We have previously conducted a study on the accuracy of the pepsinogen (PG) method and its effectiveness in reducing the mortality rate of stomach cancer. We have developed and proposed the stomach cancer screening system which is an economically feasible management method for bringing about a reduction in stomach cancer mortality rates by adopting a high risk strategy for stomach cancer screening after conducting a comprehensive economic evaluation as a countermeasure for stomach cancer on the basis of previous research findings. Method and Results ; (1) The effectiveness of reducing stomach cancer mortality rates using the PG method alone was confirmed using an observation technique in the form of a case -control study (retrospectively over the course of 13 years) based on data obtained from areas implementing stomach cancer examinations using the PG method. (2) The accuracy of the PG method was demonstrated to be nearly equal to that of X-rays (digital radiography, DR) and examinations combining the PG and X-ray methods were found to be both feasible and useful in a study of the accuracy and cost effectiveness of the PG and X-ray methods by conducting stomach cancer examinations combining the PG method and X-ray method (DR). (3) In a study of the annual incidence of stomach cancer and hazard ratio in stomach cancer examinations combining assay of Hp antibody levels and the PG method (follow-up study on healthy males over a period of 10 years), stomach cancer was observed to not have occurred for 10 years in a group free of infection by H pylori (Group A : Hp O, PG O), this Group A was designated as a low risk group and excluded from stomach cancer examinations, and stomach cancer examinations consisting of selective screening for groups complicated with atrophic gastritis (Groups B, C and D) were demonstrated to be feasible. In addition, the optimum examination intervals for each of Group B (Hp (+), PG (-)), Group C (Hp (+), PG (+)) and Group D (Hp (-), PG (+)) (namely, the risk for stomach cancer) was determined to be suitable at the rate of once every 5 years for Group A, once every 3 years for Group B, once every 2 years for Group C, and once a year for Group D. In the future, it is strongly hoped that the efficiency of stomach cancer examinations will be improved and that stomach cancer examinations that are economical while also bringing about a reduction in the stomach cancer mortality rate will be realized by promoting and proliferating stomach cancer examinations combining assay of Hp antibody levels and the PG method as described above on a national scale. In conclusion, the use of assay of Hp antibody levels and the PG method for primary screening and the use of endoscopic examinations (small diameter and transnasal) for secondary screening is considered to be the recommended approach for stomach cancer examinations as countermeasures against stomach cancer.

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It is difficult to diagnose submucosal tumor (SMT) of the large intestine only from endoscopic findings, because it is covered with normal mucosa. However, most of colonic SMT have characteristic findings, such as location and number, surface pattern, color, hardness, etc. Furthermore, confirmed diagnosis is possible in most of rectal carcinoid tumor and malignant lymphoma by endoscopic biopsy. EUS is indispensable examination for histological diagnosis of SMT, because EUS can produce direct visualization of the perpendicular tumor images in the colorectal wall. Clinical significance of EUS in diagnosing the SMT is as follows, (i) diagnosis of location and origination layer, (ii) presume of its histological nature, (iii) measure the real size of the lesion. Moreover, in the diagnosis of solid SMT near anus, histological diagnosis can be obtained by using EUS-guided fine needle aspiration (EUS-FNA). As mentioned above, it is necessary to recognize endoscopic and EUS findings of each colonic SMT in order to perform a correct diagnosis and to choose an adequate treatment including endoscopic polypectomy.

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With the advent of multi-slice CT (MSCT), CT examination has achieved increased efficiencies and improved image quality in a revolutionary scanning modality. Under the condition, virtual endoscopy (VE), a technique for visualization of gastrointestinal carcinomas, using three-dimensional (3D) volumetric data generated by MSCT helical CT scanning, has undergone rapid development. In preoperative staging of gastrointestinal cancers, we can accurately evaluate local invasion and small lymph node metastases with MSCT, and MSCT colonography has been recognized as a new diagnostic tool for primary lesions replacing colonoscopy and barium enema study. VE, MPR (multi-planar reconstruction), whole 3D view, and their combination views are currently available to clearly visualize primary lesions and metastasis. In western countries, MSCT colonography is considered to have a great potential of being a modality for colorectal cancer screening. MSCT colonography, which is based on 3D volumetric data, has great potentials for computer-aided detection (CAD) for colorectal polyps and digital preparation. MSCT colonography with CAD is surely expected to improve diagnostic performance in colorectal mass screening, and digital preparation will reduce the burden of candidates. These favorable features will lead itself to really standardized and effective colorectal screening method in near future.

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[Aim] We reviewed the importance of a patient having an active bowel prior to a percutaneous endoscopic gastrostomy.
[Method] Seventy-four patients who had a percutaneous endoscopic gastrostomy feeding tube inserted ; 11 patients who died prior to discharge were compared to 63 patients who lived and discharged. The two groups of patients were compared with respect to: the duration that the feeding tube was inserted ; the serum albumin level ; the total peripheral blood lymphocyte count ; their nasal cavity or pharyngeal MRSA carrier status ; fluid therapy before feeding tube insertion ; the presence of active bowel and the duration of time that the bowels were inactive prior to feeding tube insertion ; the duration of enteral nutrition which was started after the feeding tube was inserted ; as well as the success or failure of enteral nutrition.
[Results] Compared to the patients who lived, among the patients who died the following were noted ; a significantly greater number of patients with inactive bowels prior to treatment (p <0.01) ; a significantly longer time that the bowels were inactive prior to treatment (p < 0.05) ; and a significantly greater number of patients who failed enteral nutrition (p <0.01) . The other factors were significantly different between the groups.
[Conclusions] It is important to shorten the duration of bowel inactive prior to treatment. The bowels should be active prior to feeding tube insertion, even if due to the presence of an eating disorder or dysphagia PEG is required.

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We treated a minute, submucosal, invasive squamous cell carcinoma of the esophagus. The patient was a 63-year-old man. On routine endoscopy ared ared was seen, and the surface seemed to be slightly depressed in the central part of the lesion. A small, white elevation was noted around the lesion. On routine examination using more advanced endoscope, color changes and minute changes of small vascular network were clearly recognized. EMR was done. On histopathology a mucosal defect was seen in the central part of the lesion. The small lesion was approximately 4mm in size. Carcinomatous invasion had destroyed the muscularis mucosa and extended to the submucosal layer (sm 1 cancer). This case is being reported due to the rarity of minute submucosal invasive squamous cell carcinoma of the esophagus.

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We report a case of early gastric cancer resembling submucosal tumor derived from heterotopic gastric gland and review the literature. These cases reported to date have several common features : 1) These cases were found by chance on endoscopy. 2) Their lesions were almost always located in the gastric body (7/9 cases). 3) The lesions were small (1.7±0.7cm). 4) The lesions were located in the submucosal layer (8/9 cases). 5) The correct diagnosis was made with difficulty in 3cases/9cases. Therefore, endoscopy should be done with care so as not to miss such lesions.

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A 65-year-old man who lived in endemic schistosomal area underwent low anterior resection for rectal cancer at our hospital, and many calcified ova of schistosomiasis j aponicum were observed in the colonic wall mainly in the submucosal layer which was demonstrated by histopathological findings of resected specimen. The tumor was diagnosed as T3, N0, M0, Stage II A. On the other hand, since calcified lesions 12 mm in size were observed in the intrahepatic portal vein by computed tomography before operation, we suspected the lesion may indicate schistosomiasis ova and administered praziquantel at 40 mg/kg for 2 days after operation. Five months after operation, there was yellowish submucosal lesion in the lower rectum shown by colonoscopic examination and biopsy specimen revealed calcified ova. However, calcified lesions in the intrahepatic portal vein disappeared on computed tomography.

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A 87-year-old woman was admitted to our hospital to undergo treatment for melena, anal tumor and breast tumor. Endoscopy revealed a pedunculated and elastic soft tumor with blown, redness and black color, 2 cm in size, in the anorectal portion, suggestive of anorectal malignant melanoma. No metastatic lesion was found. Local excision of the anorectal tumor and mammarectomy were performed. Pathological examination of the resected specimen revealed anorectal malignant melanotic melanoma limited to the mucosa with lymphangiotic invaion and cut end negative. Anorectal malignant melanoma limited to the mucosa was the forth case in Japan. The present case accompanied a breast cancer at the same time.

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We report a patient with ascariasis who had recurrent acute pancreatitis. A 58-year-old woman had acute pancreatitis 3 times at 2-month intervals, but the cause was not identified. During the third episode of pancreatitis, a cylindrical object that was located in the common bile duct was identified on ultrasonography and magnetic resonancecholangiopancareto-graphy. The cylindrical object was subsequently removed during endoscopic retrograde cholangiopancreatography. The object was a live adult female Ascaris lumbricoides which appears to have caused the patient recurrent pancretitis. The patient has been followed for more than a year and is doing well. This is the first case report from Japan of recurrent pancreatitis caused by an Ascaris worm.

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This time, to get rid of stent insertion trouble in the self-expandable metallic stent (SEMS) treatment of the malignant duodenal stenosis, a new insertion method was divised. In 8 cases of malignant duodenal stenosis, the insertion method by the use of the combination of longovertube and expansion balloon for esophagus was practised. At the result of the use of this new stent insertion method, the insertion trouble experienced in the longovertube method was prevented, and moreover it is supposed to prevent of perforation at the duodenal portion. This method is surpassing in certainity and safety for stent insertion, and it is suitable to use in all cases of malignant gastrointestinal stenosis from gastric antrum to treitz without multiple malignant gastrointestinal stenosis.

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Objectives: We assessed the efficacy and safety of pancreatic stent-assisted needle-knife precut papillotomy (NKPP) for patients having difficulty in deep cannulation into the bile duct. Patients and Method : Between Jonuary 2001 and October 2006, a total of 682 ERCPs for deep cannulation into the bile duct were performed. Of these ERCPs, 72 cases were unsuccessful by the routine method. 62patients were underwent pancreatic stent-assisted NKPP. Results : Success rates of deep cannulation into bile duct was 94%. Complications included pancreatitis in 2patients (3.2%). Conclusion : Pancreatic stent assisted NKPP was fairly safe and effective for patients having difficulty in deep cannulation into the bile duct.

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Diagnosis of esophageal hiatal hernia is usually diagnosed by barium study, esophageal manometric study and endoscopic examination. The Makuuchi's classification and Hoshihara's classification are useful for endoscopic diagnosis of sliding hiatal hernia, which is most common type of hiatal hernia and frequently accompanied with reflux esophagitis. To use these classifications, the exact determination on of gastro-esophageal junction is necessary and the endoscopic observation of distal esophageal palisade vessels, and proximal end of gastric fold is valuable for distinguishing between Barrett epithelium and gastro-esophageal junction.

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