Intragastric surgeryの問題として，トラカール挿入時，内視鏡補助下で行うため腸管内に空気が流入し，後の腹腔鏡操作の妨げとなることがあげられる。現行の空気遮断法は，内視鏡施行前に腹腔鏡下で空腸もしくは十二指腸に鉗子をかける方法である。しかし，腹腔鏡下にトライツ靭帯を確認することは容易でなく，腸管に長時間鉗子をかけることによる腸管損傷・浮腫の発生が懸念される。そこでわれわれは，胃内で空気遮断が可能な方法につき検討した。方法1 : ダブルバルーン付きチューブを胃内へ挿入し，幽門輪前後で両バルーンを膨らませ，空気の流入を遮断する。方法2 : 幽門前庭-幽門輪に密着するディスクで空気の遮断を行う。ディスクの逸脱を防ぐ目的で，ディスク中心にシャフトが存在し，かつ先端に小ディスクを有し，これが幽門輪から球部内に挿入される。本ディスクの使用により3孔式intragastric surgeryが施行可能となった。

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　筆者らは，留置スネアと爪付型透明キャップを使用した内視鏡的静脈瘤結紮術（EVLsc）と，この手技で使用する留置スネアのミニループを開発した。本手技の利点は，オーバーチューブを使用せずに短時間に複数の静脈瘤結紮が可能なこと，EVLに比べると少ない結紮数で同等の効果が得られること，透明キャップにより術中の視野が良好なこと，また既存の留置スネア装置をそのまま利用できて経済的なことである。国立佐倉病院では1995年8月より12月までの5カ月間に，F₂以上の食道静脈瘤10例と噴門静脈瘤1例の計11例にEVLscを行った。治療目的は，緊急止血2例，予防的結紮9例であった。これらの11例に対して，特別な鎮痛処置を使用せず，一般の上部消化管内視鏡検査の前処置でEVLscを行ったが，患者の苦痛は少なく，偶発症は一切認めなかった。また，平均治療時間は9分40秒であった。治療結果は，緊急止血の2例では即座に止血が可能であり，また食道静脈瘤10例では，全例でF-numberの改善と，9例中8例（89％）でRC signの消失を認めた。この食道静脈瘤に対するEVLscの成績は，自験例で同程度の食道静脈瘤に対して行ったEVL成績に類似しているものの，平均結紮個数はEVLsc（4.3）ではEVL（7.2）に比べ明らかに少なかった。EVLscは，EVLと留置スネアがこなせる内視鏡医であれば容易であり，今後の静脈瘤治療に貢献する手技と考えられた。

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　食道静脈瘤に対し予防的治療目的に内視鏡的食道静脈瘤結紮術（endoscopic variceal ligation : EVL）を施行し経過観察している120例中，出血例は9例（7.5％）であった。そのうちEVL後60日以内に出血を認め，他の治療が追加施行されていない5例（4.2％）をEVL操作に起因する早期出血例と考え，そのリスクファクターなどを検討し，EVLの注意点と安全性の限界について考察した。早期出血例は男性4例，女性1例で，平均年齢は62.2歳であった。原疾患は肝硬変（C型）3例，アルコール性肝硬変1例，肝外門脈閉塞症1例で，食道静脈瘤はいずれもF₂，RC（＋）以上の症例で，初回治療例2例，硬化療法後再発例2例，手術後再発例1例であった。肝機能はChild分類でB3例，C2例で，血小板数も含め非出血例と有意差は認めなかった。施行したEVL個数は2-8個，平均5.6個であった。EVL施行から出血までの期間は2-20日，平均13.2日であった。出血はいずれもEVL施行部位の肉芽組織が壊死脱落した箇所からであった。また早期出血例は，静脈瘤治療歴のある症例や門脈腫瘍塞栓を有する肝癌合併例および糖尿病，ネフローゼ症候群，悪性腫瘍などの全身合併症を認める症例であった。EVLは侵襲が少なく，おおむね安全な治療法であるが，それでもなお，これらのリスクファクターや全身合併症を有する症例では術後出血の危険があり，細心の注意を払い慎重な治療と経過観察が必要であると考える。

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　バルーン下逆行性経静脈的塞栓術（BRTO）を施行した10人の胃静脈瘤を有する肝硬変症例に対して，術後の食道静脈瘤の変化と胃粘膜に及ぼす影響について検討した。食道静脈瘤は術後に2例に増悪を認め，うち1例にはEISを必要とした。胃粘膜の変化については，術後に胃静脈瘤直上の胃粘膜にモザイク様発赤所見「うろこ様発赤」を全例に認めたが，portal hypertensive gastropathy（PHG）の増強を認めた症例は2例のみであった。また，術前にPHGを認めなかった8例では術後にも新たなPHGの出現はなく，BRTOにより胃静脈瘤流出路を塞栓しても，PHGに対する影響は比較的少ないものと考えられた。

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　1992年7月から1995年7月までの間に，上部消化管内視鏡検査を施行した5,594例9,329件中，非上皮性腫瘍を除き，開放性潰瘍を伴い生検を施行した症例は550例である。これらのうち，初回時内視鏡診断と組織診断の相違をみた20例を対象として，それらの内視鏡像を検討し，内視鏡診断における問題点を明らかにした。内訳は偽陽性例6例（2.0％），偽陰性例14例（5.6％）であった。偽陰性例の14例中10例（71％）がⅡc＋Ⅲであり，偽陽性例は6例中5例（83％）が初回時内視鏡診断では進行癌と診断されたものであった。また偽陰性例の組織型は分化型腺癌8例，未分化型腺癌6例であった。偽陽性例6例中3例（50％），偽陰性例14例中8例（57％）が再検討時には正診可能であった。しかしながら，偽陽性例のうち辺縁の一部が不整な巨大潰瘍の1例，集中するひだ先端の変化に先細り，段差を認めた1例，および周囲に多彩なびらん発赤を伴う多発潰瘍の1例の3例は見直し診断でも正診不可能であった。偽陰性例では，幽門前部で観察困難であった1例および悪性所見の指標に乏しい5例では，見直し診断においても正診不可能であった。すなわち9例（全体の1.6％）は内視鏡的には良悪性の鑑別が困難であった。開放性潰瘍を伴う病変では，色素散布併用による注意深い観察に加えて，抗潰瘍剤の投与後の生検を含めた再検査，経過観察が必要であると考えられた。

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　当科では大腸sm癌の粘膜下層での組織学的特徴，および間質内浸潤度を細かく評価し，リンパ節転移・再発のリスクファクターを探るべく検討を行ってきた。高分化型腺癌のうち，一部の中・低分化型の混在するものを混在型として，高分化型のみからなる単純型と区別した。粘膜下層癌巣最浸潤部で癌細胞が間質内へ散在性に浸潤する所見をsingle cell infiltration（SCI），粘液結節形成をmucinous component（MUC）とした。間質内浸潤量の評価は粘膜筋板上縁より深層の癌浸潤量が重要と考え，垂直距離をsm depth，水平距離をsm widthとして計測し，Grade-1-3に分類した。大腸sm癌96症例（リンパ節転移・再発陽性例11例）について検討を行った結果，転移・再発例は，占拠部位では直腸に，肉眼型ではⅠs，Ⅰsp，Ⅱa＋Ⅱcに多く認めた。リスクファクターでは，脈管侵襲とSCIが転移・再発と有意の相関を示した。転移・再発例は，全例間質内浸潤度がGrade-3（depth＞1000µm，width＞4 mm）に分類された。当科では，これらのリスクファクターを十分に評価するために，明らかに内視鏡下の根治的摘除が不能な病変を除いて，内視鏡的摘除を行い病理学的検索の後治療方針を決定している。今回の検討の結果，SCIまたは脈管侵襲陽性，Grade-3，中・低分化腺癌成分を含む大腸sm癌は追加腸切除の適応であると考えられた。

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　表面型大腸sm癌のsm深達度診断の観点から検討し，知見を得たので報告する。表面型大腸sm癌47例（男30例，女17例，平均65.3歳），50病変を対象とし，sm癌のX線・内視鏡所見，形態計測値，リンパ節転移率，ならびにpit patternについて統計学的比較検討を行った。その結果，①リンパ節転移はsm_2,3の3例（6.0％）に認めた。3例とも初回内視鏡治療例で，初回手術群に比べ有意に転移率が高かった。②X線所見のsm₁癌とsm_2,3癌の比較では，単変量解析において壁の変形，ひだ集中，陥凹部の不均一なバリウム（Ba）斑と濃淡・凹凸の所見で，また多変量解析では，陥凹部の不均一なBa斑において有意差を認めた。③内視鏡所見の単変量解析では，ひだ集中，病変の高さ，緊満感，表面の崩れ，陥凹辺縁の明瞭な段差の所見で，また多変量解析では，陥凹辺縁の明瞭な段差の所見で有意差を認めた。④形態計測値では固有筋層の厚さ，病変の高さで有意差がみられた。⑤pit patternの比較では，sm_2,3癌で有意にⅤ型pit pattern（無構造）の所見を認めた。結論として，sm深達度診断において，X線所見では壁の変形，ひだ集中，陥凹部の不均一なBa斑と濃淡・凹凸，内視鏡像では病変の高さ，ひだ集中，緊満感，表面の崩れ，白苔，辺縁の明瞭な段差の所見，および拡大内視鏡観察におけるⅤ型pit pattern（無構造）の所見がsm_2,3癌の診断に有意な所見と思われた。

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　大腸sm癌の超音波内視鏡（EUS）を用いたsm浸潤度診断と，粘膜下層への生食水局注法（局注法）により判定したlifting signの有無とsm浸潤度との相関について検討した。対象はEUSを施行したsm癌55病変（sm₁ 18，sm₂ 17，sm₃ 20）と，内視鏡下局注法でのlifting signの判定を行った19病変（sm₁ 9，sm₂ 7，sm₃ 3）である。Lifting signの判定基準は，局注法により腫瘍全体が浮揚するものをlifting sign陽性，腫瘍の一部が浮揚しないものを偽陽性，腫瘍全体が浮揚しないものを陰性とした。EUSによる大腸sm癌の深達度診断正診率は76％（42/55病変）であった。sm浸潤度診断の正診率sm₁ 50％，sm₂ 59％，sm₃ 75％であり，sm浸潤度が深くなるほど診断成績が良好であった。治療法選択という観点からEUS診断について検討すると，sm₁の19病変で，EUSにより内視鏡的治療が可能なm癌-sm₁と診断できたのは16病変（89％），sm₂，sm₃の37病変で，外科手術が必要なsm₂以深の深達度と判定できたのは33病変（89％）であり，ともに診断成績が良好であった。局注法によるlifting signの有無とsm浸潤度との相関については，sm₁のsm癌は全例lifting signが陽性，sm₃は全例陰性であった。しかしsm₂のsm癌では，lifting signの評価が一定せず境界病変と考えられた。以上の検討より，超音波内視鏡および内視鏡下局注法によるlifting signの判定は，大腸sm癌のsm浸潤度診断さらに治療方針の決定に有用であると考えられた。

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　Buessらによって開発された経肛門的内視鏡下マイクロサージェリー（TEM）は，直径40mmの手術用硬性直腸鏡を通して内視鏡下に高周波メス，鉗子などを操作することにより腫瘍を切除する新しい手技である。当施設では1994年6月よりこの手技を導入し，現在まで6例の直腸villous tumorに対しTEMを施行した。腫瘍最大径は32-80mmで，肛門縁よりの距離は5-12cm，組織型は深達度mの高分化腺癌5例，管状絨毛腺腫1例であった。6例中3例が全層切除され，3例が粘膜切除された。合併症は術後の発熱が2例，穿孔が1例，縫合部の離開を3例に認めたが，いずれも保存的に軽快した。TEMの最大の利点は，直腸の広基性病変に対し，肛門機能を温存しながら，安全確実に任意の層で腫瘍を切除できることである。しかしリンパ節の廓清には，経括約筋的，経仙骨的切除に比べ不十分であり，深達度診断および適応には慎重を要する。

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　症例は72歳，男性。20歳頃より時折，嚥下困難を認めていた。近医にてびまん性食道痙攣（DES）と診断され経過観察していたが，2ヵ月前より症状が増悪し，6kgの体重減少を認め，精査のため入院。上部消化管内視鏡検査では特記所見なし。食道造影検査では分節状収縮と粘液の貯留を認めた。食道内圧検査ではLES静止圧28mmHg，LES弛緩不完全，静止食道内圧陽圧であり，achalasiaの所見であった。嚥下により蠕動波は出現せず，すべて多峰性同時性収縮であった。波高は40-60mmHg，durationは6秒以上であった。以上より，本症例をDESとachalasiaがオーバーラップした病態のvigorous achalasiaと診断した。nifedipine 10mg内服投与では効果がなく，内視鏡的強制噴門拡張術を施行したところ，症状は完全に消失した。本邦において5例目と極めてまれなDESからの移行が考えられたvigorous achalasiaの1例を報告する。

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　症例は60歳男性。大量飲酒後に吐血を来たし某病院を受診，出血性胃炎の診断で内服治療していたが，自宅に近い当病院を受診した。食道二重造影では気管分岐部より肛門側の粘膜は不整で，小隆起性病変と粘膜集中像もみられた。また滑脱ヘルニアも伴っていた。上部消化管内視鏡検査では，切歯列より28cm以上の肛門側の粘膜は胃粘膜類似であったが，血管透見性はなく，複数の結節と潰瘍瘢痕が認められた。同粘膜からの生検で腺癌の診断が得られた。Barrett食道癌の診断のもとに食道亜全摘を施行した。病理学的な検索では，Barrett食道の広い範囲に及ぶ管状乳頭腺癌で，大部分はm癌であったが，一部smに浸潤していた。脈管侵襲はなく，所属リンパ節転移もみられなかった。Barrett食道に合併した早期癌の報告は10数例で，本症例のように広範な病変を呈したものは非常にまれなので報告する。

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　症例は73歳女性。既往歴・家族歴に特記事項なし。平成7年6月11日夕食摂取後より胸部不快感，腹痛，嘔気，下痢が出現した後，吐血したため救急外来を受診した。緊急上部内視鏡検査を施行したところ，食道および胃に暗紫色に色調変化した巨大な粘膜の隆起を認め，内視鏡所見より粘膜下血腫と診断した。食道粘膜下血腫は，1957年にWilliamsが初めて報告して以来70症例報告されており，治療は内科的保存療法が主体で，予後は良好な疾患といわれている。本症例のように広範囲に及ぶ食道・胃粘膜下血腫は過去に報告がなく，内科的保存療法のみで順調に回復し，かつ上部内視鏡検査により粘膜下血腫が消失してゆく過程を経時的に追うことができた症例と思われたので報告した。

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　症例は65歳女性。検診で貧血を指摘され，近医を受診した。上部消化管造影検査にて胃内に多発する隆起性病変が認められ，当院を紹介され入院した。内視鏡検査で胃体上部大彎の最大径2.7cmの山田Ⅳ型のポリープをはじめ，胃体上部から中部に山田Ⅱないし山田Ⅲ型のポリープを多数認めた。生検により多発性胃カルチノイドと診断され，リンパ節郭清を含めた胃全摘術を施行した。病理組織学的にはカルチノイド腫瘍は，すべて粘膜固有層から粘膜下層に主座があった。また術前に認められた高ガストリン血症は，術後速やかに改善した。胃カルチノイドにおいて多発例は約13％-17％といわれる。しかし，有茎性ポリープを伴う多発例の報告となると，本邦では本例を含めわずか2例にすぎない。極めてまれな症例と考え，若干の文献的考察を加え報告した。

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　症例は51歳男性。当院にて1984年より定期検診を年に2回受診していた。1993年6月の定期検診時の内視鏡検査にて，胃前庭部後壁のⅡc型早期胃癌と診断され，手術を施行された。病理組織はⅡc型早期胃癌，大きさ6×5mm，中分化型腺癌であり，p53免疫染色では癌性腺管の大部分が陽性に染色された。検診時の内視鏡検査で，病変部は小発赤や小陥凹などの所見を呈し，背景胃粘膜には腸上皮化生が高度に認められた。確定診断までに3回の生検が施行されたが，group Ⅱ腸上皮化生と診断されていた。しかし，確定診断の3年前（1990年7月）に生検標本を用いた免疫染色を試みたところ，陥凹組織にp53陽性腺管が認められたため，その後定期的に内視鏡での上部消化管検診を実施し，Ⅱc型早期胃癌が発見されるに至った。免疫染色される変異p53は，多段階発癌において早期に認められるとされており，本例のごとくp53免疫染色を行うことにより，胃癌のより早期の診断に活かせる可能性が示唆された。

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　症例は63歳，男性。心窩部痛を主訴に近医受診。上部消化管内視鏡検査にて十二指腸球部前壁に隆起性病変を認め，生検でカルチノイドと診断され，加療目的で当科入院となった。病変は通常内視鏡検査で粘膜下腫瘍を呈し，超音波内視鏡検査では第2層に連続し，粘膜下層の中層まで及ぶ径5mmの粘膜下腫瘍であった。周囲のリンパ節腫大は認めなかった。内視鏡的粘膜切除術を施行し，病変は1回で完全切除された。切除標本の組織学的所見では，粘膜内から粘膜下層にひろがる径5mmのカルチノイドで，切除断端は陰性であったが，病変部中心に静脈侵襲（v₁）を，病変部近傍にリンパ管侵襲（ly₁）を認めた。現在までに局所再発は認めていないが，今後は厳重な経過観察が必要と思われた。

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　症例は73歳男性。主訴は食欲不振と体重減少。消化管X線検査，内視鏡検査で胃から大腸の消化管に多数のポリープ様隆起性病変を認めた。また，表在リンパ節とCT検査で縦隔内，腹腔内，骨盤内のリンパ節腫脹を認めた。腋窩のリンパ節生検ではmalignant lymphoma，diffuse，small cleaved，B cell typeであった。胃，十二指腸，大腸より採取された組織からも同様の結果が得られた。以上の結果よりmultiple lymphomatous polyposisと診断した。化学療法（THP-COP）施行後，表在リンパ節はほぼ消失し，消化管病変では上行結腸からS状結腸ではpolyposisの完全な消失を認めたが，胃，十二指腸，直腸では著明な変化は認められなかった。

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　今回われわれは大腸顆粒細胞腫の1例を経験し，内視鏡的に切除しえたので報告する。症例は48歳女性。近医にて大腸ポリープを指摘され，当センターに紹介された。大腸X線検査，大腸内視鏡検査にて横行結腸脾彎曲部に，表面平滑で大きさ約10mmの山田Ⅱ型の粘膜下腫瘍を認めた。同部位よりの生検にて顆粒細胞腫と診断されたために，内視鏡的ポリペクトミーにより切除した。摘出標本では大きさ10×8×5mm，病理組織学的所見では，腫瘍は粘膜下層に存在し，被膜は認めないものの，境界は明瞭であった。好酸性の顆粒を有する大型の細胞が胞巣状に増生しており，顆粒細胞腫と診断された。これらの顆粒はPAS染色にて陽性であった。また，免疫染色ではS-100蛋白，NSEで陽性であった。顆粒細胞腫は消化管での食道の報告例は増加しているが，大腸の報告例は自験例を含め21例であり，これらに対して検討を加えた。

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　症例は67歳男性。倦怠感，肝機能障害にて1994年12月内科入院。CT・ERCP検査で肝内胆管の拡張と肝門部に狭窄を認め，肝門部胆管癌の診断で1995年2月外科転科したが，癌浸潤が広汎なため放射線治療を開始した。左右よりPTCD留置し内瘻化した後，直径10mm，長さ40mmのAccuflex selfexpandable metallic stent（以下SEMS）を左右胆管に両側同時に留置した。その後減黄は維持され，退院したが，癌性腹膜炎のためステント留置後第43病日に死亡した。留置後は死亡時まで良好に減黄され，またステントは互いに拡張を妨げることなく十分な拡張が得られ，機能は保たれていた。SEMSを用いた肝両葉内瘻化を行い十分な減黄効果が得られた1例を経験し，本法は切除不能肝門部胆管癌に対し有用な方法であると思われ報告する。

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We have developed endoscopic clipping method of esophageal varices using HX-3L (Olympus Optical Co Ltd, Tokyo) since 1990. Though this method have been recognized effective and minimally invasive, small bleeding during treatment or early recurrence of varices sometimes have occurred.
Therefore, we completed a newly designed and special shaped clip for endoscopic treatment of esophageal varices. Eight patients successfully received endoscopic clipping of esophageal varices using this new type of clip.

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We performed endoscopic mucosal resection (EMR) using a cap-fitted panendoscope (EMRC) for 57 cases of 67 gastric lesions from August 1992 to October 1995.
Before resection, endoscopic examination using a cap was useful for precise diagnosis of target lesions. Usual examination by panendoscope could obtain only oblique views of lesions located at the posterior wall or lesser curvature. Using a cap, front views of those lesions could be obtained, and a size of the lesion could be measured from the proportion of the cap and the lesion in diameter.
At resection, endoscopic examination using a cap was useful for determination of resection method (an en bloc resection or a planning fractionated resection) , exact markings and submucosal injection could be made using a cap, and large specimens could be obtained using a pre-looped cap.
When bleeding was detected from the artificial ulcer, a certain hemostasis was obtained by compression by a cap or clipping method under a good view using a cap.
We consider that a transparent cap is useful for diagnosis, resection, and hemostasis in EMR for gastric lesions.

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A new proto type EUS (XGF-UM20 20MHz) has been tested in gastroenterological diseases between November 1994 and October 1995. This EUS has switchable 20MHz and 7.5MHz transducer. The operation and appearance is of the same as GF-UM20.
Using the 20MHz of XGF-UM20, gastroenterological diseases were revealed more fine, and clear, as compared with the image of GF-UM20 (12MHz) and stomach wall were detected as 9-layer structure under successful condition. The layer of muscularis mucosae can be shown 66.7% in gastric lesions. The diagnostic accuracy for diagnosing the depth of cancer invasion was 84.6% in early gastric cancers. Misdiagnosed cases were all depressed type of early gastric cancers. The penetration depth of ultrasound was not sufficient for advanced gastric cancers, because of extensive attenuation. The 20MHz of XGF-UM20 is considerd to be useful for diagnosing flat and small leions, especially in case with early cancer.

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A real time image processing system, EVIP-230, was used to improve the accuracy of colonoscopy. The assessment of crypt pattern in the normal rectal mucosa and in hyperplastic polyps was studied in 48 patients.
Crypt pattern was demonstrated in the normal rectal mucosa in 79% by dye spraying with 5 times diluted indigocarmine and 75% by enhanced image without indigocarmine. Moreover, crypt pattern was demonstrated in hyperplastic polyps in 76% by dye spraying with 5 times diluted indigocarmine and 57% by enhanced image without indigocarmine. The demonstration of crypt pattern in the rectal mucosa and hyperplastic polyps was much higher by enhanced image using image processing system EVIP-230 than by conventional colonoscopic examination.
The demonstration of crypt pattern by enhanced image was almost equal to dye spraying with 5 times diluted indigocarmine. Therefore, it is suggested that this method will become useful in the assessment of the lesions at routine colonoscopic examination and in observing the fine structure of the colonic mucosa.

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Small intestino-Videoendoscopy was performed in 5 patients using a small intestino-Videoendoscope (model XSIF-200) first developed by Olympus Optical Co Ltd, Tokyo. The clinical assessment of this scope are :
(1)Scope function ; An effective length of the scope is 2,000mm and the channel for insertion of forceps used for biopsy and polypectomy is installed in its flexible part. The distaltip at the flexible part has the up/down and left/right angulation system.
(2)Technique ; It can be carried out with the same manner as conventional intestinoscopy.
(3)Observation ; The excellent image is provided on a TV monitor, permitting smooth cooperation with examiners for biopsy or polypectpmy.
(4)Recordability ; Frozen images are available directly to color print photographing without monitoring and to 16mm still photographing through monitoring. Dynamic images can be used for VTR recording.
(5)Safety and durability ; Both are excellent compared with conventional intestino-scope.
Conclusion : This small intestino-videoendoscope was found to be superior to the conventional fiberscopes for ordinary observations and endoscopic therapy of small intestinal diseases.

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The usefulness of endoscopic hemorrhoidal ligation using Stiegmann's ligator was discussed. The advantages of this treatment are less pain and short hospitalization due to minimal invasive operation.
Thirty six cases were treated in this method and 33 cases (92%) showed excellent results. However, 3 cases needed following surgical operation because of post-ligated prolapsus in two patients and aggravation of external hemorrhoid in one patient. Thses 3 cases were patients with high grade hemorrhoids (Goligher's III, IV) .
We concluded that indication of endoscopic hemorrhoidal ligation should be limited to the low and middle grade hemorrhoids (Goligher's II, III) .

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We investigated whether pH and total bile acids concentration in refluxed esophageal fluid reflect those in gastric juice in patients with reflux esophagitis.
Thirteen patients with reflux esophagitis (8 men and 5 women ; average age : 71.3 years) were examined. Reflux esophagitis was classified according to the Savary-Miller classification. Refluxed esophageal fluid and gastric juice were collected using a novel device. The total bile acids concentration and pH in the collected samples were measured using the enzymic method and a pH meter.
Refluxed esophageal fluid could be collected in 1 of 4 patients with stage I reflux esophagitis and all patients with stage II and IV reflux esophagitis. More than 200µM of bile acids, which may be sufficient cause esophageal injury in acidic conditions could be obtained in the refluxed esophageal fluid. The relationship between total bile acids concentration and pH in refluxed esophageal fluid and gastric juice showed a positive correlation.
We concluded that bile acids are one of the major factors in the onset of reflux esophagitis. For evaluation of aggressive factors in reflux esophagitis, gastric juice can be substituted for refluxed esophageal fluid.

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We evaluated the association between flow of the splenic vein and endoscopic findings of the upper digestive tract. The subjects were 42 patients with liver cirrhosis complicated by esophageal varices in whom the clinical course were observed for 5 years. They were classified into the group who developed hepatofugal flow of the splenic vein during course (hepatofugal group) and that who did not (hepatopetal group) . Child classification, male-female ratio and average of the age before observation was similar between the two groups.
Changes in the endoscopic findings of gastroesophageal varices during the course were slighter in the hepatofugal group than the hepatopetal group. Significant differance was observed in changes of the gastric mucosal lesions in the two groups, i. e. the hepato-fugal group was not increased but the hepatopetal group was significantly increased (p<0.05) . The hepatofugal group was significantly higher incidence of the spleno-renal shunt than the other.

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Diagnosis of Helicobacter pylori (H. pylori) infection is based on the culture and isolation of this bacteria, we have developed a new endoscopic technique of targetting biopsy for isolation of H. pylori by cochineal extract spray.
The cochineal extract is a non-toxic food-dye, its use to the human and safety having been approved in a law. In the conditions at pH＞4, it indicates the distinctive color change from red to purple. H. pylori has an enzyme, urease which converts urea into ammonia. This ammonia elevates the local pH levels on the surface of gastric mucosa. Therefore, the presence of H. pylori would be expected when the color of cochineal extract sprayed on the gastric mucosa turned to purple within a few seconds. In fact, we isolated H. pylori at a high rate (90%) from the gastric mucosa where cochineal extract showed this color change.
We conclude that this technique would be very useful in the definit diagnosis of H. pylori infection.

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Helicobacter pylori (H. pylori) infection in cases of after distal gastric resection was studied. We also examined relation among H. pylori and residual superficial gastritis, bile acid refluxed into the stomach.
1) A rate of H. pylori infection in postoperative stomach shows 51.1%, which was lower than that of digestive ulcer, gastric carcinoma and control group. In cases of residual stomach, a concentration of chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) refluxed into the stomach were remarkably higher than thoes of digestive ulcer and control group. I considered the rate of H. pylori infection in postoperative stomach is low because of highly concentrated CDCA and UDCA is not adequate for habitation of H. pylori.
2) There were no correlation among pathological inflammation, activity and superficial gastritis in postoperative stomach. Inflammation and activity were frequent in H. pylori positive cases than negative cases.
3) A frequency of H. pylori infection in cases of after distal gastric resection by gastric carcinoma within 5 years was lower than 50.0%. A rate of infection increased 72.7% in patients who were operated over 5 years ago.

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An hemoglobin index (Hb index) of gastric mucosa in digestive ulcers was studied by image processing unit SP-1000. We classified gastric ulcer cases into 2 types. One type is upper placed ulcer, which has ulcer high level than middle body. Another type is lower placed ulcer, which has ulcer under lower body.
1) An average of Hb index of the stomach measured in cases of digestive ulcers was higher on the anterior wall of upper body.
2) Hb index of lower placed ulcer was higher in anterior wall of upper body than in anterior wall of lower body, greater curvature of antrum.
3) Hb index of lower placed ulcer and duodenal ulcer were higher than upper placed ulcer.

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Eleven cases of inflammatory fibroid polyp (IFP) of the stomach were studied with respect to endoscopic diagnosis. Four cases were resected by endoscopic polypectomy and the others were surgically resected. There were seven men and four women. The mean age was 59, ranging from 44 to 71.
Nine cases were in the antrum, and the other two were in the gastric body. Five cases were less than 10 mm, and two were over 20 mm. Five cases were classified into Yamada-I type, two into II type, four into III type. Initial endoscopic diagnosis was hyperplastic polyp in four, submucosal tumor in three, early gastric cancer in one, and gastric adenoma in one. Routine biopsy was done to eight cases, but the pathological diagnosis of IFP was not confirmed except one case. This may be because the biopsy specimens contained hyperplastic foveolar epithelium only, which covered the surface of the IFP in most of the cases.
These findings were compatible with previously reported characteristics of IFP. Correct diagnosis of IFP on routine endoscopy were rarely obtained and diagnosis could be made on endoscopic ultrasonography and polypectomy.

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Of 129 cases with malignant lymphoma experienced in our department during the past 13 years, involvement of the stomach was noted in 17 cases (13%) , of which 10 were treated with chemotherapy without gastric resection and the other 7 received surgical resection of the stomach.
The former non-operative cases (1 with Hodgkin's disease and 9 with non-Hodgkin's lymphoma) consisted of 5 cases with primary gastric lymphoma and 5 with gastric lesions manifested as a part of generalized malignant lymphoma. Macroscopic type of these gastric lesions was endoscopically protruding type in 1, collapsing type in 1, ulcerating type in 1, giant fold type in 3 and superficially enlarged type in 4 cases.
In 7 of 10 cases, disappearance of gastric tumors was recognized macroscopically after chemotherapy. Gastric hemorrhage occurred after chemotherapy in 3 cases invariably of primary malignancy of the stomach and bleeding from gastric lesions ocurred in none of cases with generalized malignant lymphoma. Post-chemotherapy hemorrhage was noted to occur in cases with lesions of collapsing or giant fold type, never with those of superficially enlarged type.
From these results, it is suggested that gastric hemorrhage after chemotherapy for malignant lymphoma may be caused by damage of vessels accompanied with a loss shedding of massive tumor cells invaded into the deeper layer.

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The patients with gastroduodenal ulcer or AGML frequently show massive bleeding, resulting in critical status such as shock, DIC, and MOF, moreover they have often surgical risk factors. In these surgical poor risk patients, the decision of surgical treatment is difficult and important. Five hundred and 76 patients underwent emergency gastrofiberscopy for the bleeding from gastroduodenal ulcer or AGML in the period from May 1976 to Nov 1995. Effectiveness of conservative therapies and surgical treatment were analyzed.
Effective rate of endoscopic hemostasis were over 90% for bleeding from gastroduodenal ulcer in most cases, however it was relatively low as 68.8% for bleeding with massive clot. We have been using flushing tube to remove clot, resulting in high effective rate as 80.0% in the latter period.
Recent advances in medication and endoscopic hemostatic procedure for the bleeding from gastroduodenal ulcer has remarkably decreased the patients who need surgical treatment. The number of bleeding episode during conservative therapy firmly correlates with bad postoperative course. Our criteria for converting to surgical therapy is 3 times of massive re-bleeding during conservative therapy. Operative death has decreased after introduction of this criteria.

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The early stage of colorectal cancer is divided into two morphological types ; polypoid and superficial. What percentage of advanced cancer is derived from the polypoid or superficial type is a matter of concern. We designated superficial type tumors from the both morphological and histological viewpoints. Histological designation of superficial type tumor was that there was horizontal growth of cancer in the residual mucosa.
The existence of horizontal growing mucosal cancer at the marginal area of cancer is a biomarker showing the lesion being of superficial origin. The rates of arise from superficial tumor of submucosal cancer in the residual mucosa was 29/98 (29.6%) . The cancer with invasion deeper than the muscularis propria layer usually loose cancer in the mucosa, therefore, the rates may not reflect actual incidence. The rate of submucosal cancer (29.6%) may be close to the actual rate at present.
It may be useful to focus on the horizontal growing tumor of the colorectum for understanding the advance and development of colorectal tumors.

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The patient was a 71-year-old male. He underwent distal gastrectomy (Billroth-I) for early gastric cancer. After the operation, he was troubled with severe reflex esophagitis. Eighteen months later, for common bile duct stones and gallstones, he had second operation. In order to relieve reflex esophagitis, we changed the route of reconstruction from Billroth-I to Roux-en-Y.
After the second operation, he has recovered from reflex esophagitis almost completely. The simultaneous pH monitoring in lower esophagus and remnant stomach was useful for understanding the pathophysiology and grade of reflex esophagitis.

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It has been reported that one of the effects of proton pump inhibitor (PPI) is inhibition from exocrine pancreas. We treated two cases of reflex esophagitis due to total gastrectomy with PPI and they were cured soon.
Case 1 : A 71-year-old man was operated upon total gastrectomy (6-interposition) for early gastric cancer. He had felt aphagia and heart burn from ten days after operation. We had been following up him for three years with camostat mesilate, but his symptoms had been unchanged and the endoscopy had revealed esophagitis which was Savary-Miller (SM) stage III.
Case 2 : Total gastrectomy (Roux-Y) for early gastric cancer was carried out to a woman who was 53 years old. Her symptoms were nausea and heart burn from eight days after operation. She had never been treating by any medicines. Four months after operation, her symptoms had been stronger and endoscopic findings was esophagitis of SM stage III.
In both cases, their symptoms were got under control soon and esophagitises were changed to SM stage I-II with single medication of PPI for several weeks.

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A 67-year-old man was admitted to our hospital because of dysphagia. About 6 months ago, he admitted to another hospital due to heart failure and cerebral infarction. During the admission dysphagia had developed, and he was diagnosed as gastric cancer invading the lower esophagus.
The operative therapy was considered to be difficult because of his heart and neurological complication. Therefore he was refered to our hospital for palliation of dysphagia. Marked stenosis was observed at the esphago-gastric junction by radiographical examination.
Self-expanding metalic stent, the Ultraflex esophageal prosthesis was implanted endoscopically. Dysphagia improved dramatically a week after the procedure. Thereafter he was able to stay at home without dysphagia. The Ultraflex esophageal prosthesis is suggested to be useful for the palliation of cardiac cancer as well as esophageal cancer.

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A 15-year-old child was refferred to our hospital for recurrent abdominal pain (RAP) and nausea. Laboratory data revealed a high level of IgG antibydy to Hp in serum. Upper GI endoscopy showed antral nodularity like a goose-flesh. Phenol red stain endoscopy showed a diffuse red color change in the antrum, which emphasized antral nodularity. Antral biopsy specimen showed active chronic gastritis with a well-formed lymphoid follicle in the mucosa. Hp was found by histologic examination with Warthin-Starry staining and bacterial culture.
The patient became symptomless after a period of one week of treatment that consisted of lansoprazole 30mg od, amoxicillin 500mg bid and metronidazole 250mg bid. A second endoscopy revealed no antral nodularity at all and biopsy specimens showed almost complete disappearance of the inflammatory process. Hp could not be identified by Warthin-Starry staining and culture. In children with RAP and/or a high level of serum Hp antibody endoscopic and histological examination should be performed for Hp infection.

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A 68-year-old man was admitted to our hospital with the chief complaint of hematemesis. Laboratory studies showed anemia and positive occult blood in the feces. Endoscopic examination revealed a bright red lesion, approximately 10mm in diameter, on the lesser curvature near the incisura angularis. Color Doppler endoscopic ultrasonography showed multiple capillary vessels and pulsatile flow in the lesion.
Since the gastrointestinal bleeding continued and anemia progressed, the lesion was endoscopically resected using an endoscopic variceal ligation device. Such procedure is useful for the treatment the bleeding in case of angiodysplasia of the stomach.

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An 87-year-old male received regular outpatient treatment for hypertension, chronic renal insufficiency and chronic hepatitis. He had tarry stool and marked anemia (Hb 5.0ｇ/dl) in December 1994, for which he received blood transfusion and administration of an iron preparation.
Upper gastrointestinal endoscopy revealed ectatic antral capillaries extending radially, and the disease was diagnosed as GAVE. The patient was admitted in May 1995. A total of 12ml of 1% Aethoxysklerol was injected locally into 12 sites adjacent to the ectatic capillaries (1ml per site) . After two courses of this medication, the capillary ectasis showed a tendency to improve. The effectiveness of local injection of Aethoxysklerol for GAVE was reported in this paper.

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A 69-year-old woman underwent surgery for primary malignant lymphoma of the stomach approximately 10 years ago at our hospital. The tumor was located on the lesser curvature side of the angulus and measured approximately 5cm×2cm. Histologically, lymphoma cells of the large cell type (Non-Hodgkin) had invaded the serosa.
Approximately 10 years after surgery, she sometimes complained of vague abdominal fullness. A barium-meal examination revealed a bezoar in the stomach. Most gastrointestinal bezoars develop after surgery, and the most common procedure is bilateral truncal vagotomy with pyloroplasty. However, the relationship between bezoar and surgery for malignant lymphoma of the stomach is not clear, and the 5-year survival ratio in malignant lymphoma of large cell type is approximately 33%. Since there has been no report of gastric bezoars developing after lymphoma surgery, we reported this case.

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Hyperplastic polyp in gastric polyps is the most frequent type by pathological diagnosis. Most of them are smaller than 20 mm in diameter. We experienced three cases, which had 5 huge gastric polyps type Yamada IV more than 40 mm in size, removed in safety by endoscopic polypectomy. All of their cases had multiple polyps. It is known that huge polyps rarely combine carcinoma cells and have a risk of bleeding and stenosis. We also experienced a focal carcinoma in case 3. It is necessary to remove a huge gastric polyp type Yamada's IV as soon as possible by endoscopic polypectomy.

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A 53-year-old male visited our hospital because of gastric carcinoid, which was 4mm sized Yamada-Itype polyp. The biopsy specimen showed carcinoid infiltrating to submucosa. Subtotal gastrectomy with cholecystectomy was performed as the diagnosis of gastric carcinoid with cholelithiasis. Pathologically no remained carcinoid of gastric surgical specimen and no lymphonoid metastasis was reported.
It considered repeated biopsy took the all of gastric carcinoid. It revealed that endoscopic mucosal resection could be performed up to at least 4mm sized carcinoid of the stomach.

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A 83-year-old female was admitted to our hospital because of right hypochondralgia and abdominal tumor. She was received gastrectomy for early gastric cancer at 78 years old.
Abdominal CT scan showed a tumor in the gastric stump invading to the left lobe of the liver and the pancreas. Endoscopic findings showed an irregular protruded tumor with erosion and bleeding from the gastric stump to the duodenum. Biopsy specimen showed B-cell malignant lymphoma, diffuse medium cell type. Bone marrow aspiration revealed invasion of lymphoma cell. She received dimimished chemotherapy, but she died on 6 months.
Ten cases of malignant lymphoma in the gastric stump after gastrectomy were reported in Japan. The mechanism is supposed to be concerned with metaplasia of gastric mucosa by chronic stimulation by reflux duodenal content and bile juice, depression of gastric acid and change of bacterial flora.

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The patient is a 54-year-old male who had epigastric disconfort with the duration of 3 months. Upper GI series and endoscopic examination revealed submucosal tumor with 3cm in diameter on the posterior wall of antrum. EUS revealed the main location of the tumor is proper muscle layer. Distal gastrectomy was performed and he dicharged 14 POD uneventfully. The final pathological diagnosis was malignant lymphoma (follicular medium-sized cell type) without lymph node metastasis.
Primary malignant lymphoma (ML) of GI tract comprises 1 to 2% of all malignancy is GI tract. The operative procedure commonly selected for ML of the stomach is principally the same as the procedure for cancer. On the other hand, leiomyosarcoma which is common in submucosal tumor can be treated with local resection. Submucosal tumor of the stomach should be treated considerably with proper method based on preoperative and intraoperative histological diagnosis.

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A 34 year-old female had a tumor diagnosed as early gastric cancer, type IIc. At our outpatient clinic, the tumor was diagnosed as early gastric cancer, type IIc with multiple, irregular faded areas in anterial wall of gastric body. We recognized the tumor to be malignant lymphoma by endoscopy, but histologically it did not show any malignancy. Following another endoscopy check and subsequent histological diagnosis, which showed possible malignant lymphoma so she received total gastorectomy.
By histological diagnosis, the tumor was not a MALT-lymphoma, the depth of the tumor was submucosal invasion, and there was no lymphnode metastasis. Helicobacter pylori was not detected before her operation. We reported a case of premalignant lymphoma, which was similar to early gastric cancer, type IIc.

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Two cases of liver cirrhosis (LC) with hepatocellular carcinoma (HCC) developed early gastric cancer. Follow up of esophagogastric varices by endoscopic examination detected IIc early gastric cancer.
One case was 62-year-old man and the other was 65-year-old man. Their HCCs had been already treated with transarterial embolization. Their early gastric cancers were completely resected by endoscopic mucosal resection (EMR) . Histological findings revealed moderately differentiated adenocarcinoma and that partly accompanied with poorly differentiated adenocarcinoma, respectively.
The complication of HCC with gastric cancer is reported to be relatively freguent and twenty-one cases including our two cases has been reported. These 21 cases were compared with 62 cases with early gastric cancer alone in our hospital. Seventy percent of early gastric cancer in patients with LC and HCC were located in antrum compared with 35 percent in early gastric cancer alone. Depressed type in macroscopic findings and differentiated type in histologic findings tended to be frequent. Patients with LC are usually associated with portal hypertensive gastropathy (PHG) . A causative relation of ischemic change of gastric mucosa due to PHG with gastric cancer in patients with LC could be considered.

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A 72-year-old male, who complained of hematemesis, was referred a near hospital in August 1991. He was endoscopically diagnosed as kissing-type bleeding ulcer at the gastric angulus, and he recieved conservative treatment.
The ulcer changed to the scar for a month. The histological diagnosis of the biopsied specimen was compatible with Group II. After three months, the ulcer changed to a small reddish elevated granulomatous lesion with fold concentrations around the ulcer scar.
He was followed up by endoscope and biopsy at once in three months for two years. The lesion enlarged slowly, and in March 1994, the histological diagnosis of the biopsied specimen was compatible with Group IV. In April, the lesion changed to a multiple elevated lesion with fold concentrations and a central depression. The histological diagnosis of the biopsied specimen was compatible with Group V. The lesion was diagnosed as 0'IIa＋IIc, type of gastric cancer. Distal gastrectomy, Billroth-I reconstruction and D₂ lymph node dissection was performed. Histopathological diagnosis of the lesion was 0IIa＋IIc, tub₁, sm, Ul-IVs, n₀, ly₀, v₀.
Although ulcer was recovered, cancer was undeniable and we confirm again the importance of periodical endoscopic examination for gastric ulcer scar.

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The patient was a male of 68 years old. The chest X-ray showed infiltrative shadow in the right upper lobe. The cytology by bronchoscopic brushing revealed small cell lung carcinoma. Although the radiation therapy showed good response, abdominal pain was appeared. Endoscopy showed an elevated lesion with a central ulceration in the upper part of body of stomach. The large mass in the upper abdomen was also detected by the abdominal CT.
In addition the lung and abdominal tumor, the gastric elevated lesion was remarkably responsed to chemotherapy. The biopsy specimens of intraabdominal tumor showed small cell carcinoma.

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A 16-year-old man admitted to our hospital because of severe anemia due to gastric cancer. Endoscopic findings showed that the gastric cancer was classified as Borrmann's type II. Further examinations of the colon revealed multiple polypoid lesions. Colonic polypectomy and total gastrectomy were performed.
One year later, he was suffered from epileptic seizure due to a brain tumor. The tumor was resected, and the histological findings showed a glioblastoma multiforme. The diagnosis of Turcot's syndrome was made by the complication of adenomatous polyposis coli and glioblastoma.
Turcot's syndrome is a rare congenital disease classified as adenomatous polyposis coli. Some reports show the complication of gastric and duodenal polyps with this syndrome. However, to our knowledge, this is the first case report of complication of gastric cancer with Turcot's syndrome.

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