The history of rigid gastroscopes started with the study of Kussmaul in 1868. The period of rigid and flexible gastroscopes lasted less than 100 years. In the early stage, Trouve, Nitze -Leiter and Mikulicz (1881) developed gastroscopes using platinum wire with the water cooling system as the light source. It is reported that Mikulicz' gastroscope provided pretty good images. From the end of the 19th century to the beginning of the 20th century, various rigid gastroscopes were developed by researchers such as Rosenheim (1895), Rewidzoff (1897), Kelling (1897), Kuttner (1897), Jackson (1907), Loening/Stieda (1908), Souttar/Thompson (1908), Hill (1911), Rovsing (1908) and Kolliker (1909). The gastroscope developed by Elsner in 1909 was good for practical use. After that, Sussman (1911), Steinberg (1921), Schindler (1923), Korbsch (1925) and Hiibner (1926) developed other types of rigid gastroscope, among which the device of Schindler was most widely used. 1932, Wolf and Schindler developed a flexible gastroscope, which was designed to bend to some extent. This flexible gastroscope was widely spread in the US and Europe, and when people referred to gastroenterologist, it meant specialists of this flexible gastroscope. How-ever, there were very few institutes engaging in gastroscopy in Japan at this time. Once observation by gastroscope became widely available, biopsy was attempted. Kanamore (1940), Benedict (1948), Debray (1962) announced the gastroscopes for biopsy that they developed. In this paper, development of the various apparatus from early models of rigid gastroscopes to later models of flexible gastroscope and relating matters will be introduced.

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Mucosal prolapse syndrome (MPS) is thought to occur because of chronic mechanical stimulation, and is often recognized in prolapsing colostomies or prolapsing hemorrhoid at the site of the rectum. It is important because it may be confused both clinically and histologically with carcinoma. Patient with MPS of the rectum usually have a habit of straining at defecation, and have polypoid lesions, ulcerations or erythema at the anterior wall of the rectum. The aetioligy of MPS remains unproven but there is now considerable evidence that a combination of mucosal prolapse, trauma and ischemia, caused by excessive straining at stool may be important factors. The reasons for straining at stool are also obscure, but there is electromyographic evidence in many cases of a failure in the normal mechanisms in the pelvic floor which control continence and def aecation, and in particular the activity of the puborectalis muscle (paradoxical contraction). Rectal bleeding is commonest, other symptoms include the passage of mucus, perineal pain, and tenesmus. The polypoid lesions show usually at the lower rectum, while the flat and ulcerous type show usually at the middle or upper rectum. Macroscopically they are irregular in shape and vary in size from 0.5 to 5 cm in diameter. They are usually flat, well demarcated lesions, sometimes covered by a white slough. The surrounding mucosa shows a mild proctitis. Often no ulcer is present but the rectal mucosa shows a localized roughened inflamed area. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. Microscopically, biopsy of the lesions reveals characteristic appearances : fibromuscular obliteration. The earliest and most significant change is a curious obliteration of the lamina propria by fibrosis and smooth muscle fibers growing towards the lumen from a thickened muscularis mucosae, and this change may be present without ulceration, or in the mucosa away from the immediate vicinity of the ulcer. The primary treatment is conservative, so the aim is to educate patients not to strain. But if patients suffer from indication for a long time in spite of conservative treatment or if they have indication which is hard to care, there is room for surgical treatment. When severe symptoms of MPS persist despite medical management, surgery may be necessary. We have some prognosis with various ways of surgical treatment as rectopexy, Delorme's operation, anterior resection and creation of stoma.

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[Background/Objective] Therapeutic ERCP using short guidewires provides advantages in which the irradiation and performance time are minimized, and it can be performed within a small room by a fewer number of staff members, etc. However, ENBD cannot be performed with this system, so the creation of ENBD tubes that are compatible with short guidewires was therefore attempted. [Methods] A side hole was made in a tube so that it could be used for ENBD using a short guidewire. To investigate the durability of the side hole portion, holes were made in tubes of various sizes, after which traction experiments were conducted. Furthermore, to study the safety of the use of such a tube, this method was performed on 15 patients. [Results] The JIS criteria of tensile strength were sufficiently met with all of the sizes that were studied. No obstruction, dislodging, or damage of the tubes was observed in any of the patients, and this method could be performed without any problems associated with drainage or contrast. [Conclusion] Therapeutic ERCP using short guidewires is expected to be widely used in the future in Japan using these EN BD tubes.

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A 55-years-old female had anemia and had MDL, GIF and a biopsy done at a certain clinic. The biopsy specimen of the polyp revealed f oveolate hyperplasia (Group I). The patient had an endoscopic resection since the polyp was causing anemia. The polyp was diagnosed as a gastric hyperplastic polyp (GHP) on the greater curvature of the antrum (l0mm in diameter) based on the endoscopic examination. The polyp was resected by endoscopic submucosal dissection (ESD). The resected specimen was found to be a differentiated type gastric carcinoma with a gastric mucin phenotype. The cancer cells were columnar f oveolar type cell similar to there found in GHPs. A part of the polyp was composed of a GHP without dysplasia. This case suggests that F-type carcinoma can arise from a histologically diagnosed GHP.

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We report a case of impacted diospyrobezoars in gastric antrum, which were treated successfully by dissolution therapy with Coca-Cola administration. An 87-year-old woman was admitted to our hospital because of abdominal pain and feeling of abdominal distension. Upper gastrointestinal endoscopy revealed two diospyrobezoars (each size was 7cm and 3cm in diameter) in the stomach, and one bezoar became impacted in gastric antrum at a later date. The endoscopic removal using forceps and polypectomy snare resulted in failure. Therefore., she received dissolution therapy with Coca-Cola. On the next day, the impacted bezoar was partially dissolved and turned to be softened, and that was safely-removed endoscopically. She took extra dose of Coca-Cola, and the next day, remaining bezoars were completely dissolved. The dissolution therapy with Coca-Cola may be useful in patients with diospyrobezoar resistant to endoscopic therapy.

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A 58-year-old woman complaining of a tarry stool was diagnosed with a duodenal tumor. She was recommended to receive surgery at another hospital but desired endoscopic treatment, and she was admitted to our hospital. Endoscopic examination revealed that a large pedunculated polyp, 60mm in size, arose from the duodenal bulb and its head extended to the third portion. Since the tumor was elastic hard and covered with normal duodenal mucosa, endoscopic diagnosis was Brunner's gland hyperplasia. The tumor was resected by endoscopic polypectomy. Because surgery for duodenal tumors could be associated with sever complications, endoscopic resection should be performed based on the exact diagnosis and proper indication.

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A 50-year-old man was admitted because of sudden massive hematochezia. Abdominal enhanced CT scan revealed leakage of contrast media at the oral side of the terminal ileum. Emergency colonoscopy revealed spurting bleeding from an exposed vessel in a minute ulcer at about 30cm oral to the ileocecal valve. We diagnosed it as a Dieulafoy-type ulcer of the ileum. Endoscopic clipping was performed for the exposed vessel, by which the bleeding stopped. We reviewed the cases of Dieulafoy-type ulcers and a submucosal aneurysm of the small intestine reported before.

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A 73-old-man was admitted to our hospital with weight loss and jaundice. Abdominal computed tomography showed dilatation of intrahepatic bile ducts, but did not show pancreatic swelling. ERCP showed multiple strictures in intrahepatic bile ducts and mild stricture of the main pancreatic duct. From the findings of this cholangiogram, differential diagnosis between IgG4-related autoimmune sclerosing cholangitis and primary sclerosing cholangitis was difficult. Serum IgG and IgG4 level were high, and biopsy of intrahepatic bile duct revealed infiltration of IgG4-bearing plasma cells. Therefore, we diagnosed IgG4-related autoimmune sclerosing cholangitis without pancreatic swelling, and oral steroid therapy was commenced. In this case, the diagnosis was possible based on serological and histological examination.

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In pursuit of safe, accurate and simple method of endoscopic submucosal dissection (ESD), we devised a transparent hood attached with a mucosa gripping channel. After confirmation of its utility by animal experiments, we recognized the similar utility in the clinical setting (5 cases of early esophageal cancer). The use of this assistive device has the following advantages. (1) By lifting the separated mucosa, then reversing and pressing it backward, the mucosa-stripped plane can be observed under direct vision. This procedure not only makes hemostasis and blood vessel processing easy, thereby reducing a risk of perforation. (2) Reliable counter-traction can be applied to the submucosal tissue of the stripped plane, and separation time could he shortened. (3) We could dissect submucosal layer without using a hook knife only by gripping and pushing the excised mucosa to backward, and there was little bleeding. (4) Especially this method of gripping the excised mucosa and attaching the hood to the opening side of the excised reduces the effects of respiration and pulsation, keeps the distance of the separated part and instrument constant, and enables safe separation procedure of esophagus.

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Objectives : Usefulness of clinical pathway for patients at initial examination of transnasal esophagogastroduodenoscopy (EGD) was assessed with respect to comprehension and anxiety. Patients and Methods : 83 patients who had the initial transnasal EGD were informed with clinical pathway. Difference of comprehension and anxiety between patients with or without peroral EGD experience (with experience 69, without experience 14) was investigated. Results : Good comprehension and moderate anxiety were the most observed categories. In patients with and without peroral EGD experience, good comprehension was obsesved in 71.0% and 78.6%, while moderate anxiety was observed in 44.9% and 50.0%, respectively. Transnasal EGD was well understood with clinical pathway. There was no difference of comprehension and anxiety between patients with or without peroral EGD experience. Relationship between comprehension and anxiety was not consistent, suggesting that its final evaluation needs further study of additional patients without peroral EGD experience. Conclusions : Clinical pathway was evaluated to be useful for explanation to patients at initial examination of transnasal EGD.

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Endoscopic GI cancer screening with transnasal esopahagogatroduodenoscopy (EGD) has been increasingly performed in Japan, in patients anticipating comfortable unsedated EGD. It is very important to do systematic medical interview and informed consents before the examination for maintaining its safety and quality in a high level. As 2 minute nasal anesthesia, we perform the anesthesia using one catheter (one stick method) after intranasal administration of naphazoline nitrate. The understanding of transnasal insertion is facilitated by the previous orientation of the nasal septum direction and image training with the upside down nasal cavity anatomical chart. If the scope insertion is difficult by the transnasal route, the insertion should be performed by transoral route. Precise examination with the optimal observation distance should be defined for transnasal EGD, taking into consideration its poor illumination especially in the far distance and narrow field of view. In endoscopic GI cancer screening with transnasal EGD, contents and methods of appropriate informed consents should be deliberated as well as effort to improve its diagnostic accuracy.

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Background : Transnasal esophagogastroduodenoscopy (EGD) has been suggested to be better tolerated by the cardiovascular system with a lower elevation of systolic blood pressure (BP) than oral EGD. However, limited information is available on the precise comparison of cardiovascular responses between the two endoscopic procedures using the same ultrathin scope. Methods : A prospective patientcentered randomized study was performed to examine BP, pulse rate (P) and peripheral blood oxygen saturation (SpO2) during nasal and oral EGD using the same ultrathin endoscope. The acceptability of EGD was also assessed using a visual analog scale. A total of 1147 patients were divided into four groups : patients who preferred oral or nasal EGD underwent endoscopy according to their preference (preferred group) and patients without preference were randomly assigned to oral and nasal EGD (randomized group). Results : The study design excluded a bias of the patient's preference. The randomized group involved 149 patients among whom 74 and 75 cases were assigned to the transnasal and oral EGD groups, respectively. The results in the randomized group confirmed a significantly lower elevation of BP in patients undergoing transnasal EGD than those undergoing oral EGD, while the increase in P was slightly smaller in patients undergoing the nasal procedure. Changes in SpO2 were minimal in either procedure. Analyses of patient acceptability showed a favorable evaluation of nasal EGD. Conclusions : The present study confirmed less cardiovascular stress using nasal EGD than oral endoscopy when compared using the same ultrathin scope.

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