In the clinical arena where endoscopy for the digestive system is conducted, it has been standard practice that fellows first acquire knowledge about the basic technology and observe experienced physicians in practice before they conduct the procedure directly on clinical patients. In view of the future trends in medical practice, however, endoscopic training should start with tutorial sessions and fellows should perfect their technique through the use of simulators before they face actual patients. In conducting endoscopic treatment, they should master the use of actual instruments, such as the Erlangen active simulator for interventional endoscopy (EASIE model) and acquire their clinical skills in stages under the guidance of highly experienced instructors so that the risk of accidents may be minimized, at the same time educational advantage in the process may be maximized. At present, the general attitude toward medical education is undergoing dramatic change. It is essential that physicians give further thought on the mission or role of medicine within society and establish an educational and training system that is comparable to those in the rest of the world and yet is the one that preserves the virtues of the Japanese people and the uniqueness of our practice.

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The results of total colonoscopy (TCS) preformed in 1004 patients of positive fecal occult blood test (FOBT) from 1992 to 1999 were analyzed. Sixty six colorectal cancer patients found by positive FOBT operated in the same period were also assessed and compared with 69 patients with symptoms. The final diagnosis of the 1004 patients consisted of 81 cancers (43 advanced, 38 early cancers), 345 adenomas, 169 other findings and 419 with negative findings. Polypectomy was performed in 370 patients without major complications and 51 patients were operated. Including these patients, the 66 patients found by positive FOBT had shorter hospital stay (38.1±22.5 days) and better 5-year survival rate (88.5%) compared to the other 69 patients (57.3±34.5 days and 52.3%, respectively). In the area where the hospital is situated, 13, 757 (4.9%) patients were recommended detailed examination out of 279, 064 individuals undergone FOBT at the period, and 8, 303 (60.4%) individuals responded to undergo close examination. Theoretically, it is expected to reduce tens of colon cancer death and many operation related morbidity par 100, 000 FOBT with detailed examination by TCS.

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A 30-year-old woman was admitted to our hospital with upper abdominal pain and anemia. A pedunculated giant gastric polyp was found in the middle part of gastric body by endoscopy. It was measured 76 × 46 × 25mm in size. Endoscopic polypectomy was planned. After the injection of hypersaline solution with epinephrine at the stalk of the polyp, it was endoscopically polypectomized with a 2-channel scope and clipping was added to prevent from post-bleeding. It was recovered with a capturing clamp and 5-branched basket. One month after polypectomy, the follow-up endoscopy revealed complete resection of the polyp. The pathological diagnosis was hamartomatous polyp. When endoscopic polypectomy of a giant gastric polyp is performed, the way to resect and recover should be considered as well as its indication.

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We present a case of glomus tumor of the stomach. A 37-year-old woman was found to have a small bulging of the posterior wall of the gastric antrum. UGI, endoscopy and endos-copic ultrasonography revealed a submucosal tumor of the stomach. After 4 years of close follow-up, as the possibility of malignancy could not be ruled out, excision of the tumor was performed. Histological examination showed that blood vessels lined by normal endothelial cells and surrounded by sheets of round or oval tumor cells without atypia. Immunohisto-chemical examination showed the tumor cells to be positive for a-smooth muscle actin and to be negative for Chromogranin and Grimelius staining. A diagnosis of glomus tumor of stomach was made.

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The patient was a 48year old man who visited our hospital with chief complaints of abdominal pain and nausea. A protruded lesion with a surrounding wall ledge accompanied by central necrosis was observed on the greater curvature of the lower body of the stomach on gastroscopy. On biopsy of this region, a diagnosis of poorly differentiated adenocarcinoma was made. Formation of internal gastrointestinal fistulae was observed on upper GI series, and transverse colonic invasion of the tumor was found on upper abdominal plain CT examination. Based on the above findings, a diagnosis of small intestinal penetration of stomach cancer and transverse colon invasion was made, and distal gastrectomy, partial resection of the jejunum, and partial resection of the transverse colon were performed. The tumor penetrated the jejunum and transverse colon at three and one sites, respectively, in the excised specimens. There have been only five reported cases of externally developing stomach cancer forming internal fistulae between stomach and intestinal loop in Japanese.

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A case of ulcerative colitis associated with sepsis and intra vertebral canal abscess induced by oral administration of polyethylene glycol electrolyte lavage solution (PEG) was reported. 58 year old male with three years history of persistent active and steroid resistant ulcerative colitis underwent colonoscopy to evaluate the response to merucaptopurine. He had experienced colonoscopy 3 times before, and preparation was undertaken in the same manner as before. Septic symptoms emerged with high fever and nausea 2 hours after PEG intake. Subsequently he had intra vertebral canal abscess and underwent surgical drainage for the abscess. Pulse field gel electrophoresis confirmed the monoclonal lineage of the E. coli isolated from feces and peripheral blood of the patient.

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A 61-year-old female who had been administered doxifluridine; a masked compound of 5-fluorouracil, for 9 months after gastrectomy because of advanced gastric cancer presented with diarrhea and melena. Endoscopic examination revealed multiple erosions and ulcers from rectum to sigmoid colon. Intestinal symptoms improved with cessation of doxifluridine and total parenteral nutrition. Histological examination and clinical course suggested anticancer drug-induced colitis. Though fluorouracil-induced colitis commonly occurs within a few months after starting the drug, . It should be recognized also as a possible delayed side-effect.

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A 63-year-old man was admitted to our hospital for his edema and abdominal fullness. Laboratory data revealed decreased level of serum albumin, αl-antitrypsin clearance test showed high level, and ^99mTc human serum albumin scintigraphy revealed loss of protein into the intestinal tract. Endoscopy examination showed a lot of white specks in the upper jejunum and terminal ileum. A biopsy specimen revealed dilated lymphatic vessels in the mucosa. Therefore, he was diagnosed as protein-losing enteropathy due to intestinal lymphangiectasia. He was treated with low fat diet, diuretic and steroid, but his symptoms were not improved. After he was treated with somatostatin analogue therapy, his hypoalbuminemia, edema and ascites were gradually improved and his endoscopic findings was also improved. Therefore, somatostatin analogue therapy is a very useful treatment to protein-losing enteropathy due to intestinal lymphangiectasia.

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A 30-year-old pregnant woman was admitted to a obstetric hospital because of severe lower abdominal pain. Abdominal X-ray and abdominal computed tomographic scanning revealed a warkedly distended colon. She was diagnosed as intestinal obstruction and transfer-red to our hospital. As those findings were most suggestive of sigmoid volvulus complicating pregnancy, we performed colonoscopy to reduce the volvulus. Endoscopic examination showed twisting and narrowing of the colon at 20 cm from the anus and distended large colon with mucosal redness beyond the margin. Based on those findings, we made a diagnosis of sigmoid volvulus and corrected the volvulus using colonoscope. Thereafter, the pregnancy proceeded uneventfully and she subsequently had a normal delivery of healthy female infant. Although sigmoid volvulus is relatively rare during the ptrgnant period, we should take care of it as a cause of acute abdomen in pregnant women. Furthermore, we should not hesitate to take X-ray examination for pregnant women with acute abdomen according to the guideline of International Commission on Radiological Protection.

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A 60-year-old woman with jaundice and general fatigue was referred to at our hospital for further examination. She had a past history of cholecystitis. A high echoic lesion of 2 cm in size and a dilated intrahepatic bile duct were detected with pneumobilia by abdominal ultra-sound. Gall stone with fistula was suspected by ERCP. A biliogastric fistula and biliobiliary fistula was finally detected. The gall stone was crushed by ESWL, and removed by endoscopic procedure. Biliary cytology, biliary biopsy and brushing cytology revealed no malignancy. A 7Fr plastic stent was placed in common bile duct to close the fistula. Following the treatment, the patient did not develop with any icterus or pneumobilia. We experienced a rare case of biliogastric and biliobiliaryE fistula with choledocholithiasis effectively treated by endoscopic therapy.

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Back ground : The aim of this study was to clarify the clinical significance of reddish markings appearing on the surface of the liver. Material and Method: Subjects were patients with HBV-related (n=232) or HCV-related (n = 246) chronic liver disease. Reddish lesions were obtained from this population using punch biopsy (n=30) or wedge biopsy (n=4), then studied histopathologically. In addition, the incidence and macroscopic forms of reddish markings in each laparoscopic stage for the 473 subjects were examined to determine when reddish markings appeared. Results : Reddish markings on the liver surface appeared only after the appearance of hepatic parenchymal destruction subjacent to the liver capsule, rather than with the appearance of piecemeal necrosis in the portal area. Moreover, following expansion of necrotic hepatic parenchyma subjacent to the liver capsule and distortion of hepatic lobular architecture in this lesion, net-like or hemorrhagic fleck like reddish markings appeared. This was therefore recognized as changes at the liver capsule, such as capillary proliferation and dilatation, and blood flow changes in both the capsule and hepatic parenchymal lesions subjacent to the liver capsule. With regards to timing, reddish markings were most frequently observed in the transition to liver cirrhosis. After the appearance of reddish markings on the liver surface, chronic hepatitis rapidly progressed to liver cirrhosis. Conclusion : Reddish markings correspond to hepatic parenchymal destruction subjacent to the liver capsule, and not to piecemeal necrosis. Reddish markings appear in the transition to liver cirrhosis and may offer a useful marker of progression to liver cirrhosis.

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