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Background A mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare. Case presentation: We have reported a case of a 71-year-old woman with aberrant A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 from the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins, and at the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after dissection of the inferior pulmonary vein. Then, the lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided. Conclusions Thoracic surgeons need to evaluate CT angiography or enhanced multidetector CT carefully at preoperative conferences and always keep this anomaly in mind.

Carcinomas rarely occur in the heart, and cardiac surgeons are generally not familiar with cardiac tumors. Some characteristics of cardiac and intrapericardial tumors are reviewed to understand the features of cardiac tumors. Cardiac tumors are discussed separately from intrapericardial tumors. Primary cardiac tumors are predominantly benign whereas primary intrapericardial tumors are usually malignant. The prevalence of each tumor types is presented in this review. In both cardiac and intrapericardial tumors, the incidences of metastatic tumors from cancers outside of the heart are high with carcinomas occupying more than half of the cases. Generally, the prognosis of primary malignant cardiac tumors is very poor. Cardiac tumors metastasize to other organs as hematogenous metastases. Surgery must be performed based on all the above-mentioned features of both cardiac and intrapericardial tumors.

Mediastinal schwannomas are sometimes diagnosed as pericardial or bronchogenic cysts, if cystic degeneration is extensive. When mediastinal schwannomas are not diagnosed as primary cardiac tumors, the use of cardiopulmonary bypass in their resection appears to be infrequent. We report the case of a 48-year-old woman who presented with symptoms from a suspected intrapericardial cyst. Multiple diagnostic images revealed a large mass, potentially a proteinaceous or hemorrhagic cyst, in the transverse sinus behind the ascending aorta and against the left main trunk. After complete resection with the use of cardiopulmonary bypass, the mass was identified as a benign extracardiac schwannoma. More than 3 years postoperatively, the patient had no relevant symptoms. We discuss the preoperative diagnosis, the method of resection, and our broad strategy for dealing with such a case.

In this report we describe a special method of using a pedicled latissimus dorsi muscle flap for a mycotic aneurysm. The method involves wrapping the flap around a prosthetic graft. Using this method, an in situ graft, which replaces an aneurysm, can help to avoid recurrence of local infection.

Primary intrapericardial tumors in adults, whether benign or malignant are rare. Surgical treatment for these tumors are reviewed together with their incidence, classification, clinical features, and diagnosis. doi: 10.1111/jocs.12164 (J Card Surg 2013;28:529–532)

Reports describing solitary fibrous tumors of the pericardium are rare. Surgical treatment was performed on a 49-year-old woman with a large pericardial mass. The mass was attached to the left ventricular wall with a broad stalk and was free of the parietal pericardium. It was apparent macroscopically that the tumor had invaded the left ventricular muscle. On histopathology, the tumor was diagnosed as a solitary fibrous tumor with low-grade malignancy.

Surgery was performed on a 53-year-old male patient with a painful mass in front of the elbow. The mass originally occurred after needle insertion during a routine health checkup and grew in size during a 1-year period. Intravenous tumor with arterio-venous fistula was diagnosed, and it was resected. Histopathological diagnosis of intravenous lobular capillary hemangioma was made. Occurrence of this tumor after a routine health checkup is rare. The etiology of this tumor occurring simultaneously with arteriovenous fistula is discussed.

Primary cardiac solitary fibrous tumors were reviewed. They are classified as pericardial tumors. Their incidences are very rare. Only 16 cases were reported in the literature. Basically, surgical treatments are performed. Their prognoses are generally good, although malignant cases are also reported.

A 35-year-old female presented with nonsustained ventricular tachycardia (NSVT) and a large intrapericardial mass. The mass was attached to the left ventricular wall with a broad stalk. On histopathology, the tumor was diagnosed as a lipoma. Postoperatively, the NSVT disappeared. doi: 10.1111/jocs.12095 (J Card Surg 2013;28:268–270)

OBJECTIVE To report a case of drug-induced hypersensitivity syndrome related to codeine phosphate. CASE SUMMARY A 19-year-old Japanese man was prescribed codeine phosphate 10 mg 3 times daily and several other drugs for cold symptoms. About 20 days later, an erythematous, maculopapular rash appeared and progressed to erythroderma; a spiking fever also developed. He had splenomegaly and generalized lymphadenopathy on admission. Laboratory examinations showed atypical lymphocytosis, eosinophilia, and increased liver enzyme values. The platelet count slowly decreased after admission. The increased numbers of megakaryocytes in bone marrow and platelet-associated immunoglobulin (Ig) G antibodies in serum were compatible with a diagnosis of immune thrombocytopenic purpura. A significant increase in IgG antibodies to human herpesvirus 6 (HHV6) and transient viremia were helpful in diagnosing hypersensitivity syndrome. The results of patch tests were positive for codeine phosphate. An objective causality assessment revealed that an adverse drug event was probable. DISCUSSION Codeine is an opioid analgesic. Severe adverse cutaneous reactions rarely occur. As of March 3, 2004, our case is, to our knowledge, the first report of hypersensitivity syndrome attributed to codeine phosphate. Drug-induced hypersensitivity syndrome is an acute, potentially life-threatening, idiosyncratic adverse reaction caused mainly by aromatic anticonvulsants. It is characterized by the triad of fever, skin rash, and internal organ involvement. Reactivation of HHV6 is involved in the pathogenesis of this syndrome and may have also caused the immune thrombocytopenic purpura in our patient. CONCLUSIONS Codeine phosphate may rarely be associated with hypersensitivity syndrome. Clinicians should be aware that the potentially fatal syndrome can be caused by various drugs.

Background: Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown. Methods: Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery. Results: Pre-to-postoperative change in vital capacity was 74.3 ± 10.6% in the thoracotomy group and 84.9 ± 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 ± 0.62 in the thoracotomy group and 0.55 ± 0.51 in the thoracoscopy group (p = 0.0003). Conclusions: Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.

症例は64歳の男性. 平成14年1月初旬より嚥下困難が出現し, 食道造影で頸胸境界部食道の右側に約2.5cmの隆起性病変を認め, 上部消化管内視鏡検査では, 門歯列より約20cmの食道右壁に1pl型の隆起性病変を認めた. CT, 超音波検査では明らかなリンパ節転移, 血行性転移は認めなかった. 以上より, T2N0M0, Stage IIの頸胸境界部食道癌と診断し, 平成14年5月8日に胸腔鏡下食道切除術および3領域リンパ節郭清術を施行した. 腫瘍は肉眼的に径22×16mm, 1pl型で, 病理組織診断では類基底細胞癌であった. 深達度はsmでly0, v1, pN0, pStage Ibであった. 類基底細胞癌は非常にまれであり, 予後不良とされている. リンパ節転移のない表在型は予後がよいとの報告もあるが, 頸胸境界部食道に発生した表在型類基底細胞癌は本邦では報告例がなく, また細胞増殖能が高いことより再発に留意し経過観察中である.

はじめに: pT3食道癌に対する根治術としての胸腔鏡下食道切除の是非について, historical controlであるが通常開胸例と比較することにより検討した.対象と方法: 胸腔鏡下に食道切除・リンパ節郭清を行ったpT3食道癌28例 (VATS群) と胸腔鏡下食道切除術導入以前に右開胸下に根治術を行ったpT3食道癌39例 (Control群) の臨床病理学的因子や手術侵襲の諸因子および術後合併症, 予後, 再発形式を比較した.結果: 両群の背景因子には差がなく, 胸腔内操作時間・出血量にも差がなかった. 術後合併症としては肺炎が最も多く, VATS群では乳び胸が2例にみられた. 5年生存率はVATS群53.6%・Control群45.1%で差がなく, リンパ節転移陽性例のみの生存率にも差がなかった.考察: pT3食道癌に対しても胸腔鏡下手術で従来の通常開胸と同等の根治性が得られた.

Hassab手術後に門脈血栓を形成した1例を経験した. 症例は51歳の男性. 肝硬変, 食道静脈瘤で外来通院中, 食道静脈瘤の増悪を認め, 内視鏡的硬化療法を施行するもRC (+) の食道静脈瘤ならびに胃静脈瘤の残存があり, また著しい汎血球減少症を認め, Hassab手術を施行した. 術後, 経口摂取開始とともに予防的にアスピリン81mg日の投与を行ったが, 肝内門脈ならびに肝外門脈に血栓を認めた. ただちに, ウロキナーゼ, 低分子ヘパリン, メシル酸ガベキサートの経静脈的投与を行ったところ, 数日後には血栓溶解が始まり, 10日後には, ほぼ肝内門脈, 門脈本幹の血栓が溶解された.Hassab手術の合併症として, 門脈血栓症は重大であり, 術後, 血小板凝集抑制剤の投与とともに, 画像診断にて門脈血栓形成が確認されれば, ただちに血栓溶解療法を開始し, 十分な血栓溶解が得られれば, 抗凝固療法に変更することが肝要であると思われた.

食道癌切除後, 後縦隔再建胃管に発生した胃癌に対し, 胃全摘・リンパ節郭清を施行した1例を報告する. 症例は69歳の男性で, 胸部食道癌(Im, 0-II c+III, A0, N0, M0, P10, stage I, 中分化型扁平上皮癌, sm, n0, infα, ie (+), ly0, v0, stage 0)に対し, 胸腔鏡下食道亜全摘・3領域リンパ節郭清・後縦隔胃管再建を施行後, 2年4か月目の1998年1月, 幽門部小弯にIIa+IIc型胃癌を認めた. 超音波内視鏡検査で深達度SM・N1(+)と判断し, 1998年4月開胸開腹下再建胃全摘術, 残存1群・2群リンパ節郭清, 後縦隔有茎空腸再建を行った. 病理組織検査では中分化型腺癌, 深達度m, n0, ly0, v0, stage Iaであった. 食道癌根治術後, 後縦隔再建胃管癌に対する切除術は癒着などにより困難が予想される. しかし根治可能であれば, リンパ節郭清を含めた胃全摘術を行うことが望ましいと思われた. 胸腔鏡下手術は胸腔内癒着の軽減に寄与すると考えられた.

Two hundred and twenty-five patients with intrathoracic enophageal cancer received extended lymphadenectomy were subjected to a study of the diagnosis of cervical node involvement and the indication of lymphadenectomy. In this study, lymph nodes No.100, 104 and a part of No.101, 102 which demanded cervical approach for dissection were designated cervical lymph nodes. Metastasis to the cervical nodes was found in 17 (8%) patients and a mean number of metastasized nodes was as many as 11.5. Of these 17 patients, no recurrence-free long-term survivor was noted. In six cases of them, cervical nodes involved were less in the depth of invasion as well as the number, but there were many cases of so-called “lymphatic dissemination”. It was thought that the significance of cervical node dissection might be low especially in Ei cases. Cervical lymph nodes are significantly smaller than those of the chest and abdomen. By ROC analysis, the best diagnostic size of cervical nodes for metastasis was the largest diameter of 5mm or more with sensitivity of 80% and specificity of 68%. In conclusion, the patients with metastasis to the cervical nodes might be in a state of lymphatic dissemination with a poor prognosis. Neoadjuvant multimodality therapy should be consider for the patients with nodes lager than 5mm in diameter detected by ultrasonographic examination of the neck.

Case reports of traumatic aortic regurgitation caused by detached commissures are rare. We report a case of a 56-year-old man involved in a traffic accident. During his hospitalization for subdural hematoma and pulmonary contusion, he began to suffer from heart failure. He was operated on under diagnosis of severe aortic regurgitaion. The commissure between the left and the noncoronary cusps was largely detached from the aortic wall, which was easily estimated to be the cause of the prediagnosed left cusp prolapse. His aortic valve was replaced, and his postoperative course was uneventful.

胸腔鏡補助下に切除した肋骨原発好酸球性肉芽腫の1例を報告する.症例は59歳, 男性.右胸痛を主訴とし, 単純X線撮影で右第4肋骨の融解像および胸部CT像では骨融解を伴う腫瘍陰影を認めた.RIを含む全身検索では他に異常を認めなかったため, 原発性肋骨腫瘍の診断で手術を施行した.皮切は後側方切開で腹側を後腋窩線までにとどめた縮小切開とし, 第7肋間の2ヵ所からトラコポートを挿入, 腫瘍の進展範囲を胸腔内からも観察しつつ切除した.胸腔鏡補助による胸壁切除は皮膚切開および肋間筋切離を縮小し, かつ安全に行いうることから, 非常に有用な手技であると思われた.病理組織学的には好酸球性肉芽腫と診断されたが, 肋骨原発は比較的稀である.治療は手術的に切除されることが多いが, 他臓器病変の出現にも留意して経過観察が必要である.

A 35-year-old female presented with nonsustained ventricular tachycardia (NSVT) and a large intrapericardial mass. The mass was attached to the left ventricular wall with a broad stalk. On histopathology, the tumor was diagnosed as a lipoma. Postoperatively, the NSVT disappeared.

We present a 62-year-old man with mitral regurgitation whose posterior annulus had severe calcification. Mitral valve replacement was performed by anchoring the cuff on a double-plicated posterior leaflet, and reinforcing with an equine pericardium. The patient is doing well 13 years after surgery with echocardiography showing no problems.

During a 1-year period, intra-aortic balloon pumps (IABPs) were used in open heart surgery on 57 patients. Indications were prophylactic usage for coronary artery bypass grafting (CABG) in 52 patients, prophylactic usage for valve replacement in three patients, and cardiopulmonary bypass (CPB) weaning during valve replacement in two patients. The 52 CABG patients comprised 94.5% of all CABG procedures during the period. Sheathless 8 Fr IABPs were used in all cases. The 57 patients using IABPs were analyzed. The mean duration of IABP use was 41.7 h. Morbidity was not associated with using IABPs. There was one case of balloon rupture. Hemostasis was performed easily after removing IABP catheters by compressing the groin for approximately 15 min. The lowest blood pressure during anastomosis or cardiac arrest was also assessed. The lowest peak pressure was 55.9 ± 17.3 mm Hg for patients with IABP still turned on, and the lowest mean pressure was 34.7 ± 6.5 mm Hg for patients with IABP temporarily turned off. Peak blood pressure after CPB was 73.8 ± 17.8 mm Hg. During open heart surgery under anesthesia with the low blood pressure presented by this series, use of IABPs enabled patients to tolerate the procedure. In conclusion, aggressive use of IABPs is easy, safe, and effective with no related morbidity.

In cardiomyoplasty (CMP), the strength of a skeletal muscle increases as the stimulating voltage in creases. On the other hand, timing of stimulation in CMP is a problem not yet solved. This experiment assessed the relationship between stimulating voltage and time characteristics in the contraction of skeletal muscles. In acute experiments using rabbits, the time required to reach maximal muscle contraction did not change significantly with voltage. In conclusion, stimulation voltage does not affect time characteristics. Thus, the best timing of stimulation in CMP can be assessed independently of voltage.

The newly developed Nikkiso HMS–15 is a miniaturized centrifugal pump. It has an impeller diameter of only 50 mm and a priming volume of only 25 ml. A totally new approach was applied to develop this very small pump. The new pump showed comparable hemolysis with pumps twice as big (e. g., the most widely used coneshaped centrifugal pump [index of hemolysis, 0. 005]). This finding refutes the belief that the pump diameter must be sufficiently large in size. Clinical application for cardiac assist was performed for 48 h without any thrombus formation despite low heparin dosage. Also, the pump showed quite favorable blood trauma when applied as a pump for cardiopulmonary bypass during open heart surgery. The compactness, the high controllability, and the system versatility proved to be very effective for clinical application. This pump is considered very reliable for its highly optimized design.

修正大血管転位16例に心室中隔欠損閉鎖を行った.手術時年齢は10か月より25歳であった.心室中隔欠損は,3例で経右室切開により,5例で経左室切開により,さらには8例でde Leval法により閉鎖された.心室の名称は解剖学的用語を用いた.de Leval法の左室-肺動脈心外導管を造設した1例を術後2日目に低心拍出量症候群により失った.遠隔死亡は左室切開法の突然死の1例と,右室切開法の4例(左側房室弁閉鎖不全の弁置換再手術後の心不全死2例,突然死1例,肺炎による1例)の計5例であった.術後新たに完全房室blockが左室切開法の2例に生じ永久pacemaker植込みを行った.左側房室弁閉鎖不全が右室切開法の2例とde Leval法の1例に生じ,いずれも弁置換を行った.8例で術後遠隔期に行ったgated radionuclide ventriculographyから求めた体心室駆出率は,左室切開法の2例が0.38, 0.47,右室切開法の1例が0.13, de Leval法の5例が0.29, 0.54, 0.66, 0.47, 0.36であった.本症の心室中隔欠損の閉鎖術式として,左室切開法では房室blockの発生が,右室切開法では左側房室弁閉鎖不全と体心室機能不全による遠隔死亡が多く,右房切開,de Leval法が最も有利と考えられた.

Surgical correction of adult complex aortic coarctation using hypothermic circulatory arrest often requires central cannulation to secure cerebral perfusion. It is not easy to place the cannula in the ascending aorta, however, especially in children undergoing surgery through a left thoracotomy. In a 12-year-old male with hypoplastic distal aortic arch, we placed an arterial cannula in the ascending aorta using the Seldinger puncture technique through the stenotic segment of the distal aortic arch. Replacement of the stenotic segment with a 20 mm-size Dacron graft was then routine. The ascending aorta was exposed only for the proximal anastomosis. The left subclavian artery was also reconstructed. This central cannulation technique is simple and is useful in repairing complex aortic coarctation.

We present the results of the numerical analysis for the wave drag reduction by a single pulse energy deposition in the supersonic flowfield around a sphere. The wave drag for the sphere is reduced as a result of the interaction between the blast wave produced by the energy deposition and the bow shock developed in front of the sphere. We have investigated the interaction mechanism and the drag reduction effect by the pulse energy deposition. The optimal energy deposition conditions to obtain the maximum drag reduction effect are found by the parametric studies varying the amount and the location of energy deposition. It is also found that the drag reduction effect is proportional to the freestream Mach number under the constant energy deposition condition.

A 24-year-old woman who had undergone excision of the membrane for discrete subaortic stenosis when 6 years old displayed recurrent subaortic stenosis and had a small aortic annulus, with a peak pressure gradient of 60mmHg. We chose to perform the Konno operation with a mechanical valve. This released the left ventricular outflow tract obstruction adequately, and she recovered uneventfully with New York Heart Association functional class I. In our experience, an aggressive strategy such as myectomy is an appropriate initial procedure for preventing recurrence when the geometry of the problem may lead to recurrence in the left ventricular outflow tract. The Konno operation is a good option for recurrent subaortic stenosis with small aortic annulus.

Objective: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. Methods: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n = 6). Antegrade systemic perfusion via ascending aorta was performed. Results: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32 = 3.1%), two cases of cerebral infarction (2/32 = 6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32 = 90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. Conclusions: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Acute type III perforation caused by failed angioplasty is a lethal complication that often requires emergency operation. However, the presence of multiple rigid stents beneath the subepicardial hematoma disturbs optimal revascularization and hemostasis. Teflon felt (Meadox Medical Inc, Oakland, NJ) wrapping repair is a simple salvage technique that allows stable hemostasis and the rescue of the entire blood flow of the coronary artery. This procedure was successfully performed with type III perforation of the left anterior descending coronary artery on 2 patients subjected to multiple stenting.

Helicobacter pylori infection is known to induce gastritis, oxidative stress, and cyclooxygenase (COX)-2 expression in the gastric mucosa. However, the effect of H. pylori infection on remnant gastritis has not been studied. We investigated whether the severity of remnant gastritis and COX-2 expression were affected by H. pylori infection after distal gastrectomy.The study included 97 patients with gastric cancer who underwent curative distal gastrectomy with lymphadenectomy in our department between May 1999 and April 2001. All patients underwent endoscopic examination 2 weeks before and 12 weeks after surgery. The presence of H. pylori infection was determined by urease activity, hematoxylin-eosin staining, and immunochemical staining. Histologic remnant gastritis was graded based on the degree of neutrophil infiltration using the updated Sydney System. COX-2 expression was estimated immunohistochemically.Both the degree of neutrophil infiltration and the level of COX-2 expression were significantly higher in patients with than without H. pylori (p0.05). There was a significant correlation between the degree of neutrophil infiltration and the degree of COX-2 expression (p0.001).H. pylori eradication may become a treatment for preventing both remnant gastritis as well as remnant gastric carcinoma after distal gastrectomy.

Patients who undergo distal gastrectomy often develop duodenogastric reflux and preoperative H. pylori infection is eradicated spontaneously after distal gastrectomy in some patients. However, whether a causal relationship exists has not yet been studied. This report examines the correlation between H. pylori eradication and the amount of duodenogastric reflux following distal gastrectomy.Among 72 consecutive patients who underwent curative distal gastrectomy with radical lymphadenectomy for gastric cancer, 37 patients had H. pylori infection preoperatively and were included in this study. The period of bile reflux (percent time) into the gastric remnant was measured with the Bilitec 2000 under standardized conditions on the 14th day after the surgery. Endoscopic examination was performed to determine the presence of H. pylori infection on week 12 after surgery.The percent time was higher in patients whose H. pylori infection had been eradicated after distal gastrectomy (58.1+/-9.2%) than in patients who had H. pylori infection after distal gastrectomy (33.8+/-5.7%).Duodenogastric reflux correlates with spontaneous eradication of H. pylori infection following distal gastrectomy.

A 55-year-old man was referred to us after transverse colostomy for intestinal obstruction caused by descending colon cancer with peritoneal dissemination. The colon lesion was palpated as a well-defined hard mass in the left lower abdomen and the disseminated lesion as a hard mass with an unclear border in the right lower abdomen. CEA level was 917 ng/ml at admission. Left hemicolectomy was performed for tumor reduction and TS-1 of 120 mg/day was started 6 days after surgery (4 weeks administration followed by a 2-week rest period). Administration discontinued due to nausea 4 weeks after commencement of the therapy, and restarted as a 2-week administration followed by a 2-week rest period. There has been no adverse reaction since then. Twenty-seven weeks after surgery, CEA level was reduced to 47 ng/ml and peritoneal dissemination was found to have disappeared upon physical examination and computed tomograph. TS-1 is expected to be an effective agent for the treatment of colon cancer with peritoneal dissemination.

We report a case of synchronous esophageal and gastric cancer in a patient with severe liver dysfunction who was treated successfully using TS-1/CDDP therapy combined with irradiation therapy. A 56-year-old man with a chief complaint of dysphagia was diagnosed with thoracic esophageal cancer by endoscopy, and was referred to our hospital. Synchronous esophageal and gastric cancer were diagnosed by endoscopy and barium swallow. The preoperative diagnosis was T3N0M0, Stage II esophageal cancer and T1N0M0, Stage I A gastric cancer, both of which were diagnosed to be resectable. However, surgery was contraindicated because of severe liver dysfunction, due to an ICG15 of 35%. TS-1 (80 mg/day) and CDDP (3 mg/day) therapy was combined with irradiation, 60 Gy given in a T-pattern to the mediastinum. The patient did not suffer any side-effects, and endoscopy performed 44 days after the start of treatment showed that the esophageal lesion was now only a scar. Only a slight elevation of the esophagus was seen by endoscopy 219 days after the start of the therapy. The patient is currently undergoing only TS-1 treatment as an outpatient and is under observation. No metastasis to the liver or any other organ has been detected. TS-1 and CDDP therapy combined with radiotherapy appears to be effective in treating thoracic esophageal cancer.

We report a case of esophageal cancer infiltrating the left main bronchus in which radical esophagectomy with clear surgical margins could be performed after preoperative radiochemotherapy. The patient was a 57-year-old man, who was found to have esophageal squamous cell carcinoma of the middle thoracic esophagus during a work-up of dysphagia. Bronchoscopy revealed an elevated region protruding into the lumen of the left main bronchus. After radiochemotherapy (liniac irradiation + low-dose FP therapy), the esophageal and bronchial lesion became smaller. The case was evaluated as a clinically complete response. Bronchoscopic ultrasonography showed a clear boundary between the membranous portion of the trachea and the esophageal wall. Based on these findings, the lesion was considered resectable and radical surgery, including 3-field lymph node dissection, was performed. The resected esophageal specimen had residual cancer cells in the muscularis propria covered with normal mucosa. However, the patient is currently healthy with no evidence of disease. The indication for surgical resection in cases of esophageal cancer with contiguous spread, and a good response to preoperative radiochemotherapy, is controversial. It is necessary to verify the effectiveness of surgical resection, as a secondary treatment, by accumulating data on cases such as the present one.

A no change (NC) status could be maintained in a patient with remnant gastric cancer for more than 500 days with low-dose TS-1. The patient was a 68-year-old woman who was found to have remnant gastric cancer during an endoscopic examination in follow-up on an outpatient basis after surgery for hepatocellular carcinoma in our department. Surgery was rejected as a treatment option because of severe liver dysfunction, and the patient was started on oral TS-1 80 mg/day. Both AST and ALT levels increased immediately after the start of TS-1, and TS-1 was discontinued until these levels improved. It was resumed at 50 mg/day, and there were no subsequent adverse reactions. Endoscopic examination on day 69 after the start of TS-1 showed that a partial response (PR) had not been achieved, but the lesion had shrunk. Endoscopy on day 454 after the start of TS-1 showed it had been possible to maintain a similar state. This was a rare case in which it was possible to achieve prolonged same status with low-dose TS-1.

The patient was a 69-year-old man who, during a routine health examination, was found to have irregular mucosa in the lower esophagus, which was subsequently diagnosed by endoscopy as Barrett's esophagus. Endoscopic ultrasonography led to the diagnosis of advanced esophageal cancer with a depth of invasion corresponding to T2. While surgery was indicated, it was not considered feasible because of pleural adhesions due to old tuberculosis. Therefore, chemotherapy with TS-1 at the dose of 80 mg/day (4-week therapy followed by a 2-week withdrawal period) and CDDP at the dose of 3 mg/day (4-week of 5-day therapy followed by a 2-day withdrawal period) was instituted, followed 3 weeks later by the addition of radiotherapy with 1.8 Gy/day (5 times/week). Follow-up endoscopy revealed evident reduction in the lesion size 73 days after the start of TS-1 therapy, and complete disappearance of the lesion 185 days after the start of therapy. Grade 1 leukopenia was the only adverse effect of TS-1 noted in the patient. Treatment of Barrett's esophageal cancer is often conducted in accordance with the principles of treatment of esophageal squamous cell carcinoma, and surgical resection represents the most effective treatment. On the other hand, there have been no reports of effective adjuvant therapy. Based on our experience, the therapeutic strategy employed in this patient is considered to offer promise for the treatment of Barrett's esophageal cancer.

Background . In ministernotomy operations for valvular and congenital heart diseases, several approaches exist. Because topographical relationships of the sternum, ribs, heart, and great vessels differ slightly with each patient, three-dimensional (3D) computed tomography (CT) images are valuable in deciding the best approach for each patient. Methods . Ministernotomy patients were studied preoperatively using 3D-CT images. By subtracting some parts of the sternum and the ribs from the 3D images, the topographical relationships of the structures were revealed. Results . Different methods of approach (ie, the site, shape, and length of partial sternotomy) were compared on the 3D images of each patient to decide the most appropriate incision. The images were shown to resemble closely the actual operative field. Conclusions . Three-dimensional CT images are valuable in preoperative planning of ministernotomy, and are essential to individualized planning for each operation.

We evaluated the applicability and effectiveness of support with a combination of an extra-aortic balloon (EAB) and a ventricular assist cup (VAC), using an acute heart failure model. Under general anesthesia, ten adult dogs were used. Through median sternotomy, an EAB was placed around the ascending aorta and a VAC in the pericardial cavity. After heart failure was induced by the administration of propranolol, on-off tests of devices were performed as follows: EAB only; VAC only; and both devices in operation. Regional blood flows (RBFs) in both ventricles and in the liver, kidney, and brain were measured using a colored microsphere technique. Aortic flow and cardiac output were also measured. In the heart failure model, aortic flow and cardiac output decreased to 65% and 66% of the control value, respectively. With assistance by the EAB only, RBFs in both ventricle and brain increased significantly. With only the VAC on, RBFs in all but the left ventricle significantly increased. With both the EAB and the VAC on, all five RBFs significantly increased. These results suggest that the combination of EAB and VAC is applicable and effective, and would be a very promising implantable device for chronic heart failure.