{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T06:55:07Z","timestamp":1785740107469,"version":"3.56.0"},"reference-count":26,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T00:00:00Z","timestamp":1763596800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T00:00:00Z","timestamp":1763596800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Hepatology Research"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Alcohol consumption and metabolic dysfunction are risk factors for esophageal squamous cell carcinoma (ESCC); however, their combined effects on recurrence remain unclear. This study aimed to evaluate whether metabolic dysfunction\u2010associated steatotic liver disease (MASLD) with moderate alcohol intake (MetALD) independently contributes to ESCC recurrence following curative endoscopic submucosal dissection (ESD).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a multicenter cohort study involving 63 moderate drinkers with early\u2010stage ESCC who underwent curative ESD. MetALD was defined as MASLD with moderate alcohol consumption. Recurrence\u2010free survival was compared between patients with MetALD and those without steatotic liver disease. Multivariable Cox regression, decision tree, random forest analyses, and directed acyclic graphs assessed independent predictors of recurrence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>During a median follow\u2010up of 2.3\u00a0years, 25.4% of patients experienced recurrence. Multivariable analyses identified alcohol non\u2010abstinence and MetALD as independent predictors. In supplementary analyses, hepatic steatosis and alcohol non\u2010abstinence\u2014but not metabolic dysfunction alone\u2014were significantly associated with recurrence. Decision tree and random forest analyses highlighted alcohol non\u2010abstinence and MetALD as the most influential predictors. Directed acyclic graphs demonstrated direct causal pathways from both factors to ESCC recurrence. Among non\u2010abstinent patients, those with MetALD had a markedly higher recurrence rate (54%) compared with moderate drinkers without SLD (27%), underscoring the synergistic oncogenic effect of alcohol and metabolic dysfunction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>MetALD is an independent risk factor for ESCC recurrence after curative ESD, especially among non\u2010abstainers. These findings suggest the synergistic oncogenic potential of moderate alcohol intake and MASLD, and underscore the importance of lifestyle and metabolic interventions in post\u2010ESD management.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/hepr.70080","type":"journal-article","created":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T16:27:55Z","timestamp":1763656075000},"page":"467-477","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["MetALD Was an Independent Risk Factor for the Recurrence of Early Esophageal Squamous Cell Carcinoma After Endoscopic Resection: A Multicenter Cohort Study Using Directed Acyclic Graphs"],"prefix":"10.1111","volume":"56","author":[{"given":"Michita","family":"Mukasa","sequence":"first","affiliation":[{"name":"Division of Gastroenterology, Department of Medicine Kurume University School of Medicine  Kurume 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