Radiologic and endoscopic diagnosis was developed especially in Japan and technique of diagnosis was established. Histopathologicaly divided two types of cancer, well differentiated adeno carcinoma and undifferentiated adeno carcinoma. Disappearance of gastric area was major sign of undifferentiated carcinoma, uneven mucosa was the characteristic endoscopic finding of differentiated adeno carcinoma. Changes of color was another important finding of the IIc area. In differentiated carcinoma, mucosal reddening and in undifferentiated type, discoloration and scattered reddening was frequently seen in IIc area. It is very important to know depth of cancer invasion for perform endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In three dimensional endoscopic ultrasonography (3D EUS), the destruction of the third layer suggested submucosal infiltration. Another important technique was required for the preoperative diagnosis of determining horizontal extent of invasion. Prior to endoscopic submucosal dissection, dye spreading method is one of useful technique. In addition, magnifying endoscopy and magnifying endoscopy with narrow band imaging (NBI-ME) were developed recently. The fine network pattern was seen in well differentiated adeno carcinoma and corkscrew pattern in undifferentiated adeno carcinomas.

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EUS is a combination of endoscopy and intraluminal ultrasonography . EUS also enables ultrasonographic images of high resolution to be obtained . However, whether the lesion is malignant or benign cannot be diagnosed solely from the findings of EUS. Endoscopic ultrasound guide fine needle aspiration (EUS-FNA) was developed in early 1990s to enhance the diagnostic capabilities of EUS by providing additional pathological findings . EUS-FNA has not been widely accepted in Japan. This may be due to the technical difficulties, relatively low sensitivity for the detection of malignancies and the Japanese gastroenterologist's and surgeon's inherent conservative way of thinking. We describe here the short history of EUS-FNA mainly in Japan, current indications and contraindications, diagnostic accuracy and complications in details. In the near future, EUS followed by EUS-FNA will be routinely performed in the same manner as gastrointestinal endoscopy, fllowed by biopsy under direct vision. And also therapeutic EUS may become feasible as a less invasive and safer technique.

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Methods : From January 2005 to December 2005, enrolled 600 patients taking low dose aspirin, in those endoscopies were performed. Results : The rate of upper gastrointestinal ulcers or hemorrhagic lesions was 7.7% in the total subjects ; 9.5% in the patients taking no anti-acid medicine, 8.7% in the H 2 receptor agonist (H2 RA) group, and 1.0% in the proton pump inhibiter (PPI) group. There was no significant correlation between finding ulcer lesions and aging over 70 years-old, or taking other anti-coagulant therapies. Conclusion : Treatment with PPI significantly reduced the rate of upper gastrointestinal ulcer and bleeding in the patients taking low dose aspirin.

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A 60-year-old woman was referred to our hospital for a polyp at the esophagogastric junction. Endoscopic examination revealed a semipedunculated polyp with heterogeneous color pattern about 7mm in diameter. Since biopsy specimens revealed microscopically severe inflammatory change and bizarre atypical stromal cells, pseudosarcomatous granulation was suspected. About a month after endoscopic examination, the polyp was removed endoscopically at another institution. Removed specimen showed an inflammatory polyp with pseudosarcomatous granulation. Such lesion may be often misdiagnosed as malignancy when inflammatory change is severe.

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Gastric cancers occasionally develop in the remnant stomach after distal gastrectomy, however those after proximal gastrectomy are rare. In this report, we describe an early gastric cancer which developed in the remnant stomach after proximal gastrectomy and was treated by ESD successfully. The patient was a 74-year-old man, who had received proximal gastrectomy 12 years before. A depressed lesion was found at the lesser curvature of the lower gastric body of the remnant stomach. This lesion was endoscopically supposed to be a mucosal cancer and the biopsy revealed a moderately differentiated adenocarcinoma. Curative en bloc resection of the lesion was achieved by ESD, though there was severe fibrosis along the suture line.

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Gastrointestinal syphilis is primarily located in the stomach and the rectum; it is rarely located in the ileum. A 75-year-old male was admitted to hospital due to a-l-month history of abdominal pain, constipation and a 2 kg weight loss. On endoscopy multiple irregular-shaped ulcers surrounded by uneven mucosa were noted in the stomach, hyperplastic mucosa with bulbar deformity was noted in the duodenum, and edematous mucosa with a soft elevated lesion was noted in the terminal ileum. Biopsy specimens from the stomach and terminal ileum showed marked infiltration of inflammatory cells containing plasma cells that were also positive for Treponema pallidum on immunohistochemical staining. Serological tests for syphilis were strongly positive. Oral ampicillin 1, 000 mg/day was effectively treated the for patient's symptoms and his serological tests became negative. On endoscopy done 4 months later, no ulcer scar with almost normal mucosa were found in the stomach; ileal mucosa was normal but a soft elevated lesion was found which was to be a lipoma pathologically. Syphilis is a systemic, sexually transmitted disease that may cause lesions anywhere the gastrointestinal tract.

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We report a patient with a gastrocolic fistula caused by a gastric malignant lymphoma. A 67-year-old male was admitted due to frequent diarrhea. On colonoscopy examination and gastoroscopy a fistula between the transverse colon and the middle of the body of the stomach was found. Since no evidence of malignant was found in the biopsy specimens, a gastrocolic fistula due to a gastric ulcer was diagnosised, and curative surgery was performed. Since the possibility of malignant lymphoma was suggested on quick-section examination, a total gastrectomy, transverse colectomy and a partial excision of the body of pancreas cauda were done. The final histopathological diagnosis was malignant lymphoma, with the lesion infiltrating in the pancreatic body and lymph nodes.

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We experienced two cases of mediastinal pancreatic pseudocysts that were treated endoscopically in success. One was a 41-year-old man with epigastralgia and bloody sputum. Computerized tomography (CT) showed an abdominal and mediastinal pseudocyst which ruptured into the right lung and hospitalized. The second case was 59-year-old man who felt difficulties to swallow, and came to vomit water after drink. He admitted to the hospital, and it was recognized that the esophagus was displaced by expansion of a pancreatic pseudocyst in mediastinum. He was treated conservatively at first, but the cyst remained the same size. Then he was transferred to our hospital. Transpapillary drainage was effective for both cases of mediastinal pancreatic pseudocysts. It is well-known that endoscopic drainage is effective for abdominal pseudocysts, but few reports describe successful resolution of mediastinal pseudocysts with transpapillary drainage. Our cases suggest transpapillary drainage is effective for the cyst which progresses to a mediastinum, if it's caused by main pancreatic duct stenosis. We review 35 case reports of pancreatic pseudocyst in Japanese literature and the treatment of them.

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Background : Little is known about the endurance of balloon-type gastrostomy buttons, durability of the balloon-type MIC-KEY gastrostomy button (MIC) was investigated. Method : One hundred and eighty-two MICs, which were used in this hospital (Aug. 1, 2004-Nov . 30, 2005), were studied. Their ruptures and decrease in volume of water in the balloons were investigated. Results : Within 3 months only 2 cases of spontaneous removal of balloons due to rupture were counted, so that the rate of spontaneous removal of balloons due to rupture was 0.41% per month. The water volumes in the balloons were maintained properly within 70 days. Conclusion : MICs were safe and their endurance was maintained within 3 months.

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Endoscopic treatment for colorectal epithelial neoplasms is classified into two groups as follows: 1.conventional method such as endoscopic submucosal resection (EMR) and polypectomy, 2.endoscopic submucosal dissection (ESD), excellent technique for en bloc resec-tion of large lesions newly developing in recent years. We describe how to cope with bleeding and perforation, main complications of these procedures, focusing on the difference of technique. Previous to every procedure, patients should be informed of the potential risks about possible complications. First of all, adequate colonic preparation and good operative view are indispensable for safe endoscopic treatments. EMR and polypectomy are generally accepted technique. Bleeding, a common complication in these procedures, can be managed by hemostasis using endoclips. In case of EMR for large lesions, careful snaring without involving proper muscle layer is needed for prevention of perforation. ESD is technically difficult with higher risk of perforation, and should be perfor-med only by expert therapeutic endoscopists. Good positioning and maneuverability of the endoscope is essential. Dissection manipulated under frontal view of the thickened submucosal layer is important for successful ESD. Complications may possibly be managed conservatively when coped with appropriate ways.

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Background : Mucosal surface roughness is the element of Matts grading system for endoscopic severity of ulcerative colitis. The aims of the present study were to develop an image-processing method for quantifying mucosal surface roughness and to evaluate perfor-mance of this method by comparison with visually assessed surface roughness. Methods : A total of 139 digitized colonoscopic pictures from 69 randomly selected patients with ulcerative colitis were used. The red frame of the endoscopic picture was processed for the mean spatial gradient reflecting the surface roughness. Three endoscopists (El, E2, E3, ), unaware of the study design were asked to assess the surface roughness by using a visual analog scale (VAS) from 0 to 1. A total of three sessions for surface roughness were performed by each endoscopist on different days. Results : The overall mean gradient was 28.9 + 10.9. The mean VAS did not significantly differ among endoscopists (0.42 ± 0.23 for El, 0.45 ± 0.19 for E2 and 0.43±0.28, P>0.05). The correlation coefficient of VAS between El and E2, between E2 and E3, and between E3 and El was 0.957 (P<0.0001), 0.914 (P<0.0001) and 0.950 (P<0.0001), respectively. The mean gradient correlated with the averaged VAS for each endoscopist (r = 0.711 for E1, P <0.0001; 0.672 for E2, P <0.0001; 0.826 for E3, P <0.0001). Conclusion : This method may provide a means for mucosal surface roughness as a pictorial parameter, regradless of the organ studied.

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