Gastrointestinal Endoscopy

Vol. 62, No.6 Printed in U.S.A.

GASTROENTEROLOGY

Copyright © 1972 by The Williams & Wilkins Co.

PROGRESS IN GASTROENTEROLOGY GASTROINTESTINAL ENDOSCOPY JOHN F. MORRISSEY, M.D.

Department of Medicine, University Hospitals, Madison, Wisconsin

Gastrointestinal endoscopy in the United States has advanced more in the past 5 years than in the previous 25. These years have marked the end of an era with the passing of Rudolph Schindler at the age of 80' and the final passing out of clinical use of the lens gastroscope which he introduced to this country in 1934. It was a period when the demand for endoscopy could not be met by the supply of gastroenterologists, and gastrointestinal endoscopy became the avocation of many surgeons, general internists, otolaryngologists, and radiologists. It was the time when the duodenum, the biliary tree, the pancreatic ducts, the entire colon, and even the terminal ileum became accessible to routine endoscopic examination. Most of this interesting research has been published in four journals which have very limited circulation in this country. In this review an attempt has been made to cite as many of the significant studies which have appeared in these publications as space permitted since very few readers of Gastroenterology regularly see even one of them.

Preparation of Patients for Endoscopy The major change in premedication since Laing and Klotz 2 reviewed this topic in 1967 has been a great increase in the use of diazepam. Ticktin and Trujillo 3 reported satisfactory results in 85% of Received September 24, 1971. Address requests for reprints to: Dr. John F. Morrissey, Department of Medicine, University Hospitals, 1300 University Avenue, Madison, Wisconsin 53706. The preparation of this review was assisted by grants from the Olympus Optical Corporation of America and the American Cystoscope Makers, Inc. The secretarial assistance of Miss Kay Buros and Miss Ann Morrissey is gratefully acknowledged.

patients using 75 mg of meperidine and 10 mg of diazepam intravenously immediately prior to the procedure. We prefer to give 50 to 75 mg of meperidine intramuscularly and, 30 min later, to give diazepam intravenously at a rate of 2 mg per min until a drowsy state is produced in which there is a short delay in the patient's response to commands. In individual patients, the dose requirement ranges from 0 to 60 mg, with an average of 10 mg. Most of the larger doses are given to patients with histories of either alcoholism or the prior use of tranquilizers. Giving the meperidine intramuscularly permits the completion of longer procedures without additional medication. The use of diazepam has reduced our rate of unsatisfactory examination due to poor patient cooperation to less than 1%. Waye et al. 4 have suggested that emptying of the stomach is an unnecessary step in the preparation of patients for endoscopy, based on their results in 100 cases. In our institution, the most frequent serious complication of endoscopy has been aspiration pneumonia. To reduce the danger of aspiration we continue to empty the stomach with an Ewald tube if we plan to pass an instrument which lacks a suction channel. In the remaining cases, the pool can be emptied early during the examination through the suction channel. This procedure improves visualization of the upper stomach, improves tolerance to the procedure by preventing the regurgitation of irritating gastric contents into the pharynx, and probably reduces the danger of aspiration pneumonia.

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Fiber scope s The evolution of side-viewing fiberscopes in the United States and Japan has

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been quite similar. Takemoto et al. 5-7 in of the esophagus and proximal stomthree reviews have described how, over ach. 13 - 15 The response of ACMJI6. 17 the years, Japanese fiberscopes were made was to introduce a new instrument (model smaller with shorter controllable tips and 7089) very similar to the Olympus fiberprovided with cold light illumination. The scope, but 12 cm longer (77 cm), which evolution from the earl;' ACMI (American provided equivalent esophageal examinaCystoscope Makers Inc., Pelham Manor, tion, superior gastric visualization, and in N. Y.) Hirschowitz side-viewing fiberscope skilled hands could be passed into the to the current model F05007 has followed duodenal cap in most patients. 18, 19 To a similar course. Although most end os- meet the competition provided by this copists in both countries have turned to new instrument, Olympus reluctantly instruments with added features for abandoned their one instrument for one biopsy, cytology, or intragastric photog- organ concept and lengthened their raphy, there are those who prefer fin in- model EF esophagoscope to 86 cm to prostrument designed solely to provide the vide gastric and duodenal visualization. best' possible view. The Machida model They did not change the tip flexibility or FGS-SL, (Machida Endoscope Co., Ltd., tip deflection characteristics, and as a Tokyo, Japan) is perhaps the best exam- result, the model EF-II provided poor ple of this type of instrument. Maruyama visibility of the lesser curvature of the et al. 8 regularly were able to visualize stomach and lacked maneuverability completely the stomach and proximal within the duodenal cap. In 1970, ACMI increased the length of duodenum with these fiberscopes, favoring the 200-cm over the 100-cm length for its instrument to 105 cm, which made visualizing the latter organ. duodenal passage easier and, in 1971, inThe major development in endoscopic creased the tip deflection to 180° (model instrumentation in this country in recent 7089-J) which provided the improved years has been the conversion of the for- visibility of the cardia and lesser curvature ward-viewing fiberesophagoscopes into needed to make it a true panendoscope. panendoscopes. In 1963, Hirschowitz 9 de- In 1971, Olympus introduced a signifiscribed the first fiberesophagoscope cantly improved instrument, which also which was made by ACMI. In the same qualified as a panendoscope. The model year, Inaba 10 began work in Japan with a GIF was 105 cm long and provided a varisimilar instrument made by Machida. able focus objective lens and four-way These early instruments were not very use- tip deflection. Detailed comparative evaluful because they lacked tip control and ations of these two newest forward-viewing had no mechanism to keep the lens clean. endoscopes have yet to be made. LoPresti 11 improved the ACMI instruA new type of endoscope has recently ment by changing the optical system to been described by Suzaki et al. 20 A provide a 25° fore-oblique view and, by forward-viewing fiberscope was made by adding a second open channel, to permit Olympus with a very large, open channel air or water and suction to be applied which could pass a second small fibersimultaneously to keep the lens clean. In scope 7 mm in diameter, which was de1966, Akakura et al. 12 described their signed to function as a dissecting microresults with the new Olympus fiberesoph- scope, magnifying a 5-mm square field of agoscope (Olympus Optical Co., Ltd., gastric mucosa 13 times. The authors Tokyo, Japan), and Inaba 10 described re- presented a number of color photographs sults with an improved Machida instru- which showed very clearly the openings ment. The Japanese instruments incor- of gastric glands and the capillary pattern porated automatic controls for air, water, of the mucosal surface. The authors hoped and suction and a short bendable tip that this highly magnified view would aid which greatly improved examination of the in differentiating benign and malignant distal esophagus. These instruments lesions. The masterscope with its large proved to be very effective for examination instrument channel should be very useful

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for other types of physiologic study and should facilitate the performance of a number of surgical procedures.

Gastrocameras The early history of the development of the Olympus gastrocamera in Japan has been summarized by Tasaka and Sakita. 21 Ashizawa and Oshima 22 have described an improved type of gastrocamera (model GT-5A) and Oshima 23 has provided detailed instructions for its use. The gastrocamera was the first instrument to provide excellent visualization of the body of the stomach and high quality intragastric photographs. By the mid-1960's the instrument was in use in over 100 centers in this country. The introduction of the controllable tipped Olympus gastrocamera fiberscope, model GTF-A, ended the development of the gastrocamera in this country. The model GTF-A gastrocamera fiberscope provided adequate visualization of the upper body of the stomach, thus eliminating the added value which Morrissey et al. 24 had found that examination by the model GT-5 gastrocamera added to the model GTF gastrocamera fiberscope examination. Several studies 24-27 confirmed the superiority of the gastrocamera fiberscope over the gastrocamera. Schuman, 28 in a recent editorial, lamented the "death" of such a useful technique, the clinical value of which he 29 and others 30 . 32 have attested .. Despite the "death" of the instrument in this country, except for some research applications, 33. 34 the gastrocamera remains in wide use in Japan for screening examinations. Several previously described 35 modifications of the gastrocamera have become commercially available within the past year. The model GTST uses a double lens system for stereoviewing; the model GT-W has two angle control mechanisms which improves visualization of the posterior wall of the body of the stomach; and the model GT-PA is a miniaturized instrument with automatic film advance, power air, and a built-in light meter. I have found the latter instrument to be superior to the earlier models GT-5 and GT-5A instruments, despite

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the reduction in photographic size from 5 to 4 mm. There have been no recent reports on ultraviolet or fluorescent intragastric photography. Oka and Sugiura 36 modified a gastrocamera by placing polarizing filters over the lamp and lens. The color plate in their article graphically shows a reduction of mucosal highlights and improved detail in the polaroid photographs, when compared with the same area of gastric mucosa photographed with a standard gastrocamera.

Gastrocamera Fiberscopes The model GTF-A gastrocamera fiberscope remains in wide use in Japan and favorable reports have appeared from other countries. 37 , 38 The wide-angled high quality intra gastric photographs are of great value for the diagnosis of early gastric cancer. Two improved models which incorporate automatic controls for photographs and air have been introduced, (model GTF-S and model GTF-C). The latter instrument has a channel for direct vision gastric lavage. Technical details on photography with gastrocameras have been provided by Tasaka and Oguro. 39 Hayashi et al. 40 have advocated the use of a series of 1- to 3-cm extension tubes which they positioned between the tip of a gastrocamera fiberscope and its cap in order to move the lens farther away from the gastric wall when they photographed the high lesser curvature of the stomach with the instrument in the "C curve" position. The "C curve" is preferred to the standard "U-turn" method for visualizing this area because the connecting tube of the instrument does not partially obscure the field of view. In this country, several factors have led to a decrease in the use of the gastrocamera fiberscope. Duodenal examination is not possible with the instrument and Para gas et al. 41 have shown incomplete antral and pyloric visualization in a high percentage of patients examined with it. This is in contrast to the excellent visualization of the antrum and duodenal cap which can be obtained with the short controllable tipped ACMI and Machida

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ported studies have not provided the objective data needed to critically evaluate the method. Excellent results have been reported in almost all studies of endoscopy, even those with semiflexible gastroscopes and some of the primitive fiberscopes. Skepticism will continue on the part of the nonendoscopist until adequately designed controlled studies have Gastroscopic Diagnosis demonstrated that accurate endoscopic Goldstein 42 has published the only ob- diagnosis of gastrointestinal lesions rejective study of the use of gastrocamera duces the morbidity and/or mortality films to make endoscopic diagnoses. associated with them. Yamakawa et al. 46 and Tsuda 47 used Three gastroenterology fellows independEvans blue and similar dyes to stain the ently interpreted a series of 49 selected gastric mucosa to improve the three-difilms. All three endoscopists interpreted 55% of the films correctly and at least mensional aspects of the endoscopic' two were correct in 82% of the cases. This view. The dye tended to pool in depressed author has a series of 75 difficult gastro- areas, such as in small ulcer craters, on camera films, which have been inter- the irregularities of the surface of a tumor, preted by over 100 endoscopists without or at the base of folds. Aoki and Kitaknowledge of clinical findings. Most in- mura 48 presented a series of color photodividuals scored between 80 and 85% graphs of gastric ulcers before and after staining which illustrated the value of the correct. Many of the reported studies on the technique in bringing out detail. Indicator accuracy of gastrointestinal endoscopy dyes have been sprayed on the gastric have been comparisons of endoscopic and wall in a similar way to locate the junction X-ray results without final proof of the of pyloric and fundic mucosa. 49. 50 Space does not permit a detailed disdiagnosis. This was not the case in a recent study by Kato 43 of 548 gastric and cussion of the endoscopic features of a duodenal lesions examined with the gastro- number of the rarer gastric lesions which camera with all diagnoses surgically con- have been well described in recent pubfirmed . X-ray was correct in 83% of cancer lications, including Crohn's disease, 51 and 75% of gastric ulcer cases, as com- adult hypertrophic pyloric stenosis, 52 pared to gastrocamera accuracy of 93% jejunal gastric intussusception,53 antral of the gastric cancers and 87% of the gas- web,54 gastroduodenal band, 55 early syphtric ulcers. When the results of lavage ilis,56 Mallory-Weiss syndrome, 57 mycocytology were added to the X-ray and sis,58. 5 9 xanthomata,60 malignant melaendoscopic findings, cancer was correctly noma, 61 Kaposi's sarcoma, 62 amyloidosis, 63 eosinophilic granuloma,64, 65 lipomatosis, 66 diagnosed in 99.5% of the cases. aberrant pancreas,67-69 carcinoid, 70 liBrom et al. 44 in 200 consecutive endoscopies with a Machida FGS controllable poma, 71 leiomyoma, 72 gastric varices, 7 3.74 tipped fiberscope found 72 instances of and stomach worm (Anisakis). 75 disagreement between the radiologic and Esophagoscopic Diagnosis endoscopic diagnoses. The authors concluded that four lesions were missed by Trujillo et al. 76 have reviewed the endoscopy, 11 lesions left in doubt after endoscopic diagnosis of hiatus hernia follow-up, and the remaining cases were as seen from above, and Schacter and instances of failure of radiologic diagnosis. Kobayashi 77 have discussed the use of a Morrissey 45 found that a major favor- retroflexed endoscope to diagnose hiatus able effect on patient management re- hernia from below. Roling et al. 78 sulted from 41 of 100 consecutive endo- concluded that when a patulous cardia scopies. Unfortunately, this and other re- was seen from below, the correlation fiberscopes and with the Olympus GIF fiberscope. The increased emphasis and reliance by endoscopists on biopsy as opposed to photography for diagnosis had led many endoscopists to choose a sideviewing biopsy fibersco;e, rather than a gastrocamera fiberscope to compliment their long forward-viewing panendoscope.

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was better with incompetency of the gastroesophageal sphincter as found on manometric study than with the X-ray diagnosis of hiatus hernia, a conclusion with which this author would agree. An aid to the diagnosis of hiatus hernia from above is sharp visualization of the squamocolumnar junction. Slaughter and Grayer 79 were able to identify the junction visually in 22 consecutive patients with 20 of their visual diagnoses confirmed by biopsy. The use of the valsalva or sniff test with the patient in the head down position may aid in bringing out a hernia by identifying more clearly the level of the dia. phragm. The diagnosis of lower esophageal ring is more easily made with a fiberesophagoscope than with an open-tipped esophagoscope because the esophagus can be fully inflated by a fiberesophagoscope since it provides a closed system. Nabeya et al. 80 discussed the endoscopic findings in a collected series of 24 cases of early esophageal carcinoma with invasion limited to the mucosa. Endo et al. 81 encountered seven early lesions in a series of 1300 esophageal cancers. Sakita et al. 82 reported an ulcerated early carcinoma of the esophagus in which the ulceration completely healed during a 2-month period of medical treatment. Chavy et al. 83 have pointed out the value of the routine use of bronchoscopy to detect the spread of esophageal carcinoma to the trachea or bronchi. Seventeen per cent of cases showed infiltration into the wall and 5% showed polypoid growths within the respiratory tract. The endoscopic diagnosis of esophageal varices and the management of portal hypertension were well covered in mongraphs by Conn 8' and Palmer.85 The automatic controls of the new fiberscopes which permit the rapid alternate use of air and suction have proved helpful in the diagnosis of esophageal varices. Despite the improvements in fiber optic esophagoscopes, DeGradi 86 is critical of many endoscopists, includ-

ing this author, who no longer use rigid and flexirigid esophagoscopes. He believes that the flexirigid (Eder-Hufford) esophagoscope (Eder Instrument Co., Chicago, Ill.) is the instrument of choice for the examination of actively bleeding patients and for the diagnosis of esophageal varices. Although DeGradi's view is supported by a controlled study reported by Zimmon and Tesler,87 using the old LoPresti esophagoscope, Conn et al. 88 found no difference between rigid and fiber optic esophagoscopes for the diagnosis of varices. Biopsy Direct VISIOn gastric biopsy will soon be a routine procedure in every endoscopic clinic in this country because the new, long, forward-viewing instruments which permit biopsy are replacing the side-viewing instruments which lack this capacity. The choice between the photographic capability of a gastrocamera fiberscope or the biopsy channel capability of a sideviewing biopsy fiberscope remains; but it is a choice for the second, rather than for the first instrument which an endoscopist purchases. Nearly all of the studies of the accuracy of gastric biopsy have been made with the side-viewing biopsy fiberscopes, such as the Olympus model GFB or Machida model FGS-B. There have been no comparative studies of the accuracy of forward-viewing, as opposed to side-viewing, instruments for the biopsy of comparably located lesions. Kasugai et al. 89 have emphasized the importance of taking biopsies from the inside edge of ulcerating lesions and of avoiding all hemorrhagic and necrotic areas. Ishioka et al. , 90 in a series of 213 malignant lesions, found that it was necessary to take at least six biopsies of each lesion in order to avoid false negatives and to obtain at least two positive specimens in each case. It is not possible to take six well positioned biopsies from many gastric lesions with an end-viewing instrument. It is particularly difficult to obtain a biopsy from the proximal inside edge of

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a gastric ulcer with one of these fiberscopes. Niwa 91 has pointed out the difficulty of obtaining positive biopsies in recurrent cancers after surgery. Only nine of 63 biopsy specimens from..tg patients were positive for malignancy. He also encountered difficulty in obtaining deep enough biopsies from gastric polyps to permit recognition of their histology. The latter problem has been reduced by a new type of biopsy forceps, developed by Machida Company, which has a small needle positioned between the jaws of the forceps. The needle is helpful in making tangential biopsies in addition to fixing movable targets, such as polyps, for deeper biopsy. Kasugai et al. 89 and Sakita et al. 92 have demonstrated that many more type II-C early gastric cancers will be found if endoscopists take biopsies from ulcer scars which have even slightly atypical features . Malignant tissue is frequently more accessible to biopsy after an associated ulcer has healed. Kasugai et al. 93 were able to obtain positive biopsies in 86% of advanced cancers and 89% of early lesions. Yamakawa et al. 94. 95 were able to achieve an accuracy in 220 cancer cases of 94% with biopsy, 96% by touch cytology, with an over-all accuracy of 98%. Touch smears are made by gently touching a biopsy to a glass slide, fixing and staining by the Giemsa method. Yoshii et al. 96 have duplicated these results. They found the touch smear technique to be useful for the cytologic diagnosis of lymphoma in 4 patients. Eight of 11 smears were positive in contrast to only five of 21 biopsies. The contribution of direct vision biopsy to patient management was well shown by a study by Weiss et al. 97 using the Machida model FGS-B fiberscope. Positive biopsies were obtained in 16 of 19 malignancies correcting four erroneous gastroscopic and X-ray diagnoses. There were no false-positive biopsies. Negative biopsies permitted medical management of some patients who might otherwise have been treated surgically. Similar favorable results have been reported by Williams et al.,98 using the Olympus model GFB fiberscope.

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The accuracy of gastric biopsy should be improved by features which have been built into some of the newer biopsy instruments. Both the Olympus model GF Type Band Machida model FGS-BL sideviewing biopsy fiberscopes and the Olympus GIF and Machida FES forward-viewing endoscopes have been built with four-way tip control which permits pinpoint positioning of the biopsy forceps and variable focus objective lenses which permit maximal resolution of the view of the forceps at the point of biopsy. Berci and Panish 99 have designed a zoom lens system which greatly increases the magnification of the ocular lens of a fiberscope. They have found this instrument helpful when it was necessary to biopsy lesions at some distance from the endoscope, as in the U-turn position.

Direct Cytology Kasugai 100. 101 and his colleagues, Kobayashi et al., 102 continue to achieve a very high accuracy of 97% in the diagnosis of cancer by lavage cytology under direct VISIOn using a cytology fiberscope (Machida model FGS-K) of their own design. They compared direct lavage with gastric tube lavage in 69 advanced cancers and 15 early cancers, performing both studies in each patient. The use of the direct method increased accuracy from 88 to 96% in the advanced cases and from 40 to 87% in the early cases. Cytology fiberscopes have been rarely used outside of Japan. Although the lavage technique can easily be performed using a polyethylene tube passed through the biopsy channel of a biopsy fiberscope, there have been no reports of its use from this country. The simpler technique of brushing the lesion under direct vision has been preferred. Kobayashi et al. 103 were able to obtain positive brushings in 25 of 26 consecutive cancer cases, a positive biopsy in 24, and no false negatives over-all. Although Kobayashi advocated two brushings prior to biopsy, Witte 10. believes that the brushing should be done last, withdrawing the brush only 1 cm into the biopsy channel and then withdrawing the instrument to avoid loss of cells when

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the brush is withdrawn through the entire suction channel. Kidokoro et al. 105 proposed a suction technique which utilized a Teflon tube passed through the biopsy channel of a fiberscope, for the collection of cells without lavage from the surface of lesions under direct vision. He achieved 95% accuracy in 165 malignancies. His combined accuracy of biopsy and cytology was 97%. Various blind brushing and scraping techniques 106-IOB have been proposed for collecting cytologic material from the upper gastrointestinal tract. Because there are a number of different fiberscopes available which permit the collection of material for histologic study under direct vision, there would seem to be little indication for the use of these blind techniques. There is at least one report 109 of massive bleeding following a blind scraping procedure and there is no convincing evidence that these techniques are superior to the older and simpler tube lavage. Since the reported accuracy for direct cytology is higher than that for visual or direct biopsy diagnosis, should fiberscopes be designed to maximize their potential for cytologic collection? Schuman liD believes that these extremely high accuracies can only be obtained in centers which make a major commitment to cytologic diagnosis and have cytologists standing by while the endoscopist is performing his ertdoscopy. He also suggests that there are many more pathologists who can correctly interpret biopsy specimens than there are cytologists who can accurately interpret cytologic specimens. One might also take the position that the number of malignancies which will be missed in the average hospital during a year, following a careful visual, photographic and biopsy examination, may not be large enough to justify maintenance of a trained gastrointestinal cytologist in the hospital.

Gastric Tumors Prolla et al. III have reviewed the recent Japanese experience with the diagnosis of gastric cancer and have included a detailed description of the Japanese classifi-

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cation of early gastric cancer. Kawai 112 reports that early gastric cancer in his institution accounted for 3% of all gastric cancer cases diagnosed from 1958 to 1960 and 33.1 % of the cancer cases seen from 1967 to 1969. These results would have been more encouraging if the number of advanced cases seen during the second period had decreased instead of increasing 20%. As further evidence for the refinement of gastric cancer diagnosis in Japan, 24 of 320 early gastric cancer cases found at the National Cancer Center Hospital were less than 1 cm in diameter.113 The increased use of direct vision biopsy has been responsible for correctly diagnosing many of these small lesions. The contribution made to gastric cancer diagnosis in Japan by improved radiology is often overlooked in this country. In most series of cancer cases, the accuracy of radiology and endoscopy both are in the vicinity of 90% with combined accuracy figures approaching 100% when cytology and biopsy results are added. Nishizawa et al. 114 visualized on the first routine X-ray examination, eight of the 13 cancers 5 to 10 mm in diameter which have been diagnosed in their institution. In a larger series collected from several institutions,115 62% of 196 early cancers less than 1 cm in diameter were visualized on X-ray examination. Routine examination with double contrast techniques using gasforming pills has been responsible for this success. It is only within the past few years that scattered reports of the endoscopic diagnosis of early gastric cancer have appeared from other countries.116-llB The importance of the early diagnosis of gastric cancer is illustrated by the report of a 5-year survival rate of 93% of mucosal and 89% for submucosal lesions in a group of 398 Japanese cases. 119, 120 Dozens of articles, most of them well illustrated in color, devoted to the X-ray and endoscopic diagnosis of gastric cancer have appeared in the Japanese endoscopic journals. This subject cannot be effectively presented without such illustrations and is not covered in this review. Okabe and Hirokado 121 have at-

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tempted, with the aid of a computer, to analyze objectively the diagnosis of depressed gastric lesions using gastrocamera films. They identified 22 independent objective findings and assigned weights to them, depending on..wtheir presence or absence in 32 malignant and 44 benign lesions. They then applied the system to 25 histologically proved unknown lesions. The system provided a correct diagnosis in 24 cases, including some cases where the conventional subjective diagnosis was incorrect. There have been several recent reviews of the endoscopic diagnosis of sarcoma and lymphoma of the stomach. 122-124 The declining incidence of gastric cancer in this country has resulted in a relative increase in the percentage of gastric malignancies represented by these other tumors. Dunn et al. 125 found a 7% incidence and this author has encountered 8%. The majority of sarcomas cannot be differentiated on macroscopic examination from adenocarcinomas. Only a few endoscopists 96 have attained high diagnostic accuracy with direct biopsy or cytology. Lymphoreticular hyperplasia of the stomach is an interesting benign lesion which can present an ulcerated nodular appearance indistinguishable from a malignancy. 126, 127 The management of gastric polyps is likely to become much more conservative with improvements in endoscopic biopsy and photography. Yoshimura et al. 128 and Ariga et al. 129 have confirmed the close relationship of size to malignancy. Their combined results show that three of 192 polyps under 2 cm were malignant and 14 of 25 over 2 cm in size were malignant. Uematsu et al. 130 followed 48 patients with gastric polyps by serial gastrocamera examination for from 6 months to 7 years and found that only two polyps increased in size and there was only one which might have undergone malignant degeneration. In contrast, four of five early cancers of the protruding type increased in size on follow-up examinations. Thus, it would be reasonable to manage a gastric polyp less than 2.0 cm in diameter which does not increase in size on follow-up examination as if it were benign.

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Mass survey examinations in Japan continue to prove effective for the diagnosis of early gastric cancer. Fujita et al. 131 using a model GT-P gastrocamer found a 0.5% incidence of cancer in 6167 cases with 50% of the tumors still in the early stage. They anticipate even better results in the future using the new model GT-PA gastrocamera. In 1968, in Japan, 1,500,000 patients were examined with a 0.26% cancer detection rate. 132 Although the over-all incidence of gastric cancer is too low to justify mass screening in this country, it may be worthwhile to study high risk patients. For example, Hanik and Gregor 133 followed 123 patients with pernicious anemia for 10 years and encountered nine gastric cancers or 21 times the expected incidence.

Gastric Ulcer Fujino and Kaneko 134 have made observations which emphasize the chronicity of gastric ulcer disease. They performed multiple gastrocamera examinations over a 6-year period on a population of 1000, presumably healthy individuals over 40 years of age, in a mass screening program. In 1970, 32 active ulcers and 40 ulcer scars were found in 617 examinations. Review of previous gastrocamera examinations made on the patients found to have active ulcers in 1970 showed that 30 of 32 cases had had active ulcers or ulcer scars noted on previous examinations. Their conclusion is that gastric ulcer is a very chronic disease which usually begins before the age of 40. Hara 135 has continued his endoscopic observations on the recurrence of gastric ulcer in a series of 2132 ulcer patients. Fifty-five per cent of the ulcers recurred over a 7- to 8-year follow-up with 75% of the recurrences occurring during the first 2 years. Nakamura et al. 136 compared endoscopic and histologic findings in 63 ulcer scars. Forty of the 54 patients with erythematous scars were followed up for 2 years. There were six ulcer recurrences and 18 of the scars continued to show an erythematous appearance. Histologic studies showed that the mucosa did not completely return to normal until the erythema

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disappeared. These findings would support this author's recommendation to patients that they continue on a modified ulcer therapy program for 2 to 3 years after their ulcers have healed. The relationship of benign to malignant ulcers remains a subject of great interest to endoscopists. Sakita et al. 92 has presented convincing evidence that the healing of malignant ulcers occurs at essentially the same rate as that of benign ulcers. They have observed cases of complete healing of malignant gastric ulcers and have found that most nonulcerated early gastric cancers show a scarred appearance suggesting prior ulceration. Their study emphasizes the importance of careful follow-up and liberal use of biopsy and cytology techniques in the care of gast.ric ulcer patients. Kobayshi et al. 137 suggest that the need for follow-up continues after gastric surgery, reporting 7 cases of cancer of the stomach after surgery for benign lesions.

Gastritis Little progress has been made in recent years to improve our understanding of gastritis. Macdonald and Rubin,138 in their extensive review of gastric biopsy, emphasized the need for standardized histologic criteria for the biopsy diagnosis of gastritis. They objected to the use by the endoscopist and the pathologist of the same histologic terms to describe their findings, when many studies, including a recent report by Heinkel, 139 have shown a very poor correlation between endoscopic and histologic diagnoses. Heinkel is one of the few endoscopists who has correlated histologic diagnoses with specific endoscopic findings. In other studies, the best agreement between histology and endoscopy has been found in the diagnosis of gastric atrophy. 138. 140 This correlation can be improved if careful attention is paid to the degree of visible distention of the stomach 141 or the extent to which intragastric pressure has been raised by inflation. 142 The location of the endoscopic finding is quite important because visible vessels are seen normally in the dome of the fundus and only with severe atrophy in t.he antrum.

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Kimura and Takemoto 143 have developed a technique for stepwise gastroscopic biopsy along the greater curvature of the stomach, spacing their biopsies by the use of tiny measuring tapes positioned with a biopsy forceps. Ottenjann et al. 144 have used this technique in 76 patients obtaining six evenly spaced mucosal biopsies from the entire greater curvature of the stomach. They found such variable histology from one part of the stomach to another that they concluded that blind biopsy was a very inadequate way to evaluate gastritis. In an attempt to overcome some of the confusion surrounding the use of the term, "Menetrier's disease," in describing hypertrophic changes in the stomach, Palmer 145 translated the original article published by Menetrier in 1888 in which he described the polypoid and sheetlike types of polyadenomas of the stomach and emphasized their malignant potential. A recent excellent example of the polypoid type has been described with relief of the patient's symptoms following gastrectomy.146 The criteria which various endoscopists use to decide whether to attribute a given episode of gastrointestinal bleeding to erosive gastritis must be quite variable because of the marked differences in incidence in reported studies. 147 DeGradi et al. 148 and Roesch and Ottenjann 147 have recently described two quite different classifications of gastric erosions. This author believes that localized capillary dilation is the earliest lesion and it is not included in either classification. The new Olympus model GIF fiberscope provides the high optical resolution required to differentiate areas of tiny intramucosal hemorrhage from localized capillary dilation. DeGradi et al. 148 do not mention the elevated margins which can be seen frequently around gastric erosions. Roesch and Ottenjann 147 believe elevated margins are due to edema in acute lesions and fibrosis in chronic erosions. Tani et al. 149 have emphasized the chronicity of some cases of erosive gastritis. They identified the location and followed individual chronic erosions and found that 76% of them were unimproved on a I-year follow-

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up. This author believes that routine biopsies should be taken from erosive lesions, particularly the chronic ones, in order to look for eosinophilic gastroenteritis. This lesion can be present in stomachs with minimal endoscopic findings. The importance of making this diagnosis is illustrated by the fact that 2 of the 4 cases found by this author cleared their gastrointestinal symptoms on steroid therapy after failure to respond to antacids. Ludwig et al. 150 described 5 cases of bleeding in postgastrectomy patients which they related to prestomal erosive gastritis. Duodenoscopy The early side-viewing fibergastroscopes were too large, too short, and had poor tip characteristics for predictable passage into the duodenal cap. The need for fiberscopes specifically made for duodenal examination was recognized at that time. Several prototype forward-vIewing instruments were tried whose design, in retrospect, seems to have been based on small bowel suction biopsy tubes. 151-153 They were extremely flexible, lacked tip control, and in some cases had weighted tips. They succeeded only in providing a few glimpses of duodenal mucosa. Later, Shindo et al. 154 working with Olympus, evaluated a number of prototype fiberscopes which did have tip control and, more recently, controls for air, water, and suction. They evaluated both endviewing and side-viewing instruments and an ingenious instrument which permitted both forward and lateral vision by means of two prisms. The distal prism was hollow and could alternately be filled with air or alcohol. When it was filled with air, the proximal prism acted as a mirror, providing side viewing, and when it was filled with alcohol, light passed through the system to provide end viewing. In their final design selection, both Machida and Olympus were influenced by two preliminary reports of pancreatic duct cannulation with direct pancreatography which came from this country. 155, 156 Both companies had found that the

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papilla of Vater could be seen much better with their side-viewing prototypes than with their end-viewing instruments so they selected side-viewing lenses and positioned their biopsy channels to the side of the objective lens. Soma et al. 157 were able to visualize the papilla of Vater in 88% of cases. Kozu et al. 158 have described the normal anatomy of the papilla in an article well illustrated in color. Three types-papillar, hemispherical, and flat-were found. Oi et al. 159 described the first successful cannulation of the ampulla of Vater with pancreatography and more recently, have been successful in 41 of 53 attempts (77%).160, 161 Takagi et al. 162-165 confirmed their findings and reported the first visualization of the biliary tree, as well. Ogoshi et al. 166 were successful in 21 of 25 attempts at cannulation, Kasugai et al. 167 in 26 of 30, and, in the only report of success outside of Japan, Classen 168 was successful in 16 of 20 attempts. Transient amylase elevation has frequently occurred postprocedure, but no serious complications have been reported. 160, 167 It is often quite difficult to visualize the opening of the common duct on the papilla of Vater, To facilitate visualization, indocyanine green dye has been given intravenously to turn the pancreatic juice green. 169 Alternatively, the use of secretin or a pancreozymin administration has been used to stimulate the flow of pancreatic juice to reveal the site of the ampulla. 154, 160 These techniques have been very difficult for others to learn. For most institutions it is questionable whether the great cost in physician time and equipment can be justified by the small number of cases of otherwise unrecognized cancer or stone in the biliary tree which would be diagnosed. A different approach to duodenoscopy was taken in this country. Belber 170 developed a technique for passage of the ACMI controllable tipped side-viewing endoscope into the duodenal cap. In 1968, he presented convincing cines of duodenal examination. Passage was also

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achieved with the 77 cm ACMI model 7089 fiberesophagoscope in a significant number of patients with failure most frequently due to the inadequate length of the instrument. 171 This led to the introduction by the manufacturer of the 105 cm forward-viewing model 7089-J endoscope which has made duodenal examination a routine part of all gastroscopic procedures. Morrissey 172 has found that a modification of the tip of the ACMI endoscope, which added a metal cap to keep the lens away from the mucosa, greatly facilitates passage into the duodenal cap by permitting the pylorus to be seen with the tip touching the mucosa. It also reduces the number of suction artifacts produced by the instrument. In 1971, Olympus introduced the model GIF forward-viewing endoscope which incorporated a variable focus objective lens with the resolving power to visualize individual villi, and a four-way tip control mechanism which, in our experience, did not increase the frequency of duodenal passage, but often reduced the time required for this maneuver. Controversy persists as to whether the duodenal cap can be better visualized with the smaller, more flexible, side-viewing Japanese duodenoscopes, the Olympus model JF-2 or Machida model FDS, or with the two end-viewing fiberscopes described above. Cavallaro and McCray 173 compared the ACMI model 7089-J with the Machida model FDS and found that the forward-viewing instrument visualized the duodenal cap better. The preference of the Japanese investigators for the sideviewing instrument is probably due to the fact that the forward-viewing prototypes with which they worked were far more flexible than these new forward-viewing endoscopes. Tip control mechanisms do not function effectively in highly flexible instruments because the fulcrum will shift from the bending point of the tip to the extreme tip when the slightest obstruction is met. Belber,171 using ACMI endoscopes in 200 patients, believed that he missed only two of 59 duodenal ulcers in patients in

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whom he was able to pass the instrument into their duodenum. In contrast, he believed that the radiologist missed seven duodenal ulcers and made erroneous diagnoses of active duodenal ulcer in 10 of these patients. Soma et al. 157 examined 76 patients with duodenal ulcers shown on X-ray with the Olympus model JF-2 duodenal fiberscope. They were able to visualize the duodenal ulcer in 71 of these patients. One group of 46 duodenal ulcer patients was carefully evaluated by having all of the endoscopic photographs and X-ray films interpreted independently by at least two individuals. Seven ulcers thought to be active by X-ray were healed at endoscopy and one scar seen by X-ray was found to be an open ulcer at endoscopy. The very good agreement between the two methods in this study may have been because hypotonic duodenography was a routine part of the X-ray examination. Belber 171 found a surprisingly high incidence of duodenitis occurring as a separate lesion (14%) and regularly observed duodenitis in association with duodenal ulcer. In contrast, Yamakishi and Yamagata 174 performed biopsies on the mucosa adjacent to 14 duodenal ulcers and found inflammatory changes in only 1 case. Erosive duodenitis presents an endoscopic appearance very similar to erosive gastritis.

Emergent Endoscopy The vigorous approach to the diagnosis of upper gastrointestinal bleeding continues to be advocated in the United States175-178 and in Europe 179, 180 despite the absence of convincing data that this approach reduces the morbidity or mortality associated with bleeding. It is interesting that two large series of bleeding patients have recently been reportedone in which endoscopy was rarely used by Schiller et aU 81 with 8.9% mortality in 2149 cases; the other by Palmer 175 using the vigorous diagnostic 'l.pproach with 7.9% mortality in 1400 patients. It is obvious that controlled studies are needed. Improvements in instrumentation during

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the past 3 years have made it possible for an endoscopist of average ability to work effectively in the presence of moderately active bleeding. Emergent endoscopy is no longer the province of a few experts. The new instruments have automatic controls for air, water, and suction and areas of interest can be cleared of blood by irrigation under direct vision with a polyethylene tube passed through the biopsy channel. The use of large volumes of irrigating fluid makes it easier to remove blood through the aspirating channel of the instrument. In our experience the extreme tip deflection of the ACMI model 7089-J has been very useful for examining bleeding patients, especially those with bleeding sites in the high body of the stomach. Examinations by this author are carried out without prior passage of tubes and without saline lavage to avoid artifactual lesions to which the hemorrhage may be falsely attributed. In reported series of bleeding patients, the frequency of hemorrhagic gastritis has varied from none 182 to 46%.183 Palmer'sl75 incidence of 12% corresponds to this author's experience. The high values were associated with low incidences of duodenal ulcer. The new instruments which permit direct inspection of the duodenal cap will reduce the overdiagnosis of erosive gastritis as a cause of massive bleeding. The growing importance of angiography in the diagnosis and treatment of gastrointestinal bleeding l84 . 185 further increases the value of emergent endoscopy. Many radiologists are reluctant to put barium into the stomach of a bleeding patient because if they do not find the bleeding site, the angiographer and the endoscopist cannot help for many hours. Although the use of water-soluble contrast materials does not interfere with endoscopy,182 the contrast achieved with these agents is not good and they interfere with angiography. A barium meal X-ray examination can establish the presence of a lesion, but cannot tell whether the lesion is bleeding. Selective mesenteric angiography can de-

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tect the site of bleeding, but cannot identify the nature of the lesion. McCray et al. 183 found that only 5 of 27 patients with known esophageal varices were bleeding from varices. Palmer l75 found that 51% of patients who were known to have an upper gastrointestinal lesion prior to their bleeding episode were bleeding from a different lesion. This author found that 15% of no bleeding patients examined after bleeding had stopped, had two lesions, either of which could have bled. Thus, there is no substitute for direct visualization of an actively bleeding lesion. The new instruments have the potential to control bleeding in addition to diagnosing its cause. Cautery tips have been developed for controlling bleeding after polyp removal from the stomach and colon. As yet, there have been no reports of the use of this technique to control spontaneous bleeding. Palmer I 75 was able to find the bleeding site in 93% of cases using emergent endoscopy and X-ray examination. About 60% of lesions were found first by endoscopy, using older instruments. Endoscopic results should be significantly better with the new instruments because they permit routine duodenal examination. In a small series of emergent examinations we have been able to localize the site of bleeding in all but a few patients in whom the bleeding was overwhelming. If bleeding is vigorous, the actual lesion may be obscured by large clots or active bleeding, but the essential information needed for management of the patient can be obtained. Colonoscopy The earliest efforts at colonoscopy antedate the development of the fiberscope. Starting in 1957, Matsunaga and his colleaguesl8s'188 at Hirosaki University modified the Olympus gastrocamera for use in the colon. They evaluated a sideviewing "sigmoid camera" and a forwardviewing "cavocamera." Although excellent results were obtained in some patients, with passage to the transverse

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colon in 24% of cases, the reliability was not good enough to make these devices practical. In 1963, Yamagata's associates, Oshiba and Watanabe 189 at Tohoku University, working with Machida, produced the first of seven prototype colon fiberscopes which this group subsequently evaluated. 190, 191 Niwa et al. 192 , 193 at Tokyo University and Kanazawa et al. 194. 195 at Hirosaki University developed prototype colon fiberscopes which were manufactured by Olympus and reported on in 1965 to 1966. In 1961, Overholt,196, 197 with the assistance of Eder and the Illinois Institute of Technology, began work in the United States on the development of a fibersigmoidoscope. He evaluated several instruments, none of which proved successful from either a mechanical or optical standpoint. The problems of colonoscopy were well described by Dean and Sherman 198 when they reported their results with the 86-cm Olympus model CF-SB colon fiberscope. Although outside the patient this instrument was very flexible with a two-directional controllable tip, after negotiating one of the very tight curves encountered in the sigmoid, its rotation and tip control were greatly diminished and often it was not possible to visualize the entire lumen of the bowel. Under these circumstances, Overholt 199 suggested the use of "persuasive pressure" which permitted him to advance the Olympus instrument as long as mucosa could be seen freely slipping past the tip. He was able to see the bowel well on withdrawal of the instrument. Similar techniques, involving transintestinal intubation for passing colon fiberscopes, were reported from Italy by Provenzale and Revignas 200 and from Japan by Hiratsuka. 201 In the former method, a double length of polyvinyl tube was passed from mouth to anus in order to make a pulley system with the pulley positioned in the cecum. One end of the tube was attached to a long ACMI colon fiberscope and the other end was used to pull the instrument into the upper bowel. In the latter technique, a single

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length of radio-opaque polyvinyl tubing was passed completely through the bowel. Tension was exerted on the tube to straighten the bowel as much as possible. The colon fiberscope was passed around the tube and then through the colon to the cecum in from 5 to 20 min. The first 25 cm are often passed much more easily and seen better with a standard rigid sigmoidoscope than they are with a fibersigmoidoscope. Niwa 202 used a bivalved rigid sigmoidoscope to insert the fibersigmoidoscope for the first 25 cm. This permitted passage of the scope through this area of bowel without distending it with air. It is more difficult to pass the colon fiberscope through the sigmoid if the rectum is overdistended with air. Once the fibersigmoidoscope was inserted, the rigid scope was removed, and then the bivalve mechanism was used to take it off the fiberscope. The over-all experience to date would indicate that an instrument will probably be developed which can be passed to the terminal ileum in most patients without the use of a guide string. The length will be somewhat less than 200 cm and the tip will have polydirectional control, such as is found on Olympus model CF-LB or the proposed ACMI colonoscope. Most reports on the colon fiberscope have emphasized the depth of insertion of the instrument, rather than the clinical value of the information obtained. Matsunaga 203 was able to reach the transverse colon in 86% of patients, the ascending colon in 40%, and the terminal ileum in 16% using the 187-cm Olympus model CF-LB colonoscope. His technique for passing the instrument through the sigmoid is well shown in another publication. 204 Nagasako et al. 205. 206 have described their technique for passing the 183-cm Machida model FCS fiber colonoscope into the terminal ileum and have reported their observations on disease of the terminal ileum and the endoscopic appearance of the ileocecal valve. Shinya et al. 207 in a series of 208 colon fiberscopic examinations were able to demonstrate definite colonic pathology in

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29 symptomatic patients with negative barium enemas and in 15 patients with suspicious lesions. Overholt et al. 20 8 attempted to assess the clinical value of fiber sigmoidoscopy in 70 patients. Seven erroneous X-ray diagneses were corrected by the endoscopic procedure. In 13 patients with polypoid or neoplastic disease the fiber sigmoidoscopic procedure influenced treatment by establishing a hist ologic diagnosis which, in some cases, obviated the need for surgery. They found that the procedure was useful in determining the extent of inflammatory bowel lesions. Choledochoscopy Operative biliary tract endoscopy presents technical problems which differ from those of endoscopy of the gut. The biliary tract is normally filled with opaque fluid . The early rigid lens choledochoscopes, introduced by Mclver 209 in 1941 and Wildegans in 1957,210 and the first fiberoptic choledochoscope described by Shore and Lippman in 1965, 211 provided a clear field by continuous irrigation of the biliary tree under pressure with saline. Visualization of the biliary tree with these instruments was somewhat difficult. Although the ACMI fiberoptic instrument could be maneuvered more easily than the rigid scopes, it was quite large, having a 6-mm external diameter. In 1968, Takagi et al. 21 2 reported on their 4-year effort to improve visualization, not only of the biliary tree, but also of the urinary tract and spinal canal. Working with Olympus, they were able to design a fiberscope only 2.7 mm in diameter. Their system was to irrigate the biliary tree with saline and then attempt to view the organ quickly before the field became obscured. With the use of the earlier instruments, irrigation involved the loss of large volumes of fluid into the abdominal cavity and duodenum which not infrequently came from infected biliary trees and may have contributed to some postoperative infections. In an effort to deal with this problem, Nishamura et al. 21 3 designed an instrument which eliminated the need for irrigation by

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making use of a balloon over the tip which could be inflated to provide contact viewing within the biliary tree. This system provided no potential for instrumentation and the area which could be seen at any one time was quite limited with considerable surface glare coming from the balloon. In 1971, these authors 214 abandoned the balloon approach and described a new instrument which incorporated a much improved irrigation system designed to prevent loss of fluid out of the biliary tree and to maintain adequate distention of it. This fiberscope had an external diameter of 5 mm, was 557 mm long, had a controllable tip and a fixed focus lens with a 47 ° angle of view. A short 7.2 mm diameter irrigation tube was placed in the biliary tree through a choledochotomy incision and then a balloon similar to the balloon on an endotracheal tube was inflated to seal off the bile duct, maintaining pressure within the biliary tree and preventing leakage of saline. The endoscope was passed through this irrigating cannula. Saline flowed in through the tip of the endoscope and left by way of a side channel in the irrigation cannula. The collected fluid was used for cytologic and bacteriologic studies. The photographs which were taken through this endoscope were remarkably good. Schein,2 15 using a Wildegans choledochoscope, examined 117 patients after standard common duct exploration and found only two additional solitary stones. No additional stones were visualized at operative cholangiography. Shore et al. 216, 217 using an ACMI fiberoptic choledochoscope, examined 100 patients undergoing choledocholithotomy. In contrast to Schein's results, retained stones were found in 22% of patients after standard common duct exploration. Two stones were missed by endoscopy. They also found the endoscope useful for evaluating filling defects seen on operative cholangiograms which, in several cases, turned out to be bubbles of air rather than stones. Laparoscopy There has been a great increase in interest in laparoscopy in this country in

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recent years-almost entirely on the part of gynecologists, rather than gastroenterologists. Harris et a1. 218 compared laparoscopy and culdoscopy in patients with a variety of gynecologic problems, the most common being unexplained pelvic pain. They concluded that except for fertility problems, laparoscopy was superior to culdoscopy for gynecologic diagnosis. A second stimulus to the use of the laparoscope in gynecology has been the development of the technique of sterilization by cauterization of the Fallopian tubes through a laparoscope. Lindner 219 has described the advantages of the improved optical systems which have been incorporated into some of the newer laparoscopes. The computerdesigned Wolf Lumina Phototelescope (Richard Wolf, Knittlingen, West Germany), which he prefers, incorporates a Hopkins cylindrical objective lens system which provides superior light transmission. This instrument differs from older endoscopes in that those spaces in the telescope previously occupied by air are now occupied by glass and vice versa. The effect is to create a system of air lenses. Lens surfaces in the newer instruments are now coated to reduce reflection. All the new laparoscopes make use of cold light which has greatly improved both cine and still photography. 219·223 The lumina instruments (Richard Wolf) use continuous cold light for television and cine, but make use of either a proximal or distal electronic flash for still photography. The intense illumination of the flash permits instant documentation of observations with a Polaroid Endocamera with Leitz reflex view finder. Four exposures fill one 8.3- by 10.8-cm Polaroid picture.219. 222 Detailed discussions of the technique of peritoneoscopy have been provided by Smith,224 Palmer,225 and Wittman. 226 Many laparoscopists prefer to use CO 2 to produce their pneumoperitoneum to avoid the hazard of air embolism. The use of CO 2 is facilitated by a CO 2 Pneuautomatic Insufflator (Eder) designed by Semm.227

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The failure of gastroenterologists and surgeons to make more use of laparoscopy in this country may in part be due to the absence of convincing data that the procedure makes an important contribution to patient management. Reported series do not permit the reader to separate out those cases where the diagnosis could have been made by simpler techniques, and those cases where the peritoneoscopic procedure was subsequently followed by laparotomy. Wittman,228 in a series of 393 examinations, found that the assumed diagnosis was changed in 56% of examinations. Simpler procedures, such as blind liver biopsy or peritoneal biopsy, might have clarified a number of these cases. Lindner229 found that liver biopsy under direct vision plus macroscopic inspection of the liver added important information in 21% of 236 cirrhotic patients and 11% of 71 patients with chronic hepatitis who had been subjected to blind percutaneous liver biopsy 1 to 2 days prior to the laparos(:opic procedure. Wittman 228 suspected. liver cancer on clinical grounds in 84 patients, but laparoscopy showed that cancer was present in only 34. In addition to the standard indications of jaundice, ascites, and hepatosplenomegaly, Fahrlander et al. 230 believe that laparoscopy is of definite value in the management of patients with acute abdomens. They describe their results in 160 emergency laparoscopies. Of the 89 patients who had suffered blunt trauma with no evidence of bleeding on needle aspiration of the peritoneum, 42 were found to have significant peritoneal bleeding which required surgical correction. One case of ruptured gallbladder was also diagnosed. There were 71 cases suspected of peritonitis. Eighteen of the 19 cases ultimately shown to have peritonitis were correctly diagnosed at laparoscopy. Five of 10 cases of pancreatitis and 5 of 7 cases of mesenteric infarction were also correctly identified. There were 7 unexpected cases of intraabdominal malignancy found and unnecessary surgery was avoided.

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Yamakawa 231 has reported results using an ultrasonic probe, SSD-U (Japan Radio Co., Ltd., Tokyo, Japan), which is inserted into the abdominal cavity under laparoscopic observation. The pattern of echoes recorded varie~, with the density of the tissues in the vicinity of the probe. The additive value of this technique to laparoscopy alone depends on its ability to detect abnormalities which are within organs and thus are not visible on the surface, such as tumor nodules in the liver or pancreas or gallstones. In 21 of 24 patients whose diagnosis was later surgically confirmed, laparoechoography made the correct diagnosis. Yamagata et a1. 232 described a new instrument to permit cholangiography under direct vision at laparoscopy without the hazard of the leakage of bile from the gallbladder. The instrument uses a suction technique to attach itself to the gallbladder wall and closes the opening made in the gallbladder with a clip at the end of the procedure. The authors were successful in 126 of 152 attempts at cholangiography. Postoperative complications included pain in 19%, fever in 28%, and 6 cases requiring immediate surgical intervention. Positive cytologic specimens were obtained from 13 of 30 malignant cases. Kuster et al. 233 believes that direct puncture of the gallbladder at laparoscopy and blind percutaneous transhepatic cholangiography are both dangerous procedures. They started with 46 patients who were candidates for the latter procedure. The diagnosis was established by laparoscopy alone in 16 cases. In the remaining cases, the percutaneous cholangiography was performed under direct vision. Under these conditions, the liver was separated from the abdominal wall so that respiratory motion was less likely to result in hepatic laceration. In 20 of 26 patients adequate filling of the biliary tract was obtained with four of the failures occurring in patients with parenchymal liver disease. There were no complications. In a few cases bile was seen to leak from the puncture site. This bile leakage

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was controlled by coagulation. Komibuchi et a1. 234 favored a slightly different approach which achieved a diagnostic accuracy over 90%. Initially, they attempted direct cholecystography and if this procedure failed, they performed percutaneous cholangiography under direct vision or direct vision needle liver biopsy. Endoscopic Photography The high quality of modem endoscopic photography is due to improved optical systems, increased fiber bundle clarity, and the replacement of tungsten filament lamps with fiberoptic light guides attached to more powerful external light sources. Details are provided in recent reviews of endoscopy photography by Boyce 235 and Colcher.236 The brightest light is provided by xenon arc lamps, such as are used in the Olympus CLX or CLS or Machida RX-500 power supplies. A mercury arc lamp, such as the General Electric Marc 300, used in the ACMI FCB-l002 power supply, provides somewhat less light at a greatly reduced cost. Halogen lamps are next in brightness and are found in the Olympus CLE or Machida RH-150 light sources. The least bright, but also the lightest and least expensive light sources, are provided by the use of tungsten projection bulbs, such as in the ACMI FCB-95 source. The more powerful light sources are not essential for visual examination but are needed for photography. Cinematography requires more light than still photography and the fiberscopes with small fiber bundles, such as duodenoscopes and bronchoscopes, require the brightest light sources for successful photography. Cinematography can be performed with the ACMI fiberscopes, using the Marc 300 lamp, quite successfully with a simple Kodak M-30 Super 8 Instamatic camera because of a fortuitous balance between the light requirements of the camera and the light provided by the power source. The highest quaEty cines require the use of single lens reflex cameras, such as the Beaulieu Super 8 or 16 mm or the Arriflex

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16-mm cameras because these instruments have built-in through the lens light meters to regulate exposure automatically. Sixteen-millimeter cameras are cumbersome and difficult to use, but are essential if the films are to be shown to a large audience. Some of the best endoscopic movies have been made by Holinger et al. 237 through rigid open-tipped endoscopes using an apparatus built for him over 20 years ago. Jackman 238 continues to use a similar instrument quite successfully for proctoscopic photography. A number of other optical systems have been devised to improve photography through opentipped endoscopes. 10. 239·241 Smith 242 has been quite successful in using a forwardviewing Menghini-Wildhurt peritoneoscope with electronic flash generator and a robot camera, (Storz Instrument Co., St. Louis, Mo.) for pharyngeal, rectal, upper esophageal, and vaginal photography. Almost all endoscopic systems make use of half-frame Olympus cameras for external photography. The light provided by standard power sources does not permit the projection of even a full half-frame image on the camera back. Although the average quality of still photographs taken by external cameras through the newer instruments is not as good as that obtained with the intragastric cameras, the difference is much less than it was in previous years. Extreme close-up photographs taken with the variable focus objective lenses of the Olympus models GIF or GFB-K fiherscopes provide better resolution than can be obtained with the fixed focus gastrocamera lenses.

Television Endoscopy A number of color television systems have been proposed for demonstrating endoscopy live to large audiences, including those of Ediphor (Ediphorag, Regensdorf, West Germany) , Toshiba 243 (Tokyo Shibaura Electric Co., Ltd., Tokyo, Japan), Commercial Electronics 244 (Commercial Electronics, Inc., Mountain View, Calif.), and Phillips 22 (Eindhoven,

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Holland). The cost of these systems for all but a few institutions has been prohibitive. In an effort to make television more practical, the newer systems have been designed so that the color television portion of the system can be used for a variety of teaching purposes within the institution and the television camera can be attached to a standard endoscope. The light requirements of television cameras are quite high and force the use of the xenon lamp light sources which further increases the cost of a television system. At this time it would appear that the combined use of still and cine photographs plus the use in the endoscopic clinic of teaching attachments would make any additional contribution television could make to teaching hardly defensible in view of its great cost.

Endoscopic Operative Procedures It is likely that in the very near future endoscopists will be routinely performing a wide variety of operative procedures through endoscopes. Tsuneoka et al. 245, 246 have developed, with the aid of Machida, some ingenious snares which can be passed through the biopsy channel of the fiberscope , can excise and then recover gastric polyps. They were able to remove 55 polyps in 49 patients. This procedure, as yet, is not widespread in Japan because of the fear of gastric bleeding following polypectomy. Deyhle et al. 247 described the removal of six polyps from the proximal colon using a snare cautery device passed through the biopsy channel of a colon fiberscope. They attached a neutral electrode to the thigh and then applied to the snare a high frequency AC voltage of 1 MH3 with a power rating of 40 to 80 w to produce the coagulation. Shinya and Wolff2 48 have removed 15 colonic polyps using a similar technique. The removal of polyps by these techniques would be facilitated if a biopsy fiberscope had two operative channels, so that the polyp could be held in a forceps while the snare was being tightened to reduce the danger of perforation. Chiba and Ishikawa 249 have described

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a simple technique for the removal of a bezoar. A loop of silk string was introduced into the stomach with a biopsy fiberscope in place. The loop was drawn over the bezoar using a biopsy forceps and then tightened. The fiberscope was removed and then the string was used to remove the bezoar, which measured 5.7 by 2.6 cm in size. Geduldig 250 has provided a simple solution to the problem created by failure of the gastric balloon of a Sengstaken or Patton tube to deflate. He passed a fiberesophagoscope alongside of the tube until the top of the balloon was visible and then punctured the balloon with a biopsy forceps. Rockman et al. 251 have described a simple technique for the dilation of tight esophageal strictures. The strictured area is visualized with a fiberesophagoscope, and then a wire guide, tipped with a 5F wire spring, is passed through the biopsy channel of the instrument through the stricture into the stomach. The endoscope is then removed, leaving the wire guide in place. Graduated Eder-Puestow metal olives (Eder) are then passed to dilate fibrous strictures or a Rider-Moeller pneumatic dilator (Eder) is positioned when the problem is achalasia. The authors were able to successfully dilate all peptic strictures in which this technique was attempted and have been able to position the pneumatic dilator in all patients with achalasia. Ugiie et a\.252. 253 have made use of a 120-cm flexible injection needle (Machida) which they passed through the biopsy channel of a fiberscope under direct vision . They injected various dyes into the gastric mucosa and found that when India ink was injected into the mucosa, a permanent mark was produced. An 18-month study on 10 patients showed that gastric mucosal folds do not change in shape or location. The marking technique was used by the endoscopist to indicate to the surgeon the extent of malignant lesions. The authors also made uncontrolled observations on the treatment of gastric ulcers and a gastric malig-

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nancy by direct injection of drugs into the margin of the lesions. Accidents In 1968, Katz 254 surveyed the members of the American Society for Gastrointestinal Endoscopy to determine how often they encountered endoscopic accidents. The flexible fiberscopes were not found to be safer than the older semiflexible lens gastroscopes-0.074% perforation compared to 0.05%. The fiberesophagoscopes were only slightly safer than the older instruments-0.093% perforation compared to 0.11%. Anselm et al. 255 have reported five perforations of anatomically normal esophaguses with the gastrocamera fiberscope. Factors leading to perforation were thought to be failure to control the instrument with a finger in the pharynx, excessive force, and poor patient cooperation. Anselm et al. 255 favored the standard left lateral position for instrument passage. This author believes that the sitting position is safer because the patient can respond more easily to painful pressure. Reports of impaction of fiberscopes in the esophagus continue to be made. 25 6· 258 Kavin and Schneider 258 removed an impacted fiberscope in the looped position without injury to the patient. A safer technique was used by Parker 257 who passed a Jackson esophagoscope along side the fiberscope and forced the impacted tip back into the stomach. Burke and Roling259 provide X-ray evidence to suggest that impaction is less likely to occur when the fundus is examined with the patient lying on his back, rather than on his left side, because the tip tends to stay farther away from the gastroesophageal junction. The new ACMI Model 7089-J forwardviewing fiberscope can be easily looped within the esophagus because of its 180 0 tip deflection. As yet, serious complications have not been reported with this instrument. If injury is suspected, early X-ray diagnosis with water-soluble contrast material is advised. 260 Fiberscopic injuries often result in large esophageal tears which are

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best treated by immediate surgical intervention. 261. 262 Slaughter and Boyce 26 3 described 3 cases of unexplained bilateral submaxillary salivary gland swelling following endoscopy. Rastogi and Brown 26 4 reported a case of what clinically appeared to be a surgical abdomen following endoscopy, but at laparotomy was found to be simple distention of the small bowel with air. The new instruments with their powered air supplies have a capacity to introduce large volumes of air during endoscopy. Although there have been no reports of perforation due to overdistention with air, an endoscopist must be alert to this hazard. Unrecognized painful distention of the body of the stomach with air can easily occur during attempts to distend the pyloroduodenal area. Fortunately, the suction channel of the instrument can provide the patient with immediate relief. Patients during upper gastrointestinal endoscopy265, 266 and during proctoscopy267 had their electrocardiograms continuously monitored. Only minor electrocardiographic changes were noted, confirming Schuman's268 earlier study. This author has encountered one fatal myocardial infarction in an 80-year-old woman immediately following endoscopy, and a cardiac arrest during operative choledochoscopy has been described. 269 Vilardell et al. 270 have reviewed the complications associated with their 1455 laparoscopic examinations. There were 18 complications and two deaths. The authors believed that the incidence of complications could have been reduced by improved techniques. Subcutaneous emphysema, hepatic coma, and hemorrhage were the most frequent complications. Frangenheim 271 has reviewed the complications of gynecologic laparoscopy with similar findings.

Endoscopic Training When the gastrocamera came into general use in Japan, a massive program of postgraduate training involving 110 centers was organized, which succeeded in training more than 10,000 physicians in

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this endoscopic technique. The development of the new forward-viewing panendoscopes has created a similar need in this country for a massive educational program. The latest listing of Postgraduate Courses by the American Medical Association showed only one course devoted to gastrointestinal endoscopy. This is a 2week course given at the University of Wisconsin which takes one student at a time and gives preference to trained endoscopists. The 20 students taken each year represent only a tiny fraction of the physicians who are in need ofpostgraduate training in this field. The only alternative is to visit one of the major endoscopic centers in Japan. Formal courses are not offered, but more patients are examined in many of these institutions in 1 day than would be seen in a month in the average American clinic. Several new textbooks of value to end oscopists have been published recently. 272·278 Ashizawa and Kidokoro 's book 276 provides the most comprehensive aid to endoscopic diagnosis by including 936 high quality color reproductions. Umeda and Yoshitoshi 278 provide a very brief text on endoscopy which is illustrated by a set of 45 color transparencies. In recent years, the Japanese endoscopic journals, Gastroenterological Endoscopy 279 and Stomach and Intestine,280 have become more useful for English-speaking readers. Many of the articles have English labels for charts and illustrations and most articles are accompanied by English summaries . The articles, particularly in Stomach and Intestine, are profusely illustrated in color. The new German journal, Endoscopy281 is not limited to gastrointestinal endoscopy but, I think unwisely, also includes articles of interest to urologists and gynecologists. This journal has published a number of excellent presentations in English of Japanese work. The cost of color reproduction in the United States has been so high that the American endoscopic journal, Gastrointestinal Endoscopy,282 has been almost completely limited to black and white

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illustrations. Teaching of endoscopic interpretation, which should be an important function of an endoscopic journal, is very difficult without color reproduction of high quality. It is hoped that the American Society for Gastr~ntestinal Endoscopy can provide the leadership necessary for improving postgraduate education in the field of endoscopy in the future. REFERENCES 1. Dagradi AE, Stempien SJ: In memoriam-

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13. Bautista A, DeLuca VA: Endoscopic photography, biopsy and cytology of the esophagus and stomach with the Olympus fiberesophagoscope. Gastroenterology 60:294-298, 1971 14. Morrissey JF, Koizumi H, Rockman SE, et al: Clinical use of the Olympus fiberesophagoscope. Gastrointest Endosc 16:207-209, 1970 15. Sullivan BH: Fiberoptic esophagoscopic examination of the cardia and upper stomach. Am J Gastroenterol 54:44-48, 1970 16. LoPresti PA, Cifarelli PS, Dixit N, et al: Successful examination of the esophagus and stomach with a new fiberoptic instrument. Gastrointest Endosc 17: 103-104, 1971 17. LoPresti PA, Cifarelli PS, Dixit N: A new fiberoptic esophagogastroscope. Am J Dig Dis 16:31-37, 1971 18. Belber JP: Endoscopic examination of the duodenal bulb: a comparison with X-ray. Gastroenterology 61:55-61, 1971 19. Morrissey JF: Fiberscopic examination of the duodenum. Proceedings of the Second Congress of the International Society of Endoscopy, Copenhagen, 1970 (in press) 20. Suzaki T, Miyake T, Yamamoto Y: Microgastrofiberscope-a new device in diagnoses of gastric cancer based on dissecting microscope findings. Jap Arch Intern Med 17:27-39, 1970 21. Tasaka S, Sakita T: Progress of gastrocamera examination. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 70-77 22. Ashizawa S, Oshima H: Gastrocamera type 5A. Z Gastroenterol 5:142-148, 1967 23. Oshima H: Intragastric Photography with the Gastrocamera. Dtsch Med J 21:585-594, 1970 24. Morrissey JF, Tanaka Y, Thorsen WB: The relative value of the Olympus model GT-5 gastrocamera and Olympus model GTF gastrocamera fiberscope. Gastrointest Endosc 14:197200, 1968 25. Rahbek AL, Pedersen AB: Gastrocamera fiberscope. Ugeskr Laeger 131:1881-1887, 1969 26. Ishihara K, Kidokoro I: Comparison of gastrocamera and gastrofiberscope for detection and diagnosis of the early gastric cancer. Abstracts of the 10th Annual Meeting of Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 54-56 27. Hara Y, Tobita Y, Watanabe M: Clinical use of gastrocamera with fiberscope (GTF) for detection of gastric and hepatic pathologies. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 206-207 28. Schuman BM: The American way of death for the GT-V. Gastrointest Endosc 17:66, 1970 29. Schuman BM, Carandang N, Priest RJ: The gastrocamera as a diagnostic tool for geriatric patients. J Am Geriatr Soc 16:1095-1099, 1968

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30. Rahbek, AL: Gastrocamera. Ugeskr Laeger 129: 1-5, 1967 31. Rahbek AL, Brummer S, Mosbech J: A comparison of x-ray and gastrocamera for gastric diagnosis. Ugeskr Laeger 129:685-688, 1967 32. Morrissey JF, Honda T, Hara Y, et al: The use of the gastrocamera for the diagnosis of gastric ulcer. Gastroenterology 48:711, 1965 33. Morrissey JF, Honda T, Tanaka Y, et al: Gastric mucosal coating and gastric emptying time of antacids. A gastrocamera study. Arch Intern Med 119:510-517, 1967 34. Thorsen WB, Western D, Morrissey JF, et al: Aspirin injury to the gastric mucosa. Gastrocamera observations of the effect of pH. Arch Intern Med 121:499-506, 1968 35. Morrissey JF, Tanaka Y, Thorsen WB: Gastroscopy: a review of the English and Japanese literature. Gastroenterology 53:456-476, 1967 36. Oka S, Sugiura M: Polarized light gastrocamera. Gastroenterological Endosc (Tokyo) 10:224-231, 1968 37. Cockel R, Hawkins CF: Gastroscopy and gastric photography with the Olympus GTF-A. Gut 11:176-181, 1970 38. Morrissey JF, Koizumi H: The endoscopic diagnosis of gastric cancer, Sixth National Cancer Conference Proceedings. Philadelphia, Lippincott, 1970, p 433-437 39. Tasaka S, Oguro Y: Fundamental studies on the optimum photographic conditions of the gastrofiberscopic and gastrocamera examinations. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 320-327 40. Hayashi T, Honda T, Ariga K, et al: Diagnosis of lesions of the lesser curvature below the cardia by reverse U-turn method with the fiberscope. Endoscopy 1:41-44, 1970 41. Paragas PD, Thorsen WB Jr, Morrissey JF, et al: Pyloiic visualization with the Olympus gastrocamera GT-5A and gastrocamera fiberscope GT-FA. Gastrointest Endosc 15:145-148, 1969 42. Goldstein H: Interobserver variation in gastroscopy. Gastrointest Endosc 15:156-159, 1969 4:l. Kato Y: Analysis on the diagnosis of the surgical gastric diseases by gastrocamera. Gastroenterological Endosc (Tokyo) 8:293-323, 1966 44. Brom B, Bank S, Marks N, et al: Fibre-optic gastroscopy: a review of 200 consecutive cases. S Afr Med J 43:1549-1553, 1969 45. Morrissey JF: The effect of upper gastrointestinal endoscopy on patient management. Gastroenterology 58: 1073, 1968 46. Yamakawa K, Naito S, Kanai T, et al: Superficial staining of gastric lesions by fiber gastroscope. Proceedings of the First Congress of the

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International Society of Endoscopy, Tokyo, 1966, p 586-590 Tsuda Y: A study in the diagnosis of gastric lesions using the fibergastroscope combined with a new staining process. Gastroenterological Endosc (Tokyo) 9:189-195, 1967 Aoki S, Kitamura K: Endoscopic study on gastric ulcer and scar with dye staining method. Gastroenterological Endosc (Tokyo) 10:202217, 1968 Okuda S, Saegusa T, Ito T, et al: An endoscopic method to investigate the gastric acid secretion. Annu Rep Center Adult Dis 7:46-52, 1967 Ottenjann R, Peters H, Fister K: Finding the boundary between the corpus and antrum by gastroscopy. Klin Wochenschr 45:1006-1028, 1967 Laing RR, Dunn D, Klotz AP: Crohn's disease of the stomach. Gastrointest Endosc 16:168172, 1970 Schuster MM, Smith VM: The pyloric "cervix sign" in adult hypertrophic pyloric stenosis. Gastrointest Endosc 16:210-211, 1970 Mulero HL, Carvalho HP, Knechtges TC: Jejunogastric intussusception: an infrequently recognized cause of postgastrectomy symptoms. Am J Dig Dis 12:639-645, 1967 McBee JW, North LB: Antral mucosal diaphragm in the adult. Gastrointest Endosc 16: 196-200, 1970 Smith V, Tuttle KW: Gastroduodenal (pyloric) band. Gastroenterology 56:331-336, 1969 Inuie J, Sakita T, Tomoyanaki S, et al: A case of suspected early syphilis. Gastroenterological Endosc (Tokyo) 11:384-386, 1969 Dagradi AE, Broderick JT, Juler G, et al: The Mallory-Weiss syndrome and lesion. Am J Dig Dis 11:710-722, 1966 Gabrielsson N: Growth of yeast-like fungi in the stomach. Endoscopy 2:66-73, 1971 Peterhoff R, Schonbeck J: Roentgen and gastrophotographic features of intraluminal gastric mycosis. Scand J Gastroenterol 2:301-304, 1967 Mizuoka S, Iwata S: Gastroscopic studies on gastric xanthoma. Gastroenterological Endosc (Tokyo) 8:283-297, 1966 Stalder GA: Malignant melanoma of the stomach. Gastrointest Endosc 16:30-32, 1969 Rajan RK, Goodman S, Floch MH: Gastroscopic findings in Kaposi's sarcoma. Gastrointest Endosc 16:104-106, 1969 Rivera RA: Endoscopic findings in gastroduodenal amyloidosis. Gastrointest Endosc 17: 137-144, 1971 Kishi S, Ishikawa H, Ichi S, et al: A case of eosinophilic granuloma simulating Type I early gastric cancer. Stomach Intestine (Tokyo) 5: 1493-1497, 1970 Nagasue N, Araki S, Ono M: A case of eosin-

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ophilic granuloma of the stomach. Stomach Intestine (Tokyo) 5:1499-1503, 1970 Toma H, Arai M, Ro K, et al: A case of gastric lipomatosis. Stomach Intestine (Tokyo) 6:65-70, 1971 Lukash WM, Johnson &8, Bishop RP: Aberrant pancreas in the stomach-Radiographic and gastroscopic findings. Gastrointest Endosc 16: 148-150, 1970 Nagayo T, Yokoyama H, Komagoe K, et al: Histopathological findings of the aberrant pancreas in the gastric wall. Stomach Intestine (Tokyo) 5:1423-1428, 1970 Hirase S, Yamada R, Mori S: A case of Type II-C early gastric cancer presumably arising out of aberrant pancreas tissues. Stomach Intestine (Tokyo) 5:1405-1410, 1970 Yao T, Watanabe H, Okada Y, et al: A case of carcinoid of the stomach. Stomach Intestine (Tokyo) 5:1247-1254, 1970 Fujimura K, Takahashi J, Dchimura M, et al: A case of gastric lipoma. Stomach I~testine (Tokyo) 5: 1265-1270, 1970 Das BC, Laing RR, Dunn GD, et al: Endoscopic findings in gastric leiomyomas. Gastrointest Endosc 16: 152-155, 1970 Takesawa H, Sakita T, Tomoyanagi S, et al: Endoscopic findings of gastric varices. Gastroenterological Endosc (Tokyo) 11:379-383, 1969 Akakoshi G, Takahashi M, Kawanami T, et al: A case of typical gastric varices. Stomach Intestine (Tokyo) 5:665-669, 1970 Namiki M, Moroka T, Kawauchi H, et al: The diagnosis of acute gastric anisakis. Stomach Intestine (Tokyo) 5:1437-1441, 1970 Trujillo NP, Slaughter, Boyce HW: Endoscopic diagnosis of sliding type diaphragmatic hiatus hernia. Am J Dig Dis 13:855-868, 1968 Schacter H, Kobayashi S: The gastroscopic retroflexion method in the diagnosis of sliding esophageal hiatus hernia. Gastrointest Endosc 17:78-80, 1970 Roling GT, Burke EL, Castell DO, et al: The esophago-gastric junction as evaluated by gastroscopy, esophageal manometry and roentgenography (abstr). Gastroenterology 60: 827, 1971 Slaughter RL, Grayer DI: Endoscopic identification of the esophagogastric mucosal junction. Gastroenterology 60:830, 1971 Nabeya K: Early carcinoma of esophagus. Stomach Intestine (Tokyo) 5:1205-1213, 1970 Endo M, Kobayashi S, Nakayama K, et al: Diagnosis of early esophageal cancer. Endoscopy 2:61-63, 1971 Sakita T, Miwa T, Yoshimori M, et al: A case of esophageal cancer showing an interesting course. Stomach Intestine (Tokyo) 5:659-663, 1970

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83. Chavy A, Vasselin M, Famvet J, et al: Tracheobronchoscopy in 700 patients with cancer of the esophagus. Bronches 17:320-325, 1968 84. Conn HO: The prognoses and management of bleeding esophageal varices. Ann NY Acad Sci 170:345-357, 1970 85. Palmer ED: Endoscopic contributions to the understandings of portal hypertension. Ann NY Acad Sci 170: 164-176, 1970 86. Dagradi AE: In defense of the flexi-rigid (opentube) esophagoscope. Gastrointest Endosc 17: 101-102, 1971 87. Zimmon DS, Tesler MA: A controlled comparison of rigid and fiber optic esophagoscopy. Gastrointest Endosc 14:220-221, 1968 88. Conn HO, Binder H, Brodoff M: Fiberoptic and conventional esophagoscopy in the diagnosis of esophageal varices. A comparison of techniques and observers. Gastroenterology 52:810-818, 1967 89. Kasugai T, Ito E, Tsubouchi M, et al: Gastric biopsy under direct vision. Stomach Intestine (Tokyo) 3:1211-1226, 1968 90. Ishioka K, Deno K, Yamagata S, et al: Direct vision biopsy and cytologic diagnosis. Stomach Intestine (Tokyo) 5:829-836, 1970 91. Niwa H: Re-evaluation of direct-vision biopsy: Abstracts of the 10th Annual Meeting of the Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 67-71 92. Sakita T, Oguro Y, T~kasu S, et al: Observations on the healing of ulcerations in early gastric cancer. The life cycle of the malignant ulcer. Gastroenterology 60:835-844, 1971 93. Kasugai T: Gastric biopsy under direct vision by the fibergastroscope. Gastrointest Endosc 15:33-39, 1968 94. Yamakawa T, Panish J, Berci G, et al: The correlation of target biopsy and contact smear cytology under direct visual control in malignant gastric lesions. Gastrointest Endosc 14:164-168, 1971 95. Yamakawa T: Biopsy and touch smear cytology. Gastroenterological Endosc (Tokyo) 11:4-31, 1969 96. Yoshii Y, Takahashi J, Kasugai T, et al: Significance of imprint smear in cytologic diagnosis of malignant tumors of the stomach. Acta Cytol (Baltimore) 4:249-253, 1970 97. Weiss JB, Gand MJ, McCray RS, et al: Direct vision gastric biopsy using the Machida FGS-B gastroscope. Gastrointest Endosc 17:23-27, 1970 98. Williams DG, Truelove SC, Gear MW, et al: Gastroscopy with biopsy and cytological sampling under direct vision. Br Med J 1:535-539, 1968 99. Berci G, Pan ish J: The importance of permanent film records of endoscopic procedures in the GI

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tract with special reference to a new endo zoom R system (abstr). Gastroenterology 60:812, 1971 Kasugai T: Gastric lavage cytology and biopsy for early gastric cancer under direct vision by the fibergastroscope. Gastrointest Endosc 14: 205-208, 1968 Kasugai T: Evaluation of gastric lavage cytology under direct vision by fibergastroscope employing Hanks solution as a washing solution. Acta Cytol (Baltimore) 12:345-352, 1968 Kobayashi S, Tatsuzo T, Yamaoka Y, et al: Improved technique for gastric cytology utilizing simultaneous lavage and fibergastroscopy . Gastrointest Endosc 15:198- 200, 1969 Kobayashi S, Prolla JC, Kirsner JB, et al: Improved endoscopic diagnosis of gastroesophageal malignancy. Combined use of direct vision cytology and biopsy. JAMA 212:20862090, 1970 Witte S: Gastroscopic cytology. Endoscopy 2: 88-92, 1970 Kidokoro T, Soma S, Yamakawa T , et al: Direct vision diagnosis with special reference to cytodiagnosis. Abstracts of the 10th Annual Meeting of the Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 87-93 Humphreys EA, Wolff RA, Mlecko LM: "Scrape" cytology of the esophagus and stomach. Gastrointest Endosc 14:160-161, 1968 Goldstein MJ, Fennessy JJ: Esophageal biopsy using a flexible brush. Gastrointest Endosc 15: 53-55, 1968 Cohen NN, Flowers W: Diagnosis of stenosing lesions of the esophagus using brush cytology. Gastrointest Endosc 15:213-214, 1969 Mlecko LM : Hematemesis associated with " scrape" cytology. Gastrointest Endosc 15:110111, 1968 Schuman B: Does gastroscopic diagnosis need direct vision brushing cytology? Gastrointest Endosc 17:182, 1971 Prolla JC: Kobayashi S, Kirsner JB: Gastric cancer. Some recent improvements in diagnosis based on the Japanese experience. Arch Intern Med 124:238-246, 1969. Kawai K: Diagnosis of early gastric cancer. Endoscopy 1:23-27, 1971 Fukutomi H, Takesawa H : Endoscopic diagnosis of gastric carcinoma less than 1 cm. in diameter. Stomach Intestine (Tokyo) 5:961- 970, 1970 Nishizawa M, Ito T , Nomoto K, et al: The x-ray demonstrability of microcarcinoma. Stomach Intestine (Tokyo) 5:951- 959, 1970 Shirakabe H, Kodokoro T, Takagi K: Statistical figures on very small gastric carcinoma under 1 cm. in diameter preoperatively diagnosed in Japan. Stomach Intestine (Tokyo) 5:995-998, 1970 Kobayashi S, Prolla JC, Yagi M, Kasugai T:

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Gastroscopic diagnoses of early gastric carcinoma based on Japanese classification. Gastrointest Endosc 15:92-97, 1969 Wiendl HJ, Piger A, Becker G: Early gastric cancer diagnosed with gastrocamera fiberscope. Fortschr Med 28:637-642, 1970 Rosch W: Early carcinoma. Endoscopy 1:64-66, 1970 Hayashida T , Kidokoro T: End results in early gastric carcinoma. Abstracts of the Fourth World Congress of Gastroenterology, Copenhagen, 197(" p 279 Kasugai T : Prognosis of early gastric cancer. Gastroenterology 58:429-430, 1970 Okabe H, Hirokado K: The computer analysis of gastrocamera signs of the depressed type of gastric surface cancer. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 354-362 Nelson RS, Lanza FL: Endoscopy in the diagnoses of gastric lymphoma and sarcoma. Gastroin test Endosc 15:210, 1969 Kasugai T, Kato H, Tsubouchi M, et al: Sarcoma of the stomach with special reference to its endoscopic diagnosis. Stomach Intestine (Tokyo) 5:287- 299, 1970 Rosch W, Hartwich G, Ottenjann R, et al : Gastric lymphoma. Endoscopy 1:28-33, 1971 Dunn GD, Moeller D, Laing RR: Primary reticulum cell sarcoma of the stomach. Gastrointest Endosc 17:153-158, 1971 Eras P, Winawer SJ: Benign lymphoid hyperplasia of the stomach simulating gastric malignancy. Am J Dig Dis 14:510-546, 1969 Doi K, Kudo T , Sasaki K, et al : A case of Iymphoreticular hyperplasia simulating early gastric cancer. Stomach Intestine (Tokyo) 6: 589- 594, 1971 Yoshimura M, Shimada K, Isogawa H, et al: Some observations on gastric polyp. Stomach Intestine (Tokyo) 5: 1559-1563, 1970 Ariga K, Honda T, Koizumi H: Studies on the endoscopic findings of gastric polyp. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 314-350 Uematsu T , Takekoshi T, Masuda M, et al: Long term observation of polypoid lesions by endoscopic examinations. Gastroenterological Endosc (Tokyo) 10:218-223, 1968 Fujita K, Niwa H, Sakita T, et al: Mass survey of the stomach with the gastrocamera. Stomach Intestine (Tokyo) 6:705-712, 1971 Iwasaki M: Nationwide tabulation of results in gastric mass survey. Stomach Intestine (Tokyo) 6:745-750, 1971 Hanik L, Gregor 0: Atrophic gastritis in pernicious anemia as possible gastric cancer precursor. Abstracts of the Fourth World Congress of Gastroenterology, Copenhagen, 1970 p 262

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134. Fujino M, Kaneko E: On recurrence of gastric ulcer. Stomach Intestine (Tokyo) 5:1639-1643, 1970 135. Hara Y: Of recurrence rate of gastric ulcer and its moments. Stomach Intestine (Tokyo) 5: 1619-1626, 1970 136. Nakamura K, Kawamula S, Shiraishi T, et al: Studies on the clinical course of the gastric ulcer: IV gastroendoscopic and histologic findings of the healed ulcers. Tenth Annual Meeting of the Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 143-145 137. Kobayashi S, Prolla JC, Kirsner JB: Late gastric carcinoma developing after surgery for benign conditions. Am J Dig Dis 15:905-912, 1970 138. MacDonald WC, Rubin CE: Gastric biopsya critical evaluation. Gastroenterology 53:143170, 1967 139. Heinkel K: Correlation of gastroscopy, gasttic photography and biopsy in diagnoses. Gastrointest Endosc 16:81-85, 1969 140. Muto F, Honda T, Ariga K: A study on the endoscopic diagnosis of chronic gastritis with special reference to gastric biopsy and longterm follow-up. Gastroenterological Endosc (Tokyo) 9:1-23, 1967 141. Kidokoro T, Takezoye K, Yamakawa T, et al: Reevaluation of visible vessels in gastrocamera pictures of chronic gastritis. Abstracts of the 5th Annual Meeting Japan Gastroenterological Endoscopy Society, Kyoto, 1963 142. Yamada K, Suzuki S, Takemoto T: Reevaluation of various forms of gastritis by controlled intragastric pressure simultaneously visualized via gastroscope. Gastrointest Endosc (in press) 143. Kimura K, Takemoto T: Biopsy in chronic gastritis. Stomach Intestine (Tokyo) 5:843-851, 1970 144. Ottenjann R, Kanzler G, Bartelheimer W, et al: Stepwise gastroscopic biopsy along the greater curvature. Endoscopy 1:38-40, 1971 145. Palmer E: What Menetrier really said. Gastrointest Endosc 15:83-91, 1968 146. Krone CL, Gelfand MD: Gastritis presenting as multiple polyposis of the stomach. Gastroenterology 57:703-708, 1969 147. Roesch W, Ottenjann R: Gastric erosions. Endoscopy 2:93-98, 1970 148. Dagradi AE, Stempien SJ, Lee ER, et al: Hemorrhagic-erosive gastritis. Gastrointest Endosc 14:147-150,1968 149. Tani K, Okabe H, Hirokado K, et al: Endoscopic follow-up study on erosive gastritis. Abstracts of the 10th Annual Meeting of Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 114-115 150. Ludwig WM, Eras P, Winawer SJ: Presto mal

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hemorrhagic gastritis as a cause of postgastrecto my bleeding. Gastrointest Endosc 15:208-210, 1969 Oshiba S: Upon fundamental and clinical experiment with newly devised duodenal fiberscope. Sixth Annual Meeting of the Japan Gastroenterological Endoscopy Society, Sendai, 1964, p 70-71 Rider JA, Puletti EJ, Moeller HC: The fiber duodenoscope: a preliminary report. Am J Gastroenterol 47:21-27, 1967 Takagi T, Go T, Sugiura M, et al: Fiberoptic duodenoscopy. Surgery 65:597-602, 1969 Shindo S, Kanke K, Yanagisawa F: Duodenofiberscopy. Gastroenterological Endosc (Tokyo) 12:70-82, 1970 Ravinov KR, Simon M: Peroral cannulation of the ampulla of Vater for direct cholangiography and pancreatography. Radiology 85:693-697, 1965 McCune WS, Shorb PE, Moscovitz H: Endoscopic cannulation of the ampula of Vater: a preliminary report. Ann Surg 107:752-756,1968 Soma S, Fujita R, Kodokoro T: Clinical application of a duodenal fiberscope. Gastroenterological Endosc (Tokyo) 12:97-110, 1970 Kozu T, Oi I, Suzuki S, et al: Fiberduodenoscopic observation on the dynamics of the duodenal papilla. Endoscopy 2:99-102, 1970 Oi I, Yamagata S, Tseuneoka K, et al: Clinical use of a fiberduodenoscope. Gastroenterological Endosc (Tokyo) 11:272-280, 1968 Oi I: Fiberduodenoscopy and endoscopic pancreatocholangiography. Gastrointest Endosc 17:59-62, 1970 Oi I, Kobayashi S, Kondo T: Endoscopic pancreatocholangiogra phy. Endoscopy 2: 103-106, 1970 Takagi K, Ikeda S, Nakagawa Y, et al: Retrograde pancreatography and cholangiography by fiber duodenoscope. Gastroenterology 59:445452, 1970 Takagi K, Ikeda S, Nakagawa Y: Endoscopic cannulation of the ampulla of Vater. Endoscopy 2:107-115, 1970 Takagi K, Ikeda H, Nagakawa Y, et al: Study of duodenal fiberoscopy III: retrograde pancreatography and cholangiography. Stomach Intestine (Tokyo) 5: 103-111, 1970 Takagi K, Ikeda S, Kumakura K: Study on duodenofiberscope. IV. Retrograde cholangiography. Stomach Intestine (Tokyo) 6:85-90, 1971 Ogoshi K, Tobita Y, Hara Y: Endoscopic observation of the duodenum and pane rea tocholedography using duodenal fiberscope under direct vision. Gastroenterological Endosc (Tokyo) 12:83-96, 1970

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167. Kasugai T, Kuno N, Kobayashi S, et al: Pancreato-cholangiography under fiberduodenoscopy. Gastroenterology 60:818, 1971 168. Classen M: Fibre-endoscopy of the intestines. Gut 12:330-338, 1971 169. Mori K: Insertion of the duodenofiberscopeobservation of the descending portion. Gastroenterological Endosc (Tokyo) 12:197-199, 1970 170. Belber JP: Intraduodenal cimematography in normal and pathologic duodenal bulbs. Gastrointest Endosc 15:160-161, 1969 171. Belber JP: Endoscopic examination of the duodenal bulb: a comparison with X-ray. Gastroenterology 61 :55-u1, 1971 172. Morrissey JF: Fiberscopic examination of the duodenum. Proceedings of the Second Congress of the International Society of Endoscopy, Copenhagen, 1970 (in press) 173. Cavallaro JB, McCray RS: Duodenoscopy: initial experience with 135 examinations. Gastroenterology 60:813, 1971 174. Yamakishi K, Yamagata S: Endoscopic examination of the duodenum. Gastroenterological Endosc (Tokyo) 12:195-197, 1970 175. Palmer ED: The vigorous diagnostic approach to upper gastrointestinal tract hemorrhage. JAMA 207:1477-1480, 1969 176. Palmer ED: Upper gastrointestinal hemorrhage. Springfield, Charles C Thomas, 1970 177. Dagradi AE, Stempien SJ: Esophagogastroscopy during active upper gastrointestinal bleeding. Am J Gastroenterol 51:498-502, 1969 178. Conn HO, Simpson JA: A rational program for the diagnoses and treatment of bleeding esophageal varices. Med Clin North Am 52:14571474, 1968 179. Housset P, Delluc G, Debray C: Indications and results In emergency esophagogastroscopy. Actual Hepatogastroenterol 5:A315-A322, 1969 180. Laurijssens MJ: Diagnostic approach to upper gastrointestinal bleeding using early fiberscopy. T Gastroent 12:392-398, 1970 181. Schiller KF, Truelove SC, Williams DG : Haematemesis and melaena with special reference to factors influencing the outcome. Br Med J 2: 7- 14, 1970 182. Gabriel JB, Monaco F, Dubowy J : Early diagnoses in upper gastrointestinal bleeding utilizing a water-soluble radiopaque medium . Am J Gastroenterol 49:255-262, 1968 183. McCray RS, Martin F, Amir-Ahmadi H, et al: Erroneous diagnoses of hemorrhage from esophageal varices. Am J Dig Dis 14:755-760, 1969 184. Baum S, Nusbaum M, Clearfield HR, et al: Angiography in the diagnosis of gastrointestinal bleeding. Arch Intern Med 119:16-24, 1967 185. Kanter IE, Schwartz AJ, Fleming RJ : Localization of bleeding point in chronic and acute

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gastrointestinal hemorrhage by means of selective visceral arteriography. Am J Roentgenol lO3:386-399, 1968 186. Matsunaga F, Yamaguchi T , Tanaka M, et al: Sigmoidocamera and cavocamera. Gastroenterological Endoscopy (Tokyo) 5:105-lO6, 1963 187. Matsunaga F, Yamaguchi T, Tanaka M: Study of colon photography. Gastroenterological Endosc (Tokyo) 7:37, 1965 188. Yamaguchi T , Matsunaga F: Studies on photographing the colonic membrane. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 398-403 189. Oshiba S, Watanabe A: Endoscopy of colon . Gastroenterological Endosc (Tokyo) 7:400-402, 1965 190. Yamagata S, Oshiba S, Watanabe H: New fiberendoscope and its application to the colonic diseases. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 431-433 191. Nagasaka T, Yamagata S, Miura S, et al : Description of fiber colonoscope VII. Gastroenterological Endosc (Tokyo) 12:218- 220, 1970 192. Niwa H: Endoscopy of colon. Gastroenterological Endosc (Tokyo) 7:402-408, 1965 193. Niwa H, Utsumi Y, Nakamura T : Endoscopy of the colon. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 425-430 194. Kanazawa T, Tanaka M: Endoscopy of colon. Gastroenterological Endosc (Tokyo) 7:398-400, 1965 195. Yamaguchi T , Kanazawa T : Present and future of endoscopy. Gastroenterological Endosc (Tokyo) 8:31-33, 1966 196. Overholt BF: Clinical experience with the fibersigmoidoscope. Gastrointest Endosc 15: 27, 1968 197. Overholt BF: Description and experiences with flexible fibersigmoidoscopes, Sixth National Cancer Conference Proceedings. Philadelphia, Lippincott, 1970, p 443-446 198. Dean AC, Shearman DJ: Clinical evaluation of a new fibreoptic colonoscope. Lancet 1:550552, 1970 199. Overholt BF : Technic of flexible fibersigmoidos copy. South Med J 63:787-789, 1970 200. Provenzale L, Revignas A: An original method for guided intubation of the colon. Gastrointest Endosc 16:11-17, 1969 201. Hiratsuka S : Technique for insertion of colon fiberscope by means of intestinal guide string. Gastroenterological Endosc (Tokyo) 12:209-211, 1970 202. Niwa H: Technique for use of colon fiberscope. Gastroenterological Endosc (Tokyo) 12:203222, 1970

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203. Matsunaga F: Clinical use of colon fiberscope. Proceedings of the Second Congress of the International Society of Endoscopy, Copenhagen, 1970 (in press) 204. Tajima T, Doda S: Technique of use of colonofiberscope. Stomach In~tstine (Tokyo) 5:14291436, 1970 205. Nagasako K, Endo M, Takemoto T: The insertion of fibercolonoscope into the cecum and the direct observation of the ileocecal valve. Endoscopy 2:123-126, 1970 206. Nagasako K, Yazawa C, Takemoto T : Observation of the terminal ileum. Endoscopy 1:45-51, 1971 207. Shinya H , Wolff W, Geffen A: Colonofiberoscopy-a new and valuable diagnostic modality. Gastroenterology 60:828, 1971 208. Overholt BF, Coli mann R, Laing WG: Fibersigmoidoscopy: clinical value. Gastroenterology 60:826, 1971 209. McIver MA: An instrument for visualizing the interior of the common du ct at operation. Surgery 9:112-114, 1941 210. Wildegans H: The Operative Cholangioscopy. Munich, Urban and Schwartenberg, 1960 21 1. Shore JM, Lippman HN : A flexible choledochoscope. Lancet 1:1200-1201, 1965 212 . Takagi T, Go T, Takayasu H , et al: Small caliber fiberscope for visualization of the urinary tract, biliary tract and spinal cord. Surgery 64: 1033- 1038, 1968 213. Nishimura A, Otsubo Y, Den N, et al: Endoscopic method of exam of biliary and pancreatic ducts. Stomach Intestine (Tokyo) 5:1271-1278, 1970 214. Nishimura A, Otsubo Y, Den N., et al : Endoscopic examinations of the biliary and pancreatic duct. Sixth report: a study on the development of a fiberoptic choledochoscope with the irrigation tube. Stomach Intestine (Tokyo) 6:485-492, 1971 215. Schein CJ: Biliary endoscopy: an appraisal of its value in biliary lithiasis. Surgery 65:10041006, 1969 216. Shore ,JM, Shore E : Operative biliary endoscopy : experience with the flexible choledochoscope III 100 consecutive choledocholithotomies. Ann Surg 171 :269- 278, 1970 217. Shore JM, Berci G: The clinical importance of cholangioscopy. Endoscopy 2:117-120, 1970 218. Harris JW, McQuarrie HG, Ellsworth HS, et al: The yield from pelvic endoscopy: comparison of culdoscopy and laparoscopy. JAMA 215:11171121, 1971 219. Lindner H: Advances in laparoscopy. Endoscopy 1:1-9, 1969 220. Yamagata S, Miura K, Takahashi 0, et al: On

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the new laparoscopes with external cold light source. Abstracts of the 10th Annual Meeting of the Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 216-217 Boyce W Jr, Bishop D: Polaroid endophotography. Gastrointest Endosc 14:186-189, 1968 Lindner H, Fintelman V: Peritoneoscopic phottographic documentations in the present and the future. Proceedings of the Second Congress International Society of Endoscopy, Copenhagen, 1970 (in press) Smith VM: Peritoneoscope cinematography. Am J Gastroenterol 44:28-34, 1966 Smith VM : Clinical peritoneoscopy. Am J Gastroenterol 42: 13-22, 1964 Palmer ED: Peritoneoscopic technic. Gastrointest Endosc 13:105-106, 1967 Wittman I: Peritoneoscopy, vol 1. Budapest, Akademiai Kiado, 1966, p 21-31 Semm K : Instrumentation for gynecologic pelviscopy. Endoscopy 1:36- 42, 1970 Wittman I: Peritoneoscopy, vol 1. Budapest, Akademiai Kiado, 1966, p 139-158 Lindner H: The present position of laparoscopy in liver diagnosis. Dtsch Med Wochenschr 81: 1160- 1162, 1966 Fahrlander H, Engelhardt G, Baerlocher C: Emergency peritoneoscopy: Report o n 160 cases. Endoscopy 2:120-122, 1970 Yamakawa K: Intraperitoneal ultrasonic diagnosis under laparoscopic observation. Sixth Annual Meeting of the Japan Gastroenterological Endoscopy Society, Sendai, 1964, p 52- 58 Yamagata S, Miura K, Tadaki H, et al: A new instrument for peritoneoscopic cholangiography. Proceedings of the First Congress of the International Society of Endoscopy, Tokyo, 1966, p 516-519 Kuster G, Aguayo A, Bellolio E, et al: Co mbined laparoscopy and percutaneous transhepatic cholangiography in the diagnoses of jaundice. Proceedings of the First Congress of the International Society of Endsocopy, Tokyo, 1966, p 500- 509 Komibuchi T, Nakajima K, Okamoto N, et al: Examination using direct cholecystography under laparoscopy together with percutaneous cholangiography. Abstracts of the 10th Annual Meeting Japan Gastroenterological Endoscopy Society, Fukuoka, 1968, p 218-219 Boyce HW : Endoscopic photography in gastroenterology. Ca 18:129-139, 1968 Colcher H : Gastrophotography and cinegastroscopy, Progress in Gastroenterology. Edited by GBJ Glass. New York, Grune and Stratton, 1968, p 97-128 Holinger PH, Brubaker JD, Brubaker JE: Open

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tube esophagoscopic motion picture photography. Gastrointest Endosc 14:75-79, 1967 Jackman RJ: Proctosigmoidoscopic photography. Gastrointest Endosc 14:31-33, 1967 Beck K, Dischler W, Helms M, et al: Rectoscopic photographic documentation of diffuse disease. Endoscopy 3:104-106, 1969 Shipman JJ: Illuminated telescope biopsy forceps for sigmoidoscopy or oesophagoscopy. Lancet 1:740, 1965 Beck IT, Phelps E : Esophagoscopic cinematography and biopsy through a new fiberoptic insert adapted to the Hufford esophagoscope. Gastrointest Endosc 15: 195-197, 1969 Smith VM: The most versatile photoendoscope. Gastrointest Endosc 14:91- 93, 1967 Niwa H, Kaneko E, Yoshitoshi Y, et al: Gastroendoscopic color television. Gastroenterological Endosc (Tokyo) 11:72- 77, 1969 Rider JA, Puletti EJ, Columbini PN: Color television gastroscopy-a critical analysis. Gastroenterology 60:827, 1971 Tsuneoka K, Uchida T: Fibergastroscopic polypectomy with snare method and its significance developed in our department-polyp resection and recovery instruments. Gastroenterological Endosc (Tokyo) 11:174-181, 1969 Tsuneoka K, Watanabe A, Uchida T, et al: Significance of polypectomy under direct visionhistologic findings. Stomach Intestine (Tokyo) 5:65-76, 1970 Deyhle P, Seuberth K, Demling L, et al: Endoscopic polypectomy in the proximal colon. Endoscopy 2:103-105, 1971 Shinya H, Wolff W: Therapeutic applications of colonofiberscopy: polypectomy via the colo noscope. Gastroenterology 60:830, 1971 Chiba H, Ishikawa K: A case of "confrey" bezoar treated with fiberscope for biopsy. Stomach Intestine (Tokyo) 5:1145- 1149, 1970 Geduldig MM: Esophagoscopic resolution of impacted Patton (esophageal tamponade) tube. Gastrointest Endosc 13:20-21, 1967 Rockman S, Morrissey JF, Koizumi H: A simple approach to narrow esophageal strictures. Gastrointest Endosc 16:212, 1970 Uj iie T : A study on intramural injection of the sto mach under direct vision by means of fiberscope. Stomach Intestine (Tokyo) 6:725-732, 1970 Ujiie T, Takazawa T, Ikeda S, et al: Intramural stomach injection under direct gastrofiberscope observation. Endoscopy 2:73- 84, 1971 Katz D: Morbidity and mortality in standard and flexible gastrointestinal endoscopy. Gastrointest Endosc 15: 134-141, 177, 1969 Anselm K, Shartsis JM. Charandang NV, et al:

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Perforation of the esophagus with the gastrocamera fiberscope. Am JDig Dis 15:311-315, 1970 256. Bralow SP: Fibergastroscopic technic for examination of the gastric fundus. Am J Dig Dis 12:653-656, 1967 257. Parker LS: Impacted fiberscope in the esophagus. J Laryngol Otol 83:1123-1125, 1969 258. Kavin H, Schneider J: Impaction of a fiberoptic gastroscope in the esophagus: an unusual . complication of gastroscopy. S Afr Med J 44: 478-479, 1970 259. Burker EL, Roling GT: Reflexions on retroflexions. Gastrointest Endosc 17:99-100, 1970 260. Stephenson HE, McLeod RA, McCraw JB: Perforation of the esophagus: a challenge to early diagnosis. Am J Surg 115:648-650, 1968 261. Gerard FP, Sabety AM, Trillo RA, et al: Esophageal perforation. Arch Surg 26:414-419, 1968 262. Youngs J, Nicoloff D: Management of esophageal perforation. Surgery 65:264-268, 1969 263. Slaughter RL, Boyce HW: Submaxillary salivary gland swelling developing during peroral endoscopy. Gastroenterology 57:83-88, 1969 264. Rastogi H, Brown CH: Pseudo acute abdomen following gastroscopy. Gastrointest Endosc 14: 16-18, 1967 265. Serebro HA, Cocco AE, Tabatznik B: Continuous electrocardiograph monitoring employing the electrocardiocorder during gastrointestinal endoscopy. Gastrointest Endosc 14:28-30, 1967 266. De Masi C, Akdamar K: Electrocardiography during upper gastrointestinal endoscopy. Gastrointest Endosc 16:33-34, 1969 267. Flecher GF, Earnest DL, Shuford WF, et al: Electrocardiographic changes during routine sigmoidoscopy. Arch Intern Med 122:483- 486, 1968 268. Schuman BM, Gate H: Electrocardiographic changes associated with gastroscopy. Bull Gastrointest Endosc 8:10-13, 1962 269. Grapulin G, Fontanin 0: Cardiac arrest during choledochoscopy. Chir Gastroenterol 2:478481, 1968 270. Vilardell F, Seres I, Marti-Vicente A: Complications of peritoneoscopy. A survey of 1,455 examinations. Gastrointest Endosc 14: 178-180, 1968 271. Frangenheim H : Complications of gynecologic laparoscopy. Endoscopy 1:10-20, 1971 272. Nelson RS : Gastroscopic Photography. Chicago, Year Book Medical Publishers Inc, 1966 273. Kuru M: Atlas of Early Carcinoma of the Stomach. Tokyo, Nakayama-Shoten Co Ltd, 1967 274. Nelson RS : Endoscopy in Gastric Cancer. Recent Results in Cancer Research. New York, Springer-Verlag, 1970

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275. Bruhl W, Krentz K : Clinical Gastroscopy. Stuttgart, Georg Thieme Verlag, 1970 276. Ashizawa S, Kidokoro T: Endoscopic Color Atlas of Gastric Diseases. Tokyo, Bunkodo Co Ltd, 1970 277. Beck K: Color Atlas of L/ioparoscopy. New York, Intercontinental Medical Book Corp, 1971 278. Umeda N, Yoshitoshi Y: Diagnosis by Gastro Photography. Philadelphia, WB Saunders, 1971 279. Gastroenterological Endoscopy. Japan Gastro-

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enterological Endoscopy Society, 3-4 Ogawamachi Kanda, Chiyoda-ku, Tokyo, Japan 280. Stomach and Intestine. Igaku Shoin Ltd, 5-29-11 Hongo, Bunkyo-ku, Tokyo, .Japan 281. Endoscopy. Stuttgart, Georg Thieme Verlag; New York, Intercontinental Medical Book 'Publishers Inc 282. Gastrointestinal Endoscopy. American Society for Gastrointestinal Endoscopy, 476 Prospect Street, La Jolla, Calif 92037