Little is known about how isosorbide dinitrate (ISDN) contribute to bathing effects on patients with myocardial infarction. A study using an invasive method was made on 29 patients with myocardial infarction to clarify the hemodynamic changes occurring during bathing with and without sublingual ISDN, and to evaluate the overall effects of the ISDN. In bathing after discontinuing dosing of vasodilators (PRE-ISDN), patients were divided into the following two groups depending on the difference between the peak pulmonary capillary wedge pressure (PCWP) during bathing and PCWP before bathing: Increased PCWP group [(Group A): Δ PCWP≥10mmHg] and Unincreased PCWP group [(Group B): Δ PCWP <10mmHg].
Bathing was taken for 5 minutes at 42°C in a Hubbard tank, hemodynamics were observed during bathing and for 10 minutes after bathing, and after 30 minutes of sublingual administration of 5mg ISDN, bathing was taken in a similar manner. Group A patients showed a greater increase in heart rate, blood pressure, pulmonary arterial pressure (PAP), and right artial pressure than of Group B patients during bathing before being dosed with ISDN, and it seemed to be a considerable load on the heart. Although the remarkable increase of PAP and PCWP observed during the early stage of bathing before dosing with ISDN significantly decreased after sublingual dosing of ISDN (POST-ISDN) among Group A patients, these effects were not found in Group B patients. Group A showed more frequent reinfarction from a clinical viewpoint and triple vessel disease upon coronary arteriography, a lower ejection fraction upon left ventriculography, a higher left ventricular end-diastolic pressure, and lower left ventricular performance in most cases as compared to Group B. Although ISDN was found to be effective for severe cases in which the marked pre-load was observed by bathing, no beneficial effect on mild cases with well-maintained left ventricular performance was obtained.

The patient was a 63-years-old female with early gastric cancer in her upper stomach. Widely spreading on the mucous membrane, the cancer was too big to remove by endoscopical mucosal resection, although she wanted minimal invasive treatment. Therefore, we adopted total gastrectomy with hand-assisted laparoscopic surgery (HALS) after obtaining “informed consent” from her. Five small skin-incisions were necessary to perform it-one 7cm' for hand-port and four 1.2cm' for trocars.
The dissection was started from greater omentum and proceeded counterclockwise to remove primary lymphnodes. The abdominal esophagus and the duodenum were devided with a single or double application of Endo GIA stapler (linear stapler). All these steps were accomplished safely and securely with the effective support of the left hand of the operator. After extraction of the whole stomach through the 7cm-incision, Roux-en Y reconstruction was performed laparoscopically (esophago-jejunostomy) followed by hand sewing through the 7cm-incision (jejuno-jejunostomy). The anvil of 21mm circular stapler (EEA) was inserted orally in order to anastomose the esophagus to the jejunum. The patient had acceptable results intra-operatively as well as postoperatively by HALS total gastrectomy, which had been considered to be very hard to perform up to present time.