The biopsy forceps, Model FB-40K of Olympus Optical Co, is an instrument that has been improved to increase the ease and accuracy of biopsies being taken from tangential lesions of the esophagus and stomach. To this end, a V-notch is made in its cup and a swing mechanism is provided.
Having an opportunity to use this up to the minute biopsy forceps, we compared it with conventional instruments (FB-21K, FB-25K) . As a result, it was shown that the FB-40K surpassed conventional instruments in accuracy of orientation and ease of manipulation, but appeared to have some difficulty in taking out the forceps from the biopsy channel of the scope in a few instances and cause a little more bleeding on biopsy.
Sections of biopsy specimens that were taken from the esophagus and the posterior wall of the gastric corpus by the FB-40K and conventional instruments in 30 and 27 cases, respectively, were compared with respect to surface area and depth. It was shown that the FB-40K had obtained better specimen as to better the size and depth of lesions, when used to take biopsies from flat lesions of the esophagus and posterior wall lesions of the gastric corpus.

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In recent years, endoscopic resection is widely used for early esophageal and gastric cancer. There have been patients in whom lesion was incomplete resection by the electronic endoscope of direct vision type which is usually used for resection.
In the present study, we had an opportunity to use a new treated electronic endoscope (forward-oblique viewing type ; XGIF-2TK200, Olympus) . This instrument has the following characteristics : (1) Angle of view field : 100° (45°forward-oblique viewing) , (2) Outer diameter at distal end : 13mm, (3) Two channel scope with forceps rising.
The 9 patients (12 lesions) had endoscopic resection. Lesions were 12 ; 1 lesion in esophageal cancer (0-IIb type) , 6 in gastric adenoma, 5 in gastric cancer (IIa : 4, IIc : 1 lesion) . The endoscopic resection was complete in all these lesions. The instrument was well operated even at lesser curvature of the stomach.
These findings suggest that this instrument is considered to be an excellent scope for endoscopic resection.

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We performed 1,154 image processings by using a newly developed electronic endoscope TV-Endoscope TRE-3000 (Toshiba Co, Ltd) since June to November in 1992.
The endoscope employs a CCD with about 270,000 pixels and enables us to perform 4 levels of digital band-pass filtering as structural enhancement in real-time. The peak frequency (horizontal) of the processing was set to 4.3 MHz. The band-pass filtering clarified the fine mucosal pattern and the fine vascular pattern in proportion to the gain level.

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The vascular endoscopic catheter (VEC : manufactured by Clinical Supply Co Ltd) was used for peroral transpapillary cholangiopancreatoscopy.
VEC has a build-in fiberoptic and a balloon is equipped at the tip. There are two types of VEC ; one has an outer diameter of 7 Fr and the other has that of 5 Fr. The catheter with a 7 Fr outer diameter was used for cholangioscopy and its sizes are 2,100mm in length, 2.3mm in outer diameter and 1.0mm in inner diameter. The catheter with a 5 Fr outer diameter was used for pancreatoscopy and its sizes are 2,100mm in length, 1.7mm in outer diameter, and 0.5mm in inner diameter.
Cholangiopancreatoscopy with VEC was performed on 40 patients during routine ERCP. VEC was successfully inserted into the bile duct at the rate of 100% and the pancreatic duct at the rate of 73%. We found the characteristics of VEC as follows ;
1) The catheter can be centered by inflating the balloon.
2) Water can be supplied through the inner channel. The intensity of the light, however, is not sufficient.
With this exerience, it is supposed that VEC would be a useful procedure for the diagnosis of biliary and pancreatic diseases.

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Corrosive esophagitis can safely be observed by endoscopy at an acute phase. However, histologic changes associated with corrosive esophagitis are not well studied. We made histologic observations on corrosive esophagitis induced in rabbits. We ascertained that endoscopic findings between esophagitis in patients and rabbits were similar.
Results are summarized in the table. Hydrochloric acid (HCl) produced histologic damages on the esophagus in a concentration dependent manner. Sodium hydroxide (NaOH) produced more severe injuries as compared to those induced by hydrochloric acid. Endoscopic findings on esophagitis induced by Paraquat were less severe as compared to those induced by HCl or NaOH. Histologic damages of the esophagitis induced by Paraquat were mild to moderate degree, but they involved deeper layers.
The corrosive esophagitis induced by house-hold detergents appeared to be related to the amounts of HCl or NaOH, but not to surfactants.

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When reflux esophagitis is discussed, esophagitis which persists for long time is usual. However there is superficial esophagitis of short duration by transient reflux of the gastric content. We collected 23 cases of this type observed by endoscopy.
The cause of reflux was pyloric stenosis by acute duodenal ulcer in 15 cases, vigorous vomiting of acute gastric mucosal lesion in 5 cases, of alcoholic intoxication in 3 cases. There are 21 males and 2 females and the range of their ages 26 to 76 years.
Their endoscopic findings were diffuse redness, erosion and hemorrhage at the distal part of the esophagus and these changes disappeared rapidly after the cause of the reflux was removed. We propose to name this pathology as acute reflux esophagitis.

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We have studied the endoscopical treatment of the bleeding from the tear of the esophagogastric junction in 34 cases from January 1985 to March 1992.
Electric coagulation has been done in 7 cases and rebleeding has been seen in 2 cases (28.6%) . One of them has got complete hemostasis by clipping. Clipping has been done in 6 cases and all of them have got complete hemostasis. So we believe that clipping is very effective in the treatment of bleeding from tear of the mucosa of the esophago-gastric junction. And the patient is allowed to eat soon after this procedure, so it is beneficial for the quality of life of the patient.

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We investigated how the increase in collateral circulation with progression of portal hypertension affected endoscopic features of esophageal varices in 32 patients with liver cirrhosis complicated with esophageal varices, who could be followed up for more than 5 years.
Endoscopic features of esophageal varices were analyzed as to such 3 factors as color (C) , form (F) , an location (L) , and the patients were divided into 4 groups based on changes in these 3 factors. The portal hemodynamics was measured by ultrasound and Doppler's method.
Changes in spleen size and those in sectional area, diameter and flow rate of the portal system were similar between the groups, revealing no intergroup differences. The highest incidence of collateral circulation, other than esophageal varices, was seen in the group showing no changes in endoscopic features. Since endoscopic features differed among the groups, despite of similarity in changes in portal hemodynamics between the groups, such differences were thought to result from blood flow dispersion in portal circulation.
In conclusion, it is suggested that examination should be performed with considerations of all the following matters : the existence of collateral circulation, other than esophageal varices, affects the application and effect of sclerotherapy of esophageal varices ; it is important to observe not only endoscopic features of esophageal varices but also entire portal hemodynamics, including collateral circulation, other than esophageal varices, during the clinical course of esophageal varices ; collateral circulation, other than esophageal varices, may occur in patients showing no changes in endoscopic features of esophageal varices for a long period of time.

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Omeprazole (20mg/day, orally) was administrated to 8 patients of active peptic ulcer with chronic renal failure under treatment by hemodialysis from June 1991 to May 1992. Four patients had gastric ulcer and remaining four had duodenal one. All ulcers healed quickly without evidence of side effects. The plasma concentration of omeprazole and gastrin were measured in 3 patients during the treatment.
The plasma concentration of omeprazole decreased to the level of less than 10% after every hemodialysis. The plasma gastrin levels increased generally in 2 of 3 cases but the other revealed similar levels.
In conclusion, omeprazole was also useful in patients of peptic ulcer with chronic renal failure.

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Images processed by adaptive enhancement using an Olympus image input and processing system (IP system) were studied to determine the extent of superficial spread of early gastric cancer.
Analog signals input via a change coupled device (CCD) were converted into digital signals and the target frequency components were amplified to maximum levels of 2, 3 and 5 times for three-level enhancement processing. Discolored and reddish lesions produced the highest quality images at a frequency enhancement maximum of 2 (Peak 2) , resulting in improved image clarity.
The color tone, capillary networks and borders of discolored lesions (9 cases) were clearly visualized in all cases and the system effectively defined the extent of superficial in about 80% of lesions. For one discolored lesion, the gastric mucosal pattern and lesion margin were more clearly defined compared with before processing. The capillary network and lesion margin of all reddish lesions (5 cases) could be defined, and the system was effective for all cases.
However, problems currently exist in regard to processing time and image quality, necessitating the development and improvement of peripheral instrumentation.

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Judgement of the depth of gastric cancer invasion by endoscopic ultrasonography (EUS) has become more important with the progress of the endoscopic treatment.
We applied a new radial scannig type ultrasound imaging catheter named“Ultrasonic Microprobe : UMP” (Toshiba Co) for estimation of the invasion depth in 6 cases of the gastric cancer. The new instrument UMP has a diameter of 2.4mm can be passaged down the forceps channel of a routine used endoscopes. There are three types of the tiny ultrasonic probe equipped with 10/15/20MHz high frequency transducer. Mainly 15 and 20MHz probes were used on this study.
The normal wall of stomach was imaged as 5 to 7 layers structure by the UMP. In superficial and small lesions (IIc and micro IIc type) which had mucosal invasion, the excellent capacity of the UMP was showed. The image obtained by the UMP clearly demonstrated the changes of mucosal structure reflected by these small lesions. As the depth penetration of ultrasound was limited in about 5mm because of high frequency and small caliber, in the cases of tall and wide-spreaded lesions (I and IIc like advance type) , it was difficult to judge of the invasion depth. Lesions (IIa and IIa+IIc type) with ulcer (Ul-IIs) which had mucosal invasion were overdiagnosed as submucosal invasion on account of the fibros tissue.
Intra-corporeal ultrasonography using the UMP, with some improvements, will develop the ability of EUS in estimation of the invasion depth in the early gastric cancer.

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Out of the total of 373 patients who underwent gastrectomies for mucosal gastric cancers at our department, lymphnode metastases were observed in 10 cases (2.7%) . However, there was no lymphnode metastasis in the cases who had depressed lesions ≤25mm in the major axis or elevated lesions. Therefore, the majority of mucosal gastric cancers were curatively treated by wedge resection of the stomach.
Three patients with mucosal gastric cancer were successfully treated by laparoscopic wedge resection of the stomach. The entire surgical procedure was performed laparoscopically with the assistance of gastroscopy.
The gastric wall in the vicinity of the lesion was pierced with a catheter which had a built-in straight needle. The needle and catheter was laparoscopically pulled out to the outside of the gastric wall. Finally, the lesion was lifted with the support of a small metal rod connected to the end of the catheter (Lesion Lifting Method) . Wedge resection was carried out using an Endo GIA with a sufficient distance from the lesion (more than 6mm) .
The postoperative course was uneventful. The patients could be on a diet on the following day after surgery, and were discharged after 6 days.
If a mucosal gastric cancer was accurately diagnosed preoperatively, laparoscopic wedge resection of the stomach is considered to be a curative and minimally invasive option.

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The preoperative endoscopic findings and the clinicopathological features were analyzed in the early antral cancer cases in which the center of the cancerous lesion was located within 2cm from the pyloric ring.
From April 1982 to March 1992, 46 cases of early pyloric cancers defined as above were resected in our department. In these early pyloric cancers, 22 cases were diagnosed by preoperative endoscopic examination being attached to the pyloric ring. Among these 22 cases, 7 cases revealed duodenal invasion on the resected specimen. The remaining 24 cases, which were apart from the pyloric ring by the preoperative endoscopic examination, had no duodenal invasion histologically. The characteristics of endoscopic findings of the duodenal invasion in the early pyloric cancer cases were concluded as follows :
1) The cancerous lesion attached to the pyloric ring.
2) The macroscopic type being a IIc depressed type.
3) The size of cancerous lesion measuring 2.0 cm or more, with the transverse dimension of cancerous lesion being wider than the longitudinal dimension.
4) Especially, the lesion having a formation of the pseudopyloric ring.

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The report about duodenal polyp and its polypectomy has been increasing as endoscopy has become popular.
We experienced endoscopic removal of 10 duodenal polyps in 10 cases in our clinic. All endoscopic polypectomies were performed without complications. Nine of 10 resected specimens could be studied histologically and the remaining one could not recovered. One of resected specimens was recovered from anus by using polyethylene glycol electrolyte lavage solution soon after failure to recover.
These lesions consisted of 3 cases of adenoma, 2 of cyst, 1 of hyperplasia of Brunner's gland, Brunnerioma, lipoma, and Peutz-Jeghers syndrome, respectively. Nine of them were pedunculated and the other was pestle in shape. They were about 10 to 34mm in size.
Endoscopic polypectomy in duodenum should be applied to pedunculated or semipedunculated polyps and less than 30mm in head size or 10mm in stalk size. Lavage solution would be useful for recovery of the resected polyps more than 30mm in size.

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The clinical efficacy and patient acceptability of taking the home Golytely for colonoscopy were evaluated in 78 patients. The patients received 2,000ml of Golytely together with two tablets of sennoside at home.
This preparation resulted in a feces free colon allowing colonoscopy in 95% of patients. Mild toxicities of Golytely were observed in 28% of patients. Golytely produced anal irritation or defecation in a small number of patients on the way to the hospital. The patient acceptance and compliance were good in 73% of patients who had experienced the dietary restriction method for colon-preparation.
We conclude that the means of taking the home Golytely is a useful and safety for colon preparation of colonoscopy.

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We investigated the effectiveness of Fanxieye ; a herb laxative, its effective components are sennoside A and B, which is composed of two kinds of folium sennae, Cassia angustifolia Vahl and Cassia acutifolia Delile, in preparation for colonoscopy.
There were 25 patients with colorectal polyp diagnosed by barium enema using modified Brown's method over a period between April 1992 and November 1992. Colonoscopy was performed in each patient by two colon preparation methods. One was by using Fanxieye and the other by using polyethylene glycol electrolyte lavage solution (PEG-ELS) , without dietary restriction the day before examination.
Fifteen patients (60%) liked Fanxieye among the three methods for colon preparation above-mentioned. Concerning the bowel cleansing effect, colonoscopy preparation using PEG-ELS had no problems but that using Fanxieye were poor in three patients (12%) .
In conclusion, Fanxieye was considered clinically to be useful in preparation for colonoscopy, because it was well received by patients, cheap in price, had few side effects in symptoms and blood examinations, and colonoscopy preparation using it was fairly good in the bowel cleansing effect.

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During the period between January 1988 and November 1992, twelve cases of bleeding from diverticular disease of the colon were reviewed for this clinical study. Among those 6 were males and 6 were females with 71 years old in average age. Because these lesions were required multiple sporadic, they located bilateraly in 11 cases. Of these, the bleeding from the diverticulum was identified obviously in two cases.
In comparison with non-bleeding diverticular disease (22 cases) , 67 percent of males smoked more than 20 pieces daily in the bleeding group which was significantly high. Another factors such as alcohol, hypertension, hyperlipidemia did not significantly affected the difference in both groups. The complication was noted in 4 cases ; 3 diverticulitis and 1 perforation. Except 1 case with perforation, all other cases showed hemostasis by medical treatment. Re-bleeding was found in 7 cases and in those 2 cases which had been securely enforced endoscopic hemostasis had no re-bleeding.
When“bleeding from diverticular disease”is diagnosed, emergent endoscopy is indispensable. But we should care for systemically and chose good preparation to get definite diagnose and treatment within 24 hours.

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Recently, a large number of flat elevated lesions were discovered in the large intestine, according to increasing X-ray examination by barium enema and colonoscopy. During last six years, 52 lesions of aggregated nodular and granular lesions (ANGL) were detected in 45 cases by double contrast barium enema in our hospital. Of these, we studied 40 lesions, fully demonstrated the fine network pattern on X-ray film by double contrast method, were studied for the marginal configurations and size of ANGL, and histological findings. These marginal configurations were devided into 5 types ; brushed, comb-like, serrated, wavy, semilunar.
The results were as follows ;
1) There were a significantly large number of type of brushed margin on their lateral side (x²test, p<0.01) , and other 4 types were noted on right-angled direction.
2) In comparison with marginal configuration and histological findings, most of wavy and semilunar types were significantly high in the tubular adenomas (p<0.01) , and most of comb-like and serrated types in the villous tumors (p<0.01) .
3) In tubular adenomas, most of wavy and semilunar types were significantly high in the small ANGL less than 30mm in size (p<0.01) .
4) Marginal configuration of ANGL on endoscopic picture by dyeing method were mostly same findings on X-ray.
Margin of elevated lesion were represented regular or irregular as radiological and endoscopic findings until now, but it was emphasized that the margin of ANGL and fine network pattern surrounding them by double contrast barium enema were shown more details in our study. These findings should be quite helpful for endoscopic study.

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We examined 122 lesions in 55 cases of synchronous multiple colorectal cancer clinicopathologically and endoscopically. These lesions had been resected endoscopically and surgically at the National Cancer Center Hospital during the period between January 1986 and August 1991, and also examined comparatively 903 lesions of solitary colorectal cancer that were detected in the same period.
The incidence of multiple cancers among total colorectal cancers was 6%. Among the cases with multiple cancers, the incidence of double cancer, and early cancer were 86% and 56% respectively. Fifty nine % of the lesions located at the rectum.
The multiple cancers was significantly more in male than in female (p<0.01) , but no significant difference was observed in age distribution. The incidence of well differentiated adenocarcinoma and the existence of adenoma in other sites were significantly higher in the multiple cancer than solitary cancer (p<0.01) .
We compared the multiple early cancer with the solitary early cancer cases. The significant difference was observed in macroscopic type, that is the frequency of protruding type (Ip, Isp) was higher in the multiple cancer than in the solitary cancer. Colonoscopic examination from rectum to cecum was thought to be very important in cases with protruding type early colorectal cancer.

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Laparoscopic colon resection were attempted in 3 patients. One patient who underwent sigmoidectomy had residual early cancer in sigmoid colon after endoscopic polypectomy. Two patients with IIa type early cancer in cecum and Crohn's disease in ileocecal portion underwent ileocecal resection.
Our technique was as follows ; Resecting bowel was grasped with ENDO-babcock and division of colonic mesentery vessels was performed with ultrasonic surgical aspirator. After partial mobilization, bowel was transected with ENDO-GIA. In the case of sigmoid colon, end-to-end anastomosis was intracorporeally performed with detachable EEA and side-to-side anastomosis was extracorporeally made with GIA for ileocecal portion.
The mean operating time was five hours. As complication, one patient required conversion to mini-laparotomy due to the bleeding from mesenteric vessels. One patient was died with acute heart failure which autopsy showed nothing concerned to this procedure. Laparoscopic colectomy showed less postoperative pain, earlier recovery of the bowel function, shorter hospitalization and better cosmetic benefit.
Rapid advances in laparoscopic instrumentation will undoubtedly expand the role of laparoscopic colon surgery in the near future.

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We studied whether cholecystitis after peroral endoscopic lithotripsy for common bile duct stones was related to configurations manifested in the cholangiogram, especially cystic duct.
Most cases of cholangitis occurred in both younger cases (≤70 years old) , group of large diameter, that of branching from middle common bile duct, that of angular branching by Kune and that of less spiral folds. Of these, diameter of cystic duct in cholecystitis was significantly larger than that without cholecystitis.
In conclusion, one of possible factors of cholecystitis after peroral endoscopic lithotripsy for common bile duct stones was thought to be a backwash infection.

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Laparoscopic cholecystectomy have been performed 21 patients with common bile duct stones in our Department, during the period from May 1990 to December 1992. Symptoms of the patients are jaundice in 8 cases, cholangitis in 2 cases. Of 21 patients, preoperative EST was successful in 18 cases, and preoperative PTCS in one case. Two out of 18 patients were converted to open cholecystectomy (9.5%) . In the remaining 2 cases, EST had been failed, were treated by laparoscopic choledochotomy and T-tube placement, but their hospital stay require over 4 weeks postoperatively. No recurrent stones or cholangitis were noted in those patients during postoperative follow up period.
Advantages of preoperative EST are ; short postoperative hospital stay, low incidence of bile duct injuries, and easy access for residure stones if occurred. Therefore preoperative EST should be first indicated in the patients with common bile duct stones prior to laparoscopic cholecystectomy, for the purpose of improvement of patient's quality of life.

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The laparoscopic cholecystectomy has the advantage of minimal invasion as well as high cosmetic acceptability due to the extremely small incisions required. However, there is no guarantee that all cases can be treated successfully with this new modality. A few cases are unfortunately converted from laparoscopic to conventional open cholecystectomy because of intractable severe adhesion or unexpected complications.
In our experience of 500 cases (including combined common bile duct stones, liver cirrhosis, acute cholecystitis, and history of upper abdominal surgery) , 3 were converted to conventional open surgery. One was due to bleeding encountered with the patient identified as Case No 1, which would surely be avoidable at the present that abundant experience has been accumulated. The others were due to severe adhesions encountered with the patients identified as Case No 46 and No 302, which is considered to have been a reasonable and justifiable decision.
The safety and efficacy of this new procedure seem to have been unanimously confirmed, although there still remain some minor controversies as to technical aspects of the procedure.
Judging from our results, the rates of conversion from laparoscopic to conventional open cholecystectomy should be kept to less than 1 percent at least, and we considered a new modality laparoscopic cholecystectomy as an alternative to open cholecystectomy. But the prerequisite conditions for this new procedure to replace conventional open cholecystectomy is its safety.
In laparoscopic cholecystectomy, there is an apparent learning experience which is covered only by adequate training and experience. With less experienced operators, the threshold of indication for laparoscopic cholecystectomy should be set high in order to secure the safety of the patients as well as the successful completion of the procedures.
At present in Japan, this modality of laparoscopic cholecystectomy is replacing conventional open cholecystectomy owing to its advantage of quality of life (QOL) for patients.

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Pure pancreatic juice (PPJ) was collected from 42 cases by the endoscopic retrograde cannulation through the papilla from January 1990 to September 1992. Samples were collected every 5 minutes for 20 minutes after rapid intravenous injection of secretin (100 units, Eisai) .
They were divided into 4 groups according to the clinical classification of chronic pancreatitis (CP) based on the criteria detected by the Japanese Society of Gastroenterology. They were compared with studies on pancreatic exocrine secretions (volume, maximal bicarbonate concentrations, amylase out put, lipase concentrations, trypsin concentrations) by means of biochemical analysis of endoscopically collected PPJ. The results are expressed as arithmetic means (±SD) . They were compared by Kruskal-Wallis test and Wilcoxon rank-sam test. A two-tailed P value less than 5% was considered to indicate statistical significance.
Patients with Group 1 (definite CP) showed significantly lower maximal bicarbonate concentrations than those with Group 2 (clinical CP) . Patients with Group 1 showed significantly lower volume and maximal bicarbonate concentrations than those with Group 3 (probable CP) . Patients with Group 1 and Group 2 showed significantly lower lipase concentrations than those with Group 4 (free of CP) .
In conclusion, it should be said that means of biochemical analysis of endoscopically collected PPJ was more reliable to evaluate pancreatic exocrine secretions with CP.

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A 76-year-old male visited our institution with chief complaints of pyosis and anorexia due to odynophagia.
Upper GI endoscopy showed several irregular, longitudinal erosions in the distal esophagus. The biopsy specimens taken from the marginal site of the erosions were positive for antiherpes simplex virus Type 1 (HSV-1) antibody, and the diagnosis of herpes esophagitis associated with reflux esophagitis and hiatal hernia.
Although it has generally been considered that herpes esophagitis is observed in immunosuppressive patients suffering from malignancy and severe viral infections, and incidentally observed in autopsy cases, some cases have reportedly been found in healthy immunocompetent individuals in recent years.
Endoscopically the lesions of herpes esophagitis reveals shallow punched-out erosions and ulcers. They resemble those of cytomegalovirus (CMV) esophagitis. In this case, however, the detection of HSV-1 infected cells in the biopsy specimens led to the didagnosis of herpes esophagitis. CMV infected cells are usually detected in the biopsy specimens taken from ulcer beds.
For this reason biopsy should be done not only from the ulcer margin but also from ulcer beds for the differential diagnosis between herpes and CMV esophagitis.

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Esophageal stricture after corrosive injury has various stage and extent owing to the quality and quantity of causing materials, and often accompanies gastroduodenal lesions. Patients are often infants or adults who comitted suicide. Its surgical treatment differs from that of esophageal cancer.
A 43-year-old man drank lye (KOH65%・NaOH30%) for the purpose of suicide. Emergent esophago-gastro-intestinal endoscopy was performed. From the pharynx to the duodenal 2nd portion, severe erosion and petechia were observed. Ten days after injury, at the middle thoracic esophagus, complete stricture was recognized. One month later, when mucosal inflammation was settled, endoscopic dilatation therapy was performed. But it was not effective.
Then 3 months after injury, operation (esophageal resection under thoracotomy and laparotomy) was performed. Pathologically, over 10cm of the thoracic esophagus, mucosal layer was perfectly disappeared, and inflammatory cells, mainly lymphocyte, was seen throughout the proper muscle layer.
Post operative course was eventless, and patient has begun his work 2 months after operation.

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Upper GI endoscopic examination was performed on 8,059 patients at this center in the past 6 years, and seven of them had esophageal papillomas. The male : female ratio was 4 : 3 and the median age was 53.6 years. The chief complaint was abdominal symptoms in five cases. Two patients had undergone operations on malignant tumors.
The lesion was located in the middle esophagus in four cases and in the upper esophagus in three cases. A white color and granular protrusions on the surface were observed. The Yamada type III appearance was the most common, and was seen in five cases. The other two patients had a plateaushaped lesion and a conglobate lesion, respectively. Concomitant esophageal and gastric lesions included hiatus hernia in two cases, reflux esophagitis in one case, and a gastric ulcer and acute gastritis in one case.
Biopsies were immunostainded for human papilloma virus antibody but all the patients were negative.
We followd up seven of the patients, but no marked changes occurred up to 4 years. Thus, careful observation of the course without any specific interventions such as resection appears to be sufficient for this disease.

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A 56-year-old female was referred to Saitama Cancer Center for a submucosal tumor of the esophagus.
Esophagraphy showed a filling defect with a smooth contour and sharp margins in the upper thoracic esophagus. Endoscopic examination revealed a protruded lesion covered with normal esophageal epithelium. Endoscopic ultrasonography demonstrated a low echoic solid lesion at submucosal layer of the esophagus. CT scan showed that contrast medium enhanced the mass more than the surrounding muscle, indicating the vascular nature of the lesion.
The submucosal tumor was enucleated by cervical incision. The resected specimen measured 15×13×13mm, and the cut surface demonstrated a solid tumor which exuded a small amount of blood. Microscopic examination revealed a cavernous hemangioma of the esophagus.
Hemangioma of the esophagus is a rare lesion, and 58 cases have been so far reported in Japan. Recently, most of the patients with this lesion have been treated with endoscopic polypectomy. However, in some cases like our case it is difficult to diagnose and/or difficult to perform endoscopic polypectomy.

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We reported a case of metachronous multiple esophageal dysplasia that is interesting clinically. A 78-year-old woman, who complained of epigastralgia, was detected a small iodine unstained lesion in the EGJ above by the endoscopy.
Pathologically, the biopsy was containing moderate dysplasia cells, but endoscopic mucosectomy was containing mild dysplasia. Following every 6 months, endoscopic examination showed another two iodine unstained lesions after 16 months. One was in the 35cm, another was in the 30cm from the incisor. These biopsy specimens were strongly suspected of squamous cell carcinoma, but the endoscopic mucosectomy revealed mild and severe dysplasia.
This case indicated the necessary of the endoscopic mucosectomy and careful follow up for esophageal dysplasia.

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A 54-year-old man was admitted to our hospital because of fever and dysphagia. Endoscopic examination revealed a brown-black huge mass with rich vascularity from Iu to Ea of the esophagus. According to X-ray and endoscopic findings, we suspected carcinosarcoma.
Because of the metastasis to the mediastinal lymphnodes, the invasion to the left main bronchus and the combination of liver cirrhosis, we resigned operation and radiation therapy was performed. The size of mass decreased, but the invasion to the right thorax was worsend. He was dead of hepatic failure after the rupture of it into the right thorax. We diagnosed it so-called carcinosarcoma by autopsy.
We had 3 cases of carcinosarcoma in 325 cases of esophageal carcinoma during in these 5 years. Another 2 lesions were smaller than this one and their histological diagnosis were pseudosarcoma and so-called carcinosarcoma.

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We reported an interesting case supporting the carcinogenesis of mechanical stimulation of the esophagus, which was compressed by right aortic arch in the long period.
The patient was 52-year-old male, whose chief complaint was retrosternal permeating feeling, under went esophagography, and was pointed out the compression in upper thoracic esophagus. By the esophagoscopy, the upper esophagus 24cm from the incisor, were compressed strongly and pulsated, and 0-IIa+IIb superficial carcinoma was detected on the wall. In the endoscopic ultrasonography, the depth of the cancer was mostly mm, but partially sm.
The thoracotomy revealed that esophagus was compressed by aortic arch and ductus arteriosus ligament. In the resected specimen, cancer invaded to the muscularis mucosa without lymphnode metastasis. Protrusion of the mucosa like this case is suggested to be high risk of malignancy, and should be examined carefully.

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A 66-year-old male was pointed out a lesion showing a whitish granular elevation and an accompanying reddened portion 30 cm from the incisor, both portions being unstained with Lugol solution and suspected of Type 0-IIa+IIc superficial esophageal cancer. The lesion could not be confirmed as cancer in terms of the biopsy from the whitish granular elevation. However, the lesion was successfully diagnosed as cancer in terms of the biopsy from the reddened portion, and the lesion was removed by surgical operation.
Comparing fresh resected specimen and histopathological study, in the reddened portion cancer was exposed on the mucosal surface, while in the whitish portion cancer was only present in the vicinity of the basal membrane, and the whitish elevation corresponded to hyperkeratosis.
It should be born in mind that hyperkeratosis occasionally coexists with cancer as in the present case.

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A 72-year-old man with unresectable esophageal cancer was referred and admitted to our hospital for endoscopic therapy.
The lesion located at the mid-portion of esophagus, that was completely occluded. On August 27, endoscopic placement of straight prosthetic tube was performed using a Celestin pulsion tube, but improvement of oral intake was not noted. On September 19, therefore, a prototype curved prosthetic tube was in place again.
Since then, the patient was followed up at the outpatient clinic because it made the patient oral intake of food possible. However the patient was rehospitalized 5 months later, because the prosthetic tube indwelled had migrated into the stomach. It was endoscopically extracted. Until the end of January 1993, aphagia has been completely relieved. No cancerous lesion was not endoscopically noted at the site where stricture was previously existed.
It is considered that a longstanding placement of prosthetic tube induced a necrosis of the lesion, resulted disappearance of cancer and eventually permits a long-term oral intake.

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Original type Gianturco self expandable metalic stent (EMS) were placed in a stenotic jejunal graft of a 70-year-old woman who had been operated for cervical esophageal carcinoma 9 months before.
Following endoscopic and fluoroscopic examination, two stents (15×50mm) were placed easily and safely under fluoroscopic control. Three days later, the stenotic jejunal graft was fully dilated and she got to be able to eat soft solids without discomfort. The stents did not migrate.
But 2 weeks later, she felt dysphagia again. Endoscopic and fluoroscopic examination revealed that the stents were being buried into jejunal graft wall with mucosal over-growth. We tried again to dilate with another EMS, but failed. Finally esophageal intubation was required.
We conclude that stenotic lesions of gastrointestinal tract can be dilated with Gianturco self EMS easily and safely with some modifications that prevent restenosis.

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The patient had had total thoracic esophagectomy for type 2 esophageal cancer on July 1984 when he was 55 years old. The pathological diagnosis was squamous cell carcinoma, mp in depth, n₀, ly₀, v₀.
On February 1992, endoscopic examination of upper gastrointestinal tract for anemia revealed IIc-like advanced gastric cancer in the stomach tube. Partial resection of the stomach tube was performed and histology revealed well differentiated adenocarcinoma, pm in depth.
Fifty-four cases with cancer in the stomach tube reported in Japanese literatures, including our case, were analyzed and it was concluded that careful endoscopic follow-up study after operation for esophageal cancer is necessary to detect the early cancerous lesion at the stomach tube.

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Selection of treatment for the patient of early cancer is sometime problematical in cases who have psychological disturbance or senile dementia inspite of good physical condition.
This case is a 69-year-old man who simultaneously associated with early esophageal and gastric cancer, with complications of night delirium and senile dementia. Endoscopy showed an intraepithelial or intramucosal cancer in the esophagus and a IIc+III typed cancer in the stomach. Due to his severe psychological condition, subtotal gastrectomy was selected to treat the gastric cancer, and EMR to the esophageal lesion. The postoperative course was good.
So that is worthy of note that EMR is safe and effective technique in such cases, and will be more widely utility in the near future.

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A 71-year-old man was admitted to our hospital because of abdominal mass. Upper gastrointestinal series and endoscopy revealed extraventral compression of the stomach. The tumor was found by abdominal computed tomography and nuclear magnetic resonance image, which maximal diameter was about 21cm with multiple cysts. Abdominal angiography showed expanded left gastric artery without staining.
Abdominal surgery was carried out under diagnosis of lesser sac tumor. The resected tumor was 19×17×6cm in size originated from stomach wall especially in subserosa. Massive bloody fluid was noted in the multiple cysts. Histologically, the tumor was mainly composed of large dilated blood-filled vessels lined by flattened endothelial cell, partly including smooth muscle and collagen fiber, which was diagnosed as hemangioma.
One hundred and nineteen cases of gastric hemangiomas have been reported in Japan, including only 10 cases more than 10cm in diameter.

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We reported a case of gastric leiomyoblastoma which grow in size during 2 years and 7 months and was diagnosed before resection.
A 26-year-old female, complaining of tarry stool and dizziness, visited our hospital in June 1989. The upper GI series and endoscopic examination revealed a submucosal tumor, 35×30 mm in size, on the posterior wall of middle gastric body. Although we could not diagnosed by biopsy, the tumor was suspected of malignancy and we recommended the patient resection of tumor, but she rejected.
In April 1992, the tumor enlarged 45×40 mm in size and formed an ulceration on the surface of tumor. By endoscopic biopsy and color Doppler-endoscopic ultrasonography (CD-EUS) guide tunnel biopsy from the ulcerated area of tumor we diagnosed the tumor as leiomyoblastoma of the stomach. Subtotal gastrectomy and lymphnode resection were performed. No metastasis to liver or dissemination to peritoneum were found, but a single lymphnode metastasis was observed.
CD-EUS guide tunnel biopsy is a useful method in diagnosis of the submucosal tumor of stomach, because we can obtain tumor tissues safely and certainly without bleeding or perforation. We consider that radical operation is necessary to gastric leiomyoblastoma, since it has a malignant potential and occasionally metastasize.

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The patient was a 54-year-old male. A filling defect was pointed out on the occasion of regular health examination in 1989.
In 1991 he was seen to have calcification in the stomach at X-ray and was admitted to our University Hospital for a workup on December 2, 1991. Endoscopic examination revealed a submucosal tumor, 3 to 4mm in diameter, with bridging fold in the upper greater curvature of the stomach. The tumor looked cystic and soft. Since the tumor had a delle on its surface, aspiration cytodiagnosis was performed, but was negative for any signs of malignancy.
However, since the tumor tended to grow, the patient was operated on at the Second Department of Surgery of our University Hospital in May 1992. The submucosal tumor was, in part, cystic, and was found to retain fluid matter. Biochemistry studies indicated that amylase was elevated to 15,990 IU. The patient was histologically diagnosed with large aberrant pancreas with calcification.
This case seems to be of histopathological interest, though a rather rare occurrence.

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The patient was a 72-year-old male. Because of an abnormality in the stomach suggested by health examination, he visited our hospital for a work-up.
Since a diagnosis of IIa type early gastric cancer of the cardia was made, surgical treatment was recommended, but he refused. For want of overt signs of remote metastasis, this case was considered an indication for laser therapy. After 6 years of irradiation, the tumor did not grow or show any signs of aggravation so that the course was regarded as favorable. Later on therapy was thwarted by senile dementia and other unfavorable conditions so that he was placed on annual endoscopic observation.
Two years after the discontinuation of laser therapy, a giant ulcerative lesion was found in the gastric corpus at a site removed from the cancerous lesion. A biopsy taken suggested T cell type malignant lymphoma. Seeing that there were no signs of systemic lymphoma, the fresh lesion was considered to be of gastric origin.
The patient was a case of malignant lymphoma of gastric origin which developed in the course of observation of the gastric cancer. The cause and effect relationship between two lesions is yet to be clarified, but the possibility is suggested that an extra-oridnary immune reaction to the cancer gave rise to the malignant lymphoma. This case seems intriguing from the etiological standpoint of coexsisting tumors.

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A 54-year-old man with multiple gastric cancer underwent partial gastrectomy.
According to previous reports the average age of the patient with multiple gastric cancer was higher than that of the patient with single gastric cancer. This case was younger if anything.
Preoperative examinations by endoscopy and upper GI series disclosed 4 depressed lesions and 1 elevated lesion. But histological examination of the surgical specimen revealed another small cancer lesion in addition to preoperative diagnosed 5 lesions, and the elevated lesion was IIa+IIc type according to the macroscopic classification. Depth of their invasion was as follows : m lesion was seen in 3 and sm lesion was seen in the other 3.
It was reported that the cases with multiple gastric cancer had mostly 2-4 lesions, and so our case had 6 lesions and was extremely rare.

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Adenosquamous cell carcinoma of the stomach is uncommon, especially extremely rare in the residual stomach at the site of the gastrojejunostomy. This report dealed with a case of adenosquamous cell carcinoma at the site of gastrojejunostomy that occured 30-years after the operation of distal gastorectomy and gastrojejunostomy (Billroth-II) for gastric cancer.
A 62-year-old man complaining of chest-abdominal pain and tarry stool was admitted to our hospital. Tumor at the site of gastrojejunostomy was found by both of endoscopic and X-ray examinations. Tumor was histologically diagnosed as adenosquamous carcinoma by endoscopic biopsy. Total resection of residual stomach were performed. The diagnosis after operation was advanced adenosquamous carcinoma at the site of the gastrojejunostomy, that was classified as Borrmann 3 type.
This adenosquamous carcinoma was centrally-grown-type and histologically mixed type of moderately differentiated adenocarcinoma (solid and tubular pattern) and squamous carcinoma. Based on histological examination, these component of squamous cell carcinoma was suggested to arise from squamous metaplasia of adenocarcinoma.

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This paper focused on the usefulness of endoscopic treatment performed in 5 cases suffering from the stomal stenosis after gastric surgery in recent 4 years in our department.
They are 3 males and 2 females, and 58.2 year old in average. There were no evidence of stomal recurrence in all cases. The endoscopic treatment for stomal stenosis were effective in 4 cases ; dilatation by endoscopy itself in one, dilatation using balloon dilator in one, and dilatation using balloon dilator after cutting the stenosis by high frequency electric current in two cases.
Balloon dilation procedure after cutting stenosis is more effective for severe stomal stenosis than other trials.

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We established a direct percutaneous endoscopic jejunostomy (PEJ) in a 75-year-old man with brain infarction. He had undergone total gastrectomy for gastric cancer.
This procedure has been conventionally performed in the pull or push method ; however, we have done it in the introducer method using an 11 French peel-away sheathed introducer. Postoperative adhesion between the jejunum and the abdominal wall facilitated this method. Temporary leakage of intestinal fluid occurred, but it ceased in six days.
PEJ is indicated in patients with previous gastric surgery in whom a percutaneous endoscopic gastrostomy is not easily placed.

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A case is presented of a female aged 78 whose chief complaints were pain in the right hypochondrium and fever (38.4°C) .
X-ray and endoscopic examination of the stomach revealed a well differentiated adenocarcinoma of Borrmann's type 1 in the duodenal bulb and a large amount of pus excretion into the lumen from a fingertip-sized prominence on the anterior wall of middle portion of the gastric body. Klebsiella oxytoca and α-Streptococcus, resident microbes of the upper gastrointestinal tract, were detected from the pus. A CT scan of the abdomen suggested the formation of a mass in the duodenum involving the gallbladder and the porta hepatis, and the presence of an abscess on the anterior side of the mass linked to the anterior wall of the stomach.
An exploratory laparotomy revealed that direct infiltration of the tumor had resulted in a mass involving the duodenum, gallbladder, liver, transverse colon and the anterior wall of the stomach. Penetration into the stomach due to necrosis had caused retrograde infection which resulted in the abscess and excretion of pus into the stomach.
This is thought to be a very rare case because our review of the literature found no other reports of cases of abscess due to infiltration of primary duodenal cancer into the anterior wall of the stomach and penetration into the lumen.

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A 62-year-old female was admitted to our hospital for the purpose of endoscopic polypectomy of the duodenal polyp.
Gastrointestinal fiberscopy and endoscopic ultrasonography (EUS) revealed a granular pedunculated polyp on the anterior wall of the duodenal bull. EUS demonstrated that the polyp was limited to the mucosal layer with retained continuity of the submucosal layer, and it contained some low echoic regions.
An endoscopic polypectomy was performed after drawing out the polyp into the stomach. The resected polyp was round in shape, with partially nodular surface, about 30×17×10mm in size. Histologically, hyperplasia of the proper duodenal epithelial cells was noted.
It is suggested that endoscopic ultrasonography is an armament for determination of indication of endoscopic polypectomy.

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A 73-year-old female was admitted with a complaint of right upper abdominal pain. Ultrasonography showed dilatation of the biliary tract, the pancreatic duct, and cholecystolithiasis. On endoscopic examination, a protruding lesion like submucosal tumor with redness was noted at the papilla of Vater. The biopsy specimens taken from the surface of the tumor showed only inflammation.
But, under the diagnosis of carcinoma of the Vater, a pancreatoduodenectomy was performed. On resection, the tumor was 4×3.5×3 cm in size. Tumor invasion was observed from the submucosa to proper muscle layer of the duodenum. And there were three stones in the gallbladder. No metastasis was detected at lymph node and any other regions. Histologically, the tumor was diagnosed as carcinoid. The argyrophil reaction stained by Grimelius method showed positive.
Carcinoid at the papilla of Vater is a very rare disease and only 30 cases have been reported in Japan, and the one with cholecystolithiasis is very rare being limited to only 2 cases.

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A 73-years-old male was admitted to our hospital, because of epigastralgia and anterior chest pain. Endoscopic examination revealed he had a sessile polyp in the 3rd portion of the duodenum. The polyp of 26×23×18mm was endoscopically resected, and was tubular adenoma without atypia and Paneth cells histopathologically.
Since 1975, 244 benign duodenal tumors, endoscopically polipectomized, were reported in Japan. Most of them (94%) were in the 1st or 2nd portion of the duodenum, and only 4.5% in the 3rd. Their macroscopic findings were reported mostly pedunculated or semipedunculated, 198 out of all (90.8%) . Brunner's gland hyperplasia and adenomas were over 50% of all, but only 4 adenomas of 244 tumors (1.6%) were found in the 3rd portion including our case.
It is known that the risk of cancerous change of adenomas increases in the case of over 20mm in diameter, villous change histopathologically, or existing near the papilla of Vater. It is important to challenge endoscopic polypectomy, even if the duodenal adenomas, diagnosed by biopsied specimen, have no cancerous change.

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A 58-year-old female patient was diagnosed as having adenoma of the ampulla of Vater by endoscopic observation and biopsies in 1987. Since then endoscopic examinations with biopsies were performed every six months. Every biopsy specimen showed adenoma with mild dysplasia so far until 1992 when more severe dysplasia than before was found, and malignant transformation was suspected. At duodenotomy a local papillary resection was performed. Histologic examination of the resected specimen showed completely excised papillotubular adenoma with moderately severe dysplasia and without malignancy.
The treatment of adenoma of the ampulla of Vater is controversial, because of the difficulty in discriminating“cancer in adenoma”. Local papillary resection should be regarded as the first choice for adenoma of the ampulla of Vater even if malignant transformation is suspected.
In our case, minimum and complete resection was successfully performed after the rigid follow-up program.

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Varices due to portal hypertension are usually formed in the esophagus, and small intestinal varices are quite rare. This paper describes three cases of small intestinal varices.
Case 1 was a 64-year-old female admitted with a chief complaint of melena. Varices were detected in the 2nd portion of the duodenum by endoscopy.
Case 2 was a 43-year-old male admitted for severe anemia. A diagnosis of varices in the 2nd portion of the duodenum was made by endoscopy and percutaneous transhepatic portal obliteration was carried out.
Case 3 was a 40-year-old female admitted with a chief complaint of melena. A laparotomy was conducted under the diagnosis of ileal varices since varices were detected in the ileal branch of the superior mesenteric vein by percutaneous transhepatic portography.
These two cases of duodenal varices and one of ileal varices were described and discussed with reference to the literatures.

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