Yuzo Akasaka

Endoscopic sphincterotomy of the ampulla of Vater

Endoscopic sphincterotomy at the papilla of Vater, combining and modifying technics already established for retrograde cannulation and electrosurgical polypectomy, has been successfully performed in 2 patients with removal of stones impacted in the ampulla and proximal common bile duct. The authors caution that further investigation is in order to assure the safety and efficacy of the procedure.

Direct endoscopic visualization of the bile and pancreatic duct systems by peroral cholangiopancreatoscopy (PCPS)

Peroral cholangiopancreatoscopy (PCPS), a new concept in gastrointestinal endoscopy, has been developed for direct examination of the bile and pancreatic duct systems. The procedure was successfully accomplished in 42 of 50 patients with no complications. Stones and tumors of the ducts were directly inspected by this new technique. There are still certain technical limitations in the use of our prototype instruments. When the improved instruments are available in the near future, PCPS promises to be one of the most reliable tools in the diagnosis and management of biliary and pancreatic diseases.

Endoscopy in pediatric patients with upper gastrointestinal bleeding

In 25 pediatric patients with hematemesis or melena, early or urgent endoscopy was performed with no complications. In children older than 10 years, endoscopy can be done in the same way as in adults. In patients younger than 1 year, both general anesthesia and a small caliber peroral endoscope are necessary. Endoscopy can be done usually without general anesthesia if a small caliber endoscope is used in patients from 2 to 9 years of age.

Endoscopic polypectomy for the removal of polyps of the small intestine

SummarySince intussusception is a common complication of the Peutz-Jeghers polyps, laparotomy should be recommended to remove them. However, all of them will not be palpable or discernible during laparotomy. Operative endoscopy was employed for removing polyps of the small intestine of a 22-year-old female who was previously diagnosed as Peutz-Jeghers syndrome. Using a newly designed enteroscope with two channels (SIF-2C, Olympus), four large polyps over 1 cm in size were removed from the ileum and jejunum with safety.Endoscopic polypectomy is one of the rapidly advancing fields and widely spread methods in gastrointestinal endoscopy since the introduction of electrosurgical techniques. Although the endoscopic removal of polyps arising from the esophagus, stomach, duodenum, colon and rectum can be performed with ease and safety, polypectomy for the polyps of the small intestine has never been performed because of the technical difficulties to handle the scope in the small intestine. Two channel enteroscope resolved this problem. Therefore, it is emphasized that double channel enteroscope makes the polypectomy in the small intestine possible and the indication of enteroscopy will be more widely extended.

Differential diagnosis of polypoid lesion of stomach

ConclusionIn 82 surgically resected cases of elevated lesions of the stomach, we have evaluated and discussed the findings in malignant lesions and their morphology according to our classification of protruding lesions. We can summarize as follows :1.All cases of the dish-like type are early gastric cancers. And when this lesion has a depression on its surface, cancerous changes usually infiltrate to the submucosa.2.There is no malignancy in smooth elevated lesion except in a few case of sacroma.3.All lesions of the spherical non-pedunculated type over 2 centimeters in diameter are malignant.4.In the spherical pedunculated type, the malignancy rate is high, when the diameter of the lesion is over 3 centimeters.5.Advanced cancer is found in lesions with a large nodular surface.

Endoscopic electromyography of the sphincter of ODDI

SummaryEndoscopie electromyography of the human sphincter ofODDI has provided useful information for the patho-physiological studies on the choledocho-duodenal junction. The pattern and rhythm of the electromyogram observed on the sphincter ofODDI were different from those of the duodenum recorded simultaneously in basal tracings of our initial four cases. In the half of other ten cases with consecutive tracings, the different pattern and rhythm of electromyograms between the sphincter ofODDI and the duodenum were also confirmed.It was possible, from our results, to speculate that the functional independence of the sphincter ofODDI from the duodenal wall muscles was in existance.

A newly improved sliding tube for colonoscopy for keeping the sigmoid colon in a straight condition.

SummaryAlthough a sliding tube made of plastics is very effective to keep the sigmoid colon in a straight position, there is some difficulty in handling the colonoscope, being restricted by the length of the scope. For the purpose of covering the demerits of the conventional sliding tube, a new slit sliding tube which is made up of three parts was devised by us. After straightening the sigmoidal loop, the three parts of the apparatus are joined together. Then the slit sliding tube is inserted into the descending colon with safety and ease. By using the slit sliding tube, handling of the colonoscope is scarcely restricted and becomes easy. Moreover, the slit sliding tube can be used even for the shorter scopes, by which the distal parts of the colon can be more easily examined in comparison with conventional techniques.

Proceedings of the 19th autumn meeting from October 18 to 20, 1977-Nara, Japan

The first step in the formation of bile acids is 7uhydroxylation of cholesterol. Subsequently 7ahydroxycholest-4-en-3-one is formed, which is a common precursor of the two primary bile acids, cholic acid and chenodeoxycholic acid. 5,BCholestane-3~t , 7a -d io l , a p recursor of chenodeoxycholic acid is formed from the A4-3-keto intermediate by a pathway which involves the reduction of the keto group and the saturation of the double bond but not a hydroxylation at C-12, while a pathway involving the 12a-hydroxylation of the A4-3-keto intermediate leads to the formation of 5flcholestane-3~, 7a, 12a-triol, which is a precursor of cholic acid. The C2~-bile alcohol intermediates , 5flcholestane-3a, 7t~-diol and 5,g-cholestane-3tz, 7t~, 1 2 ~ t r i o l , a r e t h e n t r a n s f o r m e d i n t o chenodeoxycholic acid and cholic acid by the degradation of the side chain which entails an moxidation followed by fl-oxidation. Chenodeoxycholic acid is also formed by a number of different pathways differing only with respect to the stage of nuclear transformation at which oxidation of the side chain is initiated. A number of cholestanepolyols such as 5flcholestane-3ct, 70t, 12ct, 25-tetrol are accumulated in the bile and feces of patients with cerebrotendinous xanthomatosis. No 26-hydroxylated bile alcohols are accumulated. The results suggest that there exists an alternative pathway of cholic acid biosynthesis involving the 25-hydroxylated bile alcohol as an intermediate. (2) Analytical methods of bile acids in biological materials

1) Diagnosis of benign papillary lesions by cholangiography and biliary pressure study

Diagnosis of benign papillary lesions including organic and functional changes is significant clinically because of a close relationship of the lesions and the diseases of the liver, biliary tract and pancreas 1). The X-ray study was made by PTC and to analyse videotaped images. The pressure study was done by using Microt ip Catheter Transducer that was inserted through T tube into the common duct. From the pressure curve, the value of the closing and opening pressure were found. The histological study was made to investigate the specimens obtained by papilloplasty and by autopsy as the control materials~L The results are as follows : 1) The pathologic findings of the papilla of Vater were divided into 3 types; inflammation type (I), glandular and/or fibrous proliferation type (II) and adenosis (adenomyosis) type (III) . 2) The pathologic findings of cholangiograms are rigidity and stenosis. The former was histopathologically based on the type I and the latter was chiefly based on the type I I or I I I . The cholangiograms of the lower end of the common bile duct were divided into 4 types; normal type, fingertip type, funnel type and sclerosed-tapering type. The fingertip type was seemed to be chracteristic of primary papillary stenosis. 3) The findings of the biliary pressure were divided into 3 types based on the level of the opening pressure; hypertensive, hypotensive and normotensive types. In cases with the hypertensive type with high level of the closing pressure, functional disturbance ot the papilla may be considered, whereas organic changes may be present in cases with low level of the closing pressure. References 1) Hess, W.: Surgery of the biliary passages and tile pancreas. D. Van fflostrand Company, Inc. 1965. 2) Tanabe, T.: Pathological study of papilla of Vater including the relationship between the biliary tract and the pancreas. Japanese Journal of Gastroenterology 71: 973-988.

Studies on duodenofiberscopic observation of the duodenal cap ulcer

Thirteen years have passed since the introduction of the mass survey technic to the actual practice and several problems have arisen in the original mass survey programme called as the Miyagi type programme. The percent of the examinee in the general population over the age of 40 remains around 14% demonstrating probably the limitatiion of our ability to accept willing examinee to the actual screening procedure. The diagnostic methods applicable in the detailed post-screening examination had shown marked improvement with the introduction of gastrocamera, fiberscope, cytological examination and biopsy. Yet, only 76 to 84% of those screened in cases received sophisticated examinations. The incidence of gastric cancer in the groups of cases with initial diagnosis of gastric ulcer, gastric polyp or polyposis, and ulcer scar were found to be 12.8~o , 3,0% and 1.5% in the successive order. This is done by checking them periodically by gastrocamera examination. The incidences are distressingly higher than the figure of 0 .19~ of over all incidence of gastric cancer found in the whole initial screening. When the medical past history of the period of one year prior to the detection of the gastric cancer found by the mass survey was analysed, interesting findings wcre found, that in 211 cases with early gastric cancer 64.2~ were those who had no previous medical check up, 23.7~D were those who had medical check up which was reported to be normal, gastric ulcer in 6.2~o, and gastric polyp or polyposis in 1.9%. In 296 cases with advanced gastric cancer, 89.2o/o had no medical check up, 5.4% were diagnosed as normal, and gastric ulcer was found in 1.7~ o. The rate of 89.9% of those who had no medical check up on one year period prior to the cancer detection is amazingly high and points out the most important problem of the cancer detection.