Home Health Care and Hospice Use Among Medicare Beneficiaries With and Without a Diagnosis of Dementia.

Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.

Accidental ABO-incompatible pediatric liver transplantation with blood group antigen immune and operational tolerance: a case report with 21 years of follow-up.

Liver transplantation is a critical procedure for patients with end-stage liver disease, but it is often hindered by ABO-incompatibility between the donor and recipient, which can lead to immediate humoral rejection. We present a unique case involving a 10-month-old patient who, by accident, received an ABO-incompatible partial liver transplant from a type A mother without undergoing desensitization. Remarkably, during a 21-year follow-up period, the patient exhibited no signs of humoral or graft rejection, despite nonadherence to medication. This case highlights the possibility of dual tolerance in pediatric ABO-incompatible liver transplantation and provides insights into immune tolerance mechanisms, with implications for enhancing patient care and reducing healthcare costs. Further research is necessary to clarify these mechanisms and to evaluate the long-term durability of tolerance in pediatric transplant recipients.

Proper position of single and large (≥5 cm) hepatocellular carcinoma in Barcelona Clinic Liver Cancer classification.

The purpose of this study was to evaluate the proper position of single large hepatocellular carcinoma (HCC) in the Barcelona Clinic Liver Cancer (BCLC) staging system. The data were collected from the nationwide multicentre database of the Korean Liver Cancer Association. Patients with single large (≥5 cm) HCC were separated from BCLC stage A patients and designated as Group X. The remaining BCLC stage A and stage B patients were classified as Group A and Group B, respectively. The survival outcomes of propensity score-matched groups were compared. Among the 3965 randomly selected patients, the number of patients in Group X, Group A, and Group B was 414, 2787, and 760, respectively. TriMatch analysis allowed us to obtain 116 well-balanced triplets. The 1-, 3-, and 5-year overall survival rates in Group X were worse than in Group A (91%, 71%, and 48% vs 90%, 78%, and 64%, respectively; P < .000). However, the rates were not different compared with those in Group B (91%, 71%, and 48% vs 90%, 69%, and 48%, respectively; P < .09). In multivariate analysis, Group X, Group B, age over 60 years, prothrombin time-international normalized ratio, and creatinine level were independent predictors of worse overall survival. Our findings suggest that Group X should be relocated to BCLC stage B rather than BCLC stage A.

Barriers to Effective Communication about Advance Care Planning and Palliative Care: A Qualitative Study.

Purpose: The purpose of this study was to identify barriers to effective conversations about advance care planning (ACP) and palliative care reported by health care and community-based service providers in Massachusetts, USA. Methods: This qualitative research analyzed open-ended responses to two survey questions, inquiring about perceived barriers to having conversations about ACP and palliative care with patients and consumers. Data were collected between November 2017 and June 2019 from nine organizations in Massachusetts, including health care provider organizations, health insurers, community-based organizations, and a nursing education institution. Two researchers reviewed and coded the responses and identified common themes inductively. Results: Across 142 responses, primary barriers to ACP included hesitation and lack of understanding and knowledge, discomfort and resistance among service providers, lack of staff knowledge, difficulties with follow-up, and differences in ACP policies across regions. Common barriers to palliative care were misconceptions about palliative care and lack of knowledge, service providers' lack of preparedness, and limited policy support and availability. Challenges relevant to both ACP and palliative care were fear and discomfort around serious illness discussions, lack of knowledge and awareness, discussions that occur too late, and cultural and language barriers. Conclusion: Health care practitioners and community-based professionals reported consumer-, service provider-, and system-level barriers to facilitating conversations about ACP and palliative care with patients experiencing serious illness. There is a need for more tools and support to strengthen service providers' ACP and palliative care competencies and to promote a structured approach to health care planning conversations.

Altered Frequency, Activation, and Clinical Relevance of Circulating Innate and Innate-Like Lymphocytes in Patients With Alcoholic Liver Cirrhosis.

Alcoholic liver cirrhosis (ALC) is caused by chronic alcohol overconsumption and might be linked to dysregulated immune responses in the gut-liver axis. However, there is a lack of comprehensive research on levels and functions of innate lymphocytes including mucosal-associated invariant T (MAIT) cells, NKT cells, and NK (NK) cells in ALC patients. Thus, the aim of this study was to examine the levels and function of these cells, evaluate their clinical relevance, and explore their immunologic roles in the pathogenesis of ALC. Peripheral blood samples from ALC patients (n = 31) and healthy controls (HCs, n = 31) were collected. MAIT cells, NKT cells, NK cells, cytokines, CD69, PD-1, and lymphocyte-activation gene 3 (LAG-3) levels were measured by flow cytometry. Percentages and numbers of circulating MAIT cells, NKT cells, and NK cells were significantly reduced in ALC patients than in HCs. MAIT cell exhibited increased production of IL-17 and expression levels of CD69, PD-1, and LAG-3. NKT cells displayed decreased production of IFN-γ and IL-4. NK cells showed elevated CD69 expression. Absolute MAIT cell levels were positively correlated with lymphocyte count but negatively correlated with C-reactive protein. In addition, NKT cell levels were negatively correlated with hemoglobin levels. Furthermore, log-transformed absolute MAIT cell levels were negatively correlated with the Age, Bilirubin, INR, and Creatinine score. This study demonstrates that circulating MAIT cells, NKT cells, and NK cells are numerically deficient in ALC patients, and the degree of cytokine production and activation status also changed. Besides, some of their deficiencies are related to several clinical parameters. These findings provide important information about immune responses of ALC patients.

Factor Analysis for Body Mass Index Changes in Kidney Transplant Recipients.

BACKGROUND: The purpose of this study was to identify factors influencing changes in the body mass index (BMI) of kidney transplant (KT) patients and provide data for the management of the BMI of patients who have undergone KT. METHOD: The participants were 106 patients who underwent KT at a single center from August 2014 to June 2017. BMIs were compared and analyzed for 6 months and 24 months after KT, and the survey details were collected through medical records. Analysis was performed between 2 groups, one with increased BMI and the other without. Multivariate logistic regression analysis was performed to identify the factors related to an increase in BMI. RESULTS: BMI increased from 22.60 ± 2.72 kg/m2 at 6 months to 23.18 ± 3.06 kg/m2 2 years after KT. The group with increased BMI (n = 39) had more patients with higher low-density cholesterol levels at the time of KT (low-density cholesterol ≥100 mg/dL; 34 [54.0%] vs 10 [26.3]; P = .008) and without statin drug use than the other group (n = 67) (statin drug use, 48 [70.6%] vs 34 [87.2%], P = .044). Multiple logistic regression analysis showed that age >50 years (odds ratio [OR] = 2.942; 95% confidence interval [CI], 1.075-8.055; P = .036), low-density lipoprotein >100 mg/dL at KT (OR = 6.618; 95% CI, 2.225-19.682; P = 0.001), and no statin drugs (OR = 5.094; 95% CI, 1.449-17.911, P = .011) were the risk factors for an increased BMI after KT. CONCLUSIONS: After KT, to prevent an increase in the BMI, clinicians should strongly recommend the use of drugs to treat hyperlipidemia, especially in elderly patients with high low-density lipoprotein levels before KT.

Clinical impact of the treatment modality on small, solitary, recurrent intrahepatic hepatocellular carcinomas after primary liver resection.

PURPOSE: The aim of this study was to determine the survival benefit based on different treatment strategies in patients with small, solitary, recurring intrahepatic hepatocellular carcinomas (HCCs) that were defined as recurred Barcelona Clinic Liver Cancer stage O (reBCLC-O). METHODS: Among the 917 patients with HCC recurrence after primary hepatic resection, 394 patients with reBCLC-O were selected. Of these, 150 patients underwent curative treatment (re-resection, radiofrequency ablation, and liver transplantation) and 203 underwent transarterial chemoembolization (TACE) group for recurrent HCC. After propensity score matching (PSM), both the groups were well balanced (89 patients in each group). RESULTS: Before PSM, the 1-, 3-, and 5-year overall survival (OS) rates of patients in the curative treatment group (96.7%, 78.6%, and 70.5%, respectively) were significantly better than those in the TACE treatment group (95.6%, 53.7%, and 44.2%, respectively) (P < 0.001). After PSM, the 1-, 3-, and 5-year OS rates also differed significantly (92.0%, 79.6%, and 71.1% in the curative treatment group vs. 88.8%, 65.6%, and 57.9% in the TACE group) (P = 0.005). The independent predictors of worse OS were tumor number at the time of resection and treatment modality for the recurrence, time interval to recurrence, and prothrombin time international normalized ratio and alpha-fetoprotein levels at the time of recurrence. CONCLUSION: The OS of patients in the curative treatment group was better than that in the non-curative treatment group after PSM. Based on our results, curative treatment should be strongly recommended in the patients with reBCLC-O recurrence for better survival.

"If We Turned Our Backs, They Would Ignore Our Wishes": Bereaved Family Perceptions of Concordance of Care at the End of Life.

Background: The key to high-quality care at the end of life is goal-concordant care, defined as care that is consistent with patient wishes. Objectives: To characterize decedent wishes for care at the end of life and to examine next of kin narratives of their loved ones' perceptions of whether wishes were honored. Design: Mortality follow-back survey and in-depth interviews. Setting/Subjects: Survey responses (n = 601) were from next of kin of decedents who died in the San Francisco Bay area of the United States. Interviews were conducted with 51 next of kin, of whom 14 indicated that the decedent received care that was inconsistent with their wishes. Measurements: The survey asked if the decedent had wishes or plans for care and if care provided ever went against those wishes. In-depth interviews focused on aspects of care at the end of life that were not consistent with the decedent's wishes. Results: Approximately 10% of next of kin who reported on the survey that the decedent had specific wishes for medical care at the end of life also reported that the decedent received care that went against their wishes in the last month of life. The main theme of the in-depth interviews with next of kin who reported care that went against wishes was that discordant care was inconsistent with wishes for comfort-focused care and a lack of symptom palliation. Conclusions: Despite decades of work to improve quality of end-of-life care, poor pain and symptom management that result in lack of comfort remain the main reason that next of kin state wishes were not honored.

Bereaved Family More Likely to Report "Too Little" Care than "Too Much" Care at the End of Life.

Background: An often-stated concern is that dying persons receive too much aggressive medical care. Objective: Examine next-of-kin perceptions of the amount of medical care received in the last month of life. Design: Mixed-methods study with 623 survey responses and in-depth interviews with a subsample of 17 respondents. Subjects: Nontraumatic deaths 18 years and older in San Francisco Bay area. Measure: The survey asked: "During the last month of your family member's life, did he or she receive too little, the right amount, or too much medical care?" Additionally, surveys examined 18 measures of quality of care in the last month of life, reporting concerns or unmet needs with staff communication, symptom management, emotional support, physician communication, treating the patient with dignity, respecting a person's culture, spiritual support, and providing timely help after hours. Results: Of the 623 survey respondents, 16.9% reported their loved one received "too little" care while only 1.4% reported "too much." Likelihood of reporting too little medical care did not differ by age, gender, or being insured by Medicaid only. Respondents who reported "too little" compared with those that stated the "right amount" reported higher unmet needs for symptom palliation, physician communication concerns, with other important opportunities to improve the quality of care. Among the 17 in-depth interviews of those indicating "too little" care on the structured survey, the predominant concern (n = 10) was inadequate symptom management. Conclusion: While the majority of respondents indicated their loved one received the right amount of medical care at the end of life, a notable minority (one in six) indicated that their loved one received too little care.

Racial Differences in End-of-Life Care Quality between Asian Americans and Non-Hispanic Whites in San Francisco Bay Area.

Background: Little is known about end-of-life care experiences of Asian Americans and gaps in end-of-life care quality between Asians and non-Hispanic whites. Objective: Compare the perceptions of next-of-kin of Asian and non-Hispanic white decedents on end-of-life care quality. Design: Mortality follow-back survey. Setting/Subjects: Population-based sample of 108 Asian and 414 non-Hispanic white bereaved family members or close friends of adult, nontraumatic deaths in the San Francisco Bay area in 2018. Measurements: Survey items examined whether health care professionals treated the dying person with respect and dignity, respected their cultural traditions, respected their religious or spiritual beliefs, provided enough information about what to expect during the last month of life, provided emotional support to the family after the patient's death, and whether the dying person and the family received the needed help after work hours. Results: Of the 623 surveys (weighted n = 6513), 108 (weighted percentage = 17.6%) were from caregivers of Asian decedents. Almost half of these respondents indicated that they did not always experience respect for their cultural traditions (45.9% vs. 21.8%, p = 0.00) or respect for their religious and spiritual beliefs (42.2% vs. 24.5%, p = 0.01). With the exception of two outcomes, worse caregiver-reported care quality for Asian decedents persisted after adjustment for cause of death, site of death, type of health insurance, respondent's relationship to decedent, decedent age, and respondent education. Conclusions: Compared with caregivers of non-Hispanic whites, caregivers of Asian decedents reported unmet needs for caregiver support and lack of respect for cultural traditions and religious/spiritual beliefs.

Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life.

Importance: End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. Objective: To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. Design, Setting, and Participants: This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Exposures: Use of NIV or IMV. Main Outcomes and Measures: Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. Results: A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Conclusions and Relevance: This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.

The Black and White of Invasive Mechanical Ventilation in Advanced Dementia.

BACKGROUND/OBJECTIVES: Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race. MEASUREMENT: Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV. RESULTS: Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51). CONCLUSION: IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

Successful Kidney Transplantation Using a Deceased Donor Graft With Fibromuscular Dysplasia.

All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the second-most-common cause of renovascular hypertension and is observed in 2%-6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.

Different prognostic factors and strategies for early and late recurrence after adult living donor liver transplantation for hepatocellular carcinoma.

BACKGROUND: Some patients with hepatocellular carcinoma (HCC) recurrence after LT show good long-term survival. We aimed to determine the prognostic factors affecting survival after recurrence and to suggest treatment strategies. METHODS: Between January 2000 and December 2015, 532 patients underwent adult living donor liver transplantation (LDLT) for HCC. Among these, 92 (17.3%) who experienced recurrence were retrospectively reviewed. RESULTS: The 1-, 3-, and 5-year survival rates after recurrence were 59.5%, 23.0%, and 11.9%, respectively. In multivariate analysis, time to recurrence >6 months and surgical resection after recurrence were related to longer survival after recurrence, while multi-organ involvement at the time of primary recurrence was related to poorer survival. We classified patients into early (≤6 months) and late (>6 months) recurrence groups. In the early recurrence group, tumor size >5 cm in the explant liver, liver as the first detected site of recurrence, and multiple organ involvement at primary recurrence were related to survival on multivariate analysis. In the late recurrence group, mammalian target of rapamycin inhibitor (mTORi) usage and multi-organ involvement were significantly associated with the prognosis on multivariate analysis. CONCLUSIONS: Various therapeutic approaches are needed depending on the period of recurrence after LT and multiplicity of involved organs.

Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations.

OBJECTIVES: To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. DESIGN: Cross-sectional observational study comparing ACO-attributed beneficiaries with propensity score-matched beneficiaries not attributed to an ACO. SETTING: A total of 21 hospital referral regions (HRRs) in the United States. PARTICIPANTS: Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013-2014. MEASUREMENTS: Outcome measures were claims-based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics. RESULTS: Compared with beneficiaries not in an ACO, ACO-attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0-4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = -1.7 percentage points; CI = -3.1 to -.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO-penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non-ACO patients in both medium and high ACO-penetration HRRs. CONCLUSION: Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019.

Does meeting the Milan criteria at the time of recurrence of hepatocellular carcinoma after curative resection have an impact on prognosis?

BACKGROUND: The survival outcomes of recurrent hepatocellular carcinoma (HCC) after curative resection remain unclear due to lack of clear basis for the selection of treatment option. We investigated overall survival (OS) after intrahepatic recurrence and re-recurrence free survival (rRFS) of the patients with recurrent HCC, and whether Milan criteria (MC) status at resection and recurrence impacts on OS and rRFS. METHOD: We enrolled 959 patients who experienced recurrence after primary hepatic resection for HCC. We divided the cohort into four groups according to MC at two periods: IN-rIN MC (HCC within MC at the time of resection-recurrence within MC), IN-rOUT MC (HCC within MC at the time of resection-recurrence outside MC), OUT-rIN MC (HCC outside MC at the time of resection-recurrence within MC), and OUT-rOUT MC (HCC outside MC at the time of resection-recurrence outside MC). RESULTS: In the entire cohort, 1-, 3-, and 5-year OS after recurrence was 81.0%, 55.7%, and 45.8%, respectively, while rRFS was 63.7%, 46.1%, and 42.0%, respectively. The IN-rIN MC group had the best outcomes (5-year OS and rRFS, 54.5% and 45.7%, respectively). The IN-rOUT and OUT-rIN MC groups had better 5-year OS outcomes than the OUT-rOUT MC group (46.5%, 38.6%, and 24.8%, respectively; P < 0.05). However, 5-year rRFS did not differ among the three groups (37.5%, 36.6%, and 31.9%, respectively; P > 0.05). CONCLUSION: Survival after first recurrence following curative primary resection for HCC was affected by MC at both time of resection and recurrence. Both the IN-rOUT and OUT-rIN MC groups with similar survival outcomes can be saved via curative treatment.

The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia.

BACKGROUND: Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. BASIC PROCEDURES: Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. MAIN FINDINGS: Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). PRINCIPAL CONCLUSION: Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. TYPE OF SUBMISSION: Original article, Case control study, Retrospective. EVIDENCE LEVEL: III.

One Hundred Fifteen Cases of Pure Laparoscopic Living Donor Right Hepatectomy at a Single Center.

BACKGROUND: The pure laparoscopic approach to donor hepatectomy is being taken more often. However, few centers perform pure laparoscopic donor right hepatectomy (PLDRH) because it requires a high level of surgical skill. Studies reporting initial outcomes of PLDRH may prompt further implementation of the technique and help reduce initial learning curves at other transplant centers. This study reports performance of PLDRH at a single center with extensive experience of adult living donor liver transplantation. METHODS: Data from 115 donors (and recipients) who underwent PLDRH between November 2015 and June 2017 were analyzed retrospectively. Subgroup analysis was performed to compare outcomes between the initial (November 2015 to October 2016) and more recent (November 2016 to June 2017) periods. RESULTS: During the initial period, 3 (2.6%) donors experienced complications greater than grade III on the Clavien-Dindo scale. By contrast, no donors developed complications during the recent period. The operative time (293.6 minutes vs 344.4 minutes; P < 0.001) and hospital stay (7.3 days vs 8.3 days; P = 0.002) were significantly shorter during the more recent period. Also, Δhemoglobin (Hb)%, calculated as ΔHb% = [(preoperative Hb - postoperative Hb)/preoperative Hb] × 100 (14.9% vs 17.5%; P = 0.042), and Δaspartate aminotransferase (AST)%, calculated as ΔAST% = [(peak AST - preoperative AST)/preoperative AST] × 100 (1048.9% vs 1316.6%; P = 0.009), were significantly lower during the recent period. CONCLUSIONS: Pure laparoscopic donor right hepatectomy is both feasible and safe when performed at a center experienced in adult living donor liver transplantation. Performance of about 60 PLDRHs over 1 year is sufficient to standardize the procedure.