A 68-year-old woman received aortic valve replacement (AVR) with a Freestyle stentless valve using a subcoronary technique for aortic stenosis and regurgitation in September 2000. She complained of chest pain, had low grade fever and findings of inflammation and was admitted to our hospital with a diagnosis of acute myocardial infarction in December 2000. She suffered from repetitive or recurrent myocardial infarction. Transesophageal echocardiogram revealed no abnormal findings of the Freestyle stentless valve, but her blood culture was positive for methicillin-resistant coagulase negative Staphylococcus aureus (MRCNS) and she underwent an emergency operation. The Freestyle stentless valve was removed and replaced with a mechanical valve. The patient's intraoperative tissue grew MRCNS and parenteral antibiotics were administered for 8 weeks after surgery. Her condition was complicated with multiple cerebral infarction, however she was discharged on the 113th postoperative day and is doing well without recurrence of infection 12 months after the operation.

We report a rare case of primary cardiac lymphoma in the right atrium. An 85-year-old woman with severe heart failure was referred to our hospital. The echocardiography revealed a huge tumor occupying the right atrial cavity. We conducted an emergency operation to resect the tumor. However, as the tumor strongly adhered to the wall of the right atrium and tricuspid valve, we performed partial resection of the tumor to improve hemodynamics. The pathological examination of the tumor was consistent with malignant lymphoma of B-cell origin. Although the postoperative chemotherapy was effective to reduce a volume of the tumor, the patient died because of the adverse reaction to medication.

We studied 73 patients, 70 years of age or older, who underwent aortic valve replacement for aortic stenosis between October, 1990 and October, 2004. There were 31 men and 42 women with a mean age of 75.7±3.6 years. Mechanical valves were implanted in 37 patients, and bioprostheses in 36 patients. Operative mortality was 1 of 73 (1.4%) and the New York Heart Association functional class improved to class I or class II in all of the hospital survivors. Follow-up (100%) extended from 0.3 to 11.6 years (mean 3.7 years). There were 16 late deaths (5.9% per patient-year), including valve-related deaths in 6 patients. The overall survival rates at 5 and 10 years was 74.2% and 44.3%, respectively. The freedom from valve-related events at 5 and 10 years was 78.8% and 78.8%, respectively. The 10-year survival rates and freedom from valve-related events were not different between the patients with mechanical valves and those with bioprostheses. The size of the implanted valve did not influence the late survival or freedom from valve-related events. The outcome after aortic valve replacement in the elderly (70 years and older) was excellent with low operative mortality, and acceptable late mortality and morbidity. Thus, aortic valve replacement for elderly patients should have the same indications as for younger patients. Bioprostheses showed good long-term results with no structural valve deterioration, thromboembolism, or bleeding events. Mechanical valves, which required the maintenance of an anticoagulant therapy, were also useful with acceptable late morbidity. The long-term results with small valves (≤19mm) were comparable to the results with large valves (>19mm) in the elderly. Thus, the use of these small valves in this particular age group seems to be acceptable.

Objective:Delayed gastric emptying (DGE) after pylorus-preservingpancreatoduodenectomy (PpPD) is a persistent and frustrating complication. Topreserve pylorus ring with denervation and devascularization may be a risk factorof DGE after pancreaticoduodenectomy. We conducted this study to confirm thehypothesis that pylorus-resecting pancreatoduodenectomy (PrPD) reduces theincidence of DGE compared to PpPD. Moreover, long-term outcomes of PrPDand the adverse effect of postsurgical DGE on long-term outcomes have not beenreported. Therefore, in addition, this study focused on long-term outcomes during24 months after surgery between PrPD versus PpPD.Methods: Between October 2005 and March 2009, at Wakayama MedicalUniversity Hospital (WMUH), 130 patients with pancreatic or periampullarylesions were randomized to preservation of the pylorus ring (PpPD) or to resectionof the pylorus ring (PrPD). In PpPD, the proximal duodenum was divided 3-4cmdistal to the pylorus ring. In PrPD, the stomach was divided just adjacent thepylorus ring and the nearly total stomach more than 95% was preserved. Shorttermand long-term outcomes were evaluated between PpPD and PrPD. Primaryendpoint is the incidence of DGE. DGE was defined according to a consensusdefinition and clinical grading about postoperative DGE proposed by theinternational study group of pancreatic surgery (ISGPS). This RCT was registeredat Clinical Trials.Gov NCT00639314.Results: Of 130 patients who were enrolled in this study, 64 patients wererandomized to PpPD and 66 to PrPD. The overall incidence of DGE in this RCTwas 10.8% (14 of 130 patients); the overall incidence of DGE was significantlylower in PrPD (4.5%) than PpPD (17.2%) (P =0 .0244). DGE was classified intothree categories proposed by the International Study Group of Pancreatic Surgery.The proposed clinical grading classified 11 cases of DGE in PpPD into grades A(n=6), B (n=5), and C (n=0), and one case in PrPD into each of the three grades.In long-term outcomes, weight loss > grade 2 (Common Terminology Criteriafor Adverse Events, Ver. 4.0) at 24 months after surgery improved significantlyin PrPD (16.2%) compared with PpPD (42.2%) (P = 0.011). Nutritional statusand late postoperative complications were similar between PpPD and PrPD. Theincidence of weight loss greater than Grade 2 at 24 months after surgery was63.6% in patients with DGE group and 25.3% in patients without DGE group (P= 0.010). Tmax (the time to peak 13CO2 content in 13C-acetate breath test) at24 months after surgery in patients with DGE was significantly delayed comparedwith those without DGE (27.9 ± 22.7min vs.16.5 ± 10.1min, P=0.023). Serumalbumin at 24 months after surgery was higher in patients without DGE than thosewith DGE (3.7±0.6 g/dl vs. 4.1±0.4 g/dl, P=0.013).Conclusion: This study clarified that PrPD can lead to a significant reduction inthe incidence of DGE compared with PpPD. Moreover, PrPD offers similar longtermoutcomes with PpPD. DGE may be associated with weight loss and poornutritional status in long-term outcomes.

Objective:Delayed gastric emptying (DGE) after pylorus-preserving pancreatoduodenectomy (PpPD) is a persistent and frustrating complication. To preserve pylorus ring with denervation and devascularization may be a risk factor of DGE after pancreaticoduodenectomy. We conducted this study to confirm the hypothesis that pylorus-resecting pancreatoduodenectomy (PrPD) reduces the incidence of DGE compared to PpPD. Moreover, long-term outcomes of PrPD and the adverse effect of postsurgical DGE on long-term outcomes have not been reported. Therefore, in addition, this study focused on long-term outcomes during 24 months after surgery between PrPD versus PpPD. Methods: Between October 2005 and March 2009, at Wakayama Medical University Hospital (WMUH), 130 patients with pancreatic or periampullary lesions were randomized to preservation of the pylorus ring (PpPD) or to resection of the pylorus ring (PrPD). In PpPD, the proximal duodenum was divided 3-4cm distal to the pylorus ring. In PrPD, the stomach was divided just adjacent the pylorus ring and the nearly total stomach more than 95% was preserved. Shortterm and long-term outcomes were evaluated between PpPD and PrPD. Primary endpoint is the incidence of DGE. DGE was defined according to a consensus definition and clinical grading about postoperative DGE proposed by the international study group of pancreatic surgery (ISGPS). This RCT was registered at Clinical Trials.Gov NCT00639314. Results: Of 130 patients who were enrolled in this study, 64 patients were randomized to PpPD and 66 to PrPD. The overall incidence of DGE in this RCT was 10.8% (14 of 130 patients); the overall incidence of DGE was significantly lower in PrPD (4.5%) than PpPD (17.2%) (P =0 .0244). DGE was classified into three categories proposed by the International Study Group of Pancreatic Surgery. The proposed clinical grading classified 11 cases of DGE in PpPD into grades A (n=6), B (n=5), and C (n=0), and one case in PrPD into each of the three grades. In long-term outcomes, weight loss > grade 2 (Common Terminology Criteria for Adverse Events, Ver. 4.0) at 24 months after surgery improved significantly in PrPD (16.2%) compared with PpPD (42.2%) (P = 0.011). Nutritional status and late postoperative complications were similar between PpPD and PrPD. The incidence of weight loss greater than Grade 2 at 24 months after surgery was 63.6% in patients with DGE group and 25.3% in patients without DGE group (P = 0.010). Tmax (the time to peak 13CO2 content in 13C-acetate breath test) at 24 months after surgery in patients with DGE was significantly delayed compared with those without DGE (27.9 ± 22.7min vs.16.5 ± 10.1min, P=0.023). Serum albumin at 24 months after surgery was higher in patients without DGE than those with DGE (3.7±0.6 g/dl vs. 4.1±0.4 g/dl, P=0.013). Conclusion: This study clarified that PrPD can lead to a significant reduction in the incidence of DGE compared with PpPD. Moreover, PrPD offers similar longterm outcomes with PpPD. DGE may be associated with weight loss and poor nutritional status in long-term outcomes.