I experienced the first successful case of ERCP as a co-worker of K. Takagi on June 6, 1969. For 33 years since then, I have been engaged in ERCP and its related procedures. The main works which I have performed are as follows:1) Department of Surgery, Cancer Institute Hospital, Tokyo (April 1967-March 1971): Development of ERCP.2) First Department of Surgery, Kyushu University School of Medicine (April 1971-March 1984): ERC & Endoscopic sphincterotomy, Intrahepatic cholangiography by endoscopic placement of an indwelling balloon catheter. Device of balloon catheter ERP-Compression Study (balloon ERP-CS).3) First Department of Surgery, Fukuoka University School of Medicine (April 1984-): Early diagnosis of pancreatic cancer with ERP & balloon ERP-CS for patients who have symptoms of obstructive pancreatitis including abdominal pain, dilatation of pancreatic ducts, hyperamylasemia, DM etc due to cancer.

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Diverticular disease of colon are very common among the increasing elder population. Review of colonic diverticulosis are described from the standpoint of endoscopy management with pathogenesis and epidemiology of diverticula. Endoscopic finding of complicated diverticulosis are discussed especially on the difficulty of narrowed segments, positive relation to the fecal occult blood testing and mucosal change of intradivertilititis, peridiverticulitis and pei-diverticulitis. Finally endoscopic therapy of bleeding diverticula are discussed. Active endoscopic approach using clipping device are stressed on the management of bleeding diverticula.

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Background : The incidence of adenocarcinoma of the esophagus or esophagogastric junction (EGJ) is increasing in the Western world, whereas in Japan the disease is still rare. We studied histological characteristics of the EGJ in relation to those of the stomach to understand the connection between adenocarcinoma and short-segment Barrett's esophagus (SSBE) in Japanese patients. Methods : The entire EGJ and gastric tissue specimens obtained at surgery from 55 patients with squamous cell carcinoma of the esophagus and 27 patients with EGJ adenocarcinoma < 4 cm in maximum diameter were examined. Tissues were examined for the presence and types of SSBE, i.e. circular SSBE (cSSBE) or tongue-like SSBE (tSSBE), specialized columnar epithelium (SCE), length of the gastric and esophageal cardiac glands, oxyntic atrophy and intestinal metaplasia (IM) of the stomach, and H. pylori infection. Results : cSSBE was found in 8 patients (10%), and tSSBE was found in 13 patients (16%). SCE was frequent in patients with cSSBE patients (75% of patients with cSSBE vs. 8% of patients with tSSBE, P<0.01). Gastric cardiac glands were present in 76 (93%) patients and ranged from 0 to 29mm in length. The mean length was 2.3mm in patients with cSSBE, 7.3mm in patients with tSSBE, and 5.7mm in patients without SSBE. Esophageal cardiac glands were present in 68 (83%) patients (50% with cSSBE, 77% with tSSBE and 85% without SSBE). cSSBE patients had significantly less oxyntic atrophy (13% vs. 43% vs. 56%, P <0.05), less IM of the stomach (0 vs. 43% vs. 57%, P<0.05), and less H. pylori infection (0% vs. 38% vs. 34%). The frequency of adenocarcinoma was higher in cases of cSSBE (50%) than in those of cSSBE and non-SSBE (both 31%). Adenocarcinoma was found in patients with cSSBE in whom the SSBE was more than 7.5mm in length. Conclusions : Japanese patients with cSSBE seem to have a gastric background that resembles that of Western type Barrett's esophagus. The risk of adenocarcinoma appears to increase when SSBE approaches 1 cm in length. Contrary to the notion that cardiac mucosa arises in response to gastroesophageal reflux disease, patients with cSSBE appear to have less cardiac mucosa than other patients.

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Abnormal findings in the upper gastrointestinal tract are often observed in patients with pancreatic cancer. We retrospectively reviewed the abnormal findings in 77 patients who were performed upper gastrointestinal endoscopy at the time of the diagnosis of pancreatic cancer during the last five years. Fifty-six percent of the patients had upper gastrointestinal lesions caused by pancreatic cancer. Seven patients (9%) had lesions in the esophagus, 23 (30%) in the stomach, and 19 (25%) in the duodenum. In cancers of the tail of the pancreas, the prevalence of abnormal findings was 88%. Specific findings caused by pancreatic cancer were varices only in the stomach, extrinsic compressions or direct invasions to the posterior wall of the upper third of the stomach, and lesions in the descending part of the duodenum. If these findings were observed by upper gastrointestinal endoscopy, it is important to consider the presence of pancreatic cancer.

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Two rare cases of T cell type primary esophageal malignant lymphoma were reported. Only six cases of T cell type esophageal lymphoma has been reported in Japan, while at least twelve cases of B cell type has been reported. One was a 76-year-old man with dysphagia. Barium swallow and endoscopy showed a large ulcer on a tumor at the upper esophagus. Biopsy revealed diffuse large lymhocytes infiltration and immunohistological examination disclosed UCHLI (+) but LC26 (-). The patient had HTLV-I antibody, and proviral DNA for ATLL was shown by the Southern blotting. From these findings, the primary esophageal malignant lymphoma was induced by ATLL. The second case was a 78-year-old female who visited our hospital due to dysphagia. Barium swallow and endoscopy showed multiple ulcerous lesion on the tops of large folds of the upper esophagus, mid-esophagus lesion apparently covered by normal mucosa and lesion with multiple erosion on low elevated submucosal tumor of the lower esophagus. The lesion of mid -esophagus was negative on lugor staining and biopsy specimen taken at that regions disclosed diffuse infiltration of medium-sized lymphocytes infiltration. The flat type of the lesion has not been reported so far. Immunohistological examination of the cells disclosed UCHLI (+) but LC26 (-).

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This paper describes a case of small cell carcinoma of the stomach with a review of 95 cases including the case seen in the Japanese literature. A 67-year-old man was admitted to our hospital complaining of epigastric pain. Barium meal roentgenogram and endoscopic study revealed the Borrmann type 3 lesion at the anterior wall of the upper body of the stomach and the O-IIc+IIa lesion at the posterior wall of the antrum. A total gastrectomy and lymph nodes dissection were performed. There were no liver metastasis, distant metastasis and peritoneal dissemination, but the metastases of # 3 and # 5 lymph nodes were found. Histopathologically, diffuse proliferation of short spindle-shaped small cells with a high N/C ratio invading to the submucosal layer was noted at the O-IIc+IIa lesion. On immunohistochemical stains, the lesion was positive for chromogranin, NSE and CEA. Based on these findings, a diagnosis of small cell carcinoma of the stomach was made. The Borrmann type 3 lesion showed well to Moderately differentiated tubular adenocarcinoma. Small cell carcinoma of the stomach associated with tubular adenocarcinoma is rare, and only seven cases have been reported in the Japanese literatures.

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A 49-year-old man was referred to our hospital because of gastrointestinal bleeding. Bleeding source cannot be detected by ordinary gastrointestinal endoscopic examination, angiography and scintigraphy. However, endoscopic observation at the time of ERCP revealed a gentle submucosal tumor with hemorrhage from a central depression like a pin hole located at the superior duodenal angle. Surgical operation was performed. The pathological findings showed aberrant pancreatic tissues of Heinrich type I.

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A 58-year-old man, who had severe liver function abnormality under the treatment of diabetes mellitus, was admitted to our hospital. Abdominal computed tomography (CT) showed diffuse enlargement of the pancreas and dilatation of the common bile duct. Magnetic resonance cholangiopancreatography (MRCP) revealed an irregular stenosis of the lower common bile duct. We firstly considered the possibility of a malignant tumor in the pancreatobile duct system because of elevated tumor markers. However, endoscopic retrograde cholangio pancreatography (ERCP) demonstrated diffuse narrowing of the main pancreatic duct, so that we started a steroid therapy under the suspicion of autoimmune pancreatitis. After steroid administration, there was drastic improvement of liver function abnormality, diffuse narrowing of the main pancreatic duct and an irregular stenosis of the lower common bile duct. We reported a rare case of autoimmune pancreatitis with severe liver function abnormality.

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Endoscopic papillary balloon dilation (EPBD) has become an option for the treatment of common bile duct stones in Japan. However, the post-procedure pancreatitis, which was an obstacle for spread of this procedure, has still been a problem. To prevent the pancreatitis, it should be performed for adequate patients by appropriate procedure.

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Background : Due to the remarkable progress of endoscopic resection techniques, endoscopic submucosal dissection (ESD) has been widely performed for larger mucosal tumors that would result in large artificial ulcers. The healing process of peptic ulcers has been previously studied in detail ; however, no precise investigation for artificial ulcers after ESD has been reported. To confirm the validity of the treatment from the aspect of wound healing, we aimed to clarify the healing process of large gastric artificial ulcers after ESD. Methods : Seventy patients with gastric mucosal tumors treated by ESD were enrolled. The size, location and time of scar formation of the ulcers were reviewed using endoscopic pictures taken from the same view and angle. Follow-up endoscopy was performed at 1, 4, 8 and 12 weeks after ESD. For postoperative medication, all patients received normal doses of proton pump inhibitors and sucralf ate for 8 weeks. Results : The average size of the resected specimen was 34.7 mm (20-90 mm). Irrespective of ulcer size and location, all of the cases healed up to scarring stages within 8 weeks. Conclusions : Gastric artificial ulcers after ESD healed within 8 weeks regardless of size and location using normal doses of medication as peptic ulcers. The fact that even giant ulcers after ESD heal within 8 weeks could be helpful information for candidates for ESD and for postoperative management of patients after ESD.

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