To clarify the risk factors for Iymph node metastasis of submucosal invasive gastric cancertreated by endoscopic mucosal resection(EMR), we investigated the histopathologic findings of 194 surgically resected suhmucosal cancers. As for the histologic types, vve reclassified thesecancers according to the dominant histologic types within the mucosa. In the result, logistic regression analysis showed that the covariants which could predict lymph nods metastasis were 1)papillary adenocarcinoma, 2)histologic heterogeneity in the submucosa, 3)lymphatic invasion. There were no lymph node metastasis and no above-mentioned risk factory in lesions of differentiated subrnucosal cancers(tubl or tub2)measuring 40mm or less in size with less than500μm invasion and measuring 20mm or less in size with less than 1000μm invasion. Furthermore, tubl or tub2 lesions with INFα showed lower lymph node metastasis significantly, suggesting that these risk factors would be useful for decision of EMR indication in borderlinelesions. And we considered that to diagnose submucosal histological findings precisely, anenblock resection method should be performed.

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A 59-year-old man under treatment fir hepatitis B, liver cirrhosis, esophageal varices arldhepatocellular carcinoma was submitted to endoscopic variceal ligation(EVL)for esophageal varices in the other hospital. During the follow-up, a superficial esophageal carcinoma was detected and the patient was referred to Tokai University hospital for further examination and treatment. Initial endoscopic examination revealed a slightly depressed lesion type 0-IIc at the louver thoracic to abdominal esophagus. The lesion vvas diagnosed to be an early stagscarcinoma limited to the muscularis mucosae (depth m3), measuring 3cm in sire, occupying onehalf of the circumference. An ulcer scar after EVL was noted on the lesion. He was assignedto no therapy because the treatment seemed too risky due to liver failure and esophageal varices adjacent to the carcinoma. The turnor progressed to a type 0-Ip+IIc invading tosubmucosa(depth sm3)in three months, and then to a type 1p+0-IIc advanced cancer extendinginto muscularis propria five months after the initial exarnination. The tumor becarne a type 2 lesion in six months, and then a type 3 lesion extending further into adventitia in eight months. Finally, the patient died for liver failure eight months after the initial endoscopic exarnination.

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A 75-year-old male was diagnosed to have a gastric polyp by routine uppergastrointestinalendoscopy in 1985. The lesion was located on the greater curvature of the antrum of thestomach. Histological examination of biopsy specimens showed hyperplastic polyp. In 1995, polypectomy was performed, because histological examination of biopsy specimensrevealed group IV prior to the treatment. Pathologically, the lesion was diagnosed as welldifferentiated adenecarcinoma. fn this study we report a case of early gastric cancer arisingfrom a hyperplastic polyp.

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Myocardial infarction is a serious compiication during digestive endoscopy. decently, "takotsubo"type cardiomyophaty has been reported as mimic rnyocardial infarction, Weexperienced this type of cardiomyophaty during upper digestive endoscopy in a 74-year old woman and could observe changes of syrnptoms and signs at the onset under vital signmonitoring."Takotsubo"type cardiornyopahty has been defined as reversible left ventricledysfunction with ST elevation in some lead of EEG and reported that the reduced cardialfunction returns to normal within several weeks. Patients with eardiomyophaty are usuallymisdiagnosed as acutc myocardial infarction through EEG findings. The causes of"takotsubo"type cardiomyopahty are uncertain, but it is reported that there is more frequently in wornenwith more than 60 year of age, and it is assumed that stress is a major trigger fer the enset ofthis type cardiomyopahty. Stress such as esophagogastroduodenoscopy(EGD)induces anunstable autonomic nervous condition. wring END, sympathetic nerve are generally in tension, but parasympathetic nerve becometense only xn the early period of END. During inversion of the scope from the pharynx into theesophagus and from the lower esophagus to the cardia of the stomach, sympathetic nerves areusually activated, which induces tachycardia of the heart. In this case, however, insersion of thescope causes bradycardia, which indicates parasympathetic nerve activation. Unstable condition of autonomic nervous system caused by this stress might be a key role of onset of"takotsubo"type cardiomyopahty in this case. Because there is a risk of myoardial infarction or myoardial infarction-like state, as thistype cardiomyopahty in the case reported here, we recommended vital sign monitoring duringdigestive endoscopy.

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A 32-year-01d woman visited our hospital complaining of postprandial epigastralgia andvomiting. She had occasionally had the same symptom from childhood. Hypotonic duQdenography revealed a barium-filled pear-shaped sac surrounded by thinradiolucent line in the second part of duodenum. The findings are most suggestive ofintraluminal duodenal diverticulum.(IDD). We performed an endoscopic excision of IDD with2-channel fiberscape. After inversion of the diverticular sac to the oral side by forceps, sac wasexcised by polybectom.y-snare with a high voltage electric current. Histological findings of theexcised specimen revealed normal duodenal mucosa on both sides of the sac. After this excisionshe obtained eomplete relief of the symptom. IDD is a rare congenital anomaly of the duodenum As far as we know, 45 cases of IDDincluding our case have been reported in Japan. furthermore, endoscopic removal of thediverticular sac would be a minimal invasive and effective method in the rnanagement of IDD.

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A case of Lemmel's syndrome caused by food impaction in a juxtapapillary diverticulurnwas reported. The patient was a 58-year-old femele admitted to our hospital with complaints of right upper abdominal pain. MRCP showed the common bile duct obstruction by a large juxtapapillary diverticulum with massive contents. Endoscopic examination showed the jux-tapapillary diverticulum filled with a food residue. Where were ne gallstenes or other potential causes of obstructicn. After endesccpicrernoval of a food residu.e using forceps, symptoms disappeared immediately. Endoscopic examination after treatment showed a bleeding ulcer caused by a massive food residue in the bottom of the large diverticulum. Follow-up MRCP 8 days after endoscopic treatment showednormal-caliber common bile duct. Follow-up endoscopy about 2 months after the treatmentshowed the intradiverticular ulcer scar. During 2 years of follow-up, this patient had norecurrent symptoms. MRCP was safe and effective for early diagllosis of Lemmel's syndromewith a large diverticulum and massive contents. Endoscopic removal provides immediate reliefof the obstruction, and may be sufficient treatment for Lemmel's syndrome caused by a lamejuxtapapillary diverticulum with massive contents.

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Cases were 32 and 41-year-old male who visited our department to be examined for anemiaat a health checkup. Both patients unaccounted anemia for even by upper and lower intestinalexaminations. Srnall intestinal fiberscope examination a tumor was fourld in the small intestine. Histopathologically, its diagnosis was gastrointestinal stromal tumor (GIST). These twocases led us to conclude that when a patient suffers from anemia whose cause cannot bedetermined, radiografhy and endoscopy of the small intestine should be carried out in view ofthe possibility of srnall intestine tumors.

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A 83-year-old man who had been followed up for severe constipation after multiple cerebral infarctions. A plain abdominal X-ray film showed marked dilatation of the large intestine. His constipation did not respond to medical management and intermittent decompression using an ileus tube. Continuous colonic decompression was performed via perctaneous endoscopic cecostomy using the kit of perctaneous endoscopic gastrostomy. He had no abdominal distention and decreased colonic gas. Furthermore, his defecation was irnproved by antegrade enema of polyethylene glycol solution through the cectomy.

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