Many studies have been made on the relation between the lesions and the function of the stomach. In this study, we endoscopically investigated how the function of the pylorus changes when there are some lesions in the pylorus and the peripyloric area. Especially, some instrumental managements were added to the fibergastroscope (FGS).(1) The peripyloric lesions and the contourr of the pyloric ring We classified the contour of the pyloric ring according to its size and the degree of deformity. The pyloric ring as large as the opened biopsy forceps (6mm), larger than it or smaller than it, is respectively labeled as "average, " "larage" or "small." About the deformity, the pyloric ring always drawing a smooth arc is classified as "no deformity, " and when there is any small degree of distortion, it is called as "deformity." The result was that the size showed no particular influence by the lesions, except, in the cases of the prepyloric ulcer, the size was always "large." and that the pyloric ring "deformity" was frequently seen in the cases of duodenal ulcer, erosive gastritis and prepyloric ulcer.(2) The peripyloric lesions and pyloric insufficiency When the pylorus remains open during the observa-tion by FGS, we call it "pyloric insufficiency." "Pyloric insufficiency" was frequent in the cases of duodenal ulcer and prepyloric ulcer, and in these cases, the pyloric ring was often "deformity.''(3) Peristaltic rhythm and peripyloric lesions Peristaltic rhythm was observed under the set intra-gastric pressure, by FGS connected to the intra-gastric pressure stabilizer, but no particular phenomenon was detected concerning the peristaltic rhythm under the intra-gastric pressure of 15cm H2O.(4) Emptying time, lesions and the contour of the pyloric ring We measured the emptying time of the 300ml of water dyed with methylene blue from the stomach. As a result, no definite tendecy could be seen between the emptying time and the lesions. In respect of the contour, however, the cases of the pyloric ring "deformity" often showed rather short emptying time.(5) Emptying time and peristaltic rhythm The examination was made on the relation between the emptying time and the peristaltic rhythm to each case. In the cases "deformity, " the emptying time tended to be short without regard to the peristaltic rhythm.(6) Duodenal regurgitation We inserted a polyethylene tube, about 10cm into the duodenum, in direct vision of FGS, injected 1 ml of Phenolsulf onphthalein (PSP) and then immediately took out the tube. After 20 minutes, we drew out all the gastric juice in direct view of FGS and measured the quantity of PSP regurgitated. By this method, which we named "PSP-Regurgitation Test, " we could recognize the quantity of the duodenal juice regurgi-tated into the stomach. The regurgitated PSP was large in quantity in the lesions of duodenal ulcer, erosive gastritis, prepyloric polyp and severe chronic gastritis and also in the cases of the pyloric ring "deformity" and pyloric insufficiency. By the way, in one case which had both deformity and pyloric insu-fficiency, the quantity was remarkably large, when this examination was made to the resected stomach.(7) Pressure waves of the pyloric ring We inserted a balloon of 1×3cm and of capacity 2nd into the pyloric ring in direct view of FGS andd recorded the pressure waves of the pyloric ring. In the cases of pyloric insufficiency, the pressure waves were even and evidently different from those of the normal cases.
We used to have considered endoscopically that the pyloric ring is a circular ring seen in most anal portion of stomach. However, the pyloric ring must be recognized not as a ring, but as a tube having some length. This portion was named as "pyloric tube". Farmerly, we have observed the pyloric ring endo-scopically from both sides (gastric side and duodenal side), and it was reported that the mucosal gastro-duodenal junction was in duodenal side of pylorus. Biopsies from pyloric tube was made in 10 cases, and it was found that mucosal gastroduodenal junction was in center of pyloric tube in one case, and the edge-mucosa of pylopic tube in gastric and duodenal side consisted of the respective mucosa. Investigating the operated specimen, the mucosal gastroduodenal junction was observed near the center of pyloric tube in 60.8%, and on the gastric side in 1.6%. The marking was made on a point of greater curvature of endoscopic pyloric ring, and the moving of the point owing to slightly preconstructive move of pyloric tube was measuued, and it was observed that the mucosa of the pyloric tube move 3.87mm on an average in human. And next, the pyloric tube of the resected specimen was investigated. It must recognized in these cases that the resected specimen has shrinkage of about 20-30% to the stomach of living body. The pyloric tube of the fixed specimen dyed from hematoxillin being observed macroscopically, the mucosal gastroduodemal junction is on duodenal side of pyloric tube, and this portion is more anal from endoscopic pyloric ring. Also, observing the fixed specimen dyed from hematxilin macroscopically, the mucosal gastro-duode-nal junction of pyloric tube can be classified into 3 types as follows: the clear type (29 cases for 103 cases, 28.1%), the indistinct type (38 for 103, 36.9%), and the type that the gastric mucosa enter into duodenal side (36 for 103, 35.0%) . The last type is most f requantly observed in cases of duodenal ulcers. Now, the structure of muscle layer of the pyloric tube is very complicated and the pyloric sphincter is not indipendent. The histological study of pyloric tube by longitudinal and cross sections reveal that the muscle fibers of pyloric tube has characteristical structure. Occasionally, the bigining of circular muscle of duodenum thicken in some cases, as the structure of pyloric muscle must be recognized as the complication of gastric and duodenal muscle. We classified the muscle layer of pylorus macroscopically in fixed spe-cimen as follows: the hill-like type (69 cases for 133 cases, 51.9%), the peak-like type (51 for 133, 38.4 %), the protruded type (8 for 133, 6.0%), and the flat type (5 for 133, 3.7%). The longitudinal length of pyloric ring was measured at lesser curvature from the point that longitudinal muscle enter the circular muscle in 116 cases, and it is appeared that longitudinal leugth of pyloric tube is about 7mm. 444 cases diagnosed as peptic ulcer clinically were studied histologically, and it was revealed that the ulcer of pyloric tube was 10.6% of them and the erosion was 11.9 %. We investigated the diagnostic ability of each type of endoscope about the ulcer of pyloric tube under the consideration that the ulcer of pyloric tube is of within abaut 1cm anal side of mucosal gastro-duodenal junction, and the ulcers of in 1cm more anal side was named as the prepyloric ulcer. It can be recognized that the frontal viewing system including PFS has more merit. Namely, the qualitative diagnosis of nar-row pyloric tube can be made by using theses scopes, and it can be insert so earily into the stomach with deformity or stenosis under the direct vision that the more anal lesions can be observed comparatively. So, the gastric mucosa and the duodenal mucosa could be differentiated from observation using PFS or GIF-D. There is no remarkable difference between each type of endoscope about prepyloric ulcers, but being not influenced by anal lesions, PFS and GIF-D are ver
Gastroendoscopy is one of the important examinations of the stomach. There are several kinds of instruments for gastroendoscopy: gastrocamera (Va) is desirable to describe stomach lesions by colorfilm. Fiberscope (SL) is very helpful in directly observating the mucosal response in the stomach. Fibercamera (GTF) has both abilities above mentioned. Fiherscorpe for biopsy (BL) is desirable to obtain biopsy specimen from mass or abnormal mucosa. It is necessary to make correct diagnosis to use several instruments one at the time according to theirr ability. For the purpose of getting the best signs for endoscopic diagnosis, we tried to examine the stomach by two orr three gastroendoscopes, some times 5, serially in one day. Therefore we took the pictures of all over the gastric mucosa first, inspecting by GTF fiber camera and then described it again by Va gastrocamera. Biopsy specimen were also obtained by BL Fiberscope from the portion where some lesions were suspected by GTF fibercamera. One thousand one huedred and eighty four gastroscopies were performed from July 1970 to September 1971 at the Keio University Hospital. We can make correct diagnosis of 1182 gastric lesions by this endoscopic approach, except 2 cases of reticulum cell sarcoma. The ratio of correct diagnosis was very high, calculated as 99.6%. As for the ratio of correct diagnosis, those were 93.8% with a single use of GTF fivercamera, 97.7% with a combined use of GTF fiber camera and Va gastrocamera, and 99.6% when BL fiherscope were additionally used to obtain the biopsies. It might be necessary to use three instruments (fiber camera, gastrocamera and fiherscope for biopsy) without hesitation in order to obtain accurate diagnosis, whenever the lesion is suspicious.
Studied cases of gastric cancer were 203 among 464 cases of gastrectomized stomach cancers for the past three years in our university hospital, to which it was possible to perform the detail analysis of endoscopic findings and biopsied specimen. As a rule, eight pieces of biopsy specimen have been taken from one lesion in this study. In order to evaluate the accuracy of reading of endoscopic findings or technical skill of biopsy, the ratio were calcurated dividing the number of biopsied specimen proved to be cancerous histolo-gically, by the number of the biopsied specimen which the examiner believed to be cancerous. The fallowing discussions will be made by this ratio. In other words, when the ratio is 100%, itmeans the excellency of technique or easy performance of the biopsy.1) Types of the stomach cancer When the lesion was protruded type of stomach cancer such as type I, IIa or Borrmann I, the ratio was almost close to 100%, wherever the biopsied specimens were taken. In type IIc, ratio was satisfac-tory (74.1%) when the biopsies were taken from the cancer of the lesion, however, the ratio was low (58.3%), when the biopsies were taken from the merginal area to dicide the extent of the lesion. In type III or type III+IIc, the ratio was 58.3% when the biopsy was taken from merginal area, and it was 20% in adjacent area. The ratio was 42.1% in average. In Borrmann II, the ratio was 80% when the specimens were obtained from the excavated area, however, it was 51.7% when obtained from the rand wall. In Borrmann III, the ratio was approximately 70% from the center of the lesion and further less in the merginal area. In Borrmann IV, the cancerous tissue could be taken from the ulcerated area and over all ratio was only 52.8%.2) Analysis to the location of the lesion The ratio was high in the cases, of which lesion located either in the anterior wall of stomach or along the lesser carvatur and low in the cases of which lesion located in posterior wall of stomach or around( the carclia. This may be clue to the difference of technical difficulties, because the former lesions can he observed in en-face view, on the contrary, the latter lesions were only seen in profil or requir the retrograde technique, which make the biopsy forceps more slippery.3) Size of the lesion It seems that the size of the lesion does not influencethe ratio significantly. Therefore the importance of biopsy for the minor gastric cancer should be stressed.4) Ratio in sequence biopsy Eight biopsiecl were taken from one lesion in sequence numbering No.l to No.8. The ratio to obtain cancerous tissue in No.1 specimenn was 66.7% and it became 88.4% in No. 1 to No. 3, 98.9% to No. 6, and 100% to No.8, respectively. Therefore it is important to perform biopsy at least 8 times to obtain 8 pieces of specimen.5) Analysis of errorneous biopsyThe following 4 major contributory factors should be listed.1) malfunction of the instrument2) the site of the lesion3) technical factor4) the type of the lesion
Since the protruding type of gastric atypical epi-therium (ATP) had been well known to he a quite resemble to early gastric cancer type Ha in the clinical macroscopical features, in the present study, the ATP was further studied to know its nature as to whether this type of ATP might have a possibility to be becoming in showing malignant signs in future or not by the observations of its clinical features upto 5 years and also using autoradiography with 3H-thymidine, which indicated mainly cell mitosis in it. Most of ATP located in areas of gastric antrum and angle were under 2 cm diameters and found in 60 years old human been, while the early gastric cancer type ha in the same areas was found mainly in 50 years ones. Another difference was found in their sizes. The early gastric cancer type IIa was much larger than that of ATP. In order to know the possibility that the ATP might show gradual change in malignancy in long periods of time, 1.4 out of 70 patients were followed up by performing a couple time of endoscopic biopsy a year upto 5 years, average 2 years, and it was found that there was no sign of malignancy in all courses of the study. Although a number of cells labelled with 3H-thymidine had heed known to be increased in all of gastric cancers, there was no increase of labelled cells in ATP as well as that found in patients with gastritis and in normal gastric mucosa. It was also noted mat the labelled cells were located only in the surface of the lesions in ATP while they were uniformly located within all parts of cancer. The facts suggested strongly that the ATP itself had a quite clear nature which was difference from the cancer. Because some investigators suggested that the intes-tinal metaplasia, which was not a cancer, was a similar in its nature to the ATP, the comparison in each was made by the labelling technique with 3H-thymidine. In the intestinal metaplasia, labelled cells located in the areas of 450-600μ from surface while they were located at the areas of 50-200μ from the surface in the ATP, indicating that the ATP was not a similarr to an intestinal metaplasia.
This is a case of the 61 years old male, who noticed to have upper abdominal pain since March, 1971. lie was admitted to the 3rd Int. Med. of Nihon Univ. Hospital, and was attempted X-ray and endoscopic examinations. He was diagnosed as elevated lsions of duodenal bulb and was performed gastrectomy. This elevated lesions consisted of adenomas of the Brunner's glands. One of this having similar finding aberrent pancreas.
Five cases of pneumobilia were presented. Fiberduo-denoscopy, hypotonic duodenography and blood che-mistry were performed in them and comparative studies were done. Case 1 : 68 year old male. In 1972, he visited our hospital due to postpr.andial pain.. Plain abdominall film showed pneumobilia. Upper-gatrointestnal series showed barium reflux into the bile duct and gastric ulcer on the posterior wall of the middle hotly. A fistula was found on the posterior wall of the duodenal cap. Case 2 : 56 year old male. In 1965, cholectstectomy with papilloplasty was performed because of choledo-cholithiasis. In 1972, he took part in photof luorography of a gastic mass survy and was suspected of having choledochoduodenal fistula. Hypotonic duodenography and endoscopy revealed a giant duodenal diverticulum and patent Vater's papilla with redness of the surro-unding mucosa. Case 3 : 65 year old female. In 1971 papilaoplasty was performed at a local hospital due to common bile duct dilatation. Plain abdominal film showed pneumobilia. Fiberscopy revealed patent Vater's papilla with redness and edma, but the biopsy specimen of Vater's papilla showed no particular findings. Case 4 : 39 year old male. In 1972, papilloplasty was perf omed due to chronic pancreatitis with papil-th is. Hypotonic duodenography revealed barium ref lux into the bile duct. Endoscopically, patent Vater's pa-pilla with redness and edema was recognized. Case 5 : 64 year old female. In 1972, she was admitted to our hospital for the control of diabetes, mellitus. Routine upper-gastrointestinal series and hypotonic duodenography revealed a duodenal diverticulum with barium ref lux into the bile duct, but no particular findings were noted on endoscopy. Summary; We presented five cases including one case of choledochoduodenal fistula and four cases of incom-petent sphincter of Oddi. There are few reports on their endoscopic appearance of Voter's papilla in the cases of pneumobilia or bihary tree on plain film of the abdomen and reflux of barum into the bile duct on hypotonic duodenogram. Encloscopic examination should be performed in those cases. Endoscopy is of great help for the diagnosis of duodenal fistula and incompetent: sphincter of Oddi.