Endoscopic mucosal resection (EMR) was developed and widely spread for the treatment of early gastric cancer because of its minimally invasiveness. Otherwise, surgical therapy should be performed if the result of the first EMR is imperfect. To evaluate the feasibility of the whole therapy such as EMR, Laser Irradiation and Endoscopic Surgery, we studied the outcome after those several treatments for early gastric cancer. The EMR was applied for gastric cancer at the mucosal (m) layer or at the superficial submucosal (sm) layer without lymphatic (ly) and venous (v) invasion. The results of EMR would be perfect if no cancer was detected at the vertical and horizontal margins in the surgical specimens after EMR. On the other hand, Laparoscopic assisted gastrectomy was applied for gastric cancer measuring 10 mm or over in diameter, lesions of type IIc, at deep sm layer or deeper location, with lyv invasion, or the resting cancer by histological diagnose after EMR.
We examined 161 early gastric carcinoma cases. 49 cases were followed after EMR, EMR added laser irradiation were 58 cases, 14 cases were followed after simple laser irradiation and surgical gastrectomy were performed 53 cases, including 44 cases of laparoscopic assisted distal gastrectomy and 3 cases of laparoscopic assisted total gastrectomy. No lymphatic metastasis, surgical complications and recurrences after the surgery were observed.
We hope to treat the early gastric cancer completely by series of endoscopic therapeutic way.

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A new ultrasonic endoscope with a broadband transducer (GF-240CPM) has been developed by OLYMPUS Optical Co. LTD. The configuration of the scope is similar to conventional ultrasonic endoscopes. The tranceducer made from CPM (Composit Pieso-electric Material) can scan wide range from approximately 5MHz to 20MHz in frequency. Twelve gastrointestinal lesions were examined by this scope. High resolusional images of the lesions with the broadband scanning range were obtained by this new instrument. Both shallow and deep lesion were clearely visualized. The new ultrasonic endoscope and monitor system was quite usefull to examine the gastrointestinal lesions, and is likely to lead to further development in this field.

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We report two cases of gastrointestinal stromal tumor (GIST) with intramural growth in the stomach.
Patient 1, a 51-year-old woman was studied and showed that upper GI endoscopy revealed a submucosal tumor in the posterior wall of the upper stomach measuring 2cm in diameter. In order to avoid post-operative bleeding, the surgical ligature as the tumor was tied before the electrical resection. Histologically, the tumor was composed of spindle shaped cells with a few mitosis and these cells were negative for S100 and SMA, but strongly positive for CD34 by immunohistochemistry, therefore this tumor correspondanded to GIST, uncommitted type.
Patient 2, a 71-year-old man was admitted to the hospital because of abdominal discomfort. Upper GI series showed a large mass with a delle, which was suspected as a submucosal tumor in the middle body of the stomach. Enhanced CT scan demonstrated that the tumor located in the anterior wall of the stomach and the mass was enhanced homogenously. Distal gastrectomy with adrenectomy was performed because of a suspicion of low grade of malignancy. Immunohistochemical examination revealed that these cells were positive for CD34, c-kit, S100 and SMA, therefore this tumor was diagnosed as GIST, combined type.

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The prototype three-dimensional ultrasonic probes are developed to improve the mobility and visibility. We study a comparative ultrasonic visibility with prototype and conventional probes.
113 cases of gastrointestinal lesions were examined with either prototype and/or conventional probes.
The rate of surface rendering image (SRI) in 83 cases except for stricturing lesions is 84.3% (84.6% in upper vs 84.1% in lower digestive tract diseases) .
Even if the distance between the center of the probe and the surface of the lesion is shorter than 4mm, we were able to get the ultrasonic SRI of the lesion by the prototype probes.
No significant difference was noted between the prototype and conventional probes in terms of the penetration depth.
In conclusion, the prototype probes could construct the SRI of the lesion scanning with optimum distance between the probes and the lesion, being closer than the conventional probes.

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Eighteen cases of serrated adenoma resected colonoscopically from 1994 to 2001 were studied, and their colonoscopic findings were discussed. Mean size of the 18 lesions was 12 mm in diameters. Twelve of the 18 lesions were elevated. Twelve of the 18 lesions were reddish, 5 were whitish and the other was the same color as normal mucosa. Pit pattern was type II in 6 lesions, type IV in 6 lesions and type III_L in 4 lesions by magnifying colonoscopy. Five lesions were diagnosed as serrated adenoma, 10 as adenoma and 3 as hyperplasic polyp by colonoscopy. As the lesions with type III_L or type IV pit pattern were diagnosed to be serrated adenoma or adenoma, they were resected colonoscopically. However, three of 6 lesions with type II pit pattern were whitish, and were diagnosed as hyperplasic polyp by magnifying colonoscopy. These 3 lesions were resected colonoscopically because of the larger size comparing with common hyperplasic polyps. The serrated adenoma with reddish color, type III_L or type IV pit pattern could be diagnosed as neoplastic lesions. However, it is difficult to discriminate serrated adenoma with whitish color and type II pit pattern from hyperplastic polyp by colonoscopy.

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CT colonography, which consists of helical scanning with multi detector CT (MDCT) that uses volume data, was performed for small (less than 20mm diameter) and invasive colorectal cancers. 11 patients underwent the study after total colonoscopy as preoperative examination confirming one lesion in each patient (types : IIa＋IIc ; 4, type2 ; 4, IIa ; 1, IIc ; 1, Isp ; 1) . The type IIa lesion, so called laterally spreading tumor (LST) , coexisted with advanced cancer.
All patients could undergo CT scanning immediately after colonoscopy. A complete 3-dimension image examination lasted about 15 minutes in all cases and there were no complications. All elevated lesions such as type2, IIa＋IIc, and Isp were visible regardless of size with CT colonography. However, superficial type tumor and depressed type tumor were undetectable.
CT colonography was considered to be a useful non-invasive examination to detect colorectal elevated lesions in a short time. In USA, the procedure has been recently introduced for screening of colorectal cancer as a replacement of colonoscopy. The idea is based on a widely known concept of the adenoma-carcinoma sequence. In Japan, CT colonography is being used to reinforce the endoscopic and radiologic diagnosis. Presently, CT colonography is not considered as ideal procedure for screening in Japan because it is unable to detect superficial and depressed type tumors. However, once CT scanning is performed we can gain enough information about the lesion such as accurate location, direct invasion to the surrounding organs, presence of lymph node metastasis and distant metastasis. Marking with clip during endoscopy, the location of superficial or depressed type tumors also will be evident.
As a preoperative examination along with colonoscopy, CT colonography might replace the barium enema examination.

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We have conducted research on three-dimentional (3D) -CT image, especially CT enema (air-contrast enema) with multidetector-row CT (MDCT) , whether CT enema is useful as preoperative examination of colorectal cancer.
The purpose of this study was to evaluate cancer location and depth of invasion using CT enema images obtained by MDCT. Eighty-seven patients (96 lesions) with pathologically proven colorectal cancer were enrolled. After conventional colonoscopy and gaseous distension of the large intestine, MDCT scans using Aquilion (TOSHIBA, Tokyo, Japan) were performed with intravenous administration of contrast medium. With the data obtained by MDCT, we reconstructed CT enema images and assessed detectability of cancer location and profile images for diagnosis of depth of invasion. The depth of invasion was evaluated by the deformity of the lesion in the colorectal wall. The deformity was classified into five groups : none, wedge shape, semilunal, trapezoid and apple-core like.
The detectability of cancer locations was 94.8% using marking clip that was applied during colonoscopy (91 of the 96cases) .
In conclusion CT enema demonstrated a good detectability of colorectal cancer location. As depth of invasion became deeper, grade of the deformity became more severe. CT enema appears to be an useful preoperative examination for laparoscopic and open surgery. Since 3D-CT is less invasive examination compared to barium-contrast enema, it might be a preferred method for preoperative examination of colorectal cancer.

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Recently large number of patients with early gastric carcinoma has been treated with endoscopically and the indication for EMR has been extended. It is important to make the EMR technique more easily and safety and it is also necessary to resect the lesion totally at once, so-called complete resection, for an appropriate pathological evaluation. Among various devices and methods invented for these purposes, we have used a translucent flexible hood and a needle knife at EMR in order to dissect the submucosal layer for complete resection.
This technique was appleied for 33 lesions of the 32 patients with early gastric carcinoma in 2001 and 30 lesions (91%) ware completely removed endoscopically without perforaiton. We can resect the lesion assuredly with identifying the submucosal and muscle layer under closed view through the translucent hood lifting the lesion. However, it is difficult to treat the lesions at the upper body of the stomach with this technique.

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Endoscopic mucosectomy was done for sixty-six lesions of early gastric cancer which were diagnosed well to moderately-differentiated adenocarcinoma during a period from 1999 to 2002 at Ibaraki Prefectural Central Hospital&Cancer Center. The depth of the cancerous invasion in the gastric wall limited to the mucosa and the lesion was not accompanied with fold convergence and ulcer. A single fragment mucosectomy was carried out in 70% of the lesions of 21 to 30mm diameter. But it was performed in 72.2% of the lesions smaller than 10mm diameter, 60% for the lesions 11 to 20mm diameter which was lower than the result of EAM (endoscpoic aspiration mucosectomy) (84.3% Ref.1) .
Endoscopic mucosectomy using insulation-tipped diathermic knife for early gastric cancer was recommendable especially for the lesion larger than 21mm diameter. EAM is rather thought to be adequate for the lesion less than 20mm diameter. Recently we use hyaluronic acid sodium for lifting submucosa, which we hope, makes the result of a single fragment mucosectomy improved.

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Percutaneous endoscopic gastrostomy (PEG) -push and pull methods need reinsertion of endoscopy for the observation of a relation between gastric wall and a PEG catheter bumper to confirm correct placement. There is a possibility that the difficult reinsertion of endoscopy induces patient's stresses and aspiration pneumonia. We tested a guide wire (GW) using new method for reinsertion of endoscopy in PEG-push method.
This new method is modified PEG-push method. The inserted GW exits the body from the patient's abdomen and mouth. Slide the device, dilator end first, over the end of the GW that is exiting the patient's mouth. Maintain firm tension on both ends of the GW as the device passes through the oropharynx and into the stomach. As the firm, tapered end of the device is pushed through the anterior abdominal wall it will also push the cannula out. Oral end of the inserted GW is introduced into the endoscopic channel with a grasping snare. Tip of the endoscope becomes near the bumper of a PEG catheter. Pull the inserted GW and tapered end of the device of a PEG catheter. The bumper of a PEG catheter and tip of the endoscope pass easily and quickly through the pharyngoesophageal junction and into the stomach.
This new GW using method is significantly reduced the reinsertion-time and shortened the rate compared with conventional method.
This new method enables us to easy and quick reinsertion of endoscopy in PEG-push method and reduces patient's damages such as stresses and aspiration pneumonia.

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Endoscopic Retrograde Chorangiography (ERC) has been used as a preoperative examination of laparoscopic cholecystectomy. Recently, we have introduced Magnetic Resonance Cholangiography (MRC) , and compared both examinations in respect to diagnostic usefulness.
Methods : The objects included 49 cases who underwent ERC and MRC prior to laparoscopic cholecystectomy. We studied the rate of visualization of biliary tracts (intrahepatic duct, extrahepatic duct, cystic duct, gallbladder) and cholelithiasis (gallstone, common bile duct stone) .
Results : (1) MRC was less invasive examination and was useful for screening test. (2) The visualization rate of extrahepatic duct, gallbladderand and gallstone was significantly higher in MRC (p＜0.05) . (3) There was no significant difference in visualization between two examinations. (4) ERC should be withheld until MRC demonstrates positive findings.

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A 75 year-old female was admitted to our hospital complaining of hematemesis and chest pain after food ingestion. Urgent upper-endoscopy revealed the existence of esophageal submucosal hematoma with dissection extending the posterior wall of the entire esophagus. The esophagograms showed so-called double barrelled esophagus. The CT scan of the chest revealed thickening of the esophageal wall and air appearance beside the true esophageal lumen. Fasting and intravenous hyperalimentation were prescribed on admission. Her condition and the endoscopic findings improved immediately. The endoscopic examination on the 22 day of hospitalization showed that the elevated lesion had disappeared and the esophagograms also improved. She started to take meal, however, the symptoms did not relapse.
Generally speaking, the prognosis of this disease is excellent under the conservative therapy. In this case, it seemed that a sudden rise of the internal pressure of the esophagus injured blood vessels in the submucosa and caused the submucosal hematoma.

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A 57-year-old male was admitted to our hospital complaining of slowly progressing dysphagia. Upper gastrointestinal endoscopy visualized stricture of the in the lower esophagus, and barium study documented smooth narrowing of the lower esophagus. Biopsy specimens taken from the narrowed segment failed to reveal any evidence of malignancy. He was diagnosed as having idiopathic benign esophageal stricture. The initial balloon dilatation succeeded to improve the narrowing of the esophagus, but he developed dysphagia again 2 months later. Repeated balloon dilatations were unsuccessful. Finally, he agreed to have operation done, and wall thickening of the lower esophagus was noted in the resected specimen. Histologically, marked fibrosis in the submucosal layer was only seen.
Benign esophageal stricture is known to be induced by infectious, chemical, physical and other factors. There have been several reports on benign esophageal stricture probably due to submucosal dissection with sudden onset of retrosternal pain. In our case, however, etiology may be different from submucosal dissection because of no episode of retrosternal pain and slowly progressing dysphagia. Surgical resection of the esophagus was performed in this case, but the best suited treatment of this pathological condition is awaiting to be solved.

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On the occasion of a screening examination of the esophago-stomach, a slight elevated lesion in the Barett's mucosa was detected at the squamo-columnar junction of a 69-year-old man. Biopsy specimens revealed well differentiated adenocarcinoma. EMR (Endoscopic Mucosal Resection) was performed.
The resected specimens revealed that its invasion was within mucosa and cut ends were negative for carcinoma.

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A 68-year-old woman was hospitalized because of dysphagia and paralysis of bilateral lower extremities. Magnetic resonance imaging of the spine showed metastatic tumor in the thoracic spines (Th) 10-12 and compression fracture in the Th11. Spinal decompression and fusion operation were performed. Endoscopic examination done for searching the primary region revealed a type 1 of esophageal tumor with marked esophageal stenosis. Histopathological examination of the spinal tumor showed the suspicion of adenoid cystic carcinoma, whereas histopathological diagnosis of the esophageal biopsy specimens was poorly differentiated squamous cell carcinoma. Thus, further immunohistochemical examinations were done for addressing the diagnostic inconsistency. Since cytokeratin 10 and α-SMA were negative and cytokeratin AE1/AE3 was positive, we reached the final diagnosis of basaloid squamous carcinoma of the esophagus. In case of basaloid squamous carcinoma, immmunostaining is considered as an essential method for differential diagnosis.

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This paper describes a case of granular cell tumor (GCT) of the esophagus, of which was detected incidentally by the demonstrational use of new two channel endoscope.
A 24-year-old female underwent an endoscopic examination as a volunteer for the demonstrational use of new endoscope.
Endoscopic examination showed a yellowish white sessile protruding lesion in the lower esophagus. Because the obtained specimen by forceps biopsy was too small to make a diagnosis, two channel endoscope was inserted and boring biopsy was performed by holding the root of the tumor with snare forceps. The obtained specimen was sufficient to make a diagnosis. EUS disclosed that the tumor had no invasion to submucosal and proper muscle layer, thus we adopted endoscopic treatment for GCT removal. Endoscopic resection should be taken into consideration as the first choice when the tumor is limited to the mucosal and submucosal layers.

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A 76-year-old woman was admitted to our hospital for an irregular elevated lesion of 20 mm in diameter located in the fornix of the stomach. Endoscopically carcinoma was highly suspected, but biopsy specimen showed granuloma with invasion of chronic inflammatory cells. EUS suggested a possibility of submucosal tumor. The shape of this lesion changed quickly to the flat after repeated biopsy. Endoscopic resection was performed to obtain the diagnosis. Histopathologically, inflammatory cell infitration was prominent, diagnosing eosinophilic granuloma (inframmatory fibroid polyp ; IFP) of the stomach. IFP in the fornix in the stomach is rare. In addition, this patient received gastroscopy one year before this episode, showing no evidence of tumor at all.
Endoscopic resection is useful for diagnosis of IFP, because it is difficult to diagnose IFP from biopsy specimens.

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A 78-year-old man had been treated for bullous pemphigoid with nicotinamide and steroid ointment, and examined for internal malignancies. He was diagnosed as elevated type of early gastric cancer (I＋IIa) by endoscopy and gastric biopsy (group V) . His past history was cerebral infarction and hypertension. Hypothalamus/adrenal function and immune function were normal. Distal gastrectomy and D1 lymph node dissection were performed with Billroth I reconstruction. Macroscopic examination revealed that elevated lesion was apparent on the specimen without mucosal tension. Once the mucosa of the specimen was spread with tension, the edge of elevated lesion became unclear. Tumor was 7×5 cm in size and diagnosed as elevated, superficial spreading type of early gastric cancer. Pathological examination revealed as papillary adenocarcinoma, m, aw (－) , ow (－) , n0 and stage IA. He was recovered quickly and discharged on 14th post-operative day. It was difficult to diagnose the edge of tumor spreading with mucosal tension in case of superficial spreading type of gastric cancer. Most of superficial spreading tumor have IIb-like invasion at the oral side of the cancer, so it is important to observe whether there is superficial invasion on the oral side of the cancer or not in this case.

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A 45-year-old man was hospitalized because of incapability of taking food by mouth due to abdominal distention. On admission an upper gastrointestinal endoscopy demonstrated gastric cancer of type 3. Abdominal CT scans revealed the presence of massive ascites. A cytological examination detected Class V. Consequently, under a diagnosis of Stage IV gastric cancer, the patient received single agent chemotherapy with TS-1. The primary cancer was reduced in size with disappearance of ascites after 5 months. Because laparoscopy demonstrated neither ascites nor any peritoneal metastasis, this patient underwent a total gastrectomy by laparotomy. Intraoperative washing cytology was also negative for tumor cells. With the surgical specimen, the cancer, remaining confined to ss, was at stages of N2 and P0. The chance of cure after the curative resection was estimated as B.
This is a report of a case in which we achieved a successful curative resection of gastric cancer with peritoneal seedings, which had been reduced in size with disappearance of ascites by oral chemotherapy with a single agent TS-1 alone and hence, had become surgically resectable. Chemotherapy, but not surgery, is the current standard treatment for advanced gastric cancer associated with peritoneal seedings because surgical resection has not significantly improved the prognosis of such advanced gastric cancer. The progress in anticancer agents has made gastric cancer chemosensitive although seldom. Consequently, neoadjuvant chemotherapy should be considered as a choice of therapeutic modalities even if gastric cancer has advanced to Stage IV.

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We report two cases of advanced gastric cancer involving the pyloric ring, which was difficult to diagnose properly by endoscopic examination and biopsy.
Case 1 : A 70 year-old male with pyloric stenosis. Six biopsy specimens were taken from the lesion, and only one of them pathologically showed gastric cancer.
Case 2 : A 69 year-old male with a type 2 gastric cancer involving the pyloric ring.
The first endoscopic examination was performed 5 months before operation, but was diagnosed as benign gastric ulcer, and biopsy specimen also showed no evidence of cancer. Endoscopic examinations were performed again twice thereafter, and only one biopsy specimen showed cancer.
The difficulty in getting precise diagnosis is due to the fact that most of the cancer cells exist in the submucosal layer or deeper. And endoscopists tend to take biopsy from the ulceration in the center of the lesion, because it is easy to reach the center of the lesion by biopsy forceps. But as for type 2 gastric cancer involving the pyloric ring, the ulceration is closed by the surrounding wall covered with normal mucosa due to the stricture of the ulcer bed. For this reason, most of the biopsy specimens from such lesions are normal mucosa. Endoscopists should be careful in the diagnosis of type 2 gastric cancer involving the pyloric ring.

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We describe an 81-year-old female, who suffered dysphagia attributable to cerebral infarction. In order to provide her long-term nutritional support, we performed percutaneous endoscopic gastrostomy (PEG) . She developed ileus on the following day, and a wound infection 6 days after the tube placement. These complications were treated successfully.
On 15th day a part of the bumper of the PEG catheter was seen at the stoma. On the following day, the patient underwent a gastric endoscopic examination, which revealed that the top of the gastrostomy tube was buried beneath the gastric mucosa. The PEG catheter was removed, followed by decompression of the gastric cavity, and disinfection of the wound by the emergency gastroendoscopy, resulting in amelioration of her general condition.
In Japan, the incidence of buried bumper syndrome is reported to be 0.4-6.3%, 1.2% on average. So it is a rare complication. Its primary cause is considered to be excessive compression toward the stomach wall. It is, however, very rare to see it shortly after that kind of operation.
The main causes of this complication in this case, seemed to be long term and excessive traction of the catheter to prevent outflow of the intestinal contents into the peritoneal cavity in case of ileus, as well as fragility of the abdominal wall due to fistula infection.

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A 83-year-old woman complaining of right hypochondralgia was transferred to our hospital for further examination from her home doctor. Investigations revealed leucocytosis, elevation of hepatobiliary enzymes, CRP and CA19-9. Abdominal US revealed heterogeneous hyperechoic mass with hypoechoic lesions and stone with acoustic shadow in the neck of the gallbladder. Abdominal CT scans showing hypovascular area in the thickening gallbladder wall and suspect of infiltrating to the duodenum. Endoscopic findings revealed edematous mucosa and stenosis of duodenum, with partially yellowish mucosa. Operation was performed under the diagnosis of gallbladder cancer infiltrating to the duodenum. The gallbladder appeared extensive adhesions was found to such adjacent organs as liver and duodenum. Diagnosis was gallbladder cancer invasion to the liver and duodenum based on operative findings. Cholecystectomy with partial hepatic resection of the gallbladder bed and a partial resection of the duodenum was done. Surgical specimen revealed marked thickened yellowish wall, the stone was impacted in the neck and made fistula to the duodenum. Histopathological findings revealed foamy histiocytes, inflammatory cells in the thickened gallbladder wall. Xanthogranulomatous cholecystitis was diagnosed. When we observed yellowish mucosa of the duodenum in GFS, xanthogranulomatous cholecystitis must be considered as one of diffential diagnosis.

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Four cases of lymphangioma of the duodenum were reported. All of the tumors were found in the second portion of the duodenum with endoscopy. They were yellowish elevated lesion with smooth surface and were 7 to 15 mm in diameter. Their appearances were quite similar to xanthoma. The histological examination revealed normal epithelium and dilated lymphatic vessels filled with lymphatic fluid in the submucosa. Lymphangioma of the duodenum is benign tumor, however, there are only 45 reports about them. The exact incidence and natural history of lymphangioma of the duodenum should be elucidated.

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We experienced two cases of early duodenal cancer treated endoscopicslly. The first case was a 79-year-old male with a flat elevated lesion at the second portion of the duodenum. Endoscopic resection using EMRC procedure was performed successfully with a good view and without perforation. The second case was a 79-year-old male with a protruded lesion at the second portion of the duodenum. After ligating the tumor with detachable snare, endoscopic resection was performed without bleeding and laser therapy was added for the residual lesion without complication. Both cases are free from the duodenal cancer up to now. We suppose that endoscopic treatment for early diodenal cancer can be performed safely and sufficiently using an adequate technique.

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A 69-year-old man who had undergone pylorus-preserving gastrectomy for early gastric cancer 7 years before was diagnosed as a B cell lymphoma (small cell type) in the duodenum by annual endoscopic examination with biopsy. The lesion was located at the anterior wall in the descending part of the duodenum, and its size was 1cm in diameter. It was considered to be a MALToma with positive for Helicobacter pylori (H.p.) infection and eradication of H.p. was performed. Four months later, the endoscopic examination revealed no apparent effect after the successful eradication. Furthermore, cytogenetic examination showed abnormality of t (14 ; 18) . Therefore, this case was suspected as follicular lymphoma. Under the clinical diagnosis of the stage I case of duodenal lymphoma without response to H.p. eradication, local resection was successfully performed and the post operative course was uneventful. The histopathological diagnosis was follicular lymphoma decisively, the surgical margin was free from lymphoma and resected regional lymph nodes were not involved. When curative resection without difficulty is predicted and least defect of post operative quality of the patient's life is expected, surgical treatment might be worth the second line of treatment after the erradication therapy for H.p.

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Multiple carcinoid tumor in the duodenal bulb was found by upper GI endoscopy performed as an annual check up of 53 years old male. His serum gastirn level was elevated to 702pg/ml. CT scan revealed no metastasis of carcinoid tumor nor lymph node swellings. The tumor was sized 7mm and 5mm, both were located in mucosa and submucosa of the duodenal bulb by EUS examination. Endoscopical mucosal resection (EMR) was performed and the tumor was completely removed. Serum gastrin level went down to 123pg/ml after the EMR. Immunohistochemical examinations of the tumor by anti-gastirnantibody and chromogranin A were both positive. 7 months after the EMR, left renal cell carcinoma was found by CT scan examination and left nephrectomy was performed. Only 6 cases of multiple duodenal carcinoid tumor were reported in recent 25 years in Japan, 3 cases with hypergastrinemia. By the pathological observation of the tumor biopsy specimen as well as the size of tumors, we chose EMR to treat this case. But It is important to keep up the close examinations to detect the recurrence however the tumor was thought to have low grade of malignancy. It is also important to check up the existence of malignant tumor of other organs when you find duodenal carcinoid tumor.

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A 31-year-old woman was admitted to the hospital because of severe abdominal pain. Her abdomen had severe tenderness, rebound tenderness, and muscle defense which presented with peritonitis. A chest X-ray showed free air under her diaphragm. She had emergency surgery. A perforation about 9mm in diameter was observed in the ileum 40cm proximal from the Bauchin valve. We found two longitudinal ulcers in the resected ileum within a perforation and checked the other small intestine with intraoperative endoscopy through a corrugated tube. We were able to find other two ulcers in the remnant ileum and remove the ileum with ulcers as shortly as possible.

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A 63-year-old man was transferred to our hospital for hematochezia syncope. First colonoscopy revealed colonic diverticulosis in the cecum and ascending colon, but the precise bleeding point diverticula was not determined. After the colon has bees purged with polyethylene glycol, the second colonoscopy was able to identify an exposed vessel with the diverticulum in the ascending colon. The diverticulum was closed by 3 pieces of clipping devices. The patient has not been re-bled. Since the wall of colon diverticulums is very thin, the clipping is better than ehanol-injection or heater-probe. To identify the precise point of bleeding make us do easy colonoscopic hemostasis. In this case, it is very important to purge the colon as much as possible to identify the precise bleeding point of the colon bleeding.

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We reported 3 cases of amebic colitis detected by positive for fecal occult blood test in mass screening. The cases were of 52 to 60 years old male. They visited to our hospitals because of positive fecal occult blood test in mass screening. All of them were free of any abdominal symptoms. In all of these cases, colonoscopic examination revealed ulcerated lesions covered with whitish exudate in the cecum, and another part of the colon and rectum appeared normal. Biopsy specimens revealed large numbers of trophozoites of Entamoeba histolytica. Out of three cases, two cases had previous history of visiting to South-East Asia, but one had no history of staying aboard. They were not homosexual and showed negative for antibody of human immunodeficiency virus. Comparing with common amebic colitis, characteristics of these cases were as follow : 1) all of them were asymptomatic, 2) ulcerated lesions existed only in the cecum. Two cases were estimated as imported enteric infection, another one was unclear.

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A 78-year-old man treated by oxygen therapy and low-dose prednisolone (5mg/day) for chronic pulmonary emphysema contracted pneumonia and was prescribed antibiotics by his home doctor. About a week later, he was admitted to our medical center because of severe hematochezia. The disease was diagnosed as the total colitis type of ulcerative colitis based on colonoscopic findings. After his pneumonia improved, the patient was started on prednisolone 40mg/day, corticosteroid enema, and total parenteral nutrition. 6 weeks later the patient's condition improved.
Ulcerative colitis in older patients aged over 70 has been considered more severe than that in younger persons, but our patient responded well to medical therapy and has not relapsed for eighteen months.
Smoking is the most common cause of chronic pulmonary emphysema. Current smokers are at a decreased risk of developing ulcerative colitis, while former smokers face an increased risk. We suspect that smoking and low-dose prednisolone protected our patient form ulcerative colitis until he reached the advanced age of 78 year-old.

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A 67-year-old man was admitted to our hospital complaining of bloody stool and abdominal pain after eating raw oyster. He ate oyster with his colleague at restaurant. Before he ate oyster, he had normal stool. After eating raw oyster, 16 peaple had watery diarrhea but no one had bloody diarrhea.
One of them was diagnosed to have Small Round-Shaped Virus by stool culture. Laboratory tests showed leukocytosis and an elevated CRP level. First we diagnosed to food poisoning and patient was thought to have infective colitis, so we prescribed antibiotics. But his symptom still continued so we repeated endoscopic examinations.
At first endoscopic examination, we thought non-specific colitis pathologically so we continued to prescribed antibiotics. At second endoscopic examination, we suspected the amabiec dysentery and prescribed metronidazole. But his symptom still continued. At the third endscopic examination, he was diagnosed to have ulcerative colitis pathologically. It took about 2 months to diagnose. We started the medical therapy with steroid and 5-ASA and soon his symptom got better. At the forth examination, endoscopic fingings were getting better remarkably. Then he had MRSA lung abscess and we prescribed Vancomycin and he got better. After that he had bleeding gastric ulcer and was treated endoscopically.

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A 75-year-old woman who had persistent right abdominal pain for 16 months visited our department for the detailed examination. Plain abdominal X-ray film showed linear calcification along the colonic wall from the ascending to the descending colon. Abdominal CT scan showed marked colonic wall thickening with calcification of the ascending and transverse colon. Colonoscopic view showed blue-purple colored mucosa with indistinct vascular pattern from the cecum to the descending colon and several erosions in the transverse colon. Histological examination of the biopsied specimen showed hyaline like degeneration aroud the small blood vesels and fibrous thickening in the submucosa. Based on these findings, the patient diagnosed ischemic intestinal lesion caused by phlebosclerosis. This disease has rarely been reported and their pathogenesis remain unknown. We discuss the clinical and histological characteristics of this disease.

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The patient was a 75-year-old woman, diagnosed with hyperlipidemia and hypertension. She was admitted to the hospital in January 2001 because of paralytic ileus accompanied with diverticulitis. Barium enema showed linear ulcers in the transverse colon in March of the same year. At colonoscopy there were active linear ulcers in splenic flexure in April and these findings were compatible with ischemic colitis. When colonoscopy was done in December, a new lesion was found in sigmoid colon. Repeated colonoscopy in January 2002, there were ischemic lesion along with bleeding and edema in the sigmoid colon, sodium picosulfate was included as pretreatment of all four of examination and after taking it she presented nausea and abdominal pain. The abdominal pain was agree with ischemic lesion in colon. The symptoms were brought about repeatedly for using sodium picosulfate and active ischemic coltis was confirmed by colonoscopy. In addition, colonoscopic pretreatment without sodium picosulfate did not result in any colonic ischemic lesion. It seems that sodium picosulfate caused illness.

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A 67 year-old male underwent endoscopic examination because of the positive occult blood test for a type Is lesion to be detected in the sigmoid colon. On the second endoscopic examination, 42 days later, the appearance came to alter very drastically to reveal the two storied arch structure of polyp on polyp measuring 10mm and indicative of sm₂ type Is early cancer, no EMR performed. More 20 days later, through detailed magnifying endoscopic examination, the protrusion on the top previously pointed out thoroughly collapsed. Cancer was present at the rising part of the lesion and a depressed territory was discernible on the surface accompanying a central internal concave. After crystal violet staining, pit pattern of type V_I was present at the rising part of the lesion, pit pattern of type V_I＋V_N was admitted in the depression territory and the internal concave. Accordingly, the lesion was concluded as sm₂, ₃ cancer to be resected by laparoscopically aided colectomy. Pathologically type Is 11×10×4mm, sm₂, moderately diff aderoca predominantly but poorly diff aderoca at the outpost of cancer, no adenoma component, ly 2, v1, n1 (＋) , polypoid growth derived. Type Is sm cancer, which should have been diagnosed as sm₂ upon close scrutiny even at the initial examination, showed proliferation and collapse resulting in the formation of the depression in the elevation, possibly or probably, associated with the progression to small type 2.

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A case of a small advanced colon cancer in Rs with a 50-year-old man. As a result of positive outcome in stool occult blood test, we carried out a barium enema examination (BE) and colonofiberscopy (CF) . BE finding showed a size of 12 mm protuberant tumor with a central hollow and the surface changed to wavy in a lateral view. CF finding showed the lesion that had fold concentration and tumor vessels on its surface. We diagnosed that cancer invaded to sm3 - mp1 layers and treated the patient with colectomy. The results of operation showed that tumor was non-polypoid growth type without adenoma and invaded to ss layer with lymph node metastases, while some normal mucosa remained in patches on the tumor. It suggests that there was imbalance between horizontal and vertical speed of evolution.

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A 75-year-old male turned out positive for the fecal occult blood test without any complaints. A pedunculated but broad-based lesion measuring about 10mm and lacking in mobility was discerned in the sigmoid colon, the top of which assumed an asymmetric and expansive growth. The surface looked uneven and reddened causing haemorrhagic fragility resulting in the formation of depressed erosions and nodules, which was deduced to be indicative of sm₂ or deeper cancer. Barium enema likewise revealed no mobility. The entire lesion comprised V_I pit, and V_N pit was also discerned in depressed portions. Pathologically, well to moderately differentiated cancer (high grade atypia) without adenoma component, cancerous depth sm₁, ly0, v0, cut end (－) , interstitial permeation from the bottom of glands present. Despite the features indicative of sm₂ or deeper, the lesion resulted in minimally invasive sm₁. The present case cautioned us not to make an over-diagnosis between mucosal and sm₂ cancer in that there actually exists the limitation or the very difficulty in the clinical diagnosis concerned.

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A 47-year-old male who had underwent surgical operation because of sigmoid colon carcinoma before 7 years was admitted to our hospital for follow-up examinations. Colonoscopic findings showed a small elevated lesion with a central depression in the descending colon. We tried to perform endoscopic mucosal resection for this lesion, but elevation of the tumor was not observed after submucosal saline injection. Magnifying colonoscopic findings with crystal violet staining showed type V_N pit pattern in a depressed area on the tumor, and histological diagnosis of the biopsied specimen was well differentiated adenocarcinoma. Left hemicolectomy was performed. Macroscopic findings of the resected specimen showed a IIa+IIc-like lesion, measuring 6×5 mm in size.
Histological findings showed adenocarcinoma invading the subserosa accompanied by fibrosis in the submucosa and marked focal hypertrophy of the muscularis propria. No metastatic lesion was detected in the resected lymphnodes.
Advanced colorectal carcinomas less than 10mm in size are very rare. We also reported the clinicopathological characteristic of these small lesions in Japanese literatures.

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An 83-year-old female admitted our hospital due to the occlusive ileus. An abdominal ultrasound and CT scan revealed the tumor at the hepatic flexure of the colon. Colonoscopy revealed the stenosis due to the tumor preventing the colonoscope passing through the lesion. Surgical operation was not indicated due to the insufficient cardiovascular function as well as dementia, while magnetic compression anastomosis was indicated. The first magnet was placed in the duodenum endoscopically. After it was confirmed by X-ray that the first magnet had moved in the ascending colon, which was the oral side of the tumor, the second one was placed endoscopically in the right side of the transverse colon, which was the anal side of the tumor. The two magnets attached the walls of both colons. Three weeks after the maneuver, the fistula between the ascending and the transverse colon was confirmed endoscopically. She started to eat and discharged safely.
This maneuver is a quite useful method for the patients with the occulusive ileus under poor general condition for surgical operations to enable them to have meals orally and without the stoma.

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A transverse colon tumor on the colonic fold, with 40 mm in size, was detected in a 58-year-old man who underwent colonoscopy for a positive occult blood test. Biopsy was taken from the tumor and it revealed tubular adenoma, but the possibility of focal cancer existed, considering the size and endoscopic appearance of the tumor. Exfoliative endoscopic mucosal resection (EMR) using a tip of an electro-surgical snare (thin type) and ICC 200 was performed because strip biopsy was associated with a high risk of piecemeal resection due to the size and the location of the tumor. The tumor was successfully resected en bloc by the exfoliative EMR. Histological examination showed a well differentiated adenocarcinoma-in-adenoma. The margin of the specimen was free of tumor along its circumference. Thus, the pathological findings fulfilled the criteria for curative EMR. This procedure seems to be useful for en bloc resection of relatively large mucosal colorectal tumors, even when they are located on the colony fold.

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An 18-year-old-woman was admitted to our hospital complaining of the abdominal pain on 2 October, 2001. Ultrasonography and CT revealed massive ascites.
Emergent laparoscopic operation was performed on the following day. Yellowish brown sticky ascites was recognized in the whole abdominal cavity and right oviduct was reddish, inflammatory and easy to bleed. The patients was diagnosed as Fitz-Hugh-Curtis syndrome. Bleeding from right oviduct could not be controlled, therefore we converted to open surgery and controlled bleeding.
As the laparoscopic procedure has been popular, the surgeon must have the capability to make decision of conversion to open surgery under the appropriate circumstances.

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A 54-year-old man was admitted with complains of epigastralgia and body weight loss. Endoscopic and barium meal studies showed an elevated lesion such as a submucosal tumor located at the posterior wall of the angulus and the antrum. The lesion was diagnosed as having poorly differentiated adenocarcinoma by the biopsied specimen. Abdominal CT showed an elevated lesion of the stomach, the irregularity of duodenal wall, lymphnode swelling and no metastasis to the liver and the lung. ERCP indicated the stenosis of distal bile duct, and adenocarcinoma cells were detected in bile juice and biopsied specimen of distal bile duct. This case was diagnosed having distal bile duct cancer, and metallic stent was inserted to the portion of stenosis. Although the patient was treated with gemcitabine, the therapy was discontinued because of thrombocytopenia. The patient died on the 47th hospital day because of peritonitis caused by gastric perforation. Autopsy findings revealed that poorly differentiated adenocarcinoma cells infiltrated into the submucosal layer of distal bile duct with lymph duct invasion and multiple lymphnode metastesis. No metastasis was found in the liver and the lung. We reported a interesting case of bile duct cancer with unusual gastric lesion.

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A 68-year-old female consulted our hospital by complaining of nausea and appetite loss, and was admitted with a diagnosis of duodenal obstruction on August 27, 2001. Duodenography showed severe stenosis of the second portion of duodenum due to invasion of bile duct carcinoma. Expandable metallic stent (EMS) was inserted for the duodenal stenosis using a sliding tube for jejunoscopy. After the treatment, abdominal symptom was relieved and no complications were developed.
EMS replacement for the duodenal stenosis is generally difficult, because the delivary system cannot easily pass through stenosis due to bending in the stomach. This procedure using a sliding tube for jejunoscopy is thought to be one of the useful methods for EMS replacement. EMS replacement could maintain patient's quality of life compared with other methods and could be palliative treatment for inoperable malignant duodenal stenosis.

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Dynamic CT and ERCP play an important role in the differential diagnosis between pancreatic cancer and chronic pancreatitis. However, we experienced a case of cancer of the pancreatic head that it was difficult to distinguish from chronic pancreatitis by the two examinations. The pancreatic tumor in this case on CT was enhanced identically to the surrounding parenchyma of the pancreas in both early and delayed phases. ERCP showed the smooth stenosis of the common bile duct and the stenosis of the main pancreatic duct with the visualization of the branches from the stenosis, suggesting chronic pancreatitis. Abdominal anginography revealed the obstruction of the pancreatic arcades and seemed to be a useful tool on the differential diagnosis between pancreatic cancer and chronic pancreatitis. In addition, the brushing cytology under ERP that demonstrated class V in this case should be performed in such a difficult case of distinguishing between these two diseases.

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A 65-year-old man was diagnosed with acute pancreatitis and admitted to our hospital. The disorder was improved by conservative therapy and the patient was discharged. However, acute pancreatitis recurred on the same day and the patient was re-admitted. Abdominal CT did not show any significant tumor in the pancreas. MRCP detected localized stenosis and dilatation of the pancreatic duct in the pancreatic tail, and acute aggravation of alcoholic chronic pancreatitis was suspected. ERCP detected obstruction of the main pancreatic duct in the pancreatic tail. EUS detected a hypoechoic tumor with a clear boundary and an irregular margin measuring 13.9×10.8mm in the pancreatic tail. A diagnosis of cancer of the pancreatic tail complicating alcoholic chronic pancreatitis was made, and pancreatectomy of the pancreatic tail was performed. A tumor measuring 1.3×1.0cm was observed in the pancreatic tail in the excised preparation. The histopathological findings showed the feature of usual invasive ductal carcinoma and papillary adenocarcinoma was partially observed.
For early detection of small pancreatic cancer, thorough examination by EUS and ERCP is necessary, even if US or CT fails to reveal a tumor even for patients admitted for pancreatitis.

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We report a case of main duct type of intraductal papillary-mucinous tumor (IPMT) with minimal invasion followed-up for eight months after initial diagnosis.
A 63-year-old man had been diagnosed with IPMT by direct biopsy of the tumor at the tail of the main pancreatic duct under endoscopic retrograde pancreatography (ERP) guidance in June 2001. The patient had refused operative treatment and had followed up as an outpatient for eight months. During this period, he had suffered from recurrent pancreatitis.
He admitted again to our institution in order to reevaluate IPMT in January 2002. Computed tomography and ERP demonstrated obvious diffuse dilataion of the whole pancreatic duct. Filling defects due to mucin and also tumor were observed on ERP. A small mass was found in the distal part of the dilated main pancreatic duct.
For gaining curative outcome, distal pancreatectomy with splenectomy and lymphoidectomy of 1st and 2nd group was performed. Pathologic findings showed that tumor was located in the tail of the main pancreatic duct, 7mm in size. Minimal invasion to pancreatic parenchyma with maximum depth in 4mm was also confirmed.
Differentiation between adenoma and carcinoma, prediction of having invasive nature, and diagnosis of minimal invasion are now clinical challenge.

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