The present status of laparoscopic and laparoscopy-assisted hepatectomy for various liver diseases was overviewed. Laparoscopic hepatectomy of benign liver diseases was first reported in 1991 by Reich et al and have been applied to a wide range of hepatic diseases from benign tumors to metastatic and primary liver cancers. In the survey conducted by the Japan Society for Endoscopic Surgery, 621 cases undergoing laparoscopic hepatectomy were accumulated by the end of 2001 and the number had gradually increased. Laparoscopic hepatectomy plays an important role in the treatment of liver cancer as a minimally invasive surgery and radical local treatment. However, it should be recognized that the skill is technically demanding and attention must be paid to avoid serious complications such as massive bleeding and CO2 gas embolism. Development of safer surgical technique, solution of the issues in medical insurance, and mufti-center clinical trials to evaluate the clinical outcomes and suitability of the treatment seem to be the remaining tasks.

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Aims: To evaluate the efficacy and limitations of endoscopic placement of self-expandable metallic stents (EMS) in cases of malignant gastroduodenal stenosis. Methods : Fourteen patients who underwent endoscopic placement of EMS for unresectable malignant gastroduodenal stricture were reviewed. Comparison of pre-and post-stenting conditions and evaluation of clinical efficacy were carried out. Results : All procedures were successful. As for food ingestion, 50.0% of the cases showed improvement and the mean dysphagia score changed from 3.5 to 2.6. In 66.7% of the cases that had a stenosis in the upper stomach, improvement of peroral food intake was achieved. However, such intake did not improve even after stenting in all but one patient with stenosis of the distal stomach or proximal duodenum. Conclusions : Use of EMS for unresectable malignant gastroduodenal stenosis is effective in patients with proximal lesions. However, physical patency of the stenosed alimentary tract by stenting is not likely to alleviate the limitation of peroral food intake in patients with distal gastric or proximal duodenal stenosis.

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A 72-year-old man with gastric cancer (type 2 in upper third of the stomach) that did not have obvious invasion to the esophagus underwent total gastrectomy by celiotomy. Pathologi-cal examination detected no cancer cells at the oral margin. However, thereafter, he com-plained of choked sensation, and endoscopy revealed narrowing of the anastomosis, and a bulging lesion on the immediately oral side. Despite repeated balloon procedure applications and biopsy, no malignant cells were detected. We had observed morphologic changes in the lesions for 7 months until a biopsy after local administration of ethanol revealed metastatic lesions in the esophageal wall, leading to a definitive diagnosis. He responded to chemotherapy conspicuously, and is living at present without recurrence thrugh 26 months passed after the recurrence. Since it is quite rare that gastric cancers that don't have obvious invasion to the esophagus recur as metastatic cancer in the esophageal wall, we will report this case, making reference to the literature.

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A 61-year-old man with epigastralgia consulted our hospital. Upper GI endoscopy demon-strated pale and uneven lesions from the antrum to the angles. Biopsy specimen showed small cleaved like cells and lymphoepithelial lesions. Metastatic lesions were not found on CT scan, bone marrow tap, and gallium scintigraphy. Therefore, we diagnosed this case as MALT lymphoma stage I. Since urea breath test and urease test of the biopsy specimen indicated Helicobacter pylori infection in the stomach, eradication therapy was performed. Six weeks after eradication, and endoscopic examination detected a protruding lesion in the antrum that had not been present before eradication. Histological finding showed large tumor cells in the biopsy specimen obtained from the lesion, although there had been no sign of neoplastic cells prior to eradication. We assumed that the eradication therapy was not only ineffective but also the lesion deteriorated. Consequently, total gastric resection was performed. We should recognize that some cases of MALT lymphoma can deteriorate after eradication of Hp. Therefore, close follow-up examinations are necessary after eradication therapy.

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The patient was a 69-year-old male with chief complaints of an abdominal sensation of flatulence feeling and edema in the lower extremities. During gastrointestinal endoscopy, a number of large and small irregular polyposd lesions were found from the upper gastric body to the antrum. On the lesser curvature, a shallow depressed lesion was found. The result of biopsy showed poorly differentiated adenocarcinoma. Therefore, total gastrectomy was performed. On the resected specimen, the tumor demonstrated porl more predominantly than port histologically and the carcinoma invaded beyond the serosa in the depressed lesion of the lesser curvature while the polyposis lesions throughout the stomach were intramucosal. Thus, it was suggested that a poorly differentiated gastric adenocarcinoma had developed in the stomach with multiple hyperplastic polyps, invaded and replaced the mucosal cells, and finally formed an extensively intramucosal filled poorly differentiated adenocarcinoma. The hypothe-sis was based on that hyperplastic epithelia were interspersed with poorly differentiated adenocarcinomatous lesions and adenocarcinoma proliferated within hyperplastic polyps.

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A 73-year-old woman, who admitted to other hospital with complaints of melena, easy f atigability and loss of weight, was transferred to our hospital for the further examination and therapy. Duodenoscopic and colonoscopic examination showed multiple polyposd lesions of the duodenal bulb, of the terminal ileum, and of the total-colon. Biopsy specimen revealed fol-licular lymphoma. CT scan showed swelling of the systemic lymph nodes and serum concentra-tions of s-IL2-R were highly elevated. We diagnosed as systemic follicular lymphoma with invasion into the intestinal tract, and CHOP therapy was performed. We report a rare case of follicular lymphoma with multiple lymphomatous polyposis of the intestinal tract.

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A 36-year-old man with systemic lupus erythematosus (SLE) was admitted to our hospital with a sudden onset of lower abdominal pain. Hematochezia was found, and an endoscopic examination was done. The endoscopy revealed circular edema of the intestinal mucosa, redness, facilitation of hemorrhage and erosions in the Rs region of the rectum. Barium enema study showed a localized circular stenosis of the rectum in that region. Surgical resection was performed. Resected specimens revealed thumb-size ulcers of the rectum. Histopathological examination suggested the presence of angitis mainly involving the subserous layer around the ulcer. This case was diagnosed as SLE colitis due to angitis.

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A 22-year-old woman was diagnosed as ulcerative colitis. Colonoscopy revealed an irregular ulcer and easy bleeding from the rectum to the descending colon. She was resistant to corticosteroid therapy, and further treatment with intravenous infusion of cyclosporine A. However, this was not effective. She was, then, treated with leukocytapheresis therapy (LCAP), and this induced a gradual improvement of gastrointestinal symptoms and endoscopic findings.

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A 36-year-old male, who had been admitted repeatedly for acute pancreatitis since 1998, was admitted to another hospital with melena in March 2002, but the origin of bleeding was not identified. On May 6, acute pancreatitis recurred and he was re-hospitalized. A cystic mass was detected in the tail of the pancreas and he was transferred to our hospital on May 10. Abdominal CT showed a cyst of approximately 50 mm in diameter with an internal high-density area at the pancreatic tail. Communication of the cyst with the main pancreatic duct was confirmed by ERCP. A diagnosis was made of hemorrhagic pancreatic pseudocyst and the patient was discharged after endoscopic pancreatic stenting. However, the size of the cyst did not decrease and he was readmitted On July 11. We performed endoscopic nasopancreatic drainage. The size of the cyst decreased, and we removed the drainage tube on July 24. Two days later, severe abdominal pain, a decrease in blood pressure and anemia appeared. The abdominal CT showed re-bleeding in the cyst. We performed endoscopic nasopancreatic drainage again. The cyst continued to reduce in size. Then, we removed nasopancreatic drainage tube and placed a 5-Fr pancreatic stent in the pseudocyst transpapillary. The cyst did not enlarge and the stent was removed on November 21. No recurrence of pancreatitis has been observed.

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Endoscopic nasobiliary drainage (ENBD), which is a method of external drainage, may cause undue stress such as pharyngeal discomfort. We, therefore, developed a new method for conversion from external to internal drainage by cutting the external drainage tube with scissor forceps using an endoscope. An endoscope was inserted until it reached the duodenal papilla, and the drainage tube was cut in the vicinity of the duodenal papilla, using scissor forceps inserted through the working channel of the endoscope. This procedure was performed for 9 patients, including 8 patients in whom a 7F ENBD tube had been used and a patient in whom a 7F endoscopic pancreatic stent, whose distal portion at the duodenal cavity was too long, had been used. In all the patients, the drainage tube was successfully cut. The cut end of the tube was not sharp and no apparent deformation was seen. In 4 of 9 patients, the cut tube was left as a temporary drainage tube until the next treatment, such as the operation, was performed. In 2 of 9 patients, ENBD tubes for treating bile leak after laparoscopic cholecystectomy were cut after confirming the stop of bile leak. The cut tubes were left for a few weeks. In the remaining 2 patients who had inoperable pancreatobiliary malignancy, the cut tube was left as a permanent drainage tube. In the remaining patient, too long distal portion of the pancreatic stent at duodenal cavity was appropriately cut. There were no complications with the clinical symptoms besides stent obstruction in two patients with the permanent stent. However, in a case of the 9 patients, the cut stent had been dislodged into the bile duct without any clinical symptoms. Our procedure is considered to be a convenient and useful method for external to internal drainage.

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Background and purpose : Although many reports have documented pain relief achieved by pancreatic stenting, the effect of stenting on pancreatic function is less clear. Additionally the effect of stent caliber and patency has not been considered in most previous studies. Pain and pancreatic function after stenting of the main pancreatic duct (MPD) were examined. Methods: Records of 24 patients of chronic pancreatitis who had a MPD stricture treated with a 10 Fr stent from June 1996 to June 2002 were reviewed. The average age was 57.0±1 years, and the male: female ratio was 7 : 1. Eleven patients had diabetes mellitus. Stent patency, pancreatic pain, and pancreatic endocrine and exocrine function were examined before stenting and 6 months afterwards. Stenting was continued for 1 year or more, with repeated stent exchange every 3 months. Results: The stent became occluded in 29% of cases, migration occurred in 15%, and the 50% patency time was 125 days. Pancreatic pain was relieved by stenting in all. The diameter of the MPD, the Bentiromide test value, weight, and body mass index were improved. Conclusion: Stenting relieves blockage of the main pancreatic duct and provides both pain relief and preservation of residual pancreatic function.

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Background: Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) was developed to attain endosonographic image in real time in endoscopic biopsy, just like in percutaneous biopsy with ultrasonic or computer-tomographic images. Results of EUS-FNAB in esophageal and mediastinal diseases were evaluated and clinical indications of this technique were investigated. Methods : The study was performed in 58 patients, consisting of 30 with esophageal or mediastinal tumors and 28 requiring mediastinal lymph node examination. The intruments were linear array EUS transducer PEF-703FA and 21G Endosonopsy. The aspirated material was recovered on a filter paper and was formalin-fixed to be examined histopath-ologically. Results : The tumors measured 6mm to 60mm (mean 29mm). Collection of tissue was successful in 95% of the patients, and diagnostic accuracy was 95%. The biopsy specimen was satisfactory to establish histological diagnosis in every case of 27 patients with malignant diseases. No complication was experienced. Conclusion : EUS-FNAB is indicated in cases where technique of EUS-guided puncture is required, or is considered optimum in view of the safety, and in cases where histological diagnosis is critical for the decision of treatment program. In many cases of mediastinal diseases, not even a detection of lesion is feasible without this technique, let alone a collection of tissue. EUS-FNAB is thus performed as first choice to obtain biopsy specimen in such cases. To patients with esophageal cancer, EUS-guided lymph node puncture is applied in order to assess the appropriateness of endoscopic mucosal resection (EMR), to follow-up the patients after EMR and chemo-radiotherapy (CRT), and to evaluate the efficacy of Neoadjuvant CRT.

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