Gastroscopy

Gastroscopy

GASTROENTEROLOGY Copyright © 1967 b y Vol. 53, No.3 Printe,d in Tl.S. A. The Williams & Wilkins Co. PROGRESS IN GASTROENTEROLOGY GASTROSCOPY A r...

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GASTROENTEROLOGY

Copyright

© 1967 b y

Vol. 53, No.3 Printe,d in Tl.S. A.

The Williams & Wilkins Co.

PROGRESS IN GASTROENTEROLOGY

GASTROSCOPY A review of the English and Japanese literature JoH N F. MoRRISSEY, M.D., YosHIHISA T ANAKA, M.D ., AND WILLIAM B . TnonsEN, M.D. · DepaTtment of 111edicine, University of Wisconsin, Madison, Wisconsin

A d ecade ago gastroscopy played a minor ro le in the management of patients with gastric disease in the United States except in a few centers where enthusiasts of the technique practiced. Only a few variants of the original Wolf-Schindler gastroscope were in use. Today at least 14 lens gastroscopes, 22 fiberscopes, and 13 gastrocameras are available. Careful, well planned clinical studies to compare these instruments are too few t o provide really helpful information. The need for such studies is apparent when the potential impact of these new instruments and techniques on the practice of gastroenterology in this country is contemplated. The best example of this problem is the paradoxical position of the Olympus gastrocamera. This instrument has been in use in Japan for nearly 15 years. Pickert 1 in 1957 and Nelson 2 in 1960 in their reviews of gastroscopic photography dismissed the technique as not worthy of trial. By 1966 in Japan 3 over 10,000 gastrocameras were in use and 108 training centers were teaching the technique of gastrocamera photogAddress requests for reprints to: Dr. John F. Morrissey, D epartment of Medicine, University Hospitals, 1300 University Avenue, Madison, Wisconsin 53706. The preparation of this report was supported in part by Public H ealth Service Contract PH 108-65-57 and Public Health Service Trainin Grant 5306A67 from the Bureau of Disease Prevention and Environmenta l Control (Doctor Tanaka) and Public Health Service Graduate Clinical Cancer Tra ining Program IT12CA08068-01 from the National Cancer Institqte (Dr. Thorsen ).

raphy, while in the United States fewer than 40 gastrocameras were in use and the authors ' institution offered t he only formal course of training in the technique. In Japan 95% of all hospitals where endoscopy is performed make routine use of the gastrocamera. 4 Despite this development, Colcher 5 and Nelson 6 continue to believe that the gastrocamera should never be used to make a diagnosis which is not confirmed by other means and would relegate the instrument to use in mass surveys. Since it is questionable if mass surveys are needed in the United States, they are not concerned by the slow development of the gastrocamera technique in this country. In contrast, Morrissey et al.7 have stated t hat gastrocamera photography can assume "a major role in the diagnosis and management of patients with gastric ulcers." The authors believe that these diametrically opposed views are due in part to problems in communica tion between centers of the details of endoscopic techniques and in part to the inaccessibility of the great mass of Japanese endoscopic literature to American physicians. Almost all of the clinical evaluations of gastroscopes which have been published consist of a series of patients with X-ray or surgically proven gastric disease who have been examined at one institution with a single instrument. Two recent studies raise a serious question as to whether the results of such studies can be used to compare instruments. Smith8 surveyed the membership of the American Society of Gastrointestinal Endoscopy to determine

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the frequency with which endoscopists believed that they had visualized the pyloric ring in their last 100 examinations. Rates of visualization from less than 10% to over 90% were recorded by individual endoscopists using each of the three most commonly used gastroscopes. Namiki and Murazima 9 described a study in which 4 endoscopists with varying experience with the new GT-P gastrocamera examined 43 patients, 30 of whom had proven gastric ulcers and 13 of whom had gastric polyps. Each physician performed gastrocamera examinations on each of the 43 patients and interpreted his gastrocamera films independently of the other three endoscopists. The individual endoscopist's accuracy varied from 38 to 77% for ulcer visualization and from 46 to 77% for photographing the polyps. The reader is advised to keep these studies in mind as he considers the significance of the results of the gastroscopic studies which are to be quoted in this review. The authors have emphasized studies in which comparisons of two or more instruments were made by the same investigator, preferably, by examining the same patients with both instruments. Lens Gastroscopes

Lens gastroscopes remain in wide use in this country despite the development of the fiberscope and the gastrocamera. A comprehensive review of the early history of the lens gastroscope has been published by W alk. 10 In recent years modifications have been made to facilitate color photography, to improve visualization of blind areas, and to permit biopsy under direct vision. Bernstein et al.U reconstructed the EderPalmer modification of the Wolf-Schindler instrument by enclosing the objective lens, mirror, and lamp in a single chamber to permit illumination of mucosa in direct contact with the gastroscope window. Although this modification is useful in visualizing lesions such as the tears of the Mallory-Weiss syndrome, it does not obviate the very difficult problem of interpreting abnormalities in mucosa magnifi.ed approximately 20 times. Later, controls were added to this instrument to deflect the tip

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upward and to move the objective lens mirror to increase the field of view. The latter modifications do not add significantly to the value of the instrument in the authors' opinion. Downward deflection of the gastroscope tip, such as was incorporated in a few of the Eder-Palmer instruments, and in the Eder-Chamberlin and Herman Taylor instruments, is a useful feature, particularly for examining the posterior wall of the stomach and gastrojejunostomy stomas. 12 Although the Herman Taylor instrument has a shorter flexible segment and is larger than the Wolf-Schindler instrument, it has many advocates among British endoscopists.12, 13 Zinberg and Berk14 examined 50 patients with an Eder-Palmer gastroscope to which an eccentrically placed balloon was attached proximal to the window to assist in visualizing blind areas within the stomach such as the cardia or lesser curvature of the antrum. They were able to visualize six of 16 antral lesions and five benign ulcers of the posterior wall of the body with the modified gastroscope which were not visible with the same instrument without the balloon. Berry et al. 15 in a report of 2843 examinations with gastroscopes of the WolfSchindler type have emphasized the advantage of examining the patient on his back and right side, in addition to the standard left-sided position. They found that moving the patient was safe, did not cause significant distress, and frequently provided a better view of the area of interest. Dagradi et aJ.l 6 provide a good description of their technique of examination and their results in a series of 81 patients with hiatal hernia studied with the Schindler gastroscope. They were unable to pass the instrument in 2 patients because of stricture. In 6 patients the gastroscope would enter the supradiaphragmatic pouch but could not be advanced further into the subphrenic segment of the stomach. Complete examination was accomplished in 72 subjects. Only two ulcerations were seen in the supradiaphragmatic portion of the stomach in this large series suggesting that

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the ability of the Schindler gastroscope to visualize this area should not be a major consideration in comparing Schindler gastroscopes with other instruments. Inokuchi and Furusawa 17 described their results with a new short rigid lens gastroscope called the "gastroviewer" which they use to examine the stomach through a surgical incision. The instrument provides excellent illumination by means of a fiber light guide, a sharp image, and a wide 60° angle of view. The gastroviewer is passed through a gastrotomy incision which is then closed around the instrument with a purse string suture to permit distension of the stomach with air. They were able to determine the margins of gastric carcinomas within 1.0 em in 97% of cases and found the technique useful in locating multiple lesions and bleeding sites. Thirteen of 46 early cancers could not be palpated through the gastric wall and were located with the instrument. The improvements which have been made in lens gastroscopes to facilitate biopsy and photography will be discussed later in this review. Fiber Optic Gastroscopes

The concept of the transmission of images by means of a bundle of transparent fibers was patented in 1928 by Baird in England. 18 Encouraged by Schindler, Lamm 19 experimented with the technique in 1930 and suggested that it might be possible to apply the principle to the construction of a flexible gastroscope. However, the practical use of fiber optics awaited the discovery in 1954 by Van HeeF 0 of the principle of coating or cladding of the individual fibers with material of lower refractive index to reduce light loss and to increase image resolution. In that same year Hopkins and Kapany 21 described a technique for fabricating fiber bundles. In 1957 Curtiss et al. 22 described a technique for producing bundles composed of glass on glass fibers of uniform size, an advance which led to the production of the ACMI (American Cystoscope Makers, Inc.) fiberscope. 23 • 24 The general subject of fiber optics in medicine has been

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recently reviewed by Goldman et al. 25 Technical discussions of fiber optics can be found in two recent publications. 20 • 27 Hiwschowitz 28 described his preliminary results with the ACMI fiberscope in 1961 emphasizing the value of the instrument for the examination of the duodenal cap. The ACMI instrument is a completely flexible side viewing fiberscope measuring 90 by 1.1 em. The variable focus objective lens provides a 34 o angle of view. The image is carried by a fiber bundle consisting of 150,000 glass fibers 11 p. in diameter. The great emphasis which was placed on duodenal examination with the ACMI fiberscope by Hirschowitz et al. 28 • 29 and the failure of other observers to reproduce these results 30 • 31 detracted from the very significant advance which this instrument represented. Burnett30 compared the results of 160 examinations with the ACMI fiberscope with 160 examinations performed with the Herman Taylor lens gastroscope. His successful examination rate was 91% with the fiberscope and 71% with the gastroscope. He was able to visualize 24 of 33 gastrojejunostomy stomas with the gastroscope and 37 of 40 stomas with the fiberscope. Cohen et al. 31 passed a lens gastroscope and an ACMI fiberscope in 234 patients and were able to visualize the pylorus in 88% with the fiberscope and in 36% with the gastroscope. By using anticholinergic drugs to stop peristalsis Fukuchi 32 was able to visualize the pylorus in 97% of 615 patients with the ACMI fiberscope. Barowsky et aJ.3 3 were able to increase their rate of pyloric visualization with the same instrument from 35% to 75% by the intravenous administration of anticholinergic drugs. Propantheline bromide, 6.0 mg, or atropine, 0.8 mg intravenously, was found to stop peristalsis completely within 5 to 7 min. LoPresti et al. 34 found that the ACMI fiberscope did not provide an adequate view of the upper stomach in contrast to the reports of Cohen et al. 31 and Hirschowitz et al. 28 • 29 The authors have been

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able at times to obtain excellent visualization of high body and fundal lesions, but frequently the view was obtained too close or too tangential to add significantly to the information obtained previously by X-ray examination. Because of the problem of orientation produced by the flexibility of the ACMI fiberscope and the narrow angle of view, the authors have had difficulty during follow-up examinations performed on patients with ulcers of the body of the stomach in deciding whether the ulcer had completely healed or whether the ulcer area had not been visualized. However, examination of the high body of the stomach with a variable focus instrument such as the ACMI fiberscope is easier than it is with a fixed focus fiberscope such as the GTF gastrocamera fiberscope. Takemoto35 attempted to visualize the upper stomach in 156 patients by retroflexing the ACMI fiberscope under fluoroscopic control. He was successful in 70% of the patients. His series included a few subjects examined with Japanese fiberscopes. Similar observations were recently reported by Edwards and Muggia 30 in a small group of patients. The authors believe that this is an undesirable procedure with fiberscopes not equipped with controllable tips because of the danger of impacting the instrument in the gastroesophageal junction and because of the distress it causes the patient. The original ACMI instrument has been improved by replacement of the tungsten lamp with an external light and a fiber bundle light guide. 27 The modified instrument has a smaller solid tip and by providing cold light eliminates the hazard of mucosal burns. A second modified instrument has been made which has a separate channel through which a biopsy forceps can be passed. These instruments incorporate an improved fiber bundle which has a maximum resolution of 40 lines per mm, comparing favorably to the 60 lines per mm resolution of lens gastroscopes. A fibergastroscope, the Machida FGS-A, which is quite similar to the early ACMI fiberscope, has been in use in Japan for several years. 37 The field of view is 50° in-

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stead of 34 o, and photography is facilitated by use of dual filament bulbs and special power supplies for still and cinephotography. The Machida FGS-8 37 and the Olympus GFS fiberscopes 38 have the additional feature of controlled upward and downward tip deflection, 110° for the Machida and 70° for the Olympus instrument. A unique feature of the Machida PS fiberscope 37 is a window nearly encircling the instrument and a central prism which, acting as a mirror for the objective lens, can be rotated to give a 220° field of view. Models for direct biopsy and direct cytology have recently been made available by both companies and will be discussed below. These newer instruments await comparative clinical evaluations. Gastrocameras

The first intragastric camera was described in 1898 by Lange and MeltzingY 0 This ingenious instrument consisted of an 80-cm rubber tube to which was attached a camera consisting of a lens, an incandescent lamp, an air channel for inflating the stomach, and a removable tip which held a 50-cm roll of film 5 mm wide. Fifty photographs could be taken at each examination. The position of the instrument was determined by viewing the light through the abdominal wall. Although recognizable photographs were obtained, technical problems persisted and, unfortunately, this work was discontinued. In 1930 Heilpern and Porges 40 described their results with an intragastric pinhole camera which they called the gastrophotor. This instrument takes a series of 16 photographs simultaneously by the discharge of a flash bulb. It never achieved widespread use, the last published reference being a brief description in 1942 by Rafsky41 of photographic results with the instrument using color film. Recently there has been a revival of the instrument by Weiss et a!. (exhibition at the Annual Meeting of The American College of Gastroenterology, New York, N.Y., October 1964 entitled "The Intragastric Camera-A New Diagnostic Tool"). The authors have examined the best of a series of

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100 photographs which had been taken by M. Caplan with the gastrophotor and interpreted by N. Weiss. In all the examinations several photographs were completely blurred and clear views of the antrum and pylorus were not seen. Most of the clear photographs were of the greater curvature of the body of the stomach. A few large ulcerations were recognizably photographed with the instrument, but the clarity of the photographs was not sufficient to permit the endoscopist to add additional diagnostic information to the results of the prior X-ray examinations. In 1950 Uji working with Sugiura and Fukami, engineers of the Olympus Optical Company of Tokyo, built a gastrocamera which closely resembled the instrument of Lange and Meltzing. 39 He published the first description of the camera in 1952. 42 Although successful photographs were obtained, development of the instrument was delayed by mechanical difficulties. In 1953 Tasaka and his associates3 at Tokyo University formed a research group to improve the gastrocamera. They developed the first gastrocamera, model GT-3, which used color film, and introduced this instrument at the First World Congress of Gastroenterology in 1958. A smaller and more flexible model was produced in 1959, and finally in 1960 the model GT -5 gastrocamera was completed. The model GT-5 is the instrument in general use in the world today. This gastrocamera has been well described in several recent publications in English. 43-46 Briefly, it consists of a camera proper consisting of lens, flash lamp, air valve, and film capsule which is attached to a control unit by means of a 75-cm vinyl-covered tube. The camera lens has an 80° angle of view and the tip can be deflected upward and downward 35° to increase further the field of view. A series of 32 5-mm color transparencies is obtained at each examination. Tanaka and Morrissey 47 have described an improved technique for photography with this instrument. In the past, routine techniques of examination with the GT-4 and GT-5 models of the gastrocamera produced high quality photographs and provided reliable cover-

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age of the lower body of the stomach and the proximal antrum but frequently lesions of the high body, cardia, fundus, and pyloric channel were not photographed. Several modifications of the gastrocamera were made in an effort to improve visualization in the upper stomach. Tanaka4s modified the model GT-4 gastrocamera by changing the standard 3.6-mm lens to a short focus 2.4-mm lens. Fugimori49 modified Tanaka's instrument by covering the tip of the instrument with a transparent cellophane balloon. Okabe and Yaouo attached an inflatable cuff proximal to the tip of a standard gastrocamera to lift the lens away from the mucosa. Nakayama51 modified the original GT-2 gastrocamera so the tip could be deviated 80° upward for cardia photography. Recently the GT5 gastrocamera has been modified in a similar way to produce the model GT -5B instrument. These techniques were largely abandoned after Yoshitoshi 52 described a technique of retroflexing the model GT-5 gastrocamera within the stomach under fluoroscopic control, thus permitting accurate photography of the entire upper stomach. Although positioning is more accurate with fluoroscopic control, it is quite possible to turn the instrument without the use of the fluoroscope. In 1961 Ashizawa (best description196453) was able to obtain photographs of the cardia by bending the tip of a GT-5 gastrocamera upward using an external string. He incorporated the string principle into the instrument by replacing the flexible joint with a 10-cm flexible segment, which was controlled by two wires, permitting upward or downward deflection of the instrument 100°. In 1964 he reported his results with 1000 patient examinations with this instrument, 53 now known as the model GT-5A gastrocamera. The authors have had an opportunity to compare the retroflexion of the model GT -5 and GT -5A gastrocameras in several hundred patients. The GT-5A gastrocamera can be turned more easily and more often than the GT-5, and a successful examination is less dependent on the availability of fluoroscopy. The turning radius of the GT5A is considerably shorter so that the pho-

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tographs of the high lesser curvature and cardia are obtained at shorter range. Retroflexion of the camera is a routine part of every gastrocamera examination at the authors' institution. In 1961 Om01·i" 4 at Tokyo University conducted the first experiments in which a gastrocamera was adapted to ultraviolet photography. He was impressed with the detail with which he could photograph the mucosal fold patterns of resected stomach specimens. In 1963 Kaneko and Yoshitoshi"" at the same institution modified the GT-3 gastrocamera by replacing the tungsten filament bulb with a xenon lamp to provide an ultraviolet light flash at 6000°K of 0.5-msec duration. They covered the lens and lamp with 3-mm U-2 filters which are impervious to visible light and permit transmission of 73% of light at 370 mp.. Kodak spectroscopic film was used. The ultraviolet photographs revealed minor mucosal details such as erosions, linear ulcerations, and early gastric cancers better than conventional photographs did. 56 Kaneko et al." 7 showed a series of gastric lesions examined with a standard and an ultraviolet camera at the First Congress of the International Society of Endoscopy, Tokyo, Japan, September 1966. One of us (J.F.M.) was impressed with the mucosal detail in the ultraviolet as compared to the visible light photographs. The technique merits a carefully controlled evaluation. Miwa 58 obtained similar results by means of fluorescence photography. He used an Olympus GT-Fl gastrocamera, which is a model GT-5 gastrocamera. modified for ultraviolet photography, as described above except that the lens was covered by a Y-38 filter instead of a U-2 filter, and Anscochrome ASA 200 daylight film was used. Mucosal fluorescence was induced by the intravenous administration of 5 ml of 20% sodium fluorescein 10 to 15 min before the procedure. Takaishi and Suzuki 59 described a technique for stereophotography by equipping a gastrocamera with two lenses 2 em apart. In a later report Sakamoto et al. 60 described a technique of projection of the developed films using polarized light and

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found that good results could be obtained with a 1-cm interlens distance. It is questionable if the advantages of stereo viewing will outweigh the reduction by one-half of the number of photographs taken at each examination. In 19623 a modification of the gastrocamera was introduced known as the GTP in which the controllable tip was eliminated, the picture size reduced to 4 by 5 mm, the number of exposures changed from 32 to 22, and the size of the connecting tube reduced from 8.5 to 5.5 mm. The new instrument could be passed without premedication or local anesthesia and thus was ideal for use in mass survey examinations to detect gastric cancer. The loss of 10 exposures proved to be disadvantageous so a new model GTP2 61 has been produced with a larger tip to hold a 32-exposure film capsule. In skilled hands, as mentioned earlier in this report, 9 good coverage of the stomach can be obtained with results which are only slightly inferior to those with the GT -5 gastrocamera. Honda and Tanaka 62 have modified the GT-P by attaching an external string to facilitate photography of the cardia. Successful cardia photographs were obtained in 160 of 277 patients. They were able to examine 8 to 10 patients per hr with the modified instrument. In 1964 a new instrument, the Olympus GTF gastrocamera fiberscope, was introduced which incorporated a gastrocamera optically similar to the model GT-5 into the tip of a fixed focus fiberscope with a 60° angle of view. 63 • 64 Morrissey and Tanaka 65 compared the GT-5 gastrocamera and GT-F gastrocamera fiberscope in a series of patients with lesions in the lower half of the stomach. The accuracy of the gastrocamera (86%) and gastrocamera fiberscope (89%) was similar, but 25% of the lesions were seen significantly better with the fiberscope and only 10% with the gastrocamera. They concluded that the fiberscope was a poor instrument for visualizing lesions in the high body of the stomach, an area where 90% of the lesions could be seen with the gastrocamera. In this study the fiberscope was at a disadvantage because the gastrocamera examina.-

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tion always preceded it. The gastrocamera missed distal lesions because intravenous propantheline bromide was not used to stop peristalsis in anticipation of the fiberscopic examination to follow. Yamagata et al. 66 describe similar results in a comparison of the GT-5 gastrocamera with the ACMI fiberscope, visualizing 86% of ulcers in the lower stomach with the gastrocamera and 93% with the fiberscope. They did not retroflex the gastrocamera so their results (39%) in the high body were poor but still better than those with the fiberscope (14%). Hara et al. 67 made a comparison in two series of patients of the Olympus GT-5 gastrocamera and GT-F gastrocamera fiberscope. They visualized 386 of 463 ulcers or 83.4% with the gastrocamera and 420 of 465 or 90% with the fiberscope. One hundred fifty-six of 170 cancers or 92% were seen with the gastrocamera and 119 of 130 cancers or 92% were seen with the fiberscope. Films were not read blindly and no evaluation was made of the quality of the view obtained. Retroflexion of the gastrocamera was not routinely performed. Two recent modifications of the Olympus gastrocamera fiberscope have been made, one, model GTF-P, in which the connecting tube has been reduced from 12 to 9.2 mm in diam, and the other, model GTF-A, in which a controllable tip which can be directed upward 70° and downward 50° has been inserted. Both new instruments take 4- by 5-mm instead of 5- by 6-mm photographs. Clinical evaluation of these instruments is in progress. The authors' preliminary observations with the GTF-A suggest that it is superior to the GT-F for examining the body of the stomach and the resected stomach, but less useful for examining the distal antrum and pylorus because of its increased flexibility . Tasaka and Oguro (Exhibition, First Congress of International Society of Endoscopy, Tokyo, Japan, September 1966) studied five color films using the GT-F gastrocamera fiberscope equipped with a special power supply which provided variable voltage and variable exposure time. They found that Ektachrome 125 had the best latitude of color balance and that

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Agfacolor CK17S had the best resolving power. Anscochrome ASA 32 and ASA 100 and Fuji color film were also studied. The authors have been able to improve the resolution and color balance of Anscochrome ASA 100 film by placing a Wratten 82A gelatin filter between the lamp and lamp window of the gastrocamera and gastrocamera fiberscope . In the same exhibit Tasaka and Oguro compared the optical properties of the ACMI and Machida fiberscopes and the Olympus model GT-5 gastrocamera and GTF gastrocamera fiberscope by measuring resolving powers and resolving distances using a disordered Siemen's test chart. (In the use of a Siemen's test chart the resolving power (RP) equals Y2 d (1/ mm). The resolving distance (d) equals 7Tp / 2 X 36 where P equals the diameter of the disordered circle.) They found that the maximum resolving powers with the focusing fiberscopes (ACMI and Machida FGS-A and FGS-S) were considerably higher, 20.7 to 23 .9, than the visual resolution with the fixed focus fiberscopes (Machida FGS-B and Olympus GTF), 2.4 to 3.3. Photographic resolution with the gastrocameras was intermediate, 10.1 to 12.5. Tasaka and Oguro did not take into consideration the vastly different angles of view of these instruments. A gastrocamera photograph encompasses approximately 7 times the field seen with the ACMI fiberscope. The gastrocamera at 23 mm from the mucosa visualizes the same area seen by the ACMI fiberscope at 50 mm, and the Olympus gastrocamera fiberscope (visual) at 33 mm. The resolving powers of the three instruments are more comparable under these conditions with the gastrocamera (5.0) being the sharpest, followed by the ACMI fiberscope (4.0) and gastrocamera fiberscope (3.3). Tasaka and Oguro believe that final interpretations of examinations with the gastrocamera fiberscope should always be deferred to the photographs, a recommendation which the authors endorse. Examination of the Duodenum

Initially, Hirschowitz believed that he could examine the duodenum with the

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ACMI fiberscope whenever he chose to ;28 however, subsequently, he found that it was possible to enter the duodenum approximately 50% of the time. 29 In the authors' opinion, Hirschowitz's published photographs of duoden a l ulcers 28 are not clear enough to give support to his conclusions. Burnett30 attempted to examine t he duodenum in 50 patients with the ACMI fiberscope and stated that he had difficulty in telling the most distal recess of the antrum beyond the point of pyloric contraction from the duodenum ; consequently, he could give no accurate figures indicating how frequently the instrument actually entered the duodenum. He did visualize six ulcerations in the duodenum which were later surgi cally confirmed. He concluded that the instrument in its present form was not suitable for duodenoscopy. Cohen et al. 31 were unable to examine the duodenum despite strenous efforts during the course of 1000 examinations of the stomach with the ACMI fib erscope. The authors, during the course of 300 examinations with this instrument, believe that the instrument entered the duodenum on one occasion. J. R. Meadows (personal comunication, November 1965 ) showed the authors an excellent photograph which was unequivocally a view of the normal duodenum taken with t he instrument but stated that he had never visualized the organ when it was the site of pathology. Rider (presented at the Annual Meeting of the American Society of Gastrointestinal Endoscopy, Chicago, Ill., May 1966) has made preliminary studies with a new 6-mm ACMI fiberscope which is p assed through the pylorus by means of a m ercury bag. At the present stage of its development he does not consider the instrument to be clinically useful. Oshiba68 has made observations with a fib erscope 2m by 9 mm which incorporated a fiber light guide and a 2-mm 2 image fiber bund le. A xenon light source was used. The obj ective lens was directed straight forward with an observation range of 5 to 50 mm and a 60° angle of view. The instrum ent has been used in the colon as well as the duodenum. Although he was able to examine the duodenum with the instru-

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ment, he considers it t oo large for effective use. Hiraki et al. 69 compared the standard and a short focus gastrocamera lens in a special 90-cm model of the GT-5 gastrocamera. They obtained sharp photographs of the duodenum in 24 of 33 patients examined with the short focus lens and 12 of 59 examined with the standard lens. They had trouble passing t he instrument if duodena l disease was present and were able to photograph only one duodenal ulcer. I shihara and Tanaka 70 compared a short focus GT -5 gastrocamera, an elongated 90-cm GT-P gastrocamera, and a gastrocamera wit h the lens directed straight ahead, known as the "Cavo Camera." They found that the increased minimal fo cal distance of 6 mm for the Cavo Camera and the GT-P resulted in less successful pictures than those t hey obtained at the 4-mm focal distance of t he modified GT-5. They were able to photograph some duodenal ulcers and found t hem to have an appearance similar t o gastric ulcers. The lens of the Cavo Camera was frequently obscured by mucus. The latter problem has been encountered with other instruments with straight ahead optics such as the ACMI fiber esophagoseope 71 and, in a trial by the authors, with the Eder fiberscope. Fiber Esophagoscopy

In 1963 Hirschowitz 2 7 • 71 reported the development of a fiber esophagoscope which incorporated straight a head viewing, a fiber light source, and channels for air, suction, and biopsy. Mucus interferred with visualization by t he esophagoscope in 20% of examinations. LoPresti and Hilmi 72 • 73 modified the instrument by deviating the principal optical axis of vision 25° from the main axis which, with t he 50° angle of view of the instrument, permits visualization of wall and lumen at all times. Two open channels instead of one were used to prevent collapse of the esophagus when suction was applied. Water can be injected to clean the lens. In addition to the obvious advantages of patient comfort and safety when compared to rigid esophagoscopes, fiber esophagoscopes permit the observation of

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peristalsis and thus are more useful for the diagnosis of achalasia. Fiber esophagoscopes have been produced in Japan by the Machida 74 and the Olympus 75 companies. The Olympus instrument utilizes a hood over the lens to prevent mucus from obscuring it, a single channel for air, suction, and biopsy, a tip which is movable 25° upward or downward, and a unique fiber light guide which circles the viewing bundle to provide uniform light and a wide 50° angle of view. The Machida instrument is extremely sophisticated and hopefully may provide a solution to some of the problems encountered with the other models if its complexity does not make it too difficult to maneuver. The lens hood is retractable, permitting the lens to be wiped clean and then the mucosa pushed back for sharp viewing. This hood also assists in directing the biopsy forceps. The tip can be directed upward or downward 90° or panned right or left 30° to improve viewing further and assist in directing the biopsy forceps. Power supplies, which provide high intensity light for photography in addition to the viewing light, are available. The problem of still photography has not been solved with these instruments, particularly in the midesophagus where motion due to heart action is maximal. The esophagus can be examined during the withdrawal of two instruments primarily designed for examination of the stomach (the Eder fiberscope and the Storz model 14025 lens gastroscope) because these instruments incorporate an ocular which permits both straight ahead and right angle viewing. Clinical evaluations of these new instruments have not been published. Photography with External Cameras

The major deterrent to the use of the lens gastroscope for photography has been the loss of light as the image is carried through the flexible portion of the instrument. Segal and Watson 76 were able to obtain excellent still photographs by selecting a gastroscope with a short flexible segment and by coating its lenses to reduce light loss further. Nelson77 • 78 simplified the

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procedure used by Segal and Watson and adapted it to the Eder-Chamberlin gastroscope. He was able to obta in good quality photographs by using a special 25-v lamp which could be stepped up to 50 v by means of a floor switch for photography. The distal portion of this instrument is shorter, stiffer, and 4 mm larger than the conventional Eder-Palmer gastroscope which greatly reduces its maneuverability within the stomach and frequently makes it necessary to pass two instruments to complete a gastroscopic examination. Barrett79 attempted to adapt the EderPalmer gastroscope to photography by replacing the standard 10-v bulb with a 25-v bulb and, by means of a special power supply, flashing this bulb at 80 v for Ys to Y-1 sec. The bulb rapidly blackened and required replacement after 20 examinations and occasionally burned out during examinations. As an alternative technique he used two 10-v bulbs and flashed them at 30 to 40 v. This modification increased the length of the rigid portion of the instrument and interfered with visualization of the distal stomach. Photographs taken with this technique were somewhat blurred because exposures of Ys to l;4 of a second are not sufficiently brief to stop motion within the stomach. The sharpest still photographs taken by lens gastroscopes have been made by the OPL Gastroflex developed by Debray and Housset. 80 This instrument incorporates an excellent lens system, an incandescent bulb for viewing, and an electronic flash for photography. Adequate light is provided by 180-v discharges of 1- to 2-msec duration. Although some minor shocking with this instrument has been described, no serious reactions have been reported. 81 Unfortunately, this gastroscope is rigid, short, has a large tip, is difficult to pass into the stomach, and is difficult to maneuver within the organ. Keever and Barborka 81 have published some excellent photographs taken with this instrument. Colcher and Katz 82 demonstrated the value of using an external lamp and a fiber bundle light guide to provide illumination for gastroscopic photography by passing a fiber bundle through the biopsy port of

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a Benedict gastroscope and photographing one patient with the instrument. This concept has been used by the Storz Company to provide illumination for their newest lens gastroscope. Their system utilizes three light sources-a 10-watt source for viewing, a 28-watt second electronic flash for still color photography, and a 70-watt cold light projector for cinematography and television applications. The development of the fiberscope provided a great incentive to gastric photography because a fiber bundle gastroscope will transmit approximately 2Y2 times as much light as a lens instrument. Thus the light provided by the standard 10-v bulb of an instrument, such ·as the ACMI fiberscope, is adequate for photography. The image resolution by a fiberscope is not as sharp as that by a lens gastroscope partly because at any instant 40% of the surface of the stomach, representing the space between the individual glass fibers within the fiber bundle, is not seen. This loss in resolution, which is very noticeable on still photographs, can be largely overcome by the use of motion pictures. Hirschowitz 83 provided a detailed description of how he adapted the ACMI fiberscope for cinegastroscopy. Nissenbaum et al. 84 described an improved bracket for attaching a camera to a fiberscope. Berci et al. 85 have developed a system in which a 16-mm motion picture camera is coupled to a fiberscope by means of a flexible film carrier. This permits mounting the heavy camera containing 400 ft of film on a .fixed support and leaves the operator free to maneuver the instrument and move the patient encumbered only by a small lens attached to the fiberscope. Cocher and Katz have developed a power supply to provide adequate light for motion pictures with the Olympus GT-F gastrocamera fiberscope (presented at Annual Meeting of American Society of Gastrointestinal Endoscopy, Chicago, Illinois, May 1966) . Similar special power supplies are available for Machida and Olympus fiberscopes which use either 2 bulbs or a bulb with 2 filaments to provide separate illumination for viewing and for either still or motion pictures.a7, 38 The

41i!i

Japanese fiberscopes and fiber esophagoscopes are designed to couple and synchronize with an Olympus Pen F halfframe single lens reflex camera equipped with a special lens. Cocher5 has stated that the technique of cinegastroscopy should replace still photography. He does not cite, nor are the authors aware of, any clinical studies which evaluate this technique in such a way that the specific contribution of the motion pictures to the visual examination can be measured. The value of cinegastroscopy as a teaching device and as a useful adjunct to the management of individual patients has been well demonstrated. However, until more information is available, the authors do not believe that widespread use of this technique should be encouraged. Television Gastroscopy

Television has yet to assume a useful role in improving gastroscopy. As far back as 1952, Wallman and Rosengren performed some experiments, reported in 1956, 86 showing that a television tube could record a recognizable endoscopie image. Unfortunately, television tubes available at that time were far too large to incorporate into the tip of a gastroscope. Bcrci and Davids, 87 adapting a system developed in France by de Montreynaud, were able to obtain fairly satisfactory images by attaching a vidicon tube to the ocular of a gastroscope. They improved this system by miniaturizing the vidicon tube so that it was only 120 mm long, 45 mm in diameter, and weighed only 350 g. Berci et al. 88 and Heinkel and Frik 811 have emphasized the value of recording on a single strip of television t ape, alternately, the gastroscopic image and the fluoroscopic position of the gastroscope. If a further miniaturization of the system can be obtained and, if it can be adapted to color, teleVISIOn may have considerable usefulness, particularly in teaching the technique of endoscopy. Gastroscopic Biopsy

In 1948 Benedict00 introduced a modification of the Wolf-Schindler gastroscope

466

PROGRESS IN GASTROENTEIWLOGY

which incorporated a biopsy forceps. A somewhat similar modification 91 · 92 of the Herman Taylor gastroscope has been made which permits the passage of a suction biopsy capsule under direct vision. Unfortunately, both of these instruments are rather large and rigid and thus quite limited in their usefulness. In 1952 Tomenius93 attached a suction biopsy capsule to the tip of a Wolf-Schindler gastroscope and more recently Berry (Exhibit, First Congress International Society of Endoscopy, Tokyo, Japan, September 1966) constructed a sheath which can be attached to an Eder-Palmer gastroscope to permit biopsy. The Storz gastroscope and ACMI fiberscope 27 have also been modified to permit passage of a biopsy forceps. Although comparative clinical evaluations of these biopsy instruments have not been published, the authors do not believe that it is possible to control the positioning of the biopsy forceps with any of these instruments accurately enough to permit biopsy of small lesions. A more useful instrument is a modification of the OPL Gastrofl.ex gastroscope made by Debray et al. in 1959 and described in English in 196294 which incorporated a suction biopsy tube within the sheath of the instrument. With this instrument they were able to obtain positive biopsies in 12 of 21 patients with gastric carcinoma. The Machida FGS-S and Olympus GFS fiberscopes have been modified to include a channel for forceps biopsy. The tips of these instruments and the angle at which the biopsy forceps protrudes from the tip are controllable so that biopsies can be performed with great accuracy. Kasugai, 95 using the Machida FGS-B, obtained positive biopsies in 126 of 154 (82%) proven gastric cancers. The upper body, cardia, and distal antrum were difficult to biopsy. Four or more biopsies were taken from each lesion. The best results in malignant ulcers were obtained when the inside edge of the margin was biopsied. Similar results, in 88% of 113 patients, were obtained by Hayashi and Sugiura96 with this instrument. Tobita and Hara 97 were able to obt ain positive biopsies in over 90% of proven

Vol . 53 , No. 3

cancers biopsied with the Olympus GFB fiberscope. Debray and Housset 98 used their biopsy lens gastroscope to obtain material for cytological examination and obtained positive diagnoses by this method in 11 of 21 patients with proven gastric cancer, 4 of whom had negative biopsies. Kasugai attached a nasogastric tube to a Machida fiberscope and obtained material for cytological examination under direct vision in 1964. In 1966 the M achida and Olympus Companies constructed fiberscopes with a small nozzle built into the tip of the instrument between the lamp and the objective lens which directs a stream of irrigating fluid into the center of the field of view. Kasugai 95 was able to obtain positive diagnoses by cytology in 89 consecutive cancers with the Machida FGS-K fiberscope and encountered only two fa lse positives in 146 patients without cancer. Hazards of Gastroscopy

Taylor's review 99 remains the best general discussion of the hazards of lens gastroscopy. Perforation represents the most frequent serious complication of gastroscopy and the one which appears to be most definitely instrument-related. Table 1 provides data as to the relative hazards of the three major types of instruments in use today. Information for Ariga's study 4 of the Japanese experience and for the report of Jones and his associates 100 of British experience was obtained by questionnaire. The British study included a recording of the accidents encountered by a group of endoscopists who had performed at least 500 examinations with each instrument. The results quoted in table 1 are from this portion of the British study and they show the increased hazard of the Herman Taylor when compared with the Wolf-Schind"ler gastroscope. This result is not surprising in view of the size and rigidity of the former instrument. Other studies suggest that an ACMI fiberscope is not a safer instrument than a Wolf-Schindler gastroscope in the hands of an experienced endoscopist. In contrast, the hazard of the gastrocamera would appear to be negligible.

l'ROGRESS IN GAS'l'ROEN'l'EIWLOGY

September 1967

TABLE

4!\7

1. Frequency of gastmscopic pe1jorations Perforation s

Author

Instrument

Year

No. of cases Pharynx or Stomcsophach agus

- 1951

Ariga 4

1966

Wolf -Schindler Herman Taylor Several gastroscopes

Hirschowitz" LoPresti 34 Cohen e t a!. 31 Morrissey et al."

1962 1962 1966 1966

ACMI ACMI ACMI ACMI

Jones et al. 100

fiberscope fiberscope fiberscope fiberscope

9,000 14,000 53,500

20

1

1 1 2 0

500 120 1, 514 300

- --Total Morrissey et al." Ariga 4

1966 1966

ACMI fiberscope Olympus GT-F fiberscope Several fiberscopes

Morrissey et al.• Ariga 4

19(i6 1966

Gastrocamera Gastrocamera

a

15

1 0 -

Total

-1 22 35 2 1 3

0

--

-

%

O.Oll

0.10 O.OG5 0.40 0.88 0.20 0.00

--

2,434 350 70,400

2 0 17

4

(i

0 4

0 21

0.25 0.00 O.D:l

1,700 829,700

0 10

0 15

0 25

0.00 0.003

Unpublished observations.

Smith and Tanner 101 have emphasized the role of cervical osteophytes in contributing to the increased hazard of endoscopy in the aged. Smith and Clifton102 have encouraged the use of gastroscopy in the aged, but their rate of perforation (0.39%) with a Wolf-Schindler gastroscope is relatively high. Delay in therapy greatly increases morbidity and mortality following esophageal perforation. 101 In contrast, gastric perforation103-105 is a more benign event, with pneumoperitoneum often the only evidence that perforation has occurred. The most common site of perforation is the high posterior wall of the body just below the gastroesophageal junction with subsequent leakage into the lesser sac. Attention was directed to the potential hazard of the lens gastroscope in producing gastric mucosal burns in dogs by Scott et al. 106 The hazard became clinically important when the ACMI fiberscope was used for prolonged viewing at maximal light intensity, particularly during cinegastroscopy.107-109 The hazard can be eliminated by the use of fiber optic light guides or by power supplies which permit synchronized intermittent flashing of the viewing lamp to prevent overheating. 27 • 37 • 38

Cardiac arrest110 is a rare but ever present hazard to endoscopy. Minor transient electrocardiographic changes were noted in 18 of 50 patients during lens gastroscopy in a study by Schuman and Gale. 111 Two instances 112 • 113 have been reported in which the ACMI fiberscope was retroflexed in the stomach and became impacted in the esophagus. On one occasion surgical removal was required.m The authors have had a similar experience with the GT-F gastrocamera fiberscope. With the availability of safer techniques for examining the cardia (gastrocameras and controllable tip fiberscopes), it is questionable if the older fiberscopes should be used for this purpose. In the view by Jones et al. 100 reactions to local anesthetics accounted for four deaths during the course of 49,000 gastroscopies. Three of these deaths were attributed to overdosage (240 mg or more of tetracaine) and one to idiosyncracy. Adriani and Campbell 114 collected a series of 15 deaths following tetracaine anesthesia. The majority of these deaths were associated with overdosage (more than 160 mg) by inexperienced physicians. These authors 114 and Vandam 115 have emphasized that the concentration used and the mode of admin-

468

PROGRESS I N GASTROENTEROLOGY TABLE

V ol. 53, No.3

2. jl,![ethods of preparation of patients for gastroscopy

Author

Liquid

Nar-

Barbi-

supper

co tic

tura te

L ocal anestl1etic

Antifoam

Gast ric

Cn,>pty-

Other

mg

------ -- --

Taylor 99 . .. . . . ....... .. .. . ' . . . . .... . .. Palmer 116 .. F ukuchi32 • ... . . ··· ·· ... . . . .. Barowsky et al. 33 . . .. .. . . .. . . . LoPresti 34 •. . . . . . . . . . . . .. . . . .. . Nelson 117 . ...... . ... . .... .. . . Zacharias et al.us. ..... .. . . . . .. . .. .. J ones 12 . . Hirsch owitz et al.'9. .. Bank et al. 11 9. . . ....... Perna e t al. 43 . .. . ... . . .. . . . .

Anticholinergic

+ 0 0

+

0 0 0

+ 0

0

0

0

±

+ + + + ± +

+ 0 +

+ + + + + +

0

istration are considerably less important than the t otal dosage in determining the peak blood level following the administration of tetracaine. They suggest a maximum dose of 100 mg per examination. Barbiturates do not exert a protective action in preventing tetracaine reactions in the sedative doses used in most endoscopic procedures. Preparation of the Patient for Endoscopy

All endoscopists agree on the importance of the psychological preparation of the patient for gastroscopy and in the use of "local" anesthesia during the procedure. However, there is great disagreement, illustrated in table 2, as to the relative value of narcotics, barbiturates, anticholinergics, local anesthesia, and gastric emptying in the preparation of patients for endoscopy. Double blind studies with careful statistical analysis are needed to evaluate each of the m any procedures recommended. Successful blind intragastric photography requires a well prep ared stomach. For this reason the authors have favored the u se of a liquid supper on the night prior to examination and emptying of the stomach with an Ewald tube prior to the procedure. Several endoscopists 120 • 121 have written on the value of silicone antifoam in preparing patients for gastroscopy. The authors have found dimethylpolysiloxane (Dow-Corning Antifoam C) a very useful preparation for this purpose, partie-

0 0

+ +

0 0

+ + 0 + + + + + +

Hyosc ine-N -b utyl bromide

0

+ +

+

0 0 0

Scopol a mine

+ +

Promethazine-1-ICI

ularly to reduce foaming in patients with Billroth II anastomoses. Emergent Endoscopy

Enthusiasts 116 • 122 - 127 continue to encourage the use of a vigorous diagnostic approach in the acute management of patients with upper gastrointestinal hemorrhage including esophagoscopy and gastroscopy with a lens gastroscope,n6, 1 2a, 124, 120 a fibergastroscope/ 25 or a combination of instruments.127 In all the reported series bleeding sites have been found in a high percentage of patients. However, incorrect endoscopic diagnoses were associated with the death of 2 patients in one study. 122 The vigorous use of ice water lavage by physicians experienced in passing large gastric tubes will frequently stop acute bleeding from the upper gastrointestinal tract. Thus the emergent endoscopy may have a therapeutic as well as a diagnostic value. What is missing from the reported studies is convincing evidence that morbidity and mortality were reduced by early diagnosis. A prospective study is needed in which random selection would be used to assign patients to either a vigorous or a standard diagnostic approach. A separate evaluation is needed of the role of ice water lavage in therapy. The Diagnosis of Gastric Cancer

In Japan gastric cancer is the most common and most feared ma lignant tumor in men. The incidence is approximately 4

September 1967

PROGRESS IN GASTROENTEROLOGY

times that found in the United States. Public awareness of this fact is such' that there has been very good acceptance of the mass screening programs which have been introduced to detect the disease. Physicians have been encouraged for as many as 50% of the cancers which were detected in some of these series were found to be in the early stage with involvement of only the mucosa and submucosa. In these surveys the initial examination is a barium meal photofluorogram which is performed by a technician. Twenty per cent of the individuals surveyed are called back, because of abnormal or equivocal X rays, for further studies which usually include gastrocamera examination with the GT-P gastrocamera. Standard barium meal examination with fluoroscopy, gastroscopy, cytology, or gastric biopsy may also be included as additional diagnostic procedures. In a series of 13,844 persons over 40 years of age examined in this way at Nihon University, Ariga and Takahashi 128 found an incidence of 0.56% gastric cancer, 0.2% gastric polyp, 2.3% gastric ulcer, and 4% duodenal ulcer. Ariga 129 reviewed the entire Japanese experience of 674,877 screening examinations. Six hundred nineteen or 0.092 % cases of gastric cancer were found, of which approximately one-third were in the early stages. Fewer cancers were found in the larger study because less endoscopy was done, more subjects were from large cities, and younger individuals were included in the survey. The much lower incidence of gastric cancer in the United States, the higher duodenal ulcer to gastric ulcer ratio, and the absence of public concern about gastric cancer would make such a mass survey in the United States impractical. On the other hand, the selection of a population of high risk patients, such as patients with pernicious anemia, for a routine annual survey might prove very worthwhile. Detailed consideration of early gastric cancer can be found in recent Japanese publications. 13°- 132 The availability of the gastrocamera has permitted Japanese endoscopists to make interesting observations on the behavior of gastric cancer, on the relation of

469

gastric ulcer to gastric cancer, and on the differentiation of benign and malignant ulcers. Sakita 133 made a study of the accuracy of the GT-5 gastrocamera in differentiating benign from malignant lesions. One advanced cancer was found among 84 patients operated on with the diagnosis of benign ulcer. All the other advanced cancers were correctly diagnosed, but 30% of the 70 early cancers limited to the mucosa were not recognized as malignancies. In 1963 Furusawa et al. described a stairlike defect found at the margin of the lesion in 80% of his patients with superficial spreading ulcer cancer of the stomach (description in English-1967 131 ) . In 90% of all patients showing this phenomenon carcinoma was found at operation. Kidokoro et aJ.l 35 made a detailed comparison of the endoscopic characteristics of 79 chronic benign ulcers and five early ulcerating cancers limited to the mucosa. Four of the five ulcer cancers had a stepwise depression of the ulcer margin, a characteristic seen in no benign ulcer. Irregular marginal elevations were seen in four benign and four malignant ulcers. Hemorrhage into the margin was seen in 11 benign and three malignant ulcers. An irregular base was seen in one cancer and three benign ulcers. Ikegawa et al. 130 confirmed the diagnostic value of a stepwise depression of the ulcer margin in a series of 33 ulcerations more than 2.5 em in diameter, 19 of which were malignant. The finding was not seen in any of the benign cases. Arai et aJ.l 47 describe a patient in whom an ulcerated carcinoma showed extensive healing over a 3-month period and a second patient in whom a benign-appearing ulceration completely healed during a 4-month period only to have an early cancer recur at the ulcer site 2 months later. Majima et aJ.l 38 reviewed the surgical specimens of 2484 patients resected for ulcer or cancer and found 25 instances of early ulcer carcinoma. Grossly these lesions were typical of chronic gastric ulcer. Thirteen patients had one or more small foci of cancer and 12 had a ring of mucosal cancer involving the circumfcr-

470

PROGRESS IN GAS'l'ROEN'l'EIWLOGY

ence of the ulcer. They believed that these lesions represented malignant degeneration of benign ulcers. Masuda et al,l 39 made a follow-up study of 952 patients with gastric ulcer. Three ulcers which had healed to scar formation recurred as carcinoma, two within 2 years. A cancer developed in a different area of the stomach in a fourth case. Y oshitoshi et al,l 40 made a long term follow-up study of 50 patients previously examined with the gastrocamera. Two gastric polyps after 7 and 9 years were unchanged in size or appearance. One of 15 ulcer patients showed a gastric cancer at the site of the previous ulcer after nearly 7 years. Review of the old film of this patient showed a depressed type of early cancer with central ulceration which had been overlooked on the initial reading. Ariga et al. 141 reported gastrocamera observations on 24 polyps, 19 of which were benign. Four of the five malignant polyps were over 2 em in diam and the fifth between 1 and 2 em in diam. Gastric Ulcer

Masuda et aU 42 described long term follow-up observations of the healing of 197 gastric ulcers. Nineteen of 44 round ulcers in the region of the angulus assumed a linear shape while healing. All of these lesions either failed to heal or relapsed within 3 months after healing. Wakabayashi et al. 143 confirmed the failure of linear ulcers to heal in 10 instances. These and many other Japanese authors advocate surgical treatment for linear ulcers near the angulus. Katsuki et al. 144 studied 55 cases of healed ulcer with simultaneous gastrocamera and X-ray examination. Gastrocamera examination revealed that 6 ulcers had healed leaving no defect, 12 ulcers with only reddening of the mucosa remaining, 27 ulcers with convergent folds, and 10 ulcers with a persistent crater-like defect remaining. Barium meal examinations in these same patients revealed 11 patients with ulcer simulating protrusions and 34 with irregularity or rigidity of gastric wall or convergence of mucosal folds. Only nine examinations were completely normal.

Vol . 53, N o. 3

Katsuki and his associates concluded that the X-ray is an inaccurate technique for determining the completeness of gastric ulcer healing, a finding which is in accord with the authors' experience. Hara 145 followed a series of 433 patients with medically treated gastric ulcers for 1 to 5 years. Eighty-three ulcers recurred, 72 of them at the site of previous ulceration as determined by gastrocamera examination. Thirty-two of these lesions recurred within 6 months. We have been advising a repeat gastrocamera examination for our gastric ulcer patients 6 months following the healing of the lesion. Hara's figures would support this policy. Another controversial subject is the condition known as erosive gastritis or multiple gastric erosions. Although this lesion has been frequently found, based on the reports of several endoscopists, the authors believe it is a rather rare conclition. Horan 146 considers this condition to represent "peptic ulcer in miniature." He believes it is associated with an acute clinical syndrome simulating duodenal or gastric ulcer and that the response to ulcer therapy is similar. We concur in this impression, having observed 2 patients with the condition who responded to ulcer therapy only to return 1 to 2 years later with recurrences of large, typical, and, in both cases, multiple gastric ulcers.



Gastritis

The subject of gastritis remains confused and controversial. Studies with lens gastroscopes have shown very poor correlation between gastroscopic diagnoses and histological findings. 14 7 - 149 The gastroscopic diagnosis of atrophy is to a great extent dependent on the visualization of submucosal vessels through the mucosa. Kidokoro et aU 50 found that the frequency with which vessels were seen was directly dependent on the degree of gastric distention. We question the significance of the presence of visible vessels in the dome of the gastric fundus when the stomach is maximally inflated; we have frequently observed these in healthy university students (unpublished observation). The most encouraging results have been reported by

September 1967

PROGRESS IN GASTROENTEROLOGY

Honda.m He was able to confirm histologically his gastrocamera diagnosis of gastric atrophy in 93% of patients and of superficial gastritis in 57%. These results should be confirmed by a study in which the films and slides are interpreted separately and blindly before it is accepted that the gastrocamera is superior to the conventional gastroscope for the diagnosis of gastric atrophy. In a gastrocamera study of aspirin toxicity to the gastric mucosa, we (unpub lished observation) were unable consistently to interpret, on blind reading of films, the extent of diffuse edema or erythema of the mucosa. Correlation between histology and gastroscopic appearance may be improved with the use of the newer biopsy instruments which permit more accurate biopsy under direct vision with simultaneous photographic recording of the mucosal appearance.u5· 07 It is possible that the newer techniques of ultraviolet 55 · 5G and fluorescence photography 58 may assist in the diagnosis of gastritis. REFERENCES 1. Pickert, H. 1957. Gastroscopic color photography. Amer. J. Dig. Dis. 7: 377-381. 2. Nelson, R. S. 1960. Progress in gastroscopic photography. Bull. Gastrosc. Esophagosc. 7(1):7-9. 3. Tasaka, S., and T. Sakita. 1967. Progress of gastrocamera examination. In Proceedings of the First Congress of the International Society of Endoscopy. In Press. 4. Ariga, K. 1966. The current aspect of endoscopic examination in J apan. Gastroent. En dose. 8: 7-19. 5. Colcher, H. 1966. Intragastric photography. Amer. J . Gastroent. 4: 374:..376. 6. Nelson, R. 1966. Intragastric photography. Amer. J. Gastroent. 45: 255-260. 7. Morrissey, J. F., T. Honda, Y. Hara, J . H. Juhl, and G. Perna. 1965. The use of the gastrocamera for the diagnosis of gastric ulcer. Gastroenterology 48: 711-717. 8. Smith, V. M. 1964. The pylorus-gastroscopic considerations. Bull. Gastroint. Endosc.10 (3): 11-14. 9. Namiki, M., and Y. Murazima. 1966. Problem of reading with miniature x-ray and films of GT-P. Gastroent. Enclose. 8: 58-

60.

471

10. Walk, L. 1966. The history of gastroscopy. Clio. Med.1: 209-222. 11. Bernstein, L. M., R. C. Fruin, and E. Gorvett. 1959. An esophagogastroscope for visualization of blind areas. Gastroenterology 37: 17-19. 12. Jones, F. A. 1963. Gastroscopy. London Clin. Med. J . I,: 25-32. 13. Sircus, W. 1956. Gastroscopy. Brit. J. Clin. Pract. 10: 579-588. 14. Zinberg, S. S., and J. E. Berk. 1966. The use of an endotracheal cuff to facilitate esophagoscopy and gastroscopy. Gastroint. Endosc.12(3): 26-27. 15. Berry, L. H., D. Feldman, and R. Schoop. 1963. Improved gastroscopic diagnosis by the use of multiple positions in 2,843 cases. Gastroenterology 44: 20-24. 16. Dagradi, A. E ., R. N. Killeen, and R. Schindler. 1958. Esophageal hiatus sliding hernia; an endoscopic study. Gastroenterology 85: 54-61. 17. Inokuchi, K., and M. Furusawa. 1966. A study of the Gastroviewer for examination of early gastric cancer at operation. Gastroent. Enclose. 8: 28-31. 18. Baird, J. L. 1928. British Patent 285,738. 19. Lamm, H. 1930. Biegsame optische Geriitc. Z. Instrumcntenkunde 50: 579-581. 20. Van Heel, A. C. S. 1954. A new method of transporting optical images without aberration. Nature (London) 178 : 39. 21. Hopkins, H. H ., and N. S. Kapany. 1954. A flexible fiberscope using static scanning. Nature (London) 173: 39-40. 22 . Curtiss, L. E., B. I. Hirschowitz, and C. W. Peters. 1957. A long fiberscope for internal medical examinations (abstr.). J. Opt. Soc. Amet'. .1,7 : 117. 23. Hirschowitz, B. I., L. E. Curtis, C. W. Peters, and H. M. Pollard. 1958. Demonstration of a new gastroscope, the "Fiberscope." Gastroenterology 35 : 50-53. 24. Hett, J . H., and L. E. Curtiss. 1961. Fiber optics duodenoscope and ureteroscope. J. Opt. Soc. Amer. 51: 581-582. 25. Goldman, J. A., B. S. Bereskin, and C. Shackney. 1965. Fiber optics in medicine. New Eng. J. Med. 273 : 1425-1426, 14771480. 26. Wallace, F. J. 1963. Fiber optic endoscopy. J. Urol. DO: 324-334. 27. Hirschowitz, B. I. 1965. Fiber optics in modern medicine . Med. Bioi. Ill us. 15: 224229. 28. Hirschowitz, B. I. 1961. Endoscopic examination of the stomach and duodenal cap with the fiberscope. Lancet 1: 1074-1094.

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PROGRESS IN GASTROENTEROLOGY

29. Hirschowitz, B. · I., J. A. Balint, and· W. F . Fulton. 1962. Gastroduodenal endoscopy with the fiberscope-an analysis of 500 cases. Surg. Clin. N. Amer. 42 : 1081-1090. 30 ... Burnett, W. 1962. An evaluation of the gastroduodenal fiberscope. Gut 3:. 361-365. 31. Cohen, N. N ., R. W. Hughes, and ' H . E. Manfredo. 1966. Experience with 1,000 fiber gastroscopic examinations oJ the stomach. Amer. J. Dig. Dis:.1 1: 943~950. 32. Fukuchi, S. 1964. The movement of the stomach observed through the fiberscope . In Abstrac.ts of the ·Si:cth Annual Meeting of the Japanese Gastroenterological Endoscopy Society, pp . 61-69. 33. Baro}Vsky, H. L ~ Greene, and D. Paulo . 1966. The effect of anticholinergic drugs on pyloric function recorded by cine gastroscopy. Gastroent. Enclose. 12 (3): 23-26. 34. Lopresti, P., N. D. Scher!, L. Greene, and J. T. Farrar. 1962. Clinical experience with a glass fiber gastroscope. Amer. J. Dig. Dis. 7: 95-101. 35. Takemoto, T. 1964. Value cif fiber gastroscopic examination for lesions of the cardia and upper corpus of the stomach. In Abstracts of the Sixth Annual Meeting of the Japanese Gastroentem logical Endoscopy Society, pp. 59-61. 36. Edwards, J. L., and A. I. Muggia. 1965. Examination of the gastric fundus with the fiber gastroscope. Amer. J. Dig. Dis. 10: 936-938. 37. Tsuneoka, K. 1965. A description of Japanese ( Machida) fiberscope. Gastroent. Endosc. 7: 134-136. 38. Kameya, S. 1965. Study of the new GFS fib erscope. Gastroent. Enclose. 7: 136-139. 39. Lange, F., and M. Meltzing. 1898. Photography of the stomach. Mlinchen . Med. Wschr. 45 : 1585-1588. 40. Heilpern, J ., and 0. Porges. 1930. A new method of gastric photography. Klin. Wschr. 9: 15-17. 41. Rafsky, H. A. 1942. Intragastric photographs in natural color. Rev. Gastroent. 9: 202. 42. Uji, T. 1952. The gastrocamera. Tokyo Med . J. 61: 135-138. 43. Perna, G., T. Honda, and J. F. Morrissey. 1965. Gastrocamera photography. Arch. Intern. M ed. (Chicago) 116: 434-441. 44. Kalokerinos, J., J. Hunt, and A. W. Pryor. 1965. The gastrocamera: its use, value, and recent developments. J. Col!. Radio!. Aust. 9: 52-58. 45. Milton, G. W., A. Lynch, and A. P. Skyring. 1965. The diagnosis of gastric lesions: an

Vol. 53, No. 3

: assessment of the role of the gastrocamera. Brit. J. Surg. 52: 607-612. 46. Hadley, G. D. 1965. The gastrocamera. Brit. Med. J. 2:,1209-1212. 47. Tanaka, Y., and J. F. Morrissey, 1967. An improved technique for examination of the stomach with the GT-5 gastrocamera. Gastroent. Endosc.13 (4): 8-11. 48. Tanaka, K. 1961. A study of the blind area with the GT-4 gastrocamera using a short focus lens. Gastroent. Enclose. 3: 154-159. 49. Fugimori, A. 1961. Studies of photography of certain areas of the stomach with the gastrocamera. Gastroent. En dose. 3 : 159162. 50. Okabe, H., and T. Yao. 1964. A study of the model GT-5 gastrocamera with an inflatable cuff attached. Gastroent. Enclose. 5: 380-382. 51. Nakayama, K. 1964. Technique of photography with Nakayama's retrograde model . II gastrocamera. Gastroent. Enclose. 6: 355. 52: Y oshitoshi, Y., T. Miwa, Y. Utsumi, K Tanaka, H. Niwa, and K. Omori. 1963. Gastrocamera diagnosis of the upper portion of the stomach. II. In Abstracts of the Fifth Annual Meeting of the Japanese Gastroenterological Endoscopy Society, pp. 78-81. 53. Ashizawa, S. 1964. A description of the model GT -5A gastrocamera. Gastroent. Enclose. 5: 358-359. 54. Omori, K. 1961. Clinical and experimental studies on the diagnosis of stomach cancer using gastrocamera. Gastroent. Enclose. 3: 257-288. 55. Kaneko, E., and Y. Yoshitoshi. 1963. Clinical and experimental studies on the early diagnosis of gastric cancer by gas trocamera using ultraviolet rays. Gastroent. Endosc. 5: 266-285. 56. Sakita, T ., and Y. Utsumi. 1964. Ultraviolet photography of the stomach. Med. Bioi. Illus. 14: 166-169. 57. Kaneko, E. Y. Utsumi, and Y. Yoshitoshi. 1967. On special photography of the gastric mucosa. In Proceedings of the First World Congress of Gastroenterology. In press. 58. Miwa, T. 1965. Studies on the course of gastric diseases and the new endoscopy m ethods. Gastroent. Enclose. 7: 263-283. 59. Takaishi, K., and Y. Suzuki. 1963. Stereo photography with the gastrocamera. In Abstracts of the Fifth Annual Meeting of the Japanese Gastroenterological Endoscopy Society, p. 84. 60. Sakamoto, M., K. Takaishi, and K. Kato.

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61.

· 62.

63.

64.

65.

66.

67.

68.

69.

70.

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