Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes.

BACKGROUND: Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. METHODS: A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. RESULTS: In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. CONCLUSION: Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.

Regional Variation in Treatment for Highest-Risk Patients With Non-Small Cell Lung Cancer.

BACKGROUND: Non-small cell lung cancer patients with multiple high-risk socioeconomic factors experience treatment and survival disparities. We aim to assess whether disparities in treatment and survival vary by region for patients with 3 or more high-risk socioeconomic factors. METHODS: The National Cancer Database was queried for patients with clinical stage I-IIA non-small cell lung cancer diagnosed between 2010 and 2015. Patients were categorized into 3 groups: standard treatment, nonstandard treatment, and no curative treatment. Multivariable logistic regression was used to evaluate regional differences in treatment. Cox proportional hazards regression and the Kaplan-Meier method were used for survival analysis. All statistical tests were 2-sided. RESULTS: A total of 93,211 patients met inclusion criteria. For patients with 3 or more high-risk socioeconomic factors, the odds of nonstandard treatment were significantly greater in 6 regions compared with New England, greatest in West North Central (odds ratio 2.09, P < .001). The odds of no curative treatment were significantly greater in 7 regions compared with New England, greatest in West South Central (odds ratio 3.56, P < .001). West North Central was associated with the highest risk of all-cause mortality compared with New England (hazard ratio 1.10, P < .001), and Middle Atlantic was associated with the lowest (hazard ratio 0.86, P < .001). The 5-year overall survival was longest in Middle Atlantic (60.8%) and shortest in Mountain (36.8%). CONCLUSIONS: Patients with 3 or more high-risk socioeconomic factors experience treatment and survival disparities across the United States, though disparities are more pronounced in certain regions. Regional interventions may help mitigate disparities among highest risk non-small cell lung cancer patients.