Utility of plasma D-dimer for diagnosis of venous thromboembolism after hepatectomy

BACKGROUND Venous thromboembolism(VTE)is a potentially fatal complication of hepatectomy.The use of postoperative prophylactic anticoagulation in patients who have undergone hepatectomy is controversial because of the risk of postoperative bleeding.Therefore,we hypothesized that monitoring plasma D-dimer could be useful in the early diagnosis of VTE after hepatectomy.AIM To evaluate the utility of monitoring plasma D-dimer levels in the early diagnosis of VTE after hepatectomy.METHODS The medical records of patients who underwent hepatectomy at our institution between January 2017 and December 2020 were retrospectively analyzed.Patients were divided into two groups according to whether or not they developed VTE after hepatectomy,as diagnosed by contrast-enhanced computed tomography and/or ultrasonography of the lower extremities.Clinicopathological factors,including demographic data and perioperative D-dimer values,were compared between the two groups.Receiver operating characteristic curve analysis was performed to determine the D-dimer cutoff value.Univariate and multivariate analyses were performed using logistic regression analysis to identify significant predictors.RESULTS In total,234 patients who underwent hepatectomy were,of whom(5.6%)were diagnosed with VTE following hepatectomy.A comparison between the two groups showed significant differences in operative time(529 vs 403 min,P=0.0274)and blood loss(530 vs 138 mL,P=0.0067).The D-dimer levels on postoperative days(POD)1,3,5,7 were significantly higher in the VTE group than in the non-VTE group.In the multivariate analysis,intraoperative blood loss of>275 mL[odds ratio(OR)=5.32,95%confidence interval(CI):1.05-27.0,P=0.044]and plasma D-dimer levels on POD 5≥21μg/mL(OR=10.1,95%CI:2.04-50.1,P=0.0046)were independent risk factors for VTE after hepatectomy.CONCLUSION Monitoring of plasma D-dimer levels after hepatectomy is useful for early diagnosis of VTE and may avoid routine prophylactic anticoagulation in the postoperative period.

Risk factors for occult metastasis detected by inflammation-based prognostic scores and tumor markers in biliary tract cancer

BACKGROUND Radiological detection of small liver metastasis or peritoneal metastasis is still difficult,and some patients with biliary tract cancer(BTC)are unresectable after laparotomy.Staging laparoscopy may help avoid unnecessary laparotomy.However,which category of BTC is amenable with staging laparoscopy remains unclear.AIM To clarify the risk factors for occult metastasis in patients with BTC.METHODS Medical records of patients with BTC who underwent surgery at our institution between January 2008 and June 2014 were retrospectively reviewed.The patients were divided into two groups,according to resection or exploratory laparotomy(EL).Preoperative laboratory data,including inflammation-based prognostic scores and tumor markers,were compared between the two groups.Prognostic importance of detected risk factors was also evaluated.RESULTS A total of 236 patients were enrolled in this study.Twenty-six(11%)patients underwent EL.Among the EL patients,there were 16 cases of occult metastasis(7 liver metastases and 9 abdominal disseminations).Serum carcinoembryonic antigen level,carbohydrate antigen 19-9 level,neutrophil-lymphocyte ratio and modified Glasgow prognostic score were significantly higher in the EL group than in the resected group,and these factors were prognostic.Among these factors,carcinoembryonic antigen>7 ng/mL was the most useful to predict occult metastasis in BTC.When patients have more than three of these positive factors,the rate of occult metastasis increases.CONCLUSION Inflammation-based prognostic scores and tumor markers are useful in detecting occult metastasis in BTC;based on these factors,staging laparoscopy may reduce the rate of EL.

Implementation of an educational program for pancreaticoduodenectomy in a university hospital: a retrospective observational study

Objective:No ideal training system exists for pancreaticoduodenectomy(PD).We developed an educational system that uses an objective structured assessment of technical skills.Methods:This retrospective observational study was conducted using the data of consecutive trainees and patients who underwent PD from 2007 to 2013 in Kansai Medical University Hospital.The total score on the task checklist(21 parameters)for measuring technical performance during PD by self assessment and instructor assessment was compared between junior(JN)and hepatobiliary pancreatic(HBP)trainees at a university hospital.Surgical outcomes of 303 PDs(2007-2013)were also compared among JN trainees,HBP trainees,and instructors,and the present position of the trainees was investigated.This study was approved by the institutional review board of Kansai Medical University on May 26,2020.Results:The self-assessment score on the task checklist was significantly higher for the HBP trainees than for the JN trainees on all parts of PD(P<.001).The discrepancy between self-assessment and instructor assessment improved in 3 JN trainees after experience with the first 5 PDs.Although total score curves rose to the right in the JN group,scores in the HBP group were stable,at 70 or higher,which correlated with the instructor assessment.The 90-day and 30-day mortality rates were 1.6%and 0.3%,respectively.Mortality and morbidity after PD did not differ between the JN and HBP trainees or between the instructors and the trainees.Four of 10 trainees became board-certified expert surgeons of the Japanese Society of Hepatobiliary Pancreatic Surgery.Conclusion:These results indicated good construct validity of the task checklist system.This program was safely and effectively implemented in terms of surgical outcomes and final outcomes of trainees becoming board-certified expert surgeons.