Medial Epicanthal Fold Correction Using a Y-W Epicanthoplasty in Asian Eyelids.

Many surgical techniques for managing epicanthal folds have been reported, but their main drawbacks include a noticeable scar in Asians, acute medial canthal angle, and applicability only in mild or moderate epicanthal folds. This study described a novel surgical technique, Y-W epicanthoplasty, and assessed the medial canthal shape and scarring in patients who underwent Y-W epicanthoplasty. Patients with moderate or severe epicanthal folds between January 2004 and February 2017 were included in this study. Pre- and postoperative intercanthal distance (ICD), inner canthal angle (ICA), and interpupillary distance (IPD) were measured. The ICD ratios (ICD/IPD) and extent of postoperative scarring were evaluated. A Y-W epicanthoplasty was performed on 18 patients. The ICD ratio of the total study cohort showed a significant reduction following surgery (preoperative ICD ratio=0.62±0.04, postoperative ICD ratio=0.58±0.03, P<0.001). The ICA was 51.8±7.7° and 49.8±5.6° in the pre- and postoperative periods, respectively (P=0.086) Eleven patients showed no apparent scar, and 6 patients were found to have minimal scarring that was visible only under close inspection. One patient had a hypertrophic scar that was successfully managed with triamcinolone acetonide injections. Y-W epicanthoplasty can provide good aesthetic results without a visible scar in patients with moderate-to-severe epicanthal folds. The Y-W epicanthoplasty avoids a medially extended skin incision and excessive tension on the skin flaps. Moreover, an acutely shaped or webbed medial canthus after epicanthoplasty can be prevented by adding a small triangular flap. The Y-W epicanthoplasty procedure is simple and straightforward, and it is appropriate for moderate-to-severe epicanthal fold correction.

Poly Lactic-co-Glycolic Acid Absorbable Plate Graft for Secondary Rhinoplasty in Asian Patients with Unilateral Cleft Lip Nose Deformity.

INTRODUCTION: In secondary cleft lip and nasal deformity (CLND) correction, structural grafts are commonly used to control the nasal tip and restore the symmetry of the ala. However, the septal cartilage in Asians often weak and small. Biocompatible absorbable materials are alternatives to autologous grafts. This study assessed the surgical outcomes and complications of poly lactic-co-glycolic acid (PLGA) plate grafts in secondary CLND correction. METHODS: This study was retrospectively analyzed for patients who underwent secondary rhinoplasty for unilateral CLND correction between March 2015 and November 2020. Using open rhinoplasty, the PLGA plate was grafted as a columellar strut. Clinical photographs taken at the initial (T0) and follow-up visits (T1: short-term, T2: long-term) were analyzed and anthropometric parameters, such as nostril height and width, dome height, and tip height, were measured. RESULTS: Twenty-four patients were included in this study. The mean T1 and T2 periods were 1.0 ± 0.4 and 15.5 ± 3.1 months, respectively. The nostril height ratio increased from 0.78 ± 0.12 at T0 to 0.88 ± 0.08 at T1 and 0.86 ± 0.09 at T2 (p < 0.001; Relapse ratio -2.6 ± 6.7%). The tip height ratio increased from 0.60 ± 0.07 (T0) to 0.66 ± 0.05 (T2) (Relapse ratio -3.7 ± 3.0%). CONCLUSIONS: The PLGA plate graft provided stable nasal tip projection and alar symmetry without major complications. It can be a good option for patients lacking available septal and concha cartilages or apprehensive of additional scarring.

An Analysis of the Demographics and Clinical Characteristics of Transgender and Intersex Populations in Korea: A Retrospective Study Using HIRA Database.

BACKGROUND: Transgender and intersex populations have long remained under-documented in South Korea, largely due to the absence of comprehensive epidemiological data. With increasing societal acknowledgment, there's an urgent need to understand the demographics and health challenges faced by these communities. METHODS: This retrospective, large-scale data study included people who received the F64 codes from the Korean Health Insurance Review & Assessment Service between January 2007 and December 2021. Demographics, gender-affirmative treatments, and psychiatric related medications were examined. RESULTS: Between 2007 and 2021, 8,602 patients were diagnosed with "gender identity disorder" and 45 with "intersex." A steadily increasing annual prevalence was observed, peaking at 986 cases in 2021. The majority (79.8%) were aged between 10 and 30. Nearly half (53.2%) exhibited mental and behavioral disorders. Two-thirds had been prescribed anxiolytics or sedatives either before or after diagnosis. Merely 12.1% received hormone therapy covered by health insurance. CONCLUSION: This is the first large-scale study highlighting the demographics and clinical characteristics of the transgender and intersex populations in Korea. The study reveals a consistent growth of these communities over the past 15 years, with a significant proportion under 30 years of age facing mental and behavioral challenges. Findings underscore the need for targeted healthcare interventions, early psychological support, and comprehensive insurance coverage tailored to the specific needs of these individuals in Korea.

Blood Concentrations of Lead, Cadmium, and Mercury Are Associated With Alcohol-Related Liver Disease.

BACKGROUND: An association between environmental pollutants and alcohol-related liver disease (ALD) has not been determined until now. The objectives of this study were to examine the association of the pollutants with ALD, and whether the pollutants together increased the risk of ALD. METHODS: Data were extracted from the Korea National Health and Nutrition Examination Survey (2010-2013 and 2016-2017; n = 11,993). Blood levels of lead, cadmium, and mercury were measured. ALD was defined by a combination of excessive alcohol consumption and ALD/non-alcoholic fatty liver disease index > 0. The aspartate aminotransferase-to-platelet ratio index and fibrosis (FIB)-4 score were used to evaluate ALD FIB. RESULTS: The odds ratios (ORs) of ALD for the highest versus the lowest quartiles of exposure were for lead, 7.39 (95% confidence interval [CI], 5.51-9.91); cadmium, 1.68 (95% CI, 1.32-2.14); and mercury, 5.03 (95% CI, 3.88-6.53). Adjusting for age, gender, smoking, occupation, education, and personal income attenuated the associations but indicated significant positive trends (all Ptrend < 0.001). A positive additive interaction between cadmium and lead was observed. The relative excess OR due to the interaction was 0.96 (95% CI, 0.41-1.51); synergy index = 2.92 (95% CI, 0.97-8.80). Among 951 subjects with ALD, advanced FIB was associated with lead and cadmium (OR, 3.46, 95% CI, 1.84-6.53; OR, 8.50, 95% CI, 2.54-28.42, respectively), but not with mercury. The effect estimates for lead and cadmium remained significant even after adjustment for daily alcohol intake. CONCLUSION: Blood levels of lead, cadmium, and mercury were significantly associated not only with the risk of ALD but also with ALD FIB. Cadmium and lead have synergistic effects that increase the risk of ALD.

The Efficacy of CT-Based Conformal Electron Beam Radiation Therapy After Keloid Excision.

BACKGROUND: Adjuvant computed tomography-based conformal electron beam radiation therapy (RT) for patients with keloids enables radiation oncologists to customize the target volume with precision and deliver the maximal prescription dose while sparing normal surrounding tissues. OBJECTIVE: To report treatment and cosmetic outcomes by the patient's self-assessment survey. METHODS: Medical records of patients with keloids, who were treated with postoperative electron beam RT between January 2015 and December 2020, were reviewed. A total of 85 consecutive patients with 136 keloids were included in this study. Subjective cosmetic outcomes were scored by each patient using a 5-point Likert scale survey. RESULTS: The median follow-up time was 29.0 months (range, 12.1-77.9 months), and local recurrence was observed in 10 lesions (7.4%). The recurrence rate of keloids occurring in the ear was 5.4%, whereas the recurrence rate of keloids occurring at other body sites was 11.4%. Among the patients who responded to the questionnaire about the cosmetic outcome, 70.2% of patients declared being either very satisfied (44.7%) or satisfied (25.5%). CONCLUSION: Surgical excision, followed by CT-based conformal electron beam RT, for patients with keloids ensures a high degree of local control resulting in good cosmetic outcomes.

A Comparative Study of Breast Sensibility and Patient Satisfaction After Breast Reconstruction: Autologous, 2-Stage Implant-Based, and Prepectoral Direct-to-Implant Reconstruction.

BACKGROUND: Currently, a variety of treatment modalities are implemented for breast reconstruction. However, clinical prognosis regarding sensory regeneration of the breast and patient-reported satisfaction remains underexamined. In this study, we aimed to compare breast sensibility after various reconstruction. METHODS: We conducted a retrospective comparative study of all patients who underwent breast reconstruction between August 2016 and October 2019 at our institution. Acellular dermal matrixes were used to cover the implant inferolaterally in a dual-plane subpectoral approach and to wrap the implant in prepectoral direct to implant (DTI). The cutaneous tactile pressure threshold and patient satisfaction outcome were tested. RESULTS: A total of 105 breasts were assessed, 30 breasts reconstructed with deep inferior epigastric perforator (DIEP) flap, 40 breasts reconstructed with 2-stage subpectoral implant, and 35 breasts reconstructed with prepectoral DTI. In the specific group-to-group analysis, DIEP and implant groups showed significant differences in sensory recovery, mainly in lateral areas of the reconstructed breast. In 2-stage reconstruction and DTI groups, there were no statistically significant differences. When comparing patient groups using only patients with follow-up lengths of more than 12 months, the difference was more clearly indicated (P = 0.049). Better sensory recovery predicted high satisfaction scores in patient-reported outcomes (P = 0.007). CONCLUSIONS: We found that subpectoral implant reconstruction and DTI show no statistically significant differences in sensory recovery, and autologous DIEP flap reconstruction results in a better prognosis than prosthesis implant reconstruction. Furthermore, the clarity of the differences increased when the follow-up length was longer than 12 months. Better patient-reported satisfaction was associated with good breast sensibility.

Direct-Acting Antivirals Improve Treatment Outcomes in Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma Treated with Transarterial Chemoembolization: A Nationwide, Multi-center, Retrospective Cohort Study.

BACKGROUND AND AIMS: The influence of direct-acting antivirals (DAAs) on chronic hepatitis C (CHC)-related hepatocellular carcinoma (HCC) remains controversial. We investigated the effect of eradicating CHC using DAAs on treatment outcomes in patients with CHC-related HCC treated with transarterial chemoembolization (TACE). METHODS: This nationwide, multi-center, retrospective study recruited patients with CHC-related HCC treated with TACE as the first-line anti-cancer treatment, and who achieved a sustained virological response (SVR) using DAAs (DAA group) between 2006 and 2017. Patients achieving an SVR following interferon-based treatment (IFN group) and those without treatment (control group) were also recruited for comparison. RESULTS: A total of 425 patients were eligible for the study. Of these, 356 (83.8%), 26 (6.1%), and 43 (10.1%) were allocated to the control, IFN, and DAA groups, respectively. A multivariate analysis showed that liver cirrhosis, segmental portal vein thrombosis, and larger maximal tumor size independently predicted an increased risk of progression (all p < 0.05), whereas, the DAA group (vs. IFN and control groups) independently predicted a reduced risk of progression (hazard ratio (HR) = 0.630, 95% confidence interval 0.411-0.966, p = 0.034). The cumulative incidence rate of HCC progression in the DAA group was significantly lower than that in the IFN and control groups (p = 0.033, log-rank test). In addition, the DAA group (vs. IFN and control groups) was independently associated with a reduced risk of mortality (p = 0.042). CONCLUSIONS: DAA treatment provided significantly prolonged progression-free survival in patients with CHC-related HCC treated with TACE compared to that in patients administered IFN or no treatment.

Early Treatment Effects of Nonablative Fractional Lasers (NAFL) on Hypertrophic Scars in an Animal Model.

BACKGROUND AND OBJECTIVES: Recently, there have been several attempts to apply the laser therapy to hypertrophic scars (HTS). In particular, the fractional laser is in the spotlight for its usefulness in rapid wound healing and dermal remodeling. However, most previous studies have focused on the ablative fractional laser (AFL), and there are no studies on the mechanism of the nonablative fractional laser (NAFL) effect in HTS treatment. In this study, we aimed to evaluate the changes in histology and molecular chemistry to provide scientific evidence for the early treatment of HTS with NAFL. STUDY DESIGN/MATERIALS AND METHODS: A total of 40 hypertrophic burn scars were made on the abdomens of two female pigs. After epithelialization, the HTS were randomly subdivided into four groups-control, AFL, NAFL (low energy), and NAFL (high energy). Laser treatment was initiated 1 week after the crust fell and the epithelium became covered, and it was repeated for six sessions over an interval of 2 weeks. Five excisional biopsies were obtained for histologic analysis and biomarker assessment. RESULTS: Histologically, dermal remodeling with thin coil-shaped collagen fibers was observed in the NAFL groups. It also showed a significant increase of matrix metalloproteinase-2 (MMP-2) and Decorin at 16 weeks in an enzyme-linked immunosorbent assay. The reverse-transcription polymerase chain reaction analysis showed a tendency that high-pulse energy of NAFL led to higher messenger RNA expression than did the low-energy group. CONCLUSION: The NAFL-treated groups showed characteristic collagen re-arrangement and a significant increase in MMP-2 and Decorin. These molecular changes suggest that MMP-2 and Decorin play a significant role in dermal remodeling. Early NAFL treatment for HTS could be supported with both histological and molecular evidence. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

The Hybrid Latissimus Dorsi Flap in Immediate Breast Reconstruction: A Comparative Study With the Abdominal-Based Flap.

PURPOSE: The implant-enhanced latissimus dorsi (LD) flap, or a hybrid LD flap, is widely used in certain indications, even though abdominal-based flaps are now considered the gold standard of autologous breast reconstruction. However, few articles distinguish the hybrid LD flap from traditional LD flaps, and not many articles have compared the surgical outcomes, with the abdominal-based flap procedure, especially in the area of immediate breast reconstruction. In addition, it is often overlooked that the reported esthetic comparisons are based on different populations and contralateral balancing procedures (CBPs). Thus, this study aimed to review the reconstruction outcomes and to compare the variable-matched esthetic outcomes between 2 groups. METHODS: A retrospective review of patients who underwent immediate breast reconstruction with either a hybrid LD flap or an abdominal-based free flap and had completed at least 2 years of follow-up visits was carried out. The patient demographics, oncologic data, breast parameters, and postoperative outcomes were compared across the entire patient group. The body mass index (BMI)- and CBP-matched cohort was randomly selected and assessed using the Aesthetic Outcome parameter of the Aesthetic Item Scale. RESULT: Thirty-eight hybrid LD flap and 51 abdominal-based free flap procedures were included. The hybrid LD group showed a shorter operation time (330 ± 260 minutes vs 550 ± 480 minutes, respectively; P < 0.01), and fewer patients in the hybrid LD group underwent additional revision surgeries (7 [18.4%] vs 20 [39.2%], respectively; P < 0.01). Other complication rates were not significantly different between groups. A BMI- and CBP-matched esthetic analysis revealed that the hybrid LD group showed superior results in symmetry (Mann-Whitney U test, P = 0.047). CONCLUSIONS: The LD flap in combination with an implant remains a viable option in immediate breast reconstruction and had a similar complication profile while having a shorter operative time compared with the abdominal-based autologous breast reconstruction procedure. If properly used in certain populations, hybrid LD flaps may offer superior results regarding symmetry over the abdominal-based flap procedure.

A Comparison of Aesthetic Outcomes of Umbilicoplasty in Breast Reconstruction with Abdominal Flap: Inverted-U Versus Vertical Oval Incision.

BACKGROUND: The umbilicus is a key aesthetic unit of the abdominal wall. It contributes to the natural curvature of the abdomen and is now considered as one of the most important factors in the overall results and patient satisfaction. In this study, we present an inverted-U incisional technique for umbilicoplasty. This study aims to describe the senior author's approach to umbilicoplasty and compare the aesthetic outcomes of the inverted-U method with those of the vertical oval incisional technique. METHODS: In this retrospective cohort study, we analyzed a total of 109 patients including 51 who underwent umbilicoplasty with the inverted-U incisional technique and 58 who had surgery with the vertical oval incisional method. With the description of our operative technique, the aesthetic outcomes of both techniques were compared by two independent surgeons using a 5-point Likert scale in terms of shape, size, depth, natural appearance and periumbilical scarring. Also, the total scores of the five items were calculated to give a final score for each patient (range, from 5 to 25 points). RESULTS: On all measured parameters, the inverted-U incisional technique produced favorable outcomes compared with the vertical oval incisional technique. Also, the inverted-U incisional technique was given significantly higher total scores than was the vertical oval incisional technique (inverted-U 14.73 ± 2.47 vs. vertical oval 11.26 ± 3.02, p = 0.002). CONCLUSIONS: In this study, an inverted-U incisional technique produced significantly favorable outcomes in terms of shape, size, depth, natural appearance and overall score compared to a vertical oval incision (p < 0.05). We believe that this technique enables surgeons to achieve a better shape, natural retrusive appearance and superior hood. LEVEL OF EVIDENCE III: In this study, an inverted-U incisional technique produced significantly favorable outcomes in terms of shape, size, depth, natural appearance and overall score compared to a vertical oval incision (p < 0.05). We believe that this technique enables surgeons to achieve a better shape, natural retrusive appearance and superior hood.

Reliability of the Patient and Observer Scar Assessment Scale in Evaluating Linear Scars after Thyroidectomy.

OBJECTIVE: To compare the reliability of the Patient and Observer Scar Assessment Scale (POSAS) with the Vancouver Scar Scale (VSS) in evaluating thyroidectomy scars. METHODS: At 6 months after the operation, 112 patients who underwent thyroid surgery via collar neck incision were evaluated by two blinded plastic surgeons and two senior residents using the VSS and the observer component of the POSAS. In addition, the observer-reported VAS score and patient-reported Likert score were evaluated. Internal consistency, interobserver reliability, and correlations between the patient- and observer-reported outcomes were examined. RESULTS: The observer component of POSAS scores demonstrated higher internal consistency and interobserver reliability than the VSS. However, the correlations between the observer-reported VAS score and the patient-reported Likert score (0.450) and between the total sum of patient and observer component scores (0.551) were low to moderate. CONCLUSIONS: The POSAS is more consistent over repeated measurements; accordingly, it may be considered a more objective and reliable scar assessment tool than the VSS. However, a clinician's perspective may not exactly match the patient's perception of the same scar.

Predictors affecting complications and aesthetic outcomes in autologous breast reconstruction with free muscle-sparing transverse rectus abdominis myocutaneous flaps.

BACKGROUND: Identification and understanding of predictors for complications and aesthetic outcomes in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap are essential for successful breast reconstruction. The purpose of this study was to investigate predictors for complications and aesthetic outcomes in patients who underwent autologous breast reconstruction with free MS-TRAM flaps. PATIENTS AND METHODS: Between March 2003 and September 2017, a total of 214 patients who underwent breast reconstruction with MS-TRAM flaps were included in this study. Mean age of the patients was 43.2 years (range, 28-61 years). Four outcome data, including operation time, hospital stay, aesthetic scores, and complications; and 12 patient data, including recipient vessel type, age, body mass index [BMI] > 25, smoking status, neoadjuvant chemotherapy, radiotherapy, nipple-sparing mastectomy, contralateral breast surgery, history of hypertension, diabetes mellitus, cardiac disease, and endocrine disease were collected. RESULTS: Five and 52 patients experienced major complications, including partial flap loss, and minor complications, respectively. In stepwise multiple logistic analysis, risk factors for complications were BMI > 25 (P < 0.001), smoking status (P = 0.012), and neoadjuvant radiotherapy (P = 0.002). BMI > 25 (P < 0.001), smoking status (P < 0.001), contralateral breast surgery (P < 0.001), and history of cardiac (P = 0.001) and endocrine disease (P = 0.003) were predictors for aesthetic outcome. CONCLUSION: Predictors for complications and aesthetic outcomes determined in this study may facilitate microsurgeons engaged in the assessment of patients needing free MS-TRAM flaps.

Comparison of the Outcomes of Closed Reduction Nasal Bone Fractures With a Surgical Navigation System.

BACKGROUND: The most prevalent form of facial bone fractures is nasal fractures. The surgical procedures used for these fractures are relatively simple, but complete correction is not easy because the nasal bone is small and identifying the fracture site by palpation is difficult. This study aimed to investigate the efficacy of intraoperative surgical navigation systems in nasal bone fracture surgery through a prospective analysis. METHODS: Between February 2019 and July 2019, 25 navigation-assisted closed reductions of nasal fractures were performed. Preoperative computed tomography images were obtained at 1-mm intervals before surgery and the navigation was set by a simulation to have an error rate of less than 1. Then, the navigation system was used to identify the fracture site. Closed reduction was performed with Asch forceps and a Langenbeck elevator based on the previous markings made using the navigation system. RESULTS: The degree of reduction was evaluated by plain X-rays and computed tomography scans, which were performed 1 month after surgery. In the navigation group, the average distance between the fragment and normal bony alignment was decreased from 2.38 to 0.49 mm and the modified Motomura score was an average of 2.40 points. The decrease in the mean distance was significantly different (P = 0.038) compared with the conventional group. CONCLUSIONS: Surgical navigation systems could be a useful tool for localizing fracture sites and guiding closed reductions. In particular, the system could be recommended for nasal bone fracture reductions in the tip or pyriform regions, which are difficult to correct. LEVEL OF EVIDENCE: II.

The Influence of Dissection Range of the Facial Nerve on Transient Postoperative Facial Palsy in Mandibular Condyle Fractures.

PURPOSE: This study examined the relation between dissection range of facial nerve branches and transient postoperative facial palsy caused by nerve traction for open treatment of mandibular condyle fractures using a preauricular approach. MATERIALS AND METHODS: This retrospective study included 58 patients who underwent rigid fixation of condylar head and upper neck fractures. Patients were divided into 3 groups based on dissection range of the frontal and zygomatic branches. For group 1 (n = 22), the dissection range was extended anteriorly and posteriorly from the condylar borders through the retroparotid approach. The transparotid approach was used in groups 2 (n = 19) and 3 (n = 17) in which nerve dissection was limited to the condylar borders and was extended only anteriorly, respectively. Using multivariate correlation and multiple regression analyses, differences in duration of nerve traction and angle difference by traction from the natural course of the nerve were analyzed according to dissection range, and the recovery period for facial palsy was evaluated. RESULTS: The duration of nerve traction for group 2 was 77.53 minutes, which was longer than that for groups 1 (66.00 minutes) and 3 (65.41 minutes). The angle differences by traction were 62.42° and 58.00° for the frontal and zygomatic branches in group 2, respectively, which were considerably greater than those in groups 1 (23.32° and 20.14°) and 3 (37.24° and 28.88°). In consequence, group 2 showed the longest recovery, requiring 64.47 days for the frontal branch and 51.63 days for the zygomatic branch. The angle difference by traction had a greater influence on the recovery period than duration of nerve traction. CONCLUSIONS: Duration of nerve traction and angle difference by traction were quantitatively dependent on the dissection range of facial nerve branches and were related to the recovery period for transient facial palsy.

Smoking-Related Differential Influence of Alcohol Consumption on the Metabolic Syndrome.

Background: There is a high propensity toward combined alcohol consumption and smoking. The aim of the study is to determine whether the association of alcohol consumption and the metabolic syndrome (MS) were different in among groups stratified by smoking exposure. Methods: Subjects consisted of 4,672 adult participants in the 2008 Korea National Health and Nutrition Examination Survey grouped into three categories of smoking using urinary cotinine concentration. Drinking categories were as follows: lifetime abstainers, ex-drinkers, responsible drinkers (<20 g alcohol/day for women; <40 g/day for men), and hazardous drinking (≥ 20 g/day for women; ≥ 40 g/day for men). Results: Compared with nonsmokers, heavy smokers had a higher risk of the MS (OR: 1.27, 95% CI: 1.00-1.62, p = .052). One standard deviation-higher urinary cotinine was also associated with higher risk of the MS (OR: 1.12, 95% CI: 1.03-1.23, p = .011). In nonsmokers and light/moderate smokers, alcohol had no effect on the MS. In heavy smokers, the risk of the MS was substantially higher in ex-drinkers (OR: 3.42; 95% CI: 0.99-11.82), responsible drinkers (OR: 2.80; 95% CI: 0.96-8.12), and hazardous drinkers (OR: 3.30; 95% CI: 1.21-9.03, p = .02) compared to lifetime abstainers. A profound effect modification of alcohol by smoking was found in current drinkers. Conclusions: Smoking is closely associated with the MS. Alcohol has detrimental effect on the risk of MS in heavy smokers and the effect of alcohol is enhanced by smoking.

Predictors of High-Risk Adenoma Occurrence at Surveillance Colonoscopy in Patients Who Undergo Colorectal Adenoma Removal.

OBJECTIVES: Surveillance colonoscopy is recommended after polypectomy because adenoma recurrence is common. The aim of this study was to evaluate the predictors of high-risk adenoma occurrence at surveillance colonoscopy in patients who undergo colorectal adenoma removal and to clarify the association between age and recurrent colorectal adenoma. METHODS: This retrospective study included 563 patients who had colorectal adenomas at baseline colonoscopy and who underwent surveillance colonoscopy. The risk factors for recurrent adenoma were evaluated and the 5-year cumulative incidence rates of overall and high-risk adenoma were compared according to age group. RESULTS: During a mean follow-up period of 3.1 years, 305 (54.2%) patients had overall adenoma recurrence, and 80 (14.2%) patients had high-risk adenoma at surveillance colonoscopy. In a multivariate analysis, old age (≥60 years) and presence of multiple adenomas (3 or more) were significantly associated with high-risk adenoma (p = 0.002 and p = 0.006 respectively). The 5-year cumulative incidence rates of high-risk adenoma were 7.4, 16.7, and 24.1% in the < 50, 50-59, and ≥60 years group respectively (p < 0.001). CONCLUSIONS: Old age (≥60 years) and presence of multiple adenomas (3 or more) were strongly associated with the occurrence of high-risk adenoma at surveillance colonoscopy. The 5-year cumulative incidence of high-grade adenoma was significantly high in the old age group.

Serum cystatin C level: An excellent predictor of mortality in patients with cirrhotic ascites.

BACKGROUND AND AIM: Although serum cystatin C level is considered a more accurate marker of renal function in patients with liver cirrhosis, its prognostic efficacy remains uncertain. This study aimed to evaluate the prognostic efficacy of serum cystatin C level in patients with cirrhotic ascites. METHODS: Patients with cirrhotic ascites from 15 hospitals were prospectively enrolled between September 2009 and March 2013. Cox regression analyses were performed to identify independent predictive factors of mortality and development of type 1 hepatorenal syndrome (HRS-1). RESULTS: In total, 350 patients were enrolled in this study. The mean age was 55.4 ± 10.8 years, and 267 patients (76.3%) were men. The leading cause of liver cirrhosis was alcoholic liver disease (64.3%), followed by chronic viral hepatitis (29.7%). Serum creatinine and cystatin C levels were 0.9 ± 0.4 mg/dL and 1.1 ± 0.5 mg/L, respectively. Multivariate analyses revealed that international normalized ratio and serum bilirubin, sodium, and cystatin C levels were independent predictors of mortality and international normalized ratio and serum sodium and cystatin C levels were independent predictors of the development of HRS-1. Serum creatinine level was not significantly associated with mortality and development of HRS-1 on multivariate analysis. CONCLUSION: Serum cystatin C level was an independent predictor of mortality and development of HRS-1 in patients with cirrhotic ascites, while serum creatinine level was not. Predictive models based on serum cystatin C level instead of serum creatinine level would be more helpful in the assessment of the condition and prognosis of patients with cirrhotic ascites.

Prognostic Significance of Hemodynamic and Clinical Stages in the Prediction of Hepatocellular Carcinoma.

BACKGROUND & GOALS: Early identification of hepatocellular carcinoma (HCC) is associated with improved survival for patients with chronic liver disease (CLD). We evaluated the prognostic significance of hemodynamic stage (HS) and clinical stage (CS) in predicting HCC in CLD patients. METHODS: Between January 2006 and May 2014, 801 patients with CLD who underwent hepatic venous pressure gradient (HVPG) measurement were prospectively enrolled. HS was classified by HVPG (mm Hg) as follows: HS-1 (HVPG≤6), HS-2 (612 mm Hg (P=0.033, OR=2.17), CS>2 (P=0.039, OR=2.36), and alpha-fetoprotein (AFP; P=0.017, OR=1.01) were significant predictors of HCC development in all patients. For patients with cirrhosis, ascites aggravation (OR=2.51), HVPG >12 mm Hg (OR=2.46), and CS >2 (OR=2.62) were correlated with HCC development. Areas under receiver operating characteristic curves of the prediction-model, CS, HVPG score, and AFP were 0.797, 0.707, 0.701, and 0.653, respectively. CONCLUSIONS: HCC development correlates with advancing liver fibrosis or disease as measured by HS and CS. In addition, ascites aggravation and elevated AFP appears to be associated with increased incidence of HCC.

Combining Data From Liver Disease Scoring Systems Better Predicts Outcomes of Patients With Alcoholic Hepatitis.

BACKGROUND & AIMS: Several models have been used to determine prognoses of patients with alcoholic hepatitis. These include static systems (the Maddrey discriminant function; age, bilirubin, international normalized ratio, creatinine [ABIC] score; and model for end-stage liver disease [MELD] score) and dynamic models (the Lille model). We aimed to combine features of all of these models to develop a better method to predict outcomes of patients with alcoholic hepatitis. METHODS: We collected data from several databases of patients with severe alcoholic hepatitis treated with corticosteroids in France and the United Kingdom to create a model to predict patient survival (derivation cohort, n = 538 patients). We compared the performances of 3 joint-effect models (Maddrey+Lille, MELD+Lille, and ABIC+Lille) to determine which combination had the best prognostic value, based on known patient outcomes. The model was validated using data from trials of the effects of corticosteroids in patients in the United States, France, Korea, and Belgium (n = 604 patients). RESULTS: We created a joint-effect model to predict patient survival after 2 and 6 months; in the derivation and validation cohorts it predicted outcome significantly better than either static or dynamic models alone (P < .01 for all comparisons). The joint model accurately predicted patient survival regardless of patient risk level. The MELD+Lille combination was better than the Maddrey+Lille or ABIC+Lille combination in predicting patient survival, with Akaike information criterion values of 1305, 1313, and 1312, respectively. For example, based on the MELD+Lille combination model, the predicted 6-month mortality of complete responders with MELD scores of 15-45 (Lille score, 0.16) was 8.5% to 49.7%, compared with 16.4%-75.2% for nonresponders (Lille score, 0.45). According to the joint-effect model, for 2 patients with the same baseline MELD score of 21, the patient with a Lille score of 0.45 had a 1.9-fold higher risk of death than the patient with a Lille score of 0.16 (23.7% vs 12.5%). CONCLUSIONS: By combining results from static and dynamic scoring systems for liver disease, we can better predict outcomes of patients with alcoholic hepatitis, compared with either model alone. This may help patient management and design of clinical trials.

Portal hypertensive gastropathy as a prognostic index in patients with liver cirrhosis.

BACKGROUND: Portal hypertensive gastropathy (PHG) is a frequently overlooked complication of liver cirrhosis (LC). The clinical implications of PHG as a prognostic factor of LC or a predictive factor for the development of hepatocellular carcinoma (HCC) have not been established. The aim of this study was to assess the clinical significance of PHG in patients with LC. METHODS: Patients with LC were prospectively enrolled and followed in a single tertiary hospital in the Republic of Korea. Baseline hepatic vein pressure gradient (HVPG) was measured, and esophagogastroduodenoscopy (EGD) was performed. The associations of PHG with HVPG, survival and the development of HCC were evaluated. RESULTS: A total of 587 patients were enrolled. The mortality rate was 20.3 % (n = 119), and HCC developed in 9.2 % (n = 54) during the follow-up period (32.6 ± 27.8 months). The grade of PHG was well correlated with HVPG (no PGH: median 9.2 [IQR: 7.2-16.7], mild PHG: 14.6 [10.1-19.3], and severe PHG: 17.3 [12.3-21.5], P < 0.001), as well as with Child-Pugh class, MELD score or survival. However, it was not associated with the development of HCC. The grade of PHG (HR 3.29, 95 % CI: 1.12-9.63, severe vs. no PHG) and Child-Pugh class (HR 3.53, 95 % CI: 1.79-6.97, Child C vs A) showed significant associations with mortality. CONCLUSION: PHG was well correlated with portal hypertension and could be used as a prognostic factor for LC but not for the prediction of HCC.