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 ≥ 21 µg/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.

LC-1000 flow cytometry system complements intraoperative peritoneal cytology for pancreatic and biliary tract cancer.

BACKGROUND: The exfoliative cell analyzer, LC-1000, is medical device that utilizes the principles of flow cytometry, and might provide digital diagnostic information for cytology using a different approach from conventional cytomorphology. In this study, wae examined the usefulness of the LC-1000 as a diagnostic support system for intraoperative peritoneal lavage cytology and its prognostic impact for pancreatic (PC) and biliary tract cancer (BTC). METHODS: Patients with PC and BTC who underwent surgical treatment were included. First, we identified useful indicators of LC-1000 and established cutoff values to discriminate positive cytology. Next, we verified the validity of these cutoff values. RESULTS: In the test set (n = 48), of the LC-1000 indicators examined, only MR-CPIx was significantly different between the negative and positive cytology groups, yielding a cutoff value of 0.86. In the validation set (n = 52), the sensitivity, specificity, positive and negative predictive value of the LC-1000 for cytology results was 1.0, 0.49, 0.11 and 1.0, respectively. In patients who had undergone radical resection, recurrence-free survival rate was significantly higher in the LC-1000 negative group than in the positive group in PC, but not in BTC. CONCLUSION: The LC-1000 was useful as digital support system for peritoneal cytology, and it might have potential as a prognostic factor for PC.

Prognostic Impact of Malnutrition Diagnosed by the GLIM Criteria for Resected Extrahepatic Cholangiocarcinoma.

BACKGROUND/AIM: Recently, the Global Leadership Initiative on Malnutrition (GLIM), which includes the world's leading clinical nutrition societies, proposed the first global diagnostic criteria for malnutrition. However, the association between malnutrition diagnosed by the GLIM criteria and prognosis in patients with resected extrahepatic cholangiocarcinoma (ECC) remains unknown. This study aimed to investigate the predictive validity of the GLIM criteria for the prognosis of patients with resected ECC. PATIENTS AND METHODS: Between 2000 and 2020, 166 patients who underwent curative-intent resection for ECC were retrospectively analyzed. Prognostic significance of preoperative malnutrition diagnosed by the GLIM criteria was investigated using a multivariate Cox proportional hazards model. RESULTS: Eighty-five (51.2%) and 46 (27.7%) patients were diagnosed with moderate and severe malnutrition, respectively. Increased malnutrition severity tended to be correlated with increased lymph node metastasis rate (p-for-trend=0.0381). The severe malnutrition group had worse 1-, 3-, and 5-year overall survival rates than the normal (without malnutrition) group (82.2% vs. 91.2%, 45.6% vs. 65.1%, 29.3% vs. 61.5%, respectively, p=0.0159). In multivariate analysis, preoperative severe malnutrition was an independent predictor for poor prognosis (hazard ratio=1.68, 95% confidence interval=1.06-2.66, p=0.0282), along with intraoperative blood loss >1,000 ml, lymph node metastasis, perineural invasion, and curability. CONCLUSION: Severe preoperative malnutrition diagnosed by the GLIM criteria was associated with poor prognosis in patients who underwent curative-intent resection for ECC.

Potential Role of Surgical Resection for Gallbladder Cancer in Elderly Patients.

INTRODUCTION: With the aging of the population in Japan, gallbladder cancer (GBC) in the elderly is increasing. However, the available clinical data are limited, and the optimal treatment is still controversial. The aim of this study was to evaluate the benefit of surgical resection in GBC patients ≥75 years of age. METHODS: A retrospective single center analysis of patients who had undergone surgical resection for GBC between 2000 and 2019 was carried out. Patients aged ≥75 years (elderly group, n = 24) or <75 years (younger group, n = 50) were compared. RESULTS: Both younger and elderly patients exhibited similar clinicopathological characteristics, but comorbidity in the latter was significantly greater, as was the frequency of less invasive surgery. Nonetheless, the incidence of postoperative complications was similar in elderly and younger patients. The proportion of patients receiving adjuvant chemotherapy was lower in the elderly. Overall survival of elderly and younger patients was not significantly different (65.0 vs 62.4% at 5 years, P = .600). In multivariate analysis, residual tumor status but not age was an independent prognostic factor. DISCUSSION: This study demonstrated that appropriate surgical treatment of elderly GBC patients was safe and effective, despite their having more comorbidities and lower rates of adjuvant chemotherapy than younger patients.

Prognostic Impact of Inflammation-Based Scores for Extrahepatic Cholangiocarcinoma.

INTRODUCTION: Although the relationship between systemic inflammatory responses and prognosis has been known in various cancers, it remains unclear which scores are most valuable for determining the prognosis of extrahepatic cholangiocarcinoma. We aimed to verify the usefulness of various inflammation-based scores as prognostic factors in patients with resected extrahepatic cholangiocarcinoma. METHODS: We analyzed consecutive patients undergoing surgical resection for extrahepatic cholangiocarcinoma at our institution between January 2000 and December 2019. The usefulness of the following inflammation-based scores as prognostic factor was investigated: glasgow prognostic score (GPS), modified GPS, neutrophil-to-lymphocyte ratio, platelet to lymphocyte ratio, lymphocyte-to-monocyte ratio, prognostic nutrition index, C-reactive protein to albumin ratio (CAR), controlling nutritional status (CONUT), and prognostic index. RESULTS: A total of 169 patients were enrolled in this study. Of the nine scores, CAR and CONUT indicated prognostic value. Furthermore, multivariate analysis for overall survival revealed that high CAR (>0.23) was an independent prognostic factor (hazard ratio: 1.816, 95% confidence interval: 1.135-2.906, p = 0.0129), along with lymph node metastasis and curability. There was no difference in tumor staging and short-term outcomes between the low CAR (≤0.23) and high CAR groups. CONCLUSIONS: CAR was the most valuable prognostic score in patients with resected extrahepatic cholangiocarcinoma.

[A Case Report of Resectable Leiomyosarcoma of the Duodenum Origin Invading to the Inferior Vena Cava].

A 40's woman had a complaint of abdominal and back pain. Enhanced CT visualized a large retroperitoneal tumor and huge multiple myomas of the uterus. The tumor was 10cm in diameter and located in the anterior of the inferior vena cava, and progressed from the posterior of the duodenum to the abdominal aortic bifurcation. Diffusion-weighted MR image showed the tumor with high signal intensity. Upper gastrointestinal endoscopy revealed a type 2 tumor at the anal side of the Vater. The patient was performed curativly abdominal total hysterectomy and pancreaticoduodenectomy with inferior vena cava resection. Immunohistochemical examination showed that the tumor cells were negative for CD34 and c-kit, and positive for desmin and a-SMA. The tumor was histopathologically diagnosed as leiomyosarcoma originating from the duodenum.

[A Case of Double Lung and Gastric Cancer Involving Para-Aortic Lymph Node Metastasis with Difficult Preoperative Diagnosis].

A man in his 60s was admitted to our hospital with anemia. An endoscopic examination revealed advanced gastric cancer. CT revealed peri-gastric and para-aortic lymphadenopathy, and a nodular shadow(20mm)in the lower lobe of the right lung. PET-CT revealed abnormal uptake in the para-aortic lymph node and stomach wall and the nodular shadow in the right lung. A bronchoscopy revealed pulmonary adenocarcinoma. From the above, he was diagnosed with gastric cancer(cT4a, cN2, cM1, cStage IV )and lung cancer(cT2a, cN0, cM0, cStage I B). Because of gastric bleeding, we decided to operate on the gastric cancer before the lung cancer. First, total gastrectomy, splenectomy, and cholecystectomy were performed and then dissection of lymph node No. 16was performed. Histopathological examination indicated that lymph node No. 16was common to lung cancer, so the final diagnosis was gastric cancer(pT4a, pN0, cM0, fStage II A)and lung cancer(cT2a, cN0, pM1, fStage IV ). In this case, lymphadenectomy of No. 16in the first and pathological diagnosis during surgery could help us avoid splenectomy and cholecystectomy, and could reduce invasion.

[A Case of Pathologically Complete Response in Ruptured Hepatocellular Carcinoma Treated with Transcatheter Arterial Embolization].

We report a case of pathologicallycomplete response in ruptured hepatocellular carcinoma(HCC)treated with transcatheter arterial embolization(TAE). A 56-year-old man presented to our hospital with a hepatic tumor. Enhanced computed tomography(CT)revealed a tumor 65mm in diameter at S7/8 of the liver and the presence of abdominal fluid collection around the tumor. We diagnosed rupture of HCC and selective TAE was subsequentlyperformed. After TAE, the elevated PIVKA- / Ⅱ tumor marker level(1,008mAU/mL)decreased to the normal level. Three weeks after TAE, we performed right hepatectomy. The resected specimen revealed that the tumor consisted of necrotic tissue. Viable tumor cells were absent in this tumor. The pathological diagnosis was therefore HCC in which complete response was obtained with TAE.

[A Case Report of Chylous Ascites after Laparoscopic Sigmoid Colectomy Treated with Conservative Therapy].

A man in his sixties with a medical history of diabetes and dyslipidemia was detected with a tumor with massive submucosal invasion on colonoscopy. He was diagnosed with sigmoid cancer and underwent laparoscopic sigmoid colectomy with D3 lymph node dissection. An electric surgical knife and an ultrasonically activated device was used to perform D3 lymph node dissection with preservation of the left colic artery(LCA)and division of the S1A and S2A. On postoperative day 4(POD4), 1 day after oral intake was started, chylous ascites began to develop. Owing to the small volume of ascites, oral feeding was continued, and chylous ascites was treated successfully with a low-fat diet. Chylous ascites immediately reduced on POD6, after which the drain was removed on POD7. He was discharged on POD9. Fasting and complete parenteral nutrition are not necessarily required in the treatment of chyle leakage after laparoscopic colorectal cancer surgery.

[A Case of Ruptured Gastrointestinal Stromal Tumor of the Stomach with Intraabdominal Bleeding].

A 50s man visited our hospital because of abdominal pain that initiated 1 day prior. An approximately 4.0×5.0×4.5c m tumor, which was in contact with the greater curvature of the gastric body, was detected on contrast-enhanced computed tomography. He was diagnosed with a ruptured gastrointestinal stromal tumor and underwent emergency surgery. During the operation, about 250mL of bloody ascites and a ruptured tumor measuring 6-7 cm in size was observed in the middle of the gastric body. Partial gastrectomy was performed. The histopathological diagnosis was GIST of the stomach. In the gene search, PDGFR-a mutation D842V was detected in exon 18. Therefore, he is undergoing a follow-up examination without postoperative adjuvant therapy even though he is classified as high-risk. Currently, the patient has survived for 8 months after surgery without recurrence. We should perform careful follow-up of the patient.