perforation of esophageal cancer followed by empyema, including the case reportedhere. In all cases except our patient, surgical procedures were perfarmed includingdrainage and esophageal resection. However, prognosis of the patients was not favorable.fur result suggest that the covered self-expanding metallic stent insertion was an effectivefor esaphagothoracic fistula caused by esophageal cancer.

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A46-year old male was admitted to our hospital because of hematemesis. Emergentendoscopic examination could not show the bleeding paint because of massive residualfoods. The following endoscopic examination showed a submucosal tumor like-lesion withagiant ulcer on the fornix of the stomach. He vomited blood again and we performedemergent operation because the bleeding point was not obvious on endoscopic examination.The histological examination showed Anisakis larva in the suhmucosal layer and markedeasinophilic infiltration between the submucosal layer and the subserosal layer. Endo-scopically gastric Anisakiasis is usually diagnosed by the finding of sewing of Anisakis andedema, redness and erosion around the sewing point. This case was a rare gastricAnisakiasis showing endoscopically a submucosal tumor-like lesion that causedhematemesis.

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A83-year-old woman presented with a 3-month history of the Ieft abdominal pain andapalpable abdominal mass m July, 1996. Barium enema showed an irregular stenosisranging ll cm in length in the descending colon. Colonoscopy revealed an irregular annularstenosis of the lumen in the descending colon. Small bowel X-ray study and jejunoscopyshowed an irregular ulcer surrounded by a ring elevation in the jejunum near the ligamentof Treitz. Endoscopic biopsy of the both lesions revealed adenocarcinoma. CT scan andMR imaging demonstrated a mass, 10 cm in size, located between the lejunum and thedescending colon. Although it was difficult to clarify the origin of the tumor preoper-atively, gross and microscopic findings of the resected specimen canffirmed the primarylesion in the descending coon, which invaded to the jejunum.Key words:1. colon cancer 2. extracolonic invasion 3. metastatic carcinoma of the smallintestine.

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A 61-year-old female was admitted due to tarry stool and anemia. On admission, laboratory examination showed 7.29/dl of Hb. Endoscopic examination revealed ableeding diverticulum with erosions in the second portion of the duodenum. The lesion wassuccessfully treated with hemostatic clipping. Surgical intervention has been the firstchoice of treatments for this disease, but with the possibility of achieving hernostasis byendoscopy, another treatme:nt could becorne available. The case in this study suggests thatendoscopic clipping rnay be a safe and effective approach to manage hemorrhage from anintradiverticular erosion.

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We experienced a rare case of multiple metastases to the small intestine and colonafter 2 years and g months from the extirpation of the right femoral leiomyosarcoma. A58-year-old xnan had been performed a extirpation of the femoral leiomyosarcoma onAugust 30, 194, and a partial resection of the left lung for a lung metastasis from the initialtumor on June 9, 197. After surgery of the lung, the patient had melena and progressiveanemia. We performed further examinations of the gastrointestinal tract. Colonoscopyshowed several submucosal tumors in the colon and rectum. Jejunogram showed twotumors in the upper jejunum. The patient was diagnosed as having multiple intestinalmetastases from the femoral leiomyosarcoma, and then, the partial resection of thejejunum and the resection of the colonic tumors were.performed under the intraoperativeendoscopy of the small intestine and the colon. In the resected specimens, the jejunaltumor, 3cm in diameter, showed a umbilication on its tap which was considered to he ableeding point. Although the patient was well and discharged from the hospital, he died ofbrain metastasis 6 months after surgery.

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A 68-year-old woman with non-Hodgikin's lymphoma was treated with etoposide.She had fever, abdominal pain, anorexia, diarrhea and rernarkable hypoproteinernia.Colonoscopy showed mtlltiple rou.nd or irregular-shaped ulcers in the ileum and some smallulcers in the ascending colon. Cytornegalic inclusien belies were seen in biepsy specimensfrom the ulcers of the ileum end positive cells were detected i.n the specimens withimmunohistochemical technique using monoclonal antibody to cytomegalovirus(CMV).She was diagnosed to have CMV enterncelitis in the setting of immunodefieiency and shewas treated with ganciclovir. Clinical symptoms and hypoproteinemia were markedlyimproved, but 3 mQnths later, she died for non-Hodgikin's lymphQma Endoscopic andhistological examinations of the terminal ileum are useful for making the diagnosis whenCMV enterocolitis is suspected.

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A 63-year-old man with neurofibromatosis-1(so called von Reck:linghausen's disease)was admitted to our hospital for endoscopic resection of early gastric cancer. Gastroscopicexamination showed a type Ilc early gastric cancer at the anterior wall of the angulus, andaprotruded lesion with smooth surface was noted at the posterior wail of the antrum.Biopsied specimen taken from antral lesion revealed an inflammatory fibroid polyp.Examination of the srnall intestine(barium meal study)showed two protrusions of whichsurface was smooth in the jejunum. Colonoscopic examination showed multiple polypoidlesions between cecum and right transversus colon. Dilated normal pits structure wasobserved on the surface of the lesions. Biopsied specimen taken from these lesions revealedaneurofibroma which was positive for 5-100 protein staining. Neurofihromatosis-1associated with colonic neurofibroma is very infrequent. In a neurofibromatosis-1 patient, therefore, colonoscopic examination should be performed paying with attention to tinyprotrusrans such as submucosal tumor.

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We experienced four inoperable patients with malignant obstruction of the lowerbiliary tract treated with self-expandable metallic scent (EMS). We diagnosed two men ascholangiocarcinoma of the lower common bile duct, and another two men as pancreaticcarcinoma. Their ages ranged from 72 to 89 years, with an average of 78 years. TwoSymphony stentsTM and twa wallstentsTM were applied, and were implanted via per-cutaneous transhepatic route. We positioned the duodenal end of EMS under endoscope inthese patents. Since a large number of the patients with malignant obstruction of the lower biliarytract have severe stenasis or ohstructian at the duodenum or hiliary tract by malignanttumor, it is hard to operate the endoscope satisfactorily and to do endoscopic biliarydrainage for these patients. So we often choose percutaneous transhepatic biliary drai:nagein the cases of lower biliary obstruction. fur method of implantation of EMS viapercutaneous transhepatic route under endoscope is very easy and reliable for positioningthe duodenal end of EMS. In conclusion, we suggested that our method of the placement of EMS under endoscopecontributed to the reduction of the complications such as intestinal bleeding and duodenalperforation caused by EMS.

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