We investigated the relationship between the severity of reflux esophagitis and total bile acid concentration or pH of the gastric juice, and between total bile acid concentration and pH of the gastric juice.
Patients with reflux esophagitis were classified into 3 groups according to the severity of reflux esophagitis as follows : Mild esophagitis was limited to discoloration (erythema, whitish mucosa) of the lower esophagus (N＝9, 6 men and 3 women ; average age, 50.8 years) ; moderate esophagitis involved non-confluent erosive and/or ulcerative lesions of the esophagus (N＝12, 9 men and 3 women ; average age 56.0 years) ; and severe esophagitis showed confluent erosive and/or ulcerative lesions of the esophagus (N＝9, 6 men and 3 women ; average age 73.7 years) .
A gastric tube was inserted into the stomach after overnight fast in a manner designed to avoid or minimize triggering of the pharyngeal reflex. After patients had rested in the right side position for 1 hour, gastric juice was aspirated. Mucus was removed from the aspirated sample by centrifugation (10min, 3000rpm) . The concentration of bile acids and pH in the collected samples were measured using the enzymic method and a pH meter.
The total bile acid concentration was significantly (p＜0.05) greater in the severe esophagitis group (1966±778µM ; mean±SE) than in the mild (45±17µM) or moderate (43±15µM) esophagitis group. There was no difference in the pH of the gastric juice among the 3 groups. The total bile acid concentration of more than 200µM, which has been found to cause esophageal mucosal injury in the strongly acidic condition, was observed in 7 patients with reflux esophagitis. The pH of the gastric juice in 5 of 7 patients with a total bile acid concentration of more than 200µM, was in the acidic range.
We conclude that the presence of bile acid in high concentrations may participate in the onset of confluent erosive and/or ulcerative type esophagitis, and the presence of bile acids can not be ruled out, even when the pH of the gastric juice is less than 4.0.

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From January 1991 to February 1995, endoscopic mucosal resection (EMR) for early esophageal cancer was carried out in 40 patients, 46 lesions in National Cancer Center Hospital. The age was 46-81, and the average was 63.8. Of the 40 cases, 35 were male and 5 female. The locations of the lesions were as follows : 32 were found in Im area, following 9 in Ei area. Histologically, all lesions were squamous cell carcinoma. Macroscopically, 34 lesions were 0-IIc type, following 6 lesions 0-IIa type and 6 lesions 0-IIb type. Thirty-one lesions (67%) were treated with EMR by en-bloc resection. As regards the depth of the cancers, 20 were ep and mm₁, 13 were mm₂, 5 were mm₃, and 2 were sm. In this series 2 cases died of other cancer, but other all cases are free of esophageal cancer up to now.
EMR is safe and useful for early esophagus cancer. In patients who have circular early esophagus cancers, we choose endoscopic surgery, because we can enlarge with bouginage the lesion of which post-procedure stricture occurred. Because one relapse of cancer tissue was diagnosed in patient who was judged complete histologically, we need to follow up all patients carefully after treatment. Further studies are needed to enlarge the criteria of EMR for early esophagus cancer.

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The importance of the fundic plexus in connection with left and short gastric veins as one of the feeders of the esophageal varix is well known. However, three dimensional analysis of relationships between these veins has never been discussed.
An endoscopic varicealography during injection sclerotherapy (EVIS) was performed both in supine and the lateral positions. In supine position, 5% ethanolamine oleate with iopamidol (5%EOI) was injected into the right and left esophageal varices in seven cases. EVIS from the varix of the right side showed that 5%EOI was flown out through the fundic plexus to the left gastric vein and the plexus mainly existed at the back of the gastric wall in all cases. Whereas, EVIS from the varix of the left side showed that 5%EOI was flowed out through the fundic plexus to the short gastric veins and the plexus mainly exited at the front of the gastric wall in all cases. EVIS from the both sides showed the connection with the parts of the plexus flowing out to both the left and short gastric veins in all cases. Existing gastric varices which were continued with esophageal varices had endoscopically disappeared after the therapy in all cases.
Therefore, it is thought that a part of fundic plexus exists inside the gastric wall and a part outside the wall, and the parts of the plexus flowing out to both the left and short gastric veins exist inside the gastric wall. Hence, it is concluded that a three dimensional analysis is important method to explain the existence of portosystemic shunt at the esophageal varices and portal blood vessels in the fundus to understand the origin of the gastric varix.

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We have laparoscopically treated 7 patients with leiomyosarcoma of the stomach. The operative procedure and outcome are as follows ; by grasping the intact wall of the stomach near the lesion with two clamps, the lesion was pulled up and resected with Endo GIA (US Surgical, USA) . The size of tumors ranged from 18 to 38 mm in diameter and all specimens had sufficient distance from the surgical margin. The average operation time was 140 minutes. All patients could start diet on 1 POD and were discharged within 5-7 days uneventfully. No recurrence of the tumor was observed in two and half years follow up.
We routinely use Laparosonic Coagulating Shears (Ultra Cision, USA) . By using LCS, the removal of the vessels around the stomach wall is much easier than before. Laparoscopic resection of the tumors on the lesser or greater curvature and also on the posterior wall of the stomach is not a time-consuming surgery in recent experience.
The laparoscopic wedge resection of the stomach for leiomyosarcoma is a safe, accurate and also minimally invasive method.

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As a new simplified technique, we introduced endoscopic mucosal resection using a cap-fitted panendoscope (EMRC) . Absolute indication of EMRC for early gastric cancer at our institute is as follows, (1) pathological : well differentiated, (2) macroscopic type and size in diameter : 0IIa type and≦2 cm, 0IIb type and≦1 cm, 0IIc type and＜1 cm without ulcer nor ulcer scars.
We perform en bloc resection for elevated lesion less than 1.5 cm in diameter and clearly depressed lesion, and to get curative resection, we aggressively perform planning fractionated resection for elevated lesion more than 1.5 cm in diameter and flat or slight depressed lesion. From August 1992 to March 1995, 50 patients of 62 lesions were treated with EMRC procedure, which contained 41 cases of en bloc resection, 17 cases of planning fractionated resection and 4 cases of additional resection.
In 14 lesions (82%) of 17 plannig fractionated resection, the specimens could be reconstructed easily because those were large in size and contained effective marks. But the specimens could not be reconstructed in all cases of additional resecton because those were small in size and contained no marks. 1 case (2.4%) of 41 en bloc resection and 1 case (25%) of 4 additional resection had residues which required laser therapy. None of 17 planning fractionated cases had residue.
We suggest that planning fractionated resection with EMRC procedure will improve the curativity of endoscopic mucosal resection for early gastric cancer.

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When selecting surgical treatment for early gastic cancer, it is important to assess the area spread and depth of the lesion using gastrofiberscopy. Our selected methods of surgery for early gastric cancer include standard radical gastrectomy (D₂) for cancers invading to the submucosal layer, modified radical gastrectomy (D₁) for cancers invading to the mucosal layer, laparoscopic surgery for cancers less than 2.5cm in diameter, and endoscopic mucosal resection for cancers less than 1cm in diameter without ulcer scar.
To improve the diagnostic accuracy of the depth of cancer invasion, we have applied endoscopic ultrasonography (EUS) with a 20MHz sonoprobe system (linear type and/or radical type) for 48 preoperative patients with early gastric cancer, and compared the preoperative diagnosis using EUS with the postoperative pathological findings in the resected specimen. EUS provided correct diagnosis of mucosal invasion in 88.9% (24/27) of cases and submucosal invasion in 71.4% (15/21) , giving an accuracy of 81.3% (39/48) .
The diagnostic accuracy obtained with the radial probe (86.6%) was higher than that with the linear probe (91.7%) . Elevated lesions, well and moderately differentiated types of adenocarcinoma and INFα were favorable factors for diagnostic accuracy using EUS. Three cases showed submucosal invasion among 27 cases diagnosed as mucosal invasion by EUS preoperatively. EUS with a 20MHz sonoprobe system appears to be useful for diagnosing mucosal invasion of gastric cancer and enabling selection of the appropriate surgical procedure.

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Ninty duodenal ulcer patients were treated for H. pylori infection. Forty-one (LA group) were treated with lansoprazole (LPZ) 30mg once daily for six weeks. Amoxicillin (AMPC) 500-750mg bid for 10 days was added to this regimen two weeks after the LPZ regimen began. Forteen (LC group) were treated with LPZ 30mg once daily for six weeks. CAM 200mg bid for 10 days was added to this regimen two weeks after the LPZ regimen began. Twenty (LAM group) were treated with LPZ 30mg once daily for six weeks. AMPC 500-750mg along with metronidazol (MNZ) 250mg bid for 10 days was added to this regimen two weeks after the LPZ regimen began. Fifteen (LCM group) were treated with LPZ 30mg once daily for six weeks. CAM 200mg along with MNZ 250mg bid for 10 days was added to this regimen two weeks after the LPZ regimen began.
All patients were endoscoped at entry and four weeks after cessation of treatment. H. pylori status was determined by urease test, histology and culture. H. pylori eradication rates were 42% (16/38) LA group, 57% (8/14) LC group, 83% (15/18) LAN group and 92% (13/14) LCM group. Minor side effects were observed in three cases in the LA group and in the LAN group and one case in the LCM group. Thus we could conclude that low dose triple therapy with lansoprazole, clarithromycin and metronidazole is a highly effective and well tolerated treatment for H. pylori infection.
Phenol red stain endoscopy was performed to investigate the gastric mucosa infected with H. pylori under direct vision in 70 duodenal ulcer patients. 0.1% phenol red solution containing 0.5M urea was sprayed onto the gastric mucosal surface via a teflon tube inserted through the the endoscope. Among 70 duodenal ulcer patients, red color changes in gastric antrum were immediately observed after spraying the dye solution in 66 cases, of which 44 showed diffuse color changes. Red color changes in gastric body were also observed in 35 cases, of which 32 showed regional red color changes in lesser curvature. In 40 eradicated patient, red color changes were not observed after spraying the dye solution in 38 patients. In 30 patients of failed eradication, red color changes were observed in 23 patients. This technique is useful to investigate the distribution of H. pylori in the stomach in vivo. In addition, it is possible to study the role of H. pylori in various gastric diseases.

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In order to clarify the cytobiological characteristics of colorectal polyps, we performed immunohistochemical stainingp, using antibodies against CEA, CA19-9, PCNA and p53. Expression of CEA, CA19-9, PCNA and p53 was studied immunohistologically in 6 mucosal cancer, 7 tubulovillous adenomas, and 16 tubular adenomas, which were obtained by endoscopic polypectomy or mucosal resection.
We obtained the following results. The positive staining rate of CEA for mucosal cancer was 100%, 85.7% in tubulovillous adenoma, and 81.3% in tubular adenoma. The positive staining rate of CA19-9 for mucosal cancer was 83.3%, 71.4% in tubulovillous adenoma, and 62.5% in tubular adenoma. The positive staining rate of PCNA for mucosal cancer was 100%, 88.9% in tubulovillous adenoma, and 56.2% in adenoma. The positive staining rate of p53 for mucosal cancer was 66.7%, 11.1% in tubulovillous adenoma, and 0% in tubular adenoma.
Our results reveals CEA, CA19-9, PCNA and p53 detection may be related to biological malignant potentiality of colorectal polyps. In CEA, CA19-9 and PCNA there were no statistically significant difference between mucosal cancer and tubular adenoma, tubulovillous adenoma. But in p53, there was statistically significant difference between mucosal cancer and tubular adenoma. Consequently, it was suggested that p53 takes a important role of cancerization from colorectal adenomas.

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Of the two hundred and sixty three colorectal tumors which were resected surgically or colonoscopically and were observed by stereomicroscopic examination in National Cancer Center Hospital, 213 tumors showed IIIL pit pattern. These 213 tumors were evaluated in relation among malignant change, depth of invasion and subtype of pit pattern. The IIIL pit pattern were classified as either regular-IIIL or irregular-IIIL according to following subjects ; distribution, configuration and equality of pits. Regular-IIIL (R-IIIL) were those showing equal distribution, smooth shape and equal size of pits, and irregular-IIIL (IR-IIIL) showing unequal distribution, irregular shape and unequal size of pits.
Of the 213 lesions, 172 showing regular-IIIL (R-IIIL) lesions and 41 showing irregular-IIIL (IR-IIIL) lesions. The 172 lesions showing R-IIIL consisted of 155 (90.1%) adenomas and 17 (9.9%) mucosal cancers. On the other hand the 41 lesions showing IR-IIIL consisted of 24 (58.5%) adenomas, 13 (31.7%) mucosal cancers and 4 (9.8%) submucosal cancers. The rate of malignancy was 9.9% in R-IIIL and 41.5% in IR-IIIL, respectively. There was no submucosal cancer in R-IIIL. The malignant rate in IR-IIIL was about 4 times higher than that of R-IIIL.
Our currest study suggested that the sub classification of IIIL pit pattern is useful in the diagnosis of colorectal tumors using magnifing endoscopy, and especially in the indication of surgical or endoscopic treatment.

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We have performed laparoscopic ethanol injection therapy (LEIT) and laparoscopic microwave coagulation therapy (LMCT) using an laparoscopic ultrasonography (LUS) for hepatocellular carcinoma, and obtained good results. Each method was performed under local anesthesia.
In LEIT, since a relatively large amount of ethanol can be injected, an extensive tumor area can be safely treated by one injection procedure. In particular, hepatocellular carcinomas on the liver surface or near the diaphragma, which are difficult to treat by PEIT, are good indications for LEIT. Another advantage is that control of breeding can be confirmed under the LUS. On the other hand, LMCT is also only slightly invasive, and coagulation results in adequate necrosis. Postoperative changes in liver function are slight. Both methods using an LUS are especially useful for treating small hepatocellular carcinomas that are difficult to visualize by other diagnostic imaging modalities.
The laparoscopic treatment of hepatocellular carcinoma not only is safe but also shortens the hospitoalization period, allows early initiation of oral feeding an walking, and produces complete necrosis of cancer nodules. This method is excellent in terms of cost benefit and the quality of life and has great potentiality.

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Endoscopic findings of the upper digestive tract caused by local portal hypertension due to portal vein invasion by pancreatic cancer were compared with those due to liver cirrhosis. The subjects were 86 patients with pancreatic cancer not including those having chronic hepatitis or liver cirrhosis and 376 patients with liver cirrhosis.
Endoscopy of the upper digestive tract was performed with special attention to gastroesophageal varices and gastric mucosal lesions. Varices were noted in 17 (20%) of the pancreatic cancer patients, but they were observed more frequently in those having cancer in the body or the tail of the pancreas than in those having cancer in the head of the pancreas. Gastric mucosal lesions were observed in 6 (7%) . Of the liver cirrhosis patients, varices were observed in 264 (70%) , and gastric mucosal lesions were noted in 138 (52%) of those having varices.
The incidence of varices was different with the site of pancreatic cancer. Also, the frequency of gastric mucosal lesions complicating varices was lower than that of portal hypertension complicating liver cirrhosis in the patients with pancreatic cancer.

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We report laparoscopic lumbar discectomy, developed and established by us through animal experiments, from the viewpoint of surgeons who applied laparoscopic surgery to orthopedics. Laparoscopic surgery practiced by surgeons occupied an important place in the development of operation field and exposure of intervertebral discs. L₅-S was reached by abdominal approach, and L_2-5 exposed by extraperitoneal approach.
The operation procedure was as follows : surgeons developed the operation field under pneumoperitoneum, and exposed the intervertebral disc. Orthopedists then took over and performed discectomy and fusion (bone graft) . Subsequently, surgeons closed the field, repairing retroperitoneum, etc, with which the operation was finished. With the intervertebral disc in front view and magnified, the operation was safe and easy for skilled orthopedists for spinal surgery. Gasless laparoscopy was used in orthopedic part of the operation because carbon dioxide embolism at osteotomy under pneumoperitoneum could interfere with fusion. We think this technique compares favorably with a procedure being tried in the US in respect to the safty and therapeutic effect. The technique of laparoscopic lumbar discectomy and fusion are described.

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Type 0-IIa of esophagus cancer limited to m mostly reveals whitish hue or discoloration. In contrast it has been taken for granted that type 0-IIa revealing reddish hue is indicative of submucosal cancer. The present case, despite of the presence of evident reddish hue on the surface, resulted in the final diagnosis of mucosal cancer (intraepithelial) .
A case of male 60 years of age. He underwent upper GI endoscopy at our clinic in the periodic health examination with no subjective complaints, followed by the detection of a very slight elevation revealing evident reddish hue on the left wall site 30cm from the upper incisors. Confirmed as squamous cell carcinoma by biopsy. Despite of the presence of reddish hue, the lesion was clinically diagnosed as limited to M₂ at the deepest in that it assumed the gathering of fine granules no arch deformation being present. Referred to Tokyo Medical Dental College (1st Department of Surgery) for EMR preceded by EUS, which supported the aforementioned view of M₂ invasion at the deepest. The lesion was pathologically confirmed as 15x15mm 0-IIa with cancerous depth invasion yet confined to the intraepithelial layer (ep) . Histologically squamous cell carcinoma, ly (-) , and v (-) .

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A 99-year-old man was admitted to our hospital with dysphagia as the chief complaint. Radiographic and endoscopic examination of the esophagus showed large mass with severe stenosis. The pathological diagnosis was well differentiated squamous cell carcinoma.
As carcinoma was far advanced, self-expanding metal stent (Ultraflex^®，esophageal prosthesis, Microvasive Division, Boston Scientific, Denmark) was implanted endoscopically. The stent expanded fully and migration did not occurred. Dysphagia disappeared dramatically and there were no complaints except just after insertion.
In comparison with plastic stent, Ultraflex^® is more easily inserted, with less discomfort and migration.

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A case was a 49-year-old man, undergoing subtotal gastrectomy (Billroth II) for gastric ulcer at the of 20. He was endoscopically diagnosed as having gastric adenoma 6 years ago. He was admitted for endoscopic mucosa resection (EMR) . At endoscopy, 2 small protrusion close to each other were observed near the lesser curvature in the upper portion of the body. The rostral one resembled a gastric adenoma, and the caudal one looked like a submucosal tumor. EMR was performed on these lesions. Histopathologically, the rostral adenoma was moderate dysplasia without focal carcinoma. The caudal protrusion was formed in the submucosal layer, where cut nurve fibers and connective tissue grew while they were twisted together, forming a tumorous node. Thus the patient was diagnosed as having amputation neuroma.
Amputation neuroma is not a true tumor, but is a reactive tumor formed when cut nerve fibers have nowhere to grow due to resection and, therefore, form a mass. It is said that this type of neuroma can occur any place if nerve fibers having Schwann's nucleus are cut. As for nerves serving as parents of amputation neuroma, these are Meissner's plexus in the submucosa and Auerbach's plexus in the lamina muscularis mucosae. Therefore, there is a strong possibility that amputation neuroma occurs as a result of resection of one or more of these nerves at the time of gastrectomy. However, there have been no reports on amputation neuroma occurring in the stomach, to our knowledge.

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Ischemic colitis is often observed on examination of emergency colonofiberscopy. The patient was a 68-year-old man who had undergone an operation for sigmoid colon cancer 3 years before this examination. Barium enema was arranged to monitor his progress. He had diarrhea and bloody stools with colonalgia when magnesium citrate and sodium picosulfate were subsequently given for preparation of his colon. Results of the emergency colonofiberscopy, barium enema and pathology of the biopsy specimen led to a diagnosis of ischemic colitis. Colonoscopic findings showed that the mucosa from the anastomosis site to the mid transverse colon were hemorrhagic, edematous and erosive.
In this patient, the disorder was allevited in a few days by coservative therapy. This case was a transient type of ischemic colitis. We conclude that preparation of colons should be carried out carefully.

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A 73-year-old man was admitted to our hospital with chief complains of nausea, mucous diarrhea, and consciousness disturbance. On admission, dehydration, hyponatremia and hypokalemia were observed, we had to perform rehydration with saline, containing potassium chloride.
Because of large amount of rectal mucous discharge (2-3 l/day) , we performed colonoscopy, and found the encircling flat protruding tumor with villous structure to arise 1cm above the anus, and to extent upward for 12cm. We diagnosed rectal villous adenoma with electrolyte depletion syndrome (EDS) by pathological examination of its biopsy specimen. It was suggested that the secretion of water and electrolytes from villous adenoma was participated in prostaglandin E₂ (PGE₂) , but indomethacin, PG-synthetase inhibitor, was not effective to decrease rectal discharge in this patient. Large amount of mucous diarrhea was continued, so Miles' operation for rectal tumor was performed, and EDS was improved after the tumor resection.
There were only twenty-five case reports of villous adenoma with EDS in Japan, we reported this patient with review of literatures.

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A 52-year-old male heavy drinker was admitted to our hospital because of the liver dysfunction and positive serum anti-HCV antibody. He had no history of photosensitivity.
Laparoscopic examination revealed multiple small hollows of dark purple color sized 5 to 10 mm in diameter on liver surface, which findings were characteristic of porphyria cutanea tarda. The liver biopsy showed mononuclear cell infiltration and fibrosis in the potal area with piecemel necrosis. Urinary excretion of uroporphyrin and coproporphyrin were high.
The second laparoscopy and biopsy was performed one year after the first examination. There was no remarkable change on liver surface. The liver biopsy specimen showed orange fluorescence under ultraviolet light. Measurements of porphyria were repeated, uroporphyrin and coproporphyrin were 342 μg/g・cr, and 23 μg/g・cr, respectively.
In this case, laparoscopy was essential for the diagnosis of porphyria cutanea tarda.

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We perform sclerotherapy using 1% Aethoxysklerol for F₀-F₁ level esophageal varices. We consider bleeding and pain after sclerotherapy to be harmful.
We therefore mixed powdered sodium alginate and thrombin, and tried to inject the mixture using Alto Shooter, to esophageal varices after sclerotherapy. The injection of the mixture was effective for stopping bleeding and reducing pain after sclerotherapy. The mixture could be fixed firmly to the mucosa. The hemostatic effect of thrombin and the mucosal protection effect of sodium alginate, could be improved using a mixture of these drugs. There have been no side effects or trouble.
In conclusion, the injection of a mixture of sodium alginate and thrombin was easy and minimally invasive. It was therefore a useful method for the prevention of bleeding and pain after sclerotherapy. We can perform sclerotherapy safely in the outpatient clinic with these methods.

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Therapeutic effect of endoscopic variceal ligation (EVL) for esophageal varices was analyzed. Subjects were 32 cases treated by EVL and 42 cases by endoscopic injection sclerotherapy (EIS) . These cases were followed up from January 1993 to January 1995 and red color signs were positive in all cases.
Twenty-six cases (84%) were effective with no red color sign at one month after EVL. The relapse rate of these effective cases was 24.9% at six months, and 60.4% at 12 months. These results were similar to those by EIS. In cases in which the findings of the esophageal varices were of form F₂ or above, relapse rate at 12 months was 95.2% on EVL, and 60% on EIS. As for prognosis, EVL had higher relapse than EIS (p<0.05) . Risk of complication was less in EVL than in EIS therapy.
These results suggest that EVL is as effective as EIS. However, in cases of form F₂ or above, efficacy of EVL treatment was shorter than that of EIS. Therefore, EVL and EIS therapy should be combined.

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The aim of the present study was to find the usefulness of gastric aspirated urea concentration in detection of the efficacy of eradication of H pylori (HP) by comparing with gastric ammonia concentration and serum pepsinogen I/II ratio.
A total of 32 subjects (15 with gastric ulcer, 15 with duodenal ulcer, and 2 with gastro-duodenal ulcer) were infected with HP. HP infection was detected by microscopic examination of slides stained by Gram's method and treated with Pfeiffer fluid. All patients received lansoprazole (30mg, every morning) and ecabet sodium (2ｇ, twice a day) for 6 or 8 weeks. Patients also received amoxicillin (750mg, three times a day) for last 2 weeks. The clearance and eradication rates were 100% (20/20) and 60% (12/20) , respectivery.
The eradicated group had significantly higher gastric urea and serum pepsinogen I/II levels, and significantly lower gastric ammonia level than before eradication and the non-eradicated group. There were few subjects overlapping in gastric ammonia and serum pepsinogen I/II levels, but no subjects overlapping in gastric urea level in the eradicated and the non-eradicated groups. Measurement of gastric urea level may provide a useful tool for detecting the efficacy of HP eradication.

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We evaluated serum pepsinogen I (PG I) and II (PG II) assay, and ¹³C-Urea breath test (¹³C-UBT) in a diagnosis of Helicobacter pylori (HP) after teatment with lansoprazole and clarithromycin. Forty two patients included 10 gastric ulcer, 7 duodenal ulcer, 8 gastroduodenal ulcer and 17 chronic gastritis, treated with 30mg of lansoprazole and 600mg of clarithromycin in a day for 14 days.
Serum PG I and PG II levels reduced and PG I/II ratio increased in effective cases after therapy significantly. There were not refractory cases in range of more than 31% of reduction rate of PG I, 41% of PG II and 161% of increasing rate of PG I/II ratio. However, 1/3 of effective cases did not demonstrate so much change in PG I and PG II levels. ¹³C-UBT of effective cases reduced within normal range of Δ¹³C after therapy. Δ¹³C of refractory cases did not decrease into normal range.
Although measurement of serum PG I and PG II was not adequate in a diagnosis of HP after therapy, ¹³C-UBT examination is not risky and can be useful in observing the eradication of HP.

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We studied on : (1) the Helicobacter pylori (Hp) eradication rate and side effects (2) the association between eradication and inflammatory reaction of gastric mucosa and (3) the correlation between serum anti-CagA antibody titer and gastric diseases. Patients formed two groups : twenty-one patients in group A recieved lansoprazole (L) 30mg, plus clarithromycin (CAM) 400mg, for two weeks ; twenty-six patients in group B were treated with L 60mg, plus CAM 800mg for two weeks.
Results : (1) Using a ¹³C-urea breath test instead of a conventional method including CLO, culture and histology, measured eradication rates fell from 43% to 19% in group A, from 58% to 31% in group B. Side effects rose in frequency as dosage increased. (2) After eradication, levels of IL-8 and myeloperoxidase (MPO) in gastric mucosa improved. There was no correlation between inflammation severity before eradication and eradication rate. (3) Serum anti-CagA antibody titer rose in patients with open ulcers and was significantly high in Hp-infected patients with. Changes in antibody titer after eradication may reflect changes in microorganism volume and host reaction.

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A new triple therapy for eradication of HP in 24 patients of peptic ulcer (13 duodenal and 11 gastric ulcers ; 18 male and 6 female ; 18-74 years, mean 49) were undergone with PPI+AMPC+ecabet sodium. We used 30mg id or bid of lansoprazole, 0.5ｇ tid of amoxicillin and 1.0ｇ ecabet sodium bid for 2 weeks. Eradication of HP infection was diagnosed by ¹³C-UBT and detection HP DNA in the gastric juice using PCR method. Eradication rate was 22/24 (92%) by ¹³C-UBT and 19/24 (79%) by PCR method. Side effect was diarrhea which was found in 1/24 (4.2%) patients.

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To evaluate the potential benefit of a 2-week regimen including lansoprazole, various antibiotics and ecabet sodium for eradication of H. pylori from the gastric mucosa.
Ninety eight patients with H. pylori infection with gastric ulcer (33 patients, mean age 56) , duodenal ulcer (23 patients, mean age 48) , and chronic gastritis (42 patients, mean age 56) were included in a randomised open pilot study ; they were treated with lansoprazole 30mg od + amoxicillin 500mg qid (LPZ+AMPC) , lansoprazole 30mg od + amoxicillin 500mg qid + ecabet sodium 1ｇ bid (LPZ+AMPC+ES) , lansoprazole 30mg od + roxithromycin 150mg bid (LPZ+RXM) , or lansoprazole 30mg od + clarithromycin 400mg bid (LPZ+CAM) for 2 weeks. Endoscopy was performed before and 3 months post-treatment. The presence of H. pylori was assessed in ulcer-border, antral and corporeal biopsies by rapid urease test (CLO test) and histology (Acridine-orange stain+HP monoclonal-antibody stain) .
H. pylori eradication was observed in 27/43 (63%) in the LPZ+AMPC group, in 22/29 (76%) in the LPZ+AMPC+ES group, in 4/19 (21%) in the LPZ+RXM group, and in 3/7 (43%) in the LPZ+CAM group. Six patients reported side effects including ; diarrhea (4) , urticaria (1) in the LPZ+AMPC group, and diarrhea (1) in the LPZ+RXM group. Because of the highest eradication rate and no side effect of the LPZ+AMPC+ES therapy, we recommend it as first-line anti H. pylori treatment for a patient with H. pylori infection.

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Helicobacter pylori (HP) has been reported to associate with gastric cancer and the eradication of HP would be of great value to reduce the incidence of gastric cancer. Although several treatment, including antibiotics and proton pump inhibitors, are utilized for the HP infected patients and effective, these drugs also produce considerable side effects.
We have reported the growth inhibitory effect of epigallocatechin gallate (EGCG) , a main constituent of Japanese green tea, on HP in vitro. Then we examined the effect of Sunphenon containing EGCG on the eradication of HP, clinically. Seven HP positive volunteers or patients without gastric dieseases were treated with Sunphenon 600-700mg daily for 4 weeks. Endoscopy was performed before and at the end of the therapy and HP was detected by culture with two pair biopsy specimens taken from the antrum and upper body of stomach. Whereas the reduction of volume of HP was revealed in 4 out of 7 (57%) , this results was not satisfactory. This reason was considered to be based on the rapid disappearance of Sunphenon from the gastric lumen. It is necessay to develop the method for remaining Sunphenon in stomach for the sufficint eradication of HP, in future.

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In the cancer screening center of Ibaraki prefectural mass survey society, the upper gastrointestinal endoscopy is performed for the checked up people with stomach cancer screening test. To evaluate our way to do the upper gastrointestinal endoscopy without examinees' uncomfortableness, we studied 919 cases using the questionnaire. A nurse or endoscopic technician asks examinees about the questionnaire (Table 1) . Most examinees who were composed of 682 males and 237 females, came to this society for the first time (Fig. 1) . In our center, examinees have a look at premedications and endoscopic examination in a video-program before examination. During examination, the endoscopist explains the endoscopic findings to them.
In conculsion, : (1)Almost examinees agreed with examinations (Table 2) , (2)The analysis of questionnaire showed that examinees, took endoscopic examination with little uncomfortableness (Table 3) . We conclude that for painless examination, it is important for examinees to understand how the examination is done.

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We studied the factors that ease pain during an endoscopic examination. The results are as follows : 1) no restriction of eating on the previous day or drinking water on the day of examination, 2) flavored local anesthetics (anestheflavor) and music anesthesia, 3) kind treatment of patients by endoscopists, 4) kind words and care of trained nurses, and 5) intravenous administration of 5mg of diazepam. It is important to do these things properly to ensure painless endoscopic examination.

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Gastrointestinal (GI) endoscopy has been recognized one of hard painful examinations. Recently, mechanical and technical advances made GI endoscopy easy and safe clinical procedures for detection and therapeutics to GI tumors.
Although these developments of clinical diagnosis and treatment, psychological and physical factors in the examination and premedication in GI endoscopy for the patients have not been yet resolved. On the other hands, many endoscopists tend to use more and more sedative and opiate drugs in routine endoscopy. This report evaluated that subjective symptoms complained by patients and objective symptoms given by endoscopists, endoscopic technicians and nurses whether the premedication is necessary or not in routine GI endoscopy.
Any other drugs using for endoscopic premedication would not be desired more than 80% of all patients recieved endoscopy were suggested in this paper. Then acceptance of GI endoscopy without any kinds of premedications was more than 80% respectively. Results of high agreement rate on endoscopy, and no desire of premedications could be achieved by endoscopists through instructions including informed consent and professional attendance by endoscopic technicians and nurses with the qualification. And additional effects can be accomplished by using with TV endoscopy which could be seen the endoscopic picture during the own examination and use of well fitted mouthpiece.

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We analysed the therapeutic result of endoscopic hemostasis for 75 cases of bleeding gastric ulcer from January 1994 to May 1995. Ethanol infusion was tried 118 times, and HSE infusion or clipping were tried 21 times each. In all 75 cases, endoscopic hemostasis was successful for the first time, but in 5 cases rebleeding was noted and 3 cases underwent operative therapy. In most cases, ethanol infusion was effective, but in some cases with a large exposed vessel or spurting bleeding, it was difficult to stop bleeding only with ethanol infusion, and clipping or HSE infusion or other method was needed.
Recently we tried continuous ethanol infusion therapy for 8 of those difficult cases. In this method, we inject 5 to 10 ml of ethanol directly into the exposed vessel continuously and very slowly over 2 to 10 minutes, and the ethanol injected into the vessel is never washed out by bleeding. So the effect to make thrombus is remarkable, and the hemostasis was successful and rebleeding was not noted in all 8 cases. Huge ulcer formation were noted in those cases because of extensive intraarterial thrombosis, but the healing of such artificial ulcers were very rapid and no trouble was aroused by those ulcers.
In conclusion, continuous ethanol infusion therapy was thought to be effective therapeutic modality for bleeding gastric ulcer especially with large exposed vessel and spurting bleeding.

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For 6 years, since 1988 to 1994, we have been performed medical treatment of the 143 gastric lesions, which were diagnosed of early gastric cancer or adenoma, by the endoscopic mucosal resection (EMR) .
Method : We have performed the EMR by the Tada's method. We have peformed the EMR by two panendoscopes before 1992, but after 1992, by one 2-channels therapeuetic scopes.
Results : (1)In this study, 60 gastric cancer lesions were examined, in which 42 lesions were already diagnosed as gastric cancer before EMR. Diagnosis of 11 lesions, which were 12% of adenoma, were corrected to the early gastric cancer after EMR. On the 7 lesions, which were suspected of gastric cancer, final diagnosed of the early gastric cancer by EMR. 48/60 lesions (80%) were intramucosal cancer.
(2)By the 2 panendoscopes method, pathological complete resection rate and no recurrence rate were 63%, 85%. Simularly, by the 2-channels therapeutic scope, there were 60%, 96%. In the two EMR methods, there was no significant difference. There were 6 recurrenced cases, all these cases were occured in the pathological incomplete resected cases. Only one complication was post EMR bleeding case.
In conclusion, EMR is effective and safety method for early gastric cancer.

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We evaluated the laparoscopic wedge resection (LWR) and percutaneus transgastricwall mucosal resection (PTEMR) for early gastric cancer. LWR indicated anterior, greater curveture and partial posterior gastricwall lesions. Under general anesthesia, 3-5 tracars are inserted abdominal wall. After crumping jejunum at Treiz ligament, two needles (18G) are injected percutaneus transgastricwall around the lesion. A suture is inserted through the needle and catched that by looped stainless wire from another site. Then two points lifting of the gastric wall is made. Same way, another two needles are inserted around the lesion for 4 points cross lifting of the gastricwall and wedge resection was perfomed with autosuture device.
PTEMR is a procedure for gastric mucosal resection under gastroendoscopy using laparoscopic forceps and scissors through gastrostomy. The lesion is grasped by the forceps and resected by a snare with electrocautery under gastroscopic view.
We have perfomed 7 lesions of 6 cases by PTEMR, and 2 cases by LWR for early gastric cancers.

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Liver cirrhosis (type B) with an esophageal varix was diagnosed in a 53-year-old male in November 1992. On February 2, 1995, epigastralgia suddenly developed. After seven days, endoscopic examination revealed peeled mucosa on the surface of a varix alongside a longitudinal ulcer in the lower half of the esophagus. After thirty days, the varix became flat and a white scar developed.
Esophageal submucosal dissection is considered to be a disorder classified between Mallory-Weiss syndrome and Boerhoave syndrome. Common causes are endoscopic injection sclerotherapy, foods, drugs, and pemphigus. It is sometimes idiopathic. Eighty-five cases of esophageal submucosal dissection have been reported in Japan, but none of them was followed by the disappearance of an esophageal varix similar to this case.

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Case 1 : A 49-year-old man was treated with antibiotics for the removement of a nail. After two weeks of treatment, he visited our hospital with a complaint of epigastralgia. On the endoscopic examination, the diagnosis was esophageal candidiasis, grade II of Kodsi's classification.
Case 2 : A 63-year-old man with a gastric polyp was resected by endoscopic polypectomy. The yearly endoscopic examination of this time, the diagnosis was a lower esophageal candidiasis, grade I of Kodsi's classification.
The diagnosis of esophageal candidiasis is comparativly easy because the endoscopic finding is characteristic. The increase of candida of the digestive system causes candidemia and dissemination of candidiasis. There is a report that the mortality rate of acute dissemination of candidiasis is about 40%. So early treatment is important for candidiasis.
In case 1, intravenous administration of fluconazole 200mg/day and case 2, oral administration of fluconazole 150mg/day were started. One week later, a diffuse white coat and a white elevated lesion disappeared from both cases on the endoscopic examination.

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A 64-year-old woman was hospitalized with heartburn and precordial pain. Cardiovascular disease was not detected. Therefore, we investigated the gastrointestinal tract. Conventional esophageal manometry and upper gastrointestinal series were normal. On endoscopy, columnar epithelium of approximately 1 cm was found around the circumference of the lower esophagus, but there was no acute reflux esophagitis. On Bernstein test, heartburn appeared, but precordial pain did not occur. On esophageal balloon dilatation, there was a sense of pressure, but precordial pain did not occur. Because heartburn occurred on Bernstein test, we considered the possibility of gastroesophageal reflux (GER) disease, and investigated 4-hour intraesophageal pH monitoring. GER occurred on several occasions during the first hour of the postprandial period, and 2 episodes of GER were accompanied by heartburn. During the first hour of the postprandial period, the percent time pH<4.0 was 9.6%.
The cause of precordial pain was unclear, but the existence of GER was established. So we administered proton pump inhibitor (PPI) to confirm the diagnosis and for treatment. After oral administration of PPI, heartburn and precordial pain completely disappeared. We concluded that the cause of precordial pain in this case originated with GER.

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We reported a case of esophageal squamous cell papilloma treated with endoscopic mucosal resection. A patient was a 41-year-old man who had a flat elevated lesion (40x20mm) with granular surface on the posterior wall of the upper esophagus. Endoscopic resection was performed on February 25, 1993. Histological findings revealed squamous cell papilloma. Immunohistochemistry for human papilloma virus using immunoperoxidase technique was negative. DNA of human papilloma virus in resected specimen (dott blott technique) was negative. HPV infection was excluded.
However, three cases of squamous cell papilloma with malignant changes have been previously reproted. Therefore, a papilloma which size is more than 10mm and one showing the change in size should be actively resected under the endoscopy.

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A 45-year-old male complaining of anorexia and heartburn was diagnosed by endoscopic findings that 0-IIc lesion with ulcer and the surrounding scattered erosion due to the reflux esophagitis on the lower esophagus (Ei) . The submucosal invasion was suspected and the total thoracic esophagectomy with reconstruction was performed. The operational findings were Ei-Im-Post, 0-IIc, Pl (-) , N (-) , M (-) , Stage I, R₃. The resected specimen revealed superficial carcinoma coexisting with a submucosal tumor in the lower part of the esophagus (Ei) . Microscopic findings showed only 2mm sized 0-IIc lesion was moderately differentiated squamous cell carcinoma with submucosal microinvasion (sm) and n₀, ly₀, v_o, ow (-) , aw (-) , ew (-) . It also revealed the submucosal tumor was leiomyoma (5x3mm) which seemed to arise from the muscularis propria. The patient was discharged with no postoperative complications.
Only 2mm in size of the 0-IIc esophageal carcinoma had sm₁ microinvasion. It was very rare case, but it provided the question about the indication of the endoscopic mucosal resection (EMR) . The post-operative pathological examination of the resected specimen is important, but also it is more important to preoperatively diagnose the acurate depth of invasion.

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A 69-year-old man was referred to our hospital for the purpose of endoscopic treatment of the early gastric carcinoma located at EGJ. As it was type IIa well differentiated adenocarcinoma, which was thought to be intramucosal, EMR was performed. The resected specimen was 8mm in diameter.
Early gastric carcinoma in a fundic gland area, espacially near EGJ, is tend to be histopathologically well defferentiated. The more close to EGJ the location is, elevated type is the more frequently found than depressed type. So it is possible that early gastric carcinoma near EGJ is misdiagnosed as adenomatous polyp. In fact, this case was misdiagnosed as benign polyp 2 years before EMR. However significant degrees of atypism was already existed in that biopsy specimens retrospectively. We should pay attention to a gastric polyp at EGJ, because it may be an early carcinoma and if it is, in case of an indication of EMR, EMR should be performed.

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A 65-year-old female visited our hospital due to the epigastralgia. An endoscopic examination for the upper gastrointestinal tract revealed the foreign body stuck in the gastric wall. It was safely removed by an endoscope and ascertained a fish bone. The fish bone was 25mm long and 11mm of it was buried in the gastric wall.
According to the literature, most of patients don't realize they have swallowed foreign bodies by mistake. Adults rarely swallowed them and foreign bodies rarely stay in the stomach. Besides, a fish bone rarely becomes a cause of foreign bodies in the stomach. On this occasion, we encountered an adult case of a foreign body, a fish bone, stuck in the gastric wall and succeeded to remove it endoscopically for the treatment.

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We report here our experience of patient treated initially with famotidine and subsequently with proton pump inhibitor omeprazole. Protein levels rose to normal range after 4 months and remained within normal limits, but upper endoscopy still showed enlarged gastric folds after 5 months. Conservative therapy with PPI and H₂-RA must be tried prior to surgery.

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A 61-year-old man was admitted to other hospital on January 13, 1995 with the complaints of vomiting and diarrhea. After admission, the hematemesis was happened to be shock state by blood loss on the 28th hospital day. Emergency gastric endoscope was revealed the bleeding from esophageal ulcer all around in upper part of EC junction, multiple gastric ulcers in lesser curvature of the angle, posterior wall of the upper body, duodenal ulcer in anterior wall of bulbs were found.
During conservative therapy, the hematemesis was found again with shock state, and the patient moved to our hospital. Serum gastrin level (450 pg/ml) , pepsinogen I level (114 ng/ml) were higher in average and Helicobacter pylori IgG antibody was positive (81Ｕ/ml) . We reported the case of multiple esophageal, gastric and duodenal ulcer that was resisted against proton pump inhibitor with repeats of shock by rebleeding due to the highly suspected gastrinoma.

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A 71-year-old man was admitted to our hospital complaining of nausea and waterly diarrhea. Physical examination on admission showed low grade fever, lower abdominal pain and increasing bowel sound. Laboratory data on admission showed leukocytosis (21,700/mm³) and hypoproteinemia (4.3g/dl) . Occult blood of stool was positive, but stool culture showed no significant bacteria.
Esophagogastroduodenoscopy showed erosions from middle to lower esophagus, edematous mucosa of the 1st and 2nd portion of duodenum and irregular open ulcers coated with white fur on the 2nd portion of the duodenum. But gastric mucosa was normal. Colonoscopy showed endematous and reddened mucosa of Bauhin's valve, sigmoid colon and rectum, but no abnormal findings were recognized from ascending to descending colon. Histological examination of biopsy specimens of these lesions showed only infiltration of inflammatory cells in the mucosal layer and fibrosis in the submucosal layer, but no granuloma was found.
We suspected Crohn's disease because of endoscopic findings and clinical course, and so prednisolone 30 mg/day and salazosulfapyridine 3 ｇ/day were given, clinical course and endoscopic findings were improved. But pathologically diagnostic creteria for Crohn's disease were not satisfied and considering of his age, ischemic change was most suspected. So careful follow-up of his clinical course and repeated endoscopic examination are important for establishment of the diagnosis.

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A 53-year-old woman was admitted for further examinations for gastric polypoid lesion which looked like submucosal tumor by X-ray examination. X-ray films revealed elevated lesion of 2cm in diameter with bridging folds located on the anterior wall of the middle gastric body close to the lesser curvature. Endoscopically, elevation had bridging folds, covered with normal gastric mucosa and a red small depression was observed on the top. The laparoscopy assisted partial resection of the stomach was performed. Laparoscopically, a white, elastic hard nodule was observed on the serosal surface. The excised specimen revealed a submucosal tumor, 23x20x12mm in size. The heterotopic gastric mucosa with cystic changes was microscopically observed in the submucosal layer extending to submucosal layer. No malignancy was detected. No acinar nor duct structures ware seen, which is pathognomonic for ectopic pancreas. No recurrence was seen 1 year after resection.

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A 60-year-old male with past medical histories of hypertension and diabetes mellitus for 13yrs, had epigastric discomfort. He was pointed out abnormality on upper gastrointestinal fiberscope. Upper GIF revealed multiple elevated lesions from cardia to lower body of the stomach, biopsy of which is carcinoid tumor. As total gastrectomy was performed, resected stomach had 9 tumors, maximum size of which was 42×35mm in diameter.
Multiple gastric carcinoid tumor which occupies about 10% of all gastric carcinoid tumors, is commonly reported to be about 10mm in diameter. It has usually metastasis if above 10mm in size. In summary, we report a rare case of carcinoid tumor characterized by large tumor size and no metastasis.

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A 65-year-old woman who had an abnormality pointed out by radiological examination at gastric mass survey in November 1994, came to our center. Endoscopic and Radiological examination revealed irregular shaped depressed lesion with fold conversion in greater curvature of the middle portion of gastric body. Clinical diagnosis was type of IIc early undifferentiated gastric cancer. But biopsy specimen was differentiated tubler adenocarcinoma.
From the result of histological diagnosis, it reversed as follows. (1) The outline of lesion was not so well defined, (2) with gradually narrowed the fold, (3) a few small nodules in the depressed lesion, (4) reddish mucosa suggested the tubuler pattern of mucosed pit. These figures were matched the typical figure of defferentiated adenocarcinoma. Gastrectomy was carried out. By the histopathological study, this carcinoma was shown to be differentiated type adenocarcinoma arising from fundic gland mucosa. It is invasion was limited to the submucosal layer.

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A 85-year-old woman visited to our hospital with epigastralgia as her complaint. Submucosal-like tumor was found on the antrum of stomach endoscopically. The biopsy specimen was taken from the tumor. However pathologic diagnosis of malignancy was not obtained, so endoscopic examination was performed every month carefully. After 4 months later from the first examination, the surface of tumor altered to be irregular endoscopically, and the biopsy was successful to diagnose the gastric cancer. Frequent examination may be useful for diagnosis of gastric cancer resembling submucosal tumor.

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Case 1 : This 46-year-old man underwent subtotal gastrectomy in 1991 for two IIc lesions. Endoscopy in 1994 revealed a polypoid lesion in the posterior wall of the gastric remnant, and biopsy results were positive for adenocarcinoma. The lesion was resected by endoscopic mucosal resection (EMR) . Pathological findings revealed well differentiated adenocarcinoma limited to the mucosal layer and the surgical margin was negative.
Case 2 : This 75-year-old man underwent subtotal gastrectomy for a IIa lesion in 1992. Endoscopy in 1994 revealed a polypoid lesion at the anastomotic site, and biopsy results were adenocarcinoma. Endoscopic ultrasonography (EUS) indicated that cancer was limited to the mucosal layer and EMR was performed. Pathological findings confirmed well differentiated adenocarcinoma limited to the mucosal layer and the surgical margin was negative.
In the Keio University Hospital, we have strict guidelines for local resection of primary gastric cancer : (1) the lesion must be limited to the mucosal layer, (2) protruding lesions must be smaller than 2.5 cm in diameter, (3) depressed lesions must be smaller than 1.5 cm in diameter and Ul (-) . The indications for EMR are even more limited ; smaller than 1 cm in diameter.
We have operated on 11 cases of early gastric remnant cancer thus far, and experienced only 1 case of lymph node metastasis in a submucosal cancer of a patient operated for gastric cancer 29 years before the second operation. There have been 124 reported cases of early cancer in the remnant stomach in Japan, and only 3 cases had lymph node metastasis, all submucosal cancers. For these reasons, we can regard EMR for early cancer in the remnant stomach as a good alternative to operation when performed along the same guidelines as primary early gastric cancer.

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A 77-year-old female was admitted diagnosed with pyloric stenosis due to Borrmann type IV gastric cancer, 8 cm in size.
Abdominal ultrasound and CT scan revealed marked irregular hypertrophy of the gastric antrum with ascites. Bloodwork reveald serum IAP level of 727µg/ml. Our diagnosis did not indicate surgical treatment, however, endoscopic treatment using Nd-YAG laser irradiation of 6,988 joules (50Ｗ, 0.5sec) with local injection of 4mg Lentinan was performed each month for three months.
The patient was able to eat soft rice gruel within 5 days of the initial treatment without experiencing nausea or vomiting. Following the third treatment, upper GI series revealed partial tumor reduction, and bloodwork results indicated serum IAP level of 373µg/ml. The patient exhibited positive recovery (QOL) for 8 months, then declined due to carcinoma pleuritis and peritonitis. The patient died 12 months after the initial endoscopic treatment. Autopsy revealed diffuse hypertrophy of the gastric antrum with signet ring cell carcinoma.

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A 39-year-old man visited my clinic because of persisitent epigastric pain. He ate raw fish“shime saba”4 days ago, and had epigastralgia since next morning. Physical examination was non-remarkable except for tenderness on epigastric region. Ultrasonography showed gall bladder debris. Endoscopic examination of upper GI tract revealed dome-shaped mucosal nodule with erosions and Anisakis penetrating the mucosa of the duodenal bulb. A warm was successfully removed with using biopsy forceps. Epigastric pain disappeared soon thereafter.
Anisakiasis is common parasitic infection of GI tract, but rarely found in duodenum (0.64%) . To my knowledge, this is the fifth case of duodenal anisakiasis reported in Japan.

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