[A very elderly case of recurrent gastric cancer with peritoneal dissemination effectively treated by combination chemotherapy of docetaxel (DOC) and S-1].

We report a case of a 77-year-old man with gastric cancer of Borrmann type 3, pyloric stenosis and liver invasion. Distal gastrectomy with liver film resection was performed. Pathological staging was IV(sig, pT4, pN2, H0, P0, CY0, M0, ly3, v3). We recommended adjuvant chemotherapy but the patient refused. He was diagnosed with a recurrence of peritoneal dissemination 4 months after the operation. He received docetaxel(DOC)at a starting dose of 40 mg/m2 by iv infusion on day 1 and S- 1 at a full dose of 100 mg/body daily for two weeks every three weeks. After 5 cycles of this combination therapy, the gastric cancer with peritoneal dissemination completely disappeared. He was recognized to have grade 2 hematologic toxicity, hand foot syndrome and stomatitis, and all treatment-related toxicities were resolved. No re-growth of gastric cancer has been seen for 9 months with this chemotherapy.

Sarpogrelate hydrochloride reduced intimal hyperplasia in experimental rabbit vein graft.

OBJECTIVES: The selective 5-HT(2A) receptor antagonist sarpogrelate has been clinically used for treatment in atherosclerotic diseases. However, it remains unknown whether administration of sarpogrelate inhibits intimal hyperplasia seen in autologous vein grafts. Therefore, we sought to clarify this question using an experimental rabbit vein graft model. METHODS: Male rabbits were divided into two groups: a control group and a sarpogrelate-treated group. The jugular vein was interposed in the carotid artery in reversed fashion for 4 weeks and intimal hyperplasia of the grafted vein was measured (n = 8, in each group). Acetylcholine (ACh)-induced endothelium-dependent relaxation was tested by precontraction with prostaglandin F(2alpha) (PGF(2alpha), 5 muM) (n = 5, in each). endothelial nitric oxide synthase (eNOS) protein expression and superoxide production of these veins were also assessed. RESULTS: The suppression of intimal hyperplasia was significantly greater in the sarpogrelate-treated group than in the control group. ACh induced an endothelium-dependent relaxation in the sarpogrelate-treated group (but not in the control group). In endothelium-intact strips from the sarpogrelate-treated group, the nitric oxide (NO) synthase inhibitor nitroarginine enhanced the PGF(2alpha)-induced contraction and blocked the ACh-induced relaxation. Immunoreactive eNOS protein expression was similar between the two groups but superoxide production (estimated from ethidium fluorescence) in endothelial cells was significantly smaller in the sarpogrelate-treated group. CONCLUSION: The present results indicate that in vivo blockade of 5-HT(2A) receptors leads to an inhibition of intimal hyperplasia in rabbit vein graft. It is suggested that an increased function of endothelium-derived NO through a reduction in endothelial superoxide production may be a possible underlying mechanism for this. These novel findings support the clinical usefulness of sarpogrelate for preventing intimal hyperplasia in vein graft after bypass grafting.

Hemoptysis as a presenting symptom of a distal aortic arch aneurysm and its repair via an L-shaped thoracotomy.

A 61-year-old man presented with multiple episodes of hemoptysis. A computed tomography scan revealed a 70-mm saccular aneurysm of the distal aortic arch. During a surgical repair via a midline sternotomy and a left thoracotomy, a saccular aneurysm was found to protrude into the lung, which had chronically healed. The patient underwent replacement of the Dacron graft, and he recovered well postoperatively. This experience prompted us to report the findings of this unique case.

The cuff technique for reconstructing an isolated left vertebral artery in total arch-replacement surgery.

In total arch-replacement surgery, careful attention must be paid to the presence of anomalous arch vessels, because their presence may require surgeons to change the brain-protection strategy during deep hypothermic circulatory arrest and selective cerebral perfusion. The anomaly we most often encounter is an isolated left vertebral artery (ILVA). We describe a case involving a straightforward but physiological way of reconstructing the ILVA in which a cuff is hollowed together with the left subclavian artery.

New MT-ND6 and NDUFA1 mutations in mitochondrial respiratory chain disorders.

OBJECTIVE: Mitochondrial respiratory chain disorder (MRCD) is an intractable disease of infants with variable clinical symptoms. Our goal was to identify the causative mutations in MRCD patients. METHODS: The subjects were 90 children diagnosed with MRCD by enzyme assay. We analyzed whole mitochondrial DNA (mtDNA) sequences. A cybrid study was performed in two patients. Whole exome sequencing was performed for one of these two patients whose mtDNA variant was confirmed as non-pathogenic. RESULTS: Whole mtDNA sequences identified 29 mtDNA variants in 29 patients (13 were previously reported, the other 13 variants and three deletions were novel). The remaining 61 patients had no pathogenic mutations in their mtDNA. Of the 13 patients harboring unreported mtDNA variants, we excluded seven variants by manual curation. Of the remaining six variants, we selected two Leigh syndrome patients whose mitochondrial enzyme activity was decreased in their fibroblasts and performed a cybrid study. We confirmed that m.14439G>A (MT-ND6) was pathogenic, while m.1356A>G (mitochondrial 12S rRNA) was shown to be a non-pathogenic polymorphism. Exome sequencing and a complementation study of the latter patient identified a novel c.55C>T hemizygous missense mutation in the nuclear-encoded gene NDUFA1. INTERPRETATION: Our results demonstrate that it is important to perform whole mtDNA sequencing rather than only typing reported mutations. Cybrid assays are also useful to diagnose the pathogenicity of mtDNA variants, and whole exome sequencing is a powerful tool to diagnose nuclear gene mutations as molecular diagnosis can provide a lead to appropriate genetic counseling.

Transumbilical Hidden-Scar High Anterior Resection for Sigmoid Colon Cancer Using GelPOINT® Through an Umbilical Zigzag Skin Incision.

Introduction: Hidden-scar surgery is a new method by which surgeons perform abdominal operations through one incision made in the folds of the patient's umbilicus. However, with a straight incision in the umbilicus, the maximal opening of the fascia is 2 cm. The 2-cm fascial opening is not enough to allow for the triangulation of instruments, the removal of specimens, and the performance of anastomosis, particularly during gastrectomy and colectomy. To overcome this problem, we developed an umbilical zigzag skin incision with a 6-cm opening of the fascia and peritoneum in collaboration with plastic surgeons and used Gelport® to maintain pneumoperitoneum, which resulted in a scarless wound.1 Plastic surgeons modified this technique from umbilicoplasties for umbilical deformities.2,3 We have performed gastrectomies, colectomies, cholecystectomies, and transabdominal preperitoneal hernia repairs using this method without any complications and have succeeded in hiding scars in the umbilicus. GelPOINT® is a newly developed device for minimally invasive surgery that provides a flexible, air-tight fulcrum to facilitate the triangulation of standard instrumentation. By offering an increased range of motion and maximum retraction and exposure, the GelPOINT platforms assure maximum versatility and access for a wide range of abdominal procedures. We report herein a video (559 seconds) describing a new method of transumbilical hidden-scar surgery using GelPOINT through an umbilical zigzag skin incision. Materials and Surgical Technique: A 64-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The procedure was performed as previously described1; after marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPOINT double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The GelPOINT was latched to the wound retractor ring, and the pneumoperitoneum was then inflated using CO2. One additional port was inserted in the right-lower abdomen for safety. Laparoscopic high anterior resection with lymph node dissection was performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical zigzag incision, and the double-staple technique was used for anastomosis without any complications. The wound in the umbilical region was virtually hidden in the bottom of the umbilicus after surgery. Results and Conclusion: We performed an umbilical zigzag skin incision technique using GelPOINT for laparoscopic high anterior resection without any complications. We consider that this zigzag skin incision technique is one way to lessen the technical difficulties of laparoscopic surgery, resulting in a hidden scar in the umbilicus. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 9 mins 19 secs.

Mitochondrial DNA mutations regulate metastasis of human breast cancer cells.

Mutations in mitochondrial DNA (mtDNA) might contribute to expression of the tumor phenotypes, such as metastatic potential, as well as to aging phenotypes and to clinical phenotypes of mitochondrial diseases by induction of mitochondrial respiration defects and the resultant overproduction of reactive oxygen species (ROS). To test whether mtDNA mutations mediate metastatic pathways in highly metastatic human tumor cells, we used human breast carcinoma MDA-MB-231 cells, which simultaneously expressed a highly metastatic potential, mitochondrial respiration defects, and ROS overproduction. Since mitochondrial respiratory function is controlled by both mtDNA and nuclear DNA, it is possible that nuclear DNA mutations contribute to the mitochondrial respiration defects and the highly metastatic potential found in MDA-MB-231 cells. To examine this possibility, we carried out mtDNA replacement of MDA-MB-231 cells by normal human mtDNA. For the complete mtDNA replacement, first we isolated mtDNA-less (ρ(0)) MDA-MB-231 cells, and then introduced normal human mtDNA into the ρ(0) MDA-MB-231 cells, and isolated trans-mitochondrial cells (cybrids) carrying nuclear DNA from MDA-MB-231 cells and mtDNA from a normal subject. The normal mtDNA transfer simultaneously induced restoration of mitochondrial respiratory function and suppression of the highly metastatic potential expressed in MDA-MB-231 cells, but did not suppress ROS overproduction. These observations suggest that mitochondrial respiration defects observed in MDA-MB-231 cells are caused by mutations in mtDNA but not in nuclear DNA, and are responsible for expression of the high metastatic potential without using ROS-mediated pathways. Thus, human tumor cells possess an mtDNA-mediated metastatic pathway that is required for expression of the highly metastatic potential in the absence of ROS production.

Gravitational wave forms for two- and three-body gravitating systems.

Different numbers of self-gravitating particles (in different types of periodic motion) are most likely to generate very different shapes of gravitational waves, some of which, however, can be accidentally almost the same. One such example is a binary and three-body system for Lagrange's solution. To track the evolution of these similar wave forms, we define a chirp mass to the triple system. Thereby, we show that the quadrupole wave forms cannot distinguish the sources. It is suggested that wave forms with higher lth multipoles will be important for classification of them (with a conjecture of l

Asymptomatic severe carotid stenosis undergoing staged carotid artery stent and coronary artery bypass grafting: decisive role of brain single photon emission computed tomography.

Effort angina of a 70-year-old man was diagnosed as due to triple coronary vessel disease, and he was scheduled to undergo coronary artery bypass surgery. Preoperative carotid duplex scan revealed more than 75% stenosis of the right internal carotid artery, which was functionally proven to be significantly ischemic on brain single photon emission computed tomography. Although he was neurologically asymptomatic, we chose staged surgery for fear of stroke during coronary artery bypass surgery. He had successful carotid artery stenting first by neurosurgeons; then, 2 months later he underwent uneventful coronary artery bypass surgery. This experience prompted us to report the case.

Successful repair of atrial fibrillation by surgical ablation in a patient with persistent left superior vena cava and mitral stenosis.

We recently cared for a woman who had mitral stenosis, atrial fibrillation, absent right superior vena cava, and persistent left superior vena cava. She underwent mitral valve replacement and surgical ablation of the pulmonary vein, and conjunction of the coronary sinus and left superior vena cava. Her atrial fibrillation was cured and successfully restored to sinus rhythm postoperatively.

Intraoperative heart rate variability of a cardiac surgeon himself in coronary artery bypass grafting surgery.

The mental strain of a cardiac surgeon may differ when he performs coronary surgery from and when he only assists in performing coronary surgery. In 50 selected cases of on-pump heart arrested coronary artery bypass grafting (CABG), an attending-consultant surgeon performed 30 procedures of CABG (Group A) and an attending-consultant surgeon supervised the remaining 20 cases of CABG performed by two resident surgeons (Group B). Intraoperative Holter electrocardiograms of the attending-consultant surgeon were recorded and analyzed for heart rate variability (HRV). In Group A, the ratio of low frequency to high frequency was at a peak in the beginning of the operation and gradually decreased toward the end of the operation. In Group B, the ratio of low frequency to high frequency was at a peak in the phase of aortic cross-clamp, coronary anastomosis, and unclamping. When an attending-consultant surgeon performed the operation himself, the most anxious part of the operation was at the beginning and thereafter the level of anxiety gradually declined. In contrast, when he assisted a resident, the highest level of anxiety was when the aortic cross-clamp was in place and out of place and during the coronary anastomosis.

Safe launching of a newly appointed cardiac surgery unit at a low-volume hospital with the use of cumulative sum analysis.

BACKGROUND: Few studies have used the cumulative sum method to examine the initial performance of a newly appointed cardiac surgery team at a low-volume hospital. METHODS AND RESULTS: In the 4 years from April 2002 to December 2006, 274 cases of open-heart surgery were performed and the overall mortality and morbidity rates were 4.01% and 5.84%, respectively. The respective rates for coronary, valvular and aortic surgery were 2.05% and 2.74%, 3.61% and 7.23%, and 11.1% and 13.3%. The overall cumulative sum curve was below the 80% upper alarm line since the 58(th) case and below the 80% lower alarm line since the 139th case. The respective values for the cumulative sum curves of valvular and coronary surgery were the 1st and 41st cases, the 22nd and the 76th cases, but for aortic surgery the cumulative sum curve remained below the 80% upper alarm line since the 1st case but did not reach below the 80% lower alarm line CONCLUSIONS: An open-heart surgery unit at a low-volume hospital could compete with a high-volume hospital if it has a safe launching and low mortality and morbidity rates. The predictor of a safe launching is not the annual volume, but the cumulative experience of the surgical team.

A simple method of inspection of proximal bleeding in Bentall procedure.

A simple method of checking for bleeding from the proximal anastomosis site in Bentall operations is described. After suturing a Carbo-Seal prosthesis to the aortic annulus, using a folding-over technique, the left ventricle is filled with cardioplegic solution through the prosthetic valve, and the heart is massaged to visualize possible leaks at the level of the suture.

Celiprolol reduces the intimal thickening of autogenous vein grafts via an enhancement of nitric oxide function through an inhibition of superoxide production.

BACKGROUND: Beta-adrenoceptor antagonist celiprolol has been widely used as an effective antihypertensive agent. Some studies reported that celiprolol enhances nitric oxide production. The purpose of the present study is to examine the effects of celiprolol on vein graft intimal hyperplasia and endothelium-dependent nitric oxide (NO)-mediated relaxation. METHODS: Japanese white rabbits were randomized to a control group that was fed regular rabbit chow or to a celiprolol group that was fed regular rabbit chow supplemented with 100 mg/body celiprolol sodium. The reversed jugular vein was implanted into the carotid artery. At 2 and 4 weeks after the operation, vein grafts in both groups were harvested, and intimal hyperplasia of the vein grafts was assessed. At 4 weeks after the operation, harvested vein grafts from both the groups were examined on the endothelium-dependent relaxation by application of Ach and were examined to detect for endothelial NO synthase (eNOS) expression and superoxide anion production. RESULTS: Celiprolol inhibited intimal hyperplasia of carotid interposition-reversed jugular vein grafts 4 weeks after implantation (Intima/media index of celiprolol group, 0.48 +/- 0.01 vs control group, 1.07 +/- 0.08, P < .05) and suppressed cell proliferation in the neointima 2 weeks after implantation. In addition, celiprolol significantly enhanced endothelium-dependent NO-mediated relaxation in the vein graft with no change in eNOS expression and a reduction in superoxide production. CONCLUSIONS: These novel findings clearly demonstrate that beta-adrenoceptor antagonist celiprolol can suppress intimal hyperplasia of the vein graft, which may be due to the enhancement of nitric oxide function through an inhibition of superoxide production. These results strongly support the clinical usefulness of celiprolol administration for preventing intimal hyperplasia of the vein graft after bypass grafting.