Changing Trends in Liver Cirrhosis Etiology and Severity in Korea: the Increasing Impact of Alcohol.

BACKGROUND: Chronic hepatitis B is the most common cause of liver cirrhosis in South Korea. However, alcoholic liver disease has shown an increasing trend. Although the clinical implications surrounding liver cirrhosis have been changing over the years, few studies have recently examined cirrhosis epidemiology. Therefore, we aimed to investigate changes in liver cirrhosis etiology and severity in Korea. METHODS: We retrospectively reviewed 16,888 records of cirrhotic patients from six tertiary hospitals in Korea from 2008 to 2017. Continuous and non-continuous variables were processed via linear and Poisson regression, expressed as beta (B) coefficients and as exponentiated values of coefficients (Exp[B]), respectively. RESULTS: Chronic hepatitis B showed a decreasing trend (Exp[B] = 0.975, P < 0.001), whereas alcohol showed an increasing trend (Exp[B] = 1.013, P = 0.003), occupying the most common etiology in 2017. The Child-Turcotte-Pugh (CTP) score and decompensated liver cirrhosis prevalence did not change over the 10-year period. The incidence of variceal bleeding, severe ascites, hepatic encephalopathy, and spontaneous bacterial peritonitis significantly decreased from 12.3% to 7.7%, 7.8% to 4.1%, 1.0% to 0.5%, and 1.9% to 1.1%, respectively (P < 0.05 for all). In the subgroup analysis, the chronic hepatitis B group showed improving CTP scores (B = -0.025, P < 0.001) and decreasing decompensated liver cirrhosis rates (Exp[B] = 0.977, P = 0.016), whereas the alcohol group demonstrated increasing CTP class C (Exp[B] = 1.031, P = 0.005) and model for end-stage liver disease scores (B = 0.081, P = 0.005) over 10 years. CONCLUSION: The chronic hepatitis B group exhibited improved results, whereas the alcohol group still presented poor liver functions and outcomes. Future national policies and systematic approaches addressing the incidence, prevention, and treatment of alcoholic liver cirrhosis are indispensable.

Correction to: A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess.

An amendment to this paper has been published and can be accessed via the original article.

Effects of Virologic Response to Treatment on Short- and Long-term Outcomes of Patients With Chronic Hepatitis B Virus Infection and Decompensated Cirrhosis.

BACKGROUND & AIMS: Little is known about the effects of antiviral therapy on short- and long-term survival of patients with hepatitis B virus (HBV)-related decompensated cirrhosis. We aimed to determine whether a maintained virologic response (MVR, defined as persistent undetectable HBV DNA during therapy) associates with short-term (6 mo) and long-term (6-120 mo) survival of patients with decompensated cirrhosis. METHODS: We performed a 10-year observation analysis using data from the Epidemiology and Natural History of Liver Cirrhosis study of patients with decompensated liver cirrhosis in Korea. Of the entire cohort (1595 patients enrolled at onset of decompensation since 2005), our analysis comprised 295 patients who immediately began treatment with entecavir (n = 179) or lamivudine (n = 116) after decompensation. We collected laboratory test results, data on hepatocellular carcinoma (HCC) development, and Child-Turcotte-Pugh and model for end-stage liver disease (MELD) scores. The mean follow-up time was 62.3 ± 36.5 months. The primary end point was time of liver transplant-free survival. RESULTS: The median survival time was 7.7 years; 60.1% of patients survived for 5 years and 45.7% survived for 10 years without liver transplantation. An MVR was observed in 116 patients (39.3%); these patients had significantly longer times of transplant-free survival than patients without MVR. Survival times associated with the occurrence of HCC; survival of patients without HCC was excellent if they survived the first 6 months after initiation of antiviral therapy, whereas the survival rates of patients with HCC decreased persistently over time. A baseline MELD score above 20 and multiple complications were associated with short-term mortality. MVR was the factor most strongly associated with long-term transplant-free survival. Significantly higher proportions of patients who received entecavir survived 10 years compared with patients who received lamivudine, but no difference was observed among patients with MVRs. Patients with MVRs had significant improvement in hepatic function over time, but nonsignificant reductions in risk of HCC or HCC-related mortality. CONCLUSIONS: In a 10-year observation study of patients in Korea with HBV-related decompensated cirrhosis, we found baseline MELD score and MVR to entecavir or lamivudine to associate with short- and long-term transplant-free survival. The benefits of an MVR are maintained for up to 10 years even after decompensation, but patients are still at risk for HCC.

A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess.

BACKGROUND: Transdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied. CASE PRESENTATION: A 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications. CONCLUSIONS: Herein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

Self-expandable metal stents for the extraction of common bile duct stones in patients receiving dual antiplatelet agents: a pilot study.

BACKGROUND: Endoscopic sphincterotomy or endoscopic papillary balloon dilatation during endoscopic retrograde cholangiopancreatography (ERCP) are associated with a high risk of bleeding in patients receiving dual antiplatelet agents (APAs). However, the discontinuation of antiplatelet agents increases the risk of thromboembolic events in these patients. To date, the placement of self-expandable metal stents (SEMSs) in patients receiving dual APAs has not been well investigated. The aim of this study was to evaluate the feasibility and safety of SEMS placement for the removal of common bile duct (CBD) stones in patients in whom APAs were not discontinued. METHODS: Ten consecutive patients who were suspected of having CBD stones and who were receiving dual APAs were prospectively enrolled and underwent temporary SEMS placement, followed by stone extraction and SEMS removal. The patients continued taking dual APAs at the time of undergoing the procedure. RESULTS: SEMS placement was successful in all ten patients. Complete duct clearance with the SEMSs was achieved in a single session in all patients with CBD stones (9/9, 100%). One patient had cholangitis, but ERCP did not reveal biliary stones. There were no cases of bleeding during or after the procedure, even though all patients continued to take dual APAs. There were no new thromboembolic events. CONCLUSIONS: SEMSs can be used for the extraction of CBD stones in patients on dual APAs, and does not lead to hemorrhagic or thromboembolic events.

Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients.

BACKGROUND: Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. METHODS: This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. RESULTS: A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. CONCLUSION: Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.

Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence.

BACKGROUND: Little information is available about the relationship between restoration of common bile duct (CBD) diameter after endoscopic stone retraction and recurrence of CBD stones in elderly patients. The present study was to determine whether restoration of CBD diameter is a preventive factor for CBD stone recurrence in elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). METHODS: From January 2006 to December 2010, 238 patients underwent the first and the second session of ERCP for the removal of CBD stones. Among them, 173 were over 65 years old. These patients were divided into recurrent group and non-recurrent group. Restoration of CBD diameter and patients' characteristics were compared. RESULTS: There was no statistical difference in patients' characteristics, associated diseases, or ERCP-related complications between the two groups. Reduction of CBD diameter was significantly larger in the non-recurrent group (2.7 ±â€¯1.7 mm) compared to that in the recurrent group (1.4 ±â€¯2.3 mm, P = 0.002). The proportion of patients with restoration of CBD diameter were significantly lower in the recurrent group (6/42, 14.3%) compared with that in the non-recurrent group (67/131, 51.1%) (P < 0.01). CONCLUSIONS: There is an inverse relationship between restoration of CBD diameter and CBD stone recurrence. Therefore, patients without restoration of CBD diameter within 2 weeks after endoscopic stone removal should be monitored more frequently.

Hepatic Alanine Differentiates Nonalcoholic Steatohepatitis From Simple Steatosis in Humans and Mice: A Proton MR Spectroscopy Study With Long Echo Time.

PURPOSE: To evaluate the hepatic metabolic alterations in nonalcoholic fatty liver disease (NAFLD) by using 1 H-MRS (proton magnetic resonance spectroscopy) with long echo time and to test the reproducibility of human study in an animal model. Liver biopsy is the gold standard for diagnosing NAFLD but with practical constraints. 1 H-MRS allows in vivo assessment of hepatocellular metabolism and has shown potential for biochemical differentiation in diffuse liver disease. MATERIALS AND METHODS: In all, 32 subjects (11 patients with nonalcoholic steatohepatitis [NASH], 15 with simple steatosis [SS], and six healthy controls) were studied. For test reproducibility, 36 C57BL/6 mice, including 10 mice with streptozotocin-induced NASH, 15 with SS, and 11 high-fat diet controls, were studied. 1 H-MRS measurements at 3T and 4.7T MRI were performed on a localized voxel of the liver using PRESS sequence. Hepatic alanine (Ala), lactate+triglyceride (Lac+TG), and TG levels were compared between NASH, SS, and control groups using analysis of variance (ANOVA) tests. Diagnostic accuracy was determined by calculating the area under the receiver operating characteristics (ROC) curve. The associations between metabolite levels and pathologic grades or NAFLD activity scores (NAS) were assessed using Pearson's correlation. RESULTS: NASH patients had higher levels of Ala (P < 0.001), Lac+TG (P < 0.001), and TG (P < 0.05) than SS patients or controls. The AUROC curve to distinguish NASH from SS was 1.00 (95% confidence interval [CI] 1.00-1.00) for Ala and 0.782 (95% CI 0.61-0.96) for Lac+TG. Ala and Lac+TG concentrations were positively correlated with steatosis grade (Ala Pearson's r = 0.723; Lac+TG r = 0.446), lobular inflammation (Ala r = 0.513), and NAS (Ala r = 0.743; Lac+TG r = 0.474). CONCLUSION: 1 H-MRS is potentially useful for noninvasive diagnosis of NASH and simple steatosis by hepatic metabolite quantification. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1298-1310.

Subjective taste to polyethylene glycol is associated with efficacy of right colon preparation.

AIM: A prospective observational trial with preparations using polyethylene glycol (PEG) to compare patient compliance and adverse events according to individual subjective taste. METHODS: A total of 299 outpatients (mean ± standard deviation [SD] 56.5 ± 13.8 years, 172 males) were recruited for our study. We assessed the efficacy of bowel preparation, subjective taste to their regimens, compliance and adverse events during the preparation. RESULTS: We achieved adequate preparation in 267 (89.3%). A total of 124 patients (41.5%) had 'unacceptable taste' to their regimens. The patients with acceptable taste had better compliance than the patients with unacceptable taste (p = .009). The patients with unacceptable taste had more frequent adverse events such as nausea, vomiting and abdominal bloating than the patients with acceptable taste (all p < .001, Table 2). Patients with unacceptable taste (16.1%) had more frequent inadequate preparation in overall colon than patients with acceptable taste (6.9%, p = .011). There was a significant difference in the efficacy of preparation of right colon between the two groups (p = .004). CONCLUSION: Subjective taste to PEG is associated with efficacy of right colon preparation. In addition, subjective taste to PEG is associated with compliance and adverse events.

Utility of baseline impedance level measurement in patients with gastroesophageal reflux symptoms.

OBJECTIVE: Twenty-four-hour multichannel intraluminal impedance (MII) and pH monitoring is used for detecting reflux episodes in patients with gastroesophageal reflux (GER) disease. However, the clinical significance of baseline impedance levels (BILs) has not been well studied. We aimed to evaluate whether BILs are related to various reflux events or acid-related parameters and to determine whether BILs during specific intervals could be substituted for 24-h BILs. MATERIAL AND METHODS: One-hundred forty-two patients GER symptoms underwent 24-h pH/impedance monitoring. We measured pH [(5 cm above the low esophageal sphincter (LES)] and BILs from three sites (3, 5, and 15 cm above the LES). RESULTS: Eighty-one subjects (57.0%) were diagnosed with gastroesophageal reflux disease, and 53 (37.3%) had acid reflux and 28 (19.7%) had nonacid reflux. The 24-h BILs at distal sites were lower in the "reflux" group than in the "no reflux" group (p < 0.001) and lower in the "acid reflux" group than in the "nonacid reflux" group (p < 0.001). However, there was no significant difference in 24-h BILs at the proximal site among the "no reflux", "acid reflux", and "nonacid reflux" groups. The interclass correlation coefficient value of 24-h BILs with daytime 6-h BILs was 0.916 (95% CI 0.882-0.940) and that with nighttime 6-h BILs was 0.909 (95% CI 0.871-0.935). CONCLUSION: BILs are related to GER, especially acid reflux. Location and duration of assessment for BILs needs to be standardized. Six-hour BILs could be substitutes for 24-h BILs. During analysis of MII-pH, more attention should be paid to BILs in the lower esophagus.

Endoscopic foreign body removal in the upper gastrointestinal tract: risk factors predicting conversion to surgery.

BACKGROUND/AIMS: Most foreign bodies of the upper gastrointestinal tract (UGIT) are successfully removed by endoscopic techniques without complications. However, some require conversion to surgery due to failure of endoscopic removal. The aim of this study was to analyze the risk factors predicting the need to convert to surgery after inability to endoscopically remove the foreign body. PATIENTS AND METHODS: The medical records of 885 patients treated between January 2006 and March 2014 for suspected foreign bodies in the UGIT were retrospectively reviewed. Patient characteristics, the type of foreign bodies, clinical outcomes, and risk factors predicting the conversion to surgery were analyzed. RESULTS: While endoscopic removal was successful in 94.7% (665/702) of the patients, the remaining 5.3% (37/702) needed conversion to surgery. There were no procedure-related deaths. According to the multivariate logistic regression analyses, older age (>70 years, p = 0.004), location (upper esophagus, p = 0.001), larger size (maximal diameter > 30 mm, p = 0.005), and longer impaction time (>40 h, p < 0.001) were significant risk factors predicting conversion to surgery due to inability to remove the foreign body endoscopically. CONCLUSIONS: Most of the foreign bodies in the UGIT were successfully removed by endoscopic techniques. However, surgical removal might need to be considered in patients with age >70 years, and those with foreign bodies in the upper esophagus, maximal diameter >30 mm, and impaction time >40 h, due to the possible high failure rate of endoscopic removal.

Intraductal US-directed management of bile duct stones without radiocontrast cholangiography.

BACKGROUND/AIMS: Intraductal US (IDUS) is an examination of the bile duct by using a thin-caliber ultrasonic probe, yielding real-time, high-quality cross-sectional images. We prospectively evaluated the feasibility and safety of IDUS-directed stone removal without radiocontrast cholangiography (RC) in naïve patients with common bile duct (CBD) stones. METHODS: A total of 38 naïve patients with suspected CBD stones (<20 mm) were enrolled in this study. If IDUS showed CBD stones, we performed endoscopic sphincterotomy and removed the identified CBD stones without RC. The primary outcome was success rate of CBD stone removal without RC. The secondary outcomes were conversion rate to conventional ERCP with RC, fluoroscopy time, clinical responses, and adverse events. RESULTS: IDUS was successfully performed in all enrolled patients (38/38, 100%). No echogenic material was observed in 3 patients (1 Mirizzi syndrome, 2 spontaneous passages of CBD stones). After endoscopic sphincterotomy, IDUS-directed stone removal was successfully performed without RC in 26 patients (74.3%) in the first session. In the 9 patients, after deployment of plastic stents, IDUS-directed stone removal was successfully completed without RC in a second session. There was no conversion to conventional ERCP with RC. Median fluoroscopy time was 10 seconds. There were no immediate and delayed adverse events related to the IDUS-directed stone removal. However, asymptomatic hyperamylasemia developed in 3 patients (7.9%), who recovered without adverse events. CONCLUSIONS: IDUS-directed stone removal without RC is feasible and safe for patients with CBD stones. We anticipate a potentially important role of IDUS in the field of various therapeutic interventions.

Pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for Helicobacter pylori eradication in a region with high rates of multiple drug resistance.

OBJECTIVES: Helicobacter pylori eradication rates with clarithromycin-based triple therapy are declining, and an alternative strategy is needed urgently. We sought to compare the efficacy of pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance. METHODS: Consecutive H. pylori-infected patients with gastric epithelial neoplasms were randomized to receive antimicrobial susceptibility-guided therapy or clarithromycin-based triple therapy for 7 days. In patients in whom the infection was not eradicated, antibiotics were given according to an initial antimicrobial susceptibility test as a second-line therapy in both groups. Eradication rates, antibiotics resistance rates, and drug compliance owing to adverse effects were compared between the groups. RESULTS: In total, 114 patients were enrolled, and 112 completed the protocols. Drug compliance and side effects were similar between the groups. The intention-to-treat eradication rates were 94.7% (95% confidence interval (CI)=88.8-100%, 54/57) in the antimicrobial susceptibility-guided group and 71.9% (95% CI=60.2-83.5%, 41/57) in the clarithromycin-based triple therapy group after the initial treatment (P=0.002), whereas the per-protocol (PP) eradication rates were 96.4% (95% CI=91.5-100%, 54/56) in the antimicrobial susceptibility-guided group and 73.2% (95% CI=61.5-84.8%, 41/56) in the clarithromycin-based triple therapy group (P=0.001). In H. pylori with clarithromycin resistance, the eradication failure rate with first-line treatment was lower in the susceptibility-guided therapy group (0%, 0/12) compared with the clarithromycin-based triple therapy group (80.0%, 95% CI=59.7-100%, 12/15) by PP analysis (P<0.001). CONCLUSIONS: Pretreatment antimicrobial susceptibility-guided therapy is more effective than clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance.

Cap-assisted gastroscope versus cap-assisted colonoscope for examination of difficult sigmoid colons in a nonsedated Asian population: a randomized study.

BACKGROUND: Studies have estimated that cecal intubation failure occurs with conventional colonoscopy in about 10% of cases. Various methods have been adopted to improve the cecal intubation rate, including a transparent cap and special colonoscopes. OBJECTIVE: To assess the efficacy of using a cap-assisted gastroscope (E-cap) compared with a cap-assisted colonoscope (C-cap) for the complete examination of the colon in nonsedated patients with technically difficult sigmoid colons. DESIGN: Randomized, controlled study. SETTING: Tertiary-care referral center. PATIENTS: One hundred thirty-nine patients with technically difficult sigmoid colons were studied. INTERVENTION: Colonoscopy with either an E-cap (n = 69) or a C-cap (n = 70). MAIN OUTCOME MEASUREMENTS: Cecal intubation rate, cecal intubation time, patient-assessed pain score, and endoscopist-assessed pain score. RESULTS: The cecal intubation rate was significantly higher in the E-cap (65/69, 94.2%) than in the C-cap group (50/70, 71.4%; P < .0001). Patient-assessed pain (moderate to severe) was more frequently reported in the C-cap (14/70, 20.0%) than in the E-cap group (5/69, 7.2%; P = .029). Endoscopist-assessed pain (moderate to severe) was more frequently reported in the C-cap (13/70, 18.6%) than in the E-cap group (3/69, 7.2%; P = .009). For patients with a low body mass index (≤ 22 kg/m(2)), the cecal intubation rate was significantly higher in the E-cap (37/38, 97.4%) than in the C-cap group (15/29, 51.7%; P < .0001). LIMITATIONS: Single-center experience, lack of a gastroscope control group without a cap. CONCLUSION: The cap-assisted gastroscope is more tolerable and effective than cap-assisted colonoscope for the complete examination of the colon in patients with technically difficult sigmoid colons. ( CLINICAL TRIAL REGISTRATION NUMBER: KCT0000744.).

Cap-assisted ERCP in patients with difficult cannulation due to periampullary diverticulum.

Selective biliary cannulation is an essential prerequisite for therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The cap-fitted forward-viewing endoscope has been used for ERCP in patients with surgically altered anatomy. In this case series, 12 patients with periampullary diverticulum underwent ERCP using the cap-assisted forward-viewing endoscope due to failure of biliary cannulation using the standard technique. Successful ERCP was achieved in all patients with no serious complications.

Various applications of endoscopic scissors in difficult endoscopic interventions.

Endoscopic scissors offer a benefit over other devices by avoiding potential complications related to thermal and mechanical injury of surrounding structures. We describe our experience with endoscopic scissors in three difficult endoscopic interventions. A fishbone embedded in the esophageal wall penetrated very close to the pulsating aorta and the bronchus. The fishbone was cut in half by endoscopic scissors and removed without injury to adjacent organs. A gastric submucosal tumor with an insulated core that could not be resected by electrosurgical devices was cut using endoscopic scissors following endoloop placement. Extravascular coil migration after transcatheter arterial embolization resulted in a duodenal ulcer. The metallic coil on the duodenal ulcer was cut by endoscopic scissors without mechanical or thermal injury.

Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation.

BACKGROUND AND AIM: Needle-knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle-knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle-knife fistulotomy between patients with and without PAD. METHODS: Data from December 2005 to October 2010 were reviewed. Patients who underwent needle-knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared. RESULTS: A total of 3012 ERCP cases were analyzed. Needle-knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n=33) and control group (n =121) (93.9% vs 88.4%; P=0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups. CONCLUSIONS: Needle-knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.

Early extrahepatic recurrence as a pivotal factor for survival after hepatocellular carcinoma resection: A 15-year observational study.

BACKGROUND: Surgical resection is one of the most widely used modalities for the treatment of hepatocellular carcinoma (HCC). Early extrahepatic recurrence (EHR) of HCC after surgical resection is considered to be closely associated with poor prognosis. However, data regarding risk factors and survival outcomes of early EHR after surgical resection remain scarce. AIM: To investigate the clinical features and risk factors of early EHR and elucidate its association with survival outcomes. METHODS: From January 2004 to December 2019, we enrolled treatment-naïve patients who were ≥ 18 years and underwent surgical resection for HCC in two tertiary academic centers. After excluding patients with tumor types other than HCC and/or ineligible data, this retrospective study finally included 779 patients. Surgical resection of HCC was performed according to the physicians' decisions and the EHR was diagnosed based on contrast-enhanced computed tomography or magnetic resonance imaging, and pathologic confirmation was performed in selected patients. Multivariate Cox regression analysis was performed to identify the variables associated with EHR. RESULTS: Early EHR within 2 years after surgery was diagnosed in 9.5% of patients during a median follow-up period of 4.4 years. The recurrence-free survival period was 5.2 mo, and the median time to EHR was 8.8 mo in patients with early EHR. In 52.7% of patients with early EHR, EHR occurred as the first recurrence of HCC after surgical resection. On multivariate analysis, serum albumin < 4.0 g/dL, serum alkaline phosphatase > 100 U/L, surgical margin involvement, venous and/or lymphatic involvement, satellite nodules, tumor necrosis detected by pathology, tumor size ≥ 7 cm, and macrovascular invasion were determined as risk factors associated with early EHR. After sub-categorizing the patients according to the number of risk factors, the rates of both EHR and survival showed a significant correlation with the risk of early EHR. Furthermore, multivariate analysis revealed that early EHR was associated with substantially worse survival outcomes (Hazard ratio, 6.77; 95% confidence interval, 4.81-9.52; P < 0.001). CONCLUSION: Early EHR significantly deteriorates the survival of patients with HCC, and our identified risk factors may predict the clinical outcomes and aid in postoperative strategies for improving survival.