A new education system, 2 years duty of primary residency for new post-graduated medical doctors was introdeced in April, 2004. How to educate gastroenterological endoscopy for them was proposed by the author as a special lecture (moderated by Prof. Y. Hiki) in the 68th congress of Japan Gastroenterological Endoscopy Society held by Prof. H. Makuuchi in November 2004. The essential concepts and main figures used in my lecture were described in this paper, as follows:1) Government's objectives introducing the new system were discussed and my considera-tions were reported.2) Difference of education system for new post-graduated medical doctors until passing governing board between Japan and USA was investigated. Two years duty of primary residency in the new system is required for international harmonization to produce qualified medical doctors.3) Our educational Techniques for young gastrointestinal endoscopists, namely, computer -based endoscopic simulator, Erlangen active simulator for interventional endoscopy, utiliza-tion of live demonstration and international TV discussion were proposed.4) Train the trainers workshop should be required for quality improvement of educational system in Japan, too.

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[Background] Endoscopic sbmucosal dissection (ESD) is a new therapeutic technology for the treatment of early gastric cancer, which enables higher rates of successful en-block resection than those with conventional endoscopic mucosal resection (EMR) technique. [Methods] A decision analysis comparing ESD with conventional EMR for the treatment of early gastric cancer according to the indication recommended by Japanese Gastric Cancer Association under Japanese health insurance scheme was performed using a decision tree model. The time period studied was 3 years and social perspective was chosen. Probabilities of clinical events were estimated from meta-analyses. [Results] ESD was consistently superior to conventional EMR with regard to clinical outcomes for the patient. Since the formal technical fee for ESD procedure is not yet given under current Japanese health insurance scheme, a threshold analysis was performed on the technical fee for ESD procedure to identify how this variable must change in order for both strategies to be equal on total direct medical costs. This analysis indicated that the threshold technical fee for ESD procedure was 209, 061 yen in base case analyses. Extensive sensitivity analyses disclosed that the cost-effectiveness of ESD was sensitive to the rates of curative en -block resection. [Conclusions] ESD is superior to conventional EMR with regard to both clinical outcomes and cost-effectiveness under the estimated threshold technical fee for ESD in this analysis and therefore, is the preferred therapeutic technique for the treatment of early gastric cancer. Hence, we strongly recommend that an appropriate formal technical fee for ESD should be given under Japanese health insurance scheme on the ground of the results of this study, since the diffusion of ESD means the improvement of clinical outcomes as well as the reduction of medical costs for the treatment of early gastric cancer. A proper training program is necessary to ensure the quality of ESD procedure in order to maintain its advantage.

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(Purpose) Although there are few reports of what, we found that gastric polyps frequently occurred around the internal bumper following PEG. We characterized the endoscopic features of these polyps and investigated the relevance to the internal bumper. [Methods] Endoscopic examinations of upper gastrointestinal tract were periodically performed by transgastrostomic endoscopy (TGE) when the PEG buttons were replaced. We investigated the endoscopic and histological findings of the polyps, and detected Helicobacter pylori infection and measured serum levels of gastrin, pepsinogen I and II. [Results] TEG examinations were conducted 149 times in 70 patients, and 17 new polyps were found around the internal bumper in 11 cases. Polyps were classified into three types based on their locations ; basal-bumper type, pen-bumper type, opposite-bumper type. His-tological examinations revealed all polyps were foveolar hyperplastic polyps except for two lesions in the basal-bumper type that were inflammatory granulation. No obvious relations between the occurrence of these polyps and Helicobacter pylori infection or the serum levels of gastrin or pepsinogen I/II ratio were observed. [Conclusion] The polyps are supposed to occur by the repeated stimulation of the internal bumper against the gastric mucosa.

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A 58-year-old man was referred to our hospital for general fatigue. Upper gastrointes-stinal endoscopy revealed a number of telangiectatic lesions in the lower esophagus and throughout the stomach. Frequent nasal bleeding and several telangiectatic lesions on his tongue and digestive tract were observed. Therefore, he was diagnosed as Osler-Rendu-Weber disease. We considered that bleeding from the telangiectatic lesions on the digestive tract caused anemia. Argon plasma coagulation was used to treat the telangiectasia resulting in an improvement of his anemia. The argon plasma coagulation should be the first choice for telangiectasia, because the procedure is easy, safe and repeatable.

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A 84-year-old woman was admitted to our hospital to have the further examination of the colonic tumor. She had the positive of occult stool blood, then she had colonoscopic examination at the other clinic which demonstrated the tumor of the transverse colon. Endoscopic findings showed the submucosal tumor with depression at the center of the tumor, and histological findings revealed mucinous adenocarcinoma. Barium enema showed an elevated lesion with a smooth surface of the transverse colon and high frequency ultrasound probe findings showed the hypoechoic mass extended into the propiaceptive muscle layer. Therefore, we diagnosed mucinous adenocarcinoma of the transverse colon. The patient underwent partial colectomy. Histological finding showed mucinous adenocarcinoma with invasion of serosal layer. This colonic mucinous carcinoma, showing the characteristic of colonoscopic findings of a submucosal tumor was rare and impressive.

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A 62-year-old man complaining of change of stool was admitted to our hospital. Colonoscopy revealed type2' advanced cancer of the descending colon of which ulcer bed was more whitish than usual advanced cancer. Many white and round structures were observed on the surface of the round wall. A biopsied specimen revealed squamous cell carcinoma. He underwent left hemicolectomy, and histological diagnosis of adenosquamous carcinoma (ss, n2+, ly1, v0, P0, H0, stage IIIb) was made. 4 months after surgery, metapaatic carcinoma of th jejunum was found because of melena. It was thought that white and round structures observed in our case were characteristic findings of squamous cell carcinoma. The most possible presumption in our case is that squamous cell carcinoma in adenosquamous carcinoma could be secondary metaplastic modification of adenocarcinoma.

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Two cases were 2 females (63 and 68-year-old) who visited hospital for liver dysfunction. The blood examination showed hypergammaglobulinemia, antinucleolar antibody and HLADR4 were all positive. One patient (BMI 31.2, HbA1C 6.7 %) was diagnosed as fatty liver by laparoscopy, and recovered by diet therapy. The other patient (BMI 24.8, HbA1C 8.0%) was diagnosed as non alcoholic steatohepatitis by laparoscopy and liver biopsy, and treated by pioglitazone. Diagnosing non alcoholic fatty liver disease discriminately from autoimmune hepatitis only by serological examination is very difficult . We reported two cases of non alcoholic fatty liver disease where laparoscopy and liver biopsy were useful for distinguishing autoimmune hepatitis.

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Self-expandable metallic stent (EMS) is considered to be useful for improving the quality of life (QOL) in patients with malignant duodenal stricture. However, the procedure is difficult to perform in severe or lengthy strictures of the duodenum and the standard procedure has not been established yet. Our experience shows that the placement of duodenal metallic stent through percutaneous external gastrostomy (PEG) allows precise stenting and can reduce a procedure-related pain. PEG is useful for decompression in cases of re-stenosis of the duodenum by tumor infiltration.

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Endoscopic mucosal resection (EMR) allows histopathological examination to be performed because specimens are collected as with surgical resection . It can also provide equivalent curability to surgical resection, depending on the patient . In recent years, the development of endoscopic submucosal dissection (ESD) has made it possible to resect large lesions and the surrounding normal tissues in an en bloc manner . Accordingly, it is necessary to properly handle the specimens obtained by EMR as with surgically resected specimens, and it is important to make an accurate histopathological diagnosis . For this purpose, it is important to assess complete resection correctly by handling EMR specimens according to a strict protocol and conducting stereoscopic microscopy.

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