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Background/Objectives: Liver transplantation (LT) is typically performed as a surgery to treat end-stage liver disease (ESLD). Factors influencing acute kidney injury (AKI) post-living-donor LT (LDLT) have been identified; however, the potential role of the D-dimer-to-fibrinogen ratio (DFR) in predicting AKI remains unexplored. Therefore, we analyzed the relationship between DFR levels and the occurrence of AKI following LT. Methods: We retrospectively analyzed 648 recipients after 76 were excluded based on the exclusion criteria. Multivariate logistic regression and propensity score (PS) matching analyses were performed to evaluate the association between a high DFR (>1.05) and AKI. Results: After LDLT, AKI was observed in 148 patients (22.8%). A high DFR (>1.05) was independently associated with AKI. Multivariate logistic regression analysis showed that patients with a DFR above this threshold were four times more susceptible to AKI than those with a low DFR. A high DFR was also significantly associated with AKI in the propensity score-matched patients. Conclusions: Our findings suggest that incorporating preoperative DFR assessment into the management of patients undergoing LDLT could enhance the risk stratification for postoperative AKI.

BACKGROUND Robot-assisted laparoscopic partial nephrectomy (RAPN) has been increasingly used for treating renal tumors due to its advantages over other approaches. However, RAPN can induce acute incisional, peritoneal, visceral, and referred pain. Therefore, acute pain control in robotic surgery is a concern. This retrospective study aimed to evaluate the efficacy of intrathecal morphine (ITM) for postoperative analgesia and recovery after RAPN. MATERIAL AND METHODS We retrospectively investigated consecutive patients who underwent RAPN at our institute between 2020 and 2021. Among the 272 patients who met the inclusion criteria, 135 patients were administered 200 µg of ITM preoperatively (ITM group), while 137 patients were not (control group). Postoperative pain assessments using the numeric rating scale (NRS), opioid requirements, and recovery profiles during the first postoperative 24 h were compared between the 2 groups. RESULTS As the primary endpoint, the incidence of moderate-to-severe pain (24-h average NRS pain score ≥4) was significantly lower in the ITM group than in the control group (36.3% vs 61.3%, P<0.001). Pain scores and cumulative opioid requirements were also significantly lower in the ITM group for all assessments (P<0.001). Moreover, the ITM group had a higher score on the Quality of Recovery-15 questionnaire on the first postoperative day (129 vs 120, P=0.003) despite an increased rate of postoperative nausea/vomiting (27.4% vs 13.1%, P=0.003). CONCLUSIONS Our findings indicate that ITM provided superior pain control during the early period following RAPN, with reduced postoperative opioid requirements. Moreover, ITM improved patient satisfaction with recovery.

Background: Robot-assisted laparoscopic partial nephrectomy (RAPN) for renal tumor treatment provides ergonomic advantages to surgeons and improves surgical outcomes. However, moderate-to-severe pain is unavoidable even after minimally invasive surgery. Despite the growing interest in multimodal analgesia, few studies have directly compared its efficacy with intrathecal morphine, a traditional opioid-based analgesic. Methods: We retrospectively investigated the efficacy of multimodal analgesia compared with that of intrathecal analgesia and intravenous patient-controlled analgesia (IV-PCA) in patients who underwent transperitoneal RAPN at our institute between 2020 and 2022. Among the 334 patients who met the inclusion criteria, intrathecal analgesia using morphine 200 µg was performed in 131 patients, and multimodal analgesia, including transversus abdominis plane block and intraoperative infusion of paracetamol 1 g and nefopam 20 mg, was administered to 105 patients. The remaining 98 patients received postoperative IV-PCA alone. Results: As the primary outcome, the area under the curve of pain scores over 24 h was significantly lower in the intrathecal analgesia and multimodal analgesia groups than in the IV-PCA group (89 [62-108] vs. 86 [65-115] vs. 108 [87-126] h, p < 0.001). Cumulative opioid requirements were also significantly lower in the intrathecal analgesia and multimodal analgesia groups at 24 h after surgery ( p < 0.001). However, postoperative nausea and vomiting were significantly increased in the intrathecal analgesia group (27.5% vs. 13.3% vs. 13.3%, p = 0.005). Conclusions: Multimodal analgesia with a transversus abdominis plane block is an efficient analgesic method with fewer adverse effects compared to other analgesic methods. Our findings suggest the efficacy and safety of a multimodal approach for opioid-sparing analgesia after RAPN in the current opioid epidemic.

We developed a method for the early on-site detection of strawberry anthracnose using a portable Raman system with multivariate statistical analysis algorithms. By using molecular markers based on Raman spectra, the proposed method can detect anthracnose in strawberry stems 3 days after exposure to Colletotrichum gloeosporioides. A fiber-optic probe was applied for the portable Raman system, and the acquisition time was 10 s. We found that the molecular markers were closely related to the following subjects: i) an increase in amide III and fatty acids of C. gloeosporioides invading strawberry stems (Raman bands at 1180-1310 cm -1 ) and ii) a decrease in metabolites in strawberry plants, such as phenolic compounds and terpenoids (Raman bands at 760, 800, and 1523 cm -1 ). We also found that the increased fluorescence background caused by various chromophores within the invading C. gloeosporioides could serve as a marker. A two-dimensional cluster plot obtained by principal component analysis (PCA) showed that the three groups (control, fungal infection, and pathogen) were distinguishable. The linear discriminant analysis (LDA)-based prediction algorithm could identify C. gloeosporioides infection with a posterior probability of over 40%, even when no symptoms were visible on the inoculated strawberry plants., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The analgesic efficacy of peri-incisional infiltration and intraperitoneal instillation of ropivacaine in laparoscopic donor nephrectomy has not been clearly established., Methods: This randomized, controlled, double-blind trial allocated living donors undergoing left-sided laparoscopic donor nephrectomy to one of the following 4 groups: peri-incisional normal saline (NS) and intraperitoneal NS (group A, n = 30), peri-incisional 0.375% ropivacaine and intraperitoneal NS (group B, n = 31), peri-incisional NS and intraperitoneal 0.15% ropivacaine (group C, n = 31), and peri-incisional 0.375% and intraperitoneal 0.15% ropivacaine (group D, n = 32). Pain status was assessed using the visual analog scale at rest and during coughing at 2, 12, 24, and 48 hours postoperatively. Patient-controlled analgesia and additional rescue analgesic consumption were calculated by conversion to an equivalent dosage of morphine. This study did not include prisoners or those individuals who were coerced or paid as study participants., Results: The patient demographics and perioperative outcomes, including operative time, blood loss, and incision length, were comparable between the groups. The pain scores and number of patients who experienced shoulder pain at all postoperative time points did not differ significantly among the 4 groups. Postoperative analgesic consumption was similar in all groups, and there was no difference in the length of hospital stay., Conclusion: Peri-incisional infiltration and intraperitoneal instillation of ropivacaine did not reduce postoperative pain or analgetic consumption., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Robot-assisted laparoscopic prostatectomy (RALP) is a favored surgical approach for treating prostate cancer. However, RALP does not decrease postoperative pain significantly despite its minimal invasiveness. The pain associated with robot-assisted surgery is most severe during the immediate postoperative period. We aimed to demonstrate that preoperative rectus sheath block (RSB) can reduce acute pain after RALP., Methods: A prospective non-randomized study with two parallel groups was performed from June 2020 to August 2020. A total of 100 patients undergoing RALP were divided into two groups: the RSB group (n = 50) and the non-RSB group (n = 50). Ultrasound-guided RSB was performed preoperatively only in the RSB group. The primary outcome of the study was the visual analog scale (VAS) pain score during coughing (VAS-C) 1 h after surgery. In addition, the VAS pain score at rest (VAS-R) and the VAS-C were assessed up to 24 h after surgery. The doses of postoperative opioids consumed were also recorded., Results: The RSB group had a significantly lower VAS-C 1 h after RALP (58 [47-73] vs. 74 [63-83] mm, p = 0.001). In addition, the RSB group had significantly lower VAS-R and VAS-C scores, and postoperative opioid requirement, up to 6 h after surgery compared to the non-RSB group. Moreover, the VAS-R was significantly lower in the RSB group than in the non-RSB group 24 h after surgery., Conclusion: Preoperative RSB significantly improved analgesia during the early period after RALP. The long-term analgesic efficacy of RSB needs further study., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021. Published by Elsevier B.V.)

Few studies have examined the clinical utility of ultrasonography-guided pectoralis nerve block II (PECS II) during wide flap dissection of a robot-assisted transaxillary thyroidectomy (RATT). We assessed the ability of PECS II to reduce postoperative pain. We retrospectively reviewed 62 patients who underwent elective RATT from December 2021 to April 2022 at Seoul St. Mary's Hospital (Seoul, Korea). The patients were divided into a block group (n = 28, 50.9%) and no-block group (n = 27, 49.1%). Pain was measured using a visual analog scale (VAS) at 4, 10, 20, 25, 35, and 45 h after surgery, and the requirements for rescue painkillers in the post-anesthesia care unit and ward were recorded. The VAS scores did not differ significantly between the two groups at 4 h postoperatively. The block group had significantly lower VAS scores at 10 and 25 h ( p = 0.017 and p = 0.034, respectively). The block group required fewer painkillers in the post-anesthesia care unit than the no-block group, although the difference was not statistically significant in the ward. PECS II may serve as a new pain relief modality and valuable addition to the current multimodal analgesic strategy for patients undergoing RATT.

We investigated the clinical implication of the Hypotension Prediction Index (HPI) in decreasing amount of surgical haemorrhage and requirements of blood transfusion compared to the conventional method (with vs. without HPI monitoring). A prospective, randomised controlled-trial of 19- to 73-year-old patients (n = 76) undergoing elective lumbar spinal fusion surgery was performed. According to the exclusion criteria, the patients were divided into the non-HPI (n = 33) and HPI (n = 35) groups. The targeted-induced hypotension systolic blood pressure was 80−100 mmHg (in both groups), with HPI > 85 (in the HPI group). Intraoperative bleeding was lower in the HPI group (299.3 ± 219.8 mL) than in the non-HPI group (532 ± 232.68 mL) (p = 0.001). The non-HPI group had a lower level of haemoglobin at the end of the surgery with a larger decline in levels. The incidence of postoperative transfusion of red blood cells was higher in the non-HPI group than in the HPI group (9 (27.3%) vs. 1 (2.9%)). The use of HPI monitoring may play a role in providing timely haemodynamic information that leads to improving the quality of induced hypotension care and to ameliorate intraoperative surgical blood loss and postoperative demand for blood transfusion in patients undergoing lumbar fusion surgery.

A new design for light-emitting diodes (LEDs) with on-chip photocatalysts is presented for purification applications. An array of disk-shaped TiO 2 , with a diameter of several hundred nanometers, combined with SiO 2 pedestals was fabricated directly on the surface of an InGaN-based near-ultraviolet (UV) LED using a dry etching process. The high refractive-index contrast at the boundary and the circular shape can effectively confine the near-UV light generated from the LED through multiple internal reflections inside the TiO 2 nanodisks. Such a feature results in the enhancement of light absorption by the photocatalytic TiO 2 . The degradation of the organic dye malachite green was monitored as a model photocatalytic reaction. The proposed structure of LEDs with TiO 2 /SiO 2 nanodisk/pedestal array exhibited a photocatalytic activity that was three times higher than the activity of LEDs with a TiO 2 planar layer. The integration of photocatalytic materials with near-UV LEDs in a single system is promising for various purification applications, such as sterilization and disinfection., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Background: Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly. It is usually found incidentally on examination or during invasive procedures. In most cases, the blood flows back to the right atrium through the coronary sinus without hemodynamic abnormalities and it is usually asymptomatic. There is some controversy regarding the clinical use of PLSVC. In a few cases, a PLSVC has been used for hemodialysis or large-bore intravenous access., Case Report: A 62-year-old woman with a previous hepatectomy for hepatocellular carcinoma and liver cirrhosis developed hepatic failure. Owing to her worsening condition, she needed liver transplantation (LT). However, a superior vena cava thrombus was found between the right atrium and proximal superior vena cava on preoperative transesophageal echocardiography. Usually, right-sided central venous catheterization is performed for LT preparation, but the embolic risk was very high in our patient. Fortunately, she had already been diagnosed with PLSVC. Therefore, we decided to perform fluoroscopy-guided catheterization through the PLSVC. For the safe use of a PLSVC catheter during surgery, the rapid infusion system pressure, coronary sinus inflow pressure, and intraoperative transesophageal echocardiography were monitored. The patient successfully underwent LT., Conclusions: Based on a literature review and this case, PLSVC can be used clinically when accompanied by a detailed history, preoperative imaging examination, and close intraoperative monitoring. We suggest that a PLSVC is a feasible alternative to central venous access for LT., (Copyright © 2022 Elsevier Inc. All rights reserved.)

We investigated the effects of multimodal combined bundle therapy, consisting of remote ischemic preconditioning (RIPC) and intrathecal morphine block (ITMB), on the early recovery of kidney function after robot-assisted laparoscopic partial nephrectomy (RALPN) in patients with renal cell carcinoma (RCC). In addition, we compared the surgical and analgesic outcomes between patients with and without bundle treatment. This prospective randomized double-blind controlled trial was performed in a cohort of 80 patients with RCC, who were divided into two groups: a bundle group ( n = 40) and non-bundle group ( n = 40). The primary outcome was postoperative kidney function, defined as the lowest estimated glomerular filtration rate (eGFR) on postoperative day (POD) 2. Surgical complications, pain, and length of hospital stay were assessed as secondary outcomes. The eGFR immediately after surgery was significantly lower in the bundle group compared to the preoperative baseline, but serial levels on PODs 1 and 2 and at three and six months after surgery were comparable to the preoperative baseline. The eGFR level immediately after surgery was lower in the non-bundle than bundle group, and serial levels on PODs 1 and 2 and at three months after surgery remained below the baseline. The eGFR level immediately after surgery was higher in the bundle group than in the non-bundle group. The eGFR changes immediately after surgery, and on POD 1, were smaller in the bundle than in the non-bundle group. The non-bundle group had longer hospital stays and more severe pain than the bundle group, but there were no severe surgical complications in either group. The combined RIPC and ITMB bundle may relieve ischemia-reperfusion- and pain-induced stress, as a safe and efficient means of improving renal outcomes following RALPN in patients with RCC.

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

Background: Minimally invasive robot-assisted laparoscopic radical prostatectomy (RALP) has replaced open prostatectomy. However, RALP does not reduce postoperative pain compared to the open approach. We explored whether bundled intraoperative intravenous infusion of dexmedetomidine and ketorolac reduced opioid requirements during the 24 h after RALP., Methods: Eighty patients (two parallel groups) were enrolled in this prospective non-randomized study from September 2020 to November 2020. All received preoperative rectus sheath blocks for analgesia after RALP. A multimodal analgesic bundle (dexmedetomidine and ketorolac) was administered intraoperatively in the study group (n = 39) but not in the control group (n = 40). The total postoperative opioid requirements (expressed in milligrams of intravenous morphine) and pain scores (derived using a visual analog scale) were compared between the two groups up to 24 h after surgery., Results: The two groups were demographically similar. During surgery, patients in the study group received less remifentanil and more ephedrine than controls. The study group required significantly less opioids during the 24 h after surgery (28.3 vs. 40.0 mg, p = 0.006). The between-group pain scores differed significantly at 1 and 6 h after surgery. All other postoperative characteristics were comparable between the two groups., Conclusions: The intraoperative multimodal analgesic bundle (intravenous dexmedetomidine and ketorolac) improved postoperative analgesia after RALP in patients with rectus sheath blocks, as evidenced by the opioid-sparing effect after surgery., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Purpose: To evaluate the postoperative outcomes of a multimodal perioperative pain management protocol with rectus sheath blocks (RSBs) or intrathecal morphine (ITM) injection for minimally invasive colorectal cancer surgery., Methods: A total of 112 patients underwent minimally invasive colorectal surgery. Forty-one patients underwent RSB (group 1), whereas 71 patients underwent ITM (group 2) in addition to multimodal pain management using enhanced recovery after the surgery protocol. To adjust for the baseline differences and selection bias, baseline characteristics and postoperative outcomes were compared using propensity score matching., Results: Forty patients were evaluated in each group. There was no significant difference in the length of hospital stay between the two groups. According to the Comprehensive Complication Index (CCI) score, the postoperative complication rate was significantly lower in the RSB group (3.0 ± 7.8) than in the ITM group (8.1 ± 10.9; p = 0.016). During the first 24 h after surgery, the median postoperative visual analog scale score was significantly higher in the RSB group than in the ITM group (2.0 ± 1.1 vs. 1.5 ± 1.2; p = 0.048). Postoperative morphine use was also significantly higher in the RSB group than in the ITM group in the first 24 h (23.7 ± 19.8 vs 11.6 ± 15.6%; p = 0.003) and 48 h (16.9 ± 24.8 vs. 7.5 ± 11.9; p = 0.036) after surgery. Significant urinary retention occurred after the in the RSB and ITM groups (5% vs. 45%; p < 0.001)., Conclusion: Although the RSB group had higher morphine use during the first 48 h after surgery, the length of hospital stay remained the same and the complications were less in terms of the CCI score. Thus, transperitoneal RSB is a safe and feasible approach for postoperative pain management following minimally invasive procedures., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Somatic tissue oxygen saturation (SstO2) is associated with systemic hypoperfusion. Kidney dysfunction may lead to increased mortality and morbidity in patients who undergo living donor liver transplantation (LDLT). We investigated the clinical utility of SstO2 during LDLT for identifying postoperative kidney dysfunction., Patients and Methods: Data from 304 adults undergoing elective LDLT between January 2015 and February 2020 at Seoul St. Mary's Hospital were retrospectively collected. Thirty-six patients were excluded based on the exclusion criteria. In total, 268 adults were analyzed, and 200 patients were 1:1 propensity score (PS)-matched., Results: Patients with early kidney dysfunction had significantly lower intraoperative SstO2 values than those with normal kidney function. Low SstO2 (< 66%) 1 h after graft reperfusion was more highly predictive of early kidney dysfunction than the values measured in other intraoperative phases. A decline in the SstO2 was also related to kidney dysfunction., Conclusions: Kidney dysfunction after LDLT is associated with patient morbidity and mortality. Our results may assist in the detection of early kidney dysfunction by providing a basis for analyzing SstO2 in patients undergoing LDLT. A low SstO2 (< 66%), particularly 1 h after graft reperfusion, was significantly associated with early kidney dysfunction after surgery. SstO2 monitoring may facilitate the identification of early kidney dysfunction and enable early management of patients., Competing Interests: No author has any conflict of interest regarding the publication of this article.

This study aimed to determine the association between serum D-dimer levels and the risk of acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT). Clinical data of 675 patients undergoing LDLT were retrospectively analyzed. The exclusion criteria included a history of kidney dysfunction, emergency cases, and missing data. The final study population of 617 patients was divided into the normal and high D-dimer groups (cutoff: 0.5 mg/L). After LDLT, 145 patients (23.5%) developed AKI. A high D-dimer level (>0.5 mg/L) was an independent predictor of postoperative development of AKI in the multivariate analysis when combined with diabetes mellitus [DM], platelet count, and hourly urine output. AKI was significantly higher in the high D-dimer group than in the normal D-dimer group (odds ratio [OR], 2.792; 95% confidence interval [CI], 1.227-6.353). Patients with a high D-dimer exhibited a higher incidence of early allograft dysfunction, longer intensive care unit stay, and a higher mortality rate. These results could improve the risk stratification of postoperative AKI development by encouraging the determination of preoperative D-dimer levels in patients undergoing LDLT.

Background: As postoperative pain after laparoscopic cholecystectomy may delay recovery and discharge, a multimodal and pre-emptive analgesic approach is necessary. This study demonstrated that a multimodal analgesic bundle improves postoperative recovery, using the Quality of Recovery-40K (QoR-40K) questionnaire during the first 24 h after laparoscopic cholecystectomy., Methods: In this prospective non-randomized study with two parallel groups, 80 patients undergoing laparoscopic cholecystectomy were allocated into either the multimodal analgesia group or the conventional analgesia group. The multimodal analgesia group received a pre-emptive analgesic bundle (preoperative intravenous administration of paracetamol, ketorolac, and dexamethasone, and a posterior approach to the transversus abdominis plane block), while the conventional analgesia group did not. The primary outcome was the QoR-40K score during the first 24 h after surgery. Secondary outcomes were the peak visual analog scale pain score at rest and the incidence rates of rescue analgesic use and nausea/vomiting during the first 24 h after surgery., Results: The QoR-40K score was higher in the multimodal analgesia group than in the conventional analgesia group (196 [190-199] vs. 182 [172-187], p < 0.001). The peak visual analog scale pain score was significantly lower in the multimodal analgesia group than in the conventional analgesia group. Multimodal analgesia also reduced the incidence rates of rescue analgesic use and postoperative nausea/vomiting (22.5% [95% CI, 9.6-35.4%] vs. 55.0% [39.6-70.4%], p = 0.003), compared to conventional analgesia., Conclusions: Multimodal analgesia significantly improves the quality of early postoperative recovery after laparoscopic cholecystectomy, as shown by the QoR-40K score., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Purpose: Intrathecal analgesia (ITA) and transverse abdominis plane block (TAPB) are effective pain control methods in abdominal surgery. However, there is still no gold standard for postoperative pain control in minimally invasive colorectal surgery. This study aimed to investigate whether the analgesic effect could be increased when TAPB, which can further reduce wound somatic pain, was administered in low-dose morphine ITA patients., Methods: Patients undergoing elective colorectal surgery were randomized into an ITA with TAPB group or an ITA group. Patients were evaluated for pain 0, 8, 16, 24, and 48 hours after surgery. The primary outcome was the total morphine milligram equivalents administered 24 hours after surgery. The secondary outcomes were pain scores, ambulatory variables, inflammation markers, hospital stay duration, and complications within 48 hours after surgery., Results: A total of 64 patients were recruited, and 55 were compared. There was no significant difference in morphine use over the 24 hours after surgery in the 2 groups (ITA with TAPB, 15.3 mg vs. ITA, 10.2 mg; P = 0.270). Also, there was no significant difference in pain scores. In both groups, the average pain score at 24 and 48 hours was 2 points or less, showing effective pain control., Conclusion: ITA for pain control in patients with colorectal surgery is an effective pain method, and additional TAPB was not effective., Competing Interests: Conflict of Interest: No potential conflict of interest relevant to this article was reported., (Copyright © 2021, the Korean Surgical Society.)

Malignant hyperthermia (MH) is a potentially fatal hypermetabolic syndrome that occurs when susceptible individuals are exposed to triggering agents. Variability in the order and time of occurrence of symptoms often makes clinical diagnosis difficult. A late diagnosis or misdiagnosis of delayed-onset MH may lead to fatal complications. We herein report a case of delayed-onset MH in the postoperative recovery room. A 77-year-old man awoke from anesthesia and was transferred to the recovery room. Ten minutes after his arrival, his mental status became stuporous and he developed masseter muscle rigidity, hyperventilation, and a body temperature of 39.8°C. The patient was suspected to have MH, and 60 mg of dantrolene sodium (1 mg/kg) was administered via intravenous drip with symptomatic treatment. Within 10 minutes of dantrolene administration, the patient's clinical signs subsided. This case report demonstrates that rapid diagnosis and treatment are crucial to ensure a good prognosis for patients with MH. A high level of suspicion based on clinical symptoms and early administration of therapeutic drugs such as dantrolene will also improve the clinical course. Therefore, suspicion and prompt diagnosis are absolutely essential. This case report emphasizes the importance of continuous education in the diagnosis and treatment of MH.

Background: This study investigated the association between the fibrinogen level and the risk of acute kidney injury (AKI) in patients who have undergone living donor liver transplantation (LDLT)., Patients and Methods: A total of 676 patients who underwent LDLT were analyzed retrospectively. Exclusion criteria included a history of severe kidney dysfunction, emergency operation, deceased donor, ABO-incompatible transplantation, and missing data. The study population was divided into low and normal fibrinogen groups. A 1:1 propensity score (PS) matching analysis was used to evaluate the association between a low fibrinogen level (< 160 mg/dL) and postoperative development of AKI., Results: In total, 142 patients (23.1%) developed AKI after LDLT. The PS matching analysis showed that the probability of AKI was two-fold higher in the low fibrinogen group than in the normal fibrinogen group. In addition, patients with AKI had poorer postoperative outcomes such as longer hospitalization, longer ICU stay, and higher mortality than patients without AKI., Conclusions: The preoperative fibrinogen level may be useful for risk stratification of patients undergoing LDLT in terms postoperative development of AKI., Competing Interests: The authors have declared that no competing interests exist.

Background: Although many reports have shown that enhanced recovery after surgery (ERAS) programs improve the perioperative outcomes of patients undergoing colorectal surgery, the prevalence of early acute kidney injury (AKI) after surgery in such patients requires attention. Protective roles of the female sex in terms of chronic kidney disease and progression of ischemic renal injury have been described in many studies. We thus explored whether a sex difference was evident in terms of postoperative AKI in a colorectal ERAS setting., Methods: From January 2017 to August 2019, 453 patients underwent laparoscopic colorectal cancer resection in an enhanced recovery program. Of these, 217 female patients were propensity score (PS)-matched with 236 male patients. Then, 215 patients of either sex were compared in terms of postoperative renal function and complications., Results: Among the PS-matched patients, the incidence of AKI was significantly higher in male than female patients (24.2% vs. 9.8%, P < 0.001). Male patients also exhibited a greater reduction in the postoperative estimated glomerular filtration rate, compared with female patients. The male sex was associated with an approximately threefold increase in the risk of AKI. The rate of surgical complications was significantly higher in male than female patients., Conclusions: Caution must be taken to prevent postoperative AKI in patients (particularly males) participating in colorectal ERAS programs. The mechanism underlying the sex difference remains unclear. Additional studies are required to determine whether male patients require perioperative management that differs from that of females, to prevent postoperative AKI.

The aim of our study was to investigate pre and intraoperative clinical factors, including platelet count, which could inform risk stratification of early acute kidney injury (AKI) after living donor liver transplantation (LDLT). Additionally, the impact of severe thrombocytopenia on AKI risk was assessed using a propensity score (PS)-matched analysis. In total, 591 adult patients who underwent LDLT between January 2009 and December 2018 at our hospital were retrospectively analyzed. Early postoperative AKI was determined based on the KDIGO criteria, and 149 patients (25.2%) developed AKI immediately after surgery. In a multivariate analysis, a lower preoperative platelet count was significantly associated with early postoperative AKI, together with diabetes mellitus, lower hourly urine output, and longer graft ischemic time; furthermore, a decrease in platelet count was correlated with AKI severity. After adjusting for the PS, the probability of AKI was significantly (1.9-fold) higher in patients with severe thrombocytopenia than in those without severe thrombocytopenia. Patients with thrombocytopenia showed a higher postoperative incidence of AKI and a higher requirement for dialysis than those without thrombocytopenia. The platelet count can easily be obtained via regular blood analysis of patients scheduled for LDLT and can be used to identify patients at risk for AKI.

Background: B-type natriuretic peptide (BNP) is a well-known predictor for prognosis in patients with cardiac and renal diseases. However, there is a lack of studies in patients with advanced hepatic disease, especially patients who underwent liver transplantation (LT). We evaluated whether BNP could predict the prognosis of patients who underwent LT. Material and Methods: The data from a total of 187 patients who underwent LT were collected retrospectively. The serum levels of BNP were acquired at four time points, the pre-anhepatic (T1), anhepatic (T2), and neohepatic phases (T3), and on postoperative day 1 (T4). The patients were dichotomized into survival and non-survival groups for 1-month mortality after LT. Combined BNP (cBNP) was calculated based on conditional logistic regression analysis of pairwise serum BNP measurements at two time points, T2 and T4. The area under the receiver operating characteristic curve (AUROC) was analyzed to determine the diagnostic accuracy and cut-off value of the predictive models, including cBNP. Results: Fourteen patients (7.5 %) expired within one month after LT. The leading cause of death was sepsis (N = 9, 64.3 %). The MELD and MELD-Na scores had an acceptable predictive ability for 1-month mortality (AUROC = 0.714, and 0.690, respectively). The BNPs at each time point (T1 - T4) showed excellent predictive ability (AUROC = 0.864, 0.962, 0.913, and 0.963, respectively). The cBNP value had an outstanding predictive ability for 1-month mortality after LT (AUROC = 0.976). The optimal cutoff values for cBNP at T2 and T4 were 137 and 187, respectively. Conclusions: The cBNP model showed the improved predictive ability for mortality within 1-month of LT. It could help clinicians stratify mortality risk and be a useful biomarker in patients undergoing LT., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: The present study was performed to investigate the analgesic efficacy of intrathecal morphine and bupivacaine (ITMB) in terms of treating early postoperative pain in adult patients who underwent robotic-assisted laparoscopic prostatectomy (RALP)., Methods: Fifty patients were prospectively enrolled and randomly classified into the non-ITMB (n = 25) and ITMB (n = 25) groups. The ITMB therapeutic regimen consisted of 0.2 mg morphine and 7.5 mg bupivacaine (total 1.7 mL). All patients were routinely administered the intravenous patient-controlled analgesia and appropriately treated with rescue intravenous (IV) opioid drugs, based on the discretion of the attending physicians who were blinded to the group assignments. Cumulative IV opioid consumption and the numeric rating scale (NRS) score were assessed at 1, 6, and 24 h postoperatively, and opioid-related complications were measured during the day after surgery., Results: Demographic findings were comparable between patients who did and did not receive ITMB. The intraoperative dose of remifentanil was lower in the ITMB group than in the non-ITMB group. Pain scores (i.e., NRS) at rest and during coughing as well as cumulative IV opioid consumption were significantly lower in patients who received ITMB than in those who did not in the post-anesthesia care unit (PACU; i.e., at 1 h after surgery) and the ward (i.e., at 6 and 24 h after surgery). ITMB was significantly associated with postoperative NRS scores of ≤ 3 at rest and during coughing in the PACU (i.e., at 1 h after surgery) before and after adjusting for cumulative IV opioid consumption. In the ward (i.e., at 6 and 24 h after surgery), ITMB was associated with postoperative NRS scores of ≤ 3 at rest and during coughing before adjusting for cumulative IV opioid consumption but not after. No significant differences in complications were observed, such as post-dural puncture headache, respiratory depression, nausea, vomiting, pruritus, or neurologic sequelae, during or after surgery., Conclusion: A single spinal injection of morphine and bupivacaine provided proper early postoperative analgesia and decreased additional requirements for IV opioids in patients who underwent RALP., Trial Registration: Clinical Research Information Service, Republic of Korea; approval number: KCT0004350 on October 17, 2019. https://cris.nih.go.kr/cris/en/search/search&#95;result&#95;st01.jsp?seq=15637.

Background: Reducing postoperative pain with less opioid is critical in postoperative care. Author developed our multimodal perioperative pain management protocol and it consists of preoperative medication, intraoperative ultrasound-guided laparoscopic transverse abdominis plane (LTAP) block and postoperative medication. This study aimed to evaluate the clinical effect of the multimodal perioperative pain management protocol for minimally invasive colorectal cancer surgery., Methods: Of 596 colorectal surgery cases for colorectal cancer, 133 patients managed with multimodal perioperative pain protocol (group 1) and 463 patients managed without multimodal perioperative pain protocol (group 2) were enrolled in this study. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM)., Results: After 1:1 propensity score matching, well-matched 133 patients in each group were evaluated. The median VAS scores on post-operative day 1 (2.1 ± 1.1 vs. 3.9 ± 1.8, p < 0.001) and day 2 (2.0 ± 1.2 vs. 3.8 ± 1.7, p < 0.001) was significantly reduced in group 1. The length of postoperative hospital stays was also significantly shorter in Group 1 (4.4 ± 3.0 vs. 5.8 ± 5.6; p = 0.014)., Conclusion: Implementing multimodal perioperative pain protocols reduced postoperative pain and hospital stay of minimally invasive colorectal surgery., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interests., (Copyright © 2020. Published by Elsevier Taiwan LLC.)

Rationale: We present the case of a patient with autoimmune hepatitis who suffered fatal intracardiac and pulmonary arterial thromboembolic complications after ABO-incompatible living donor liver transplantation (ABOi LDLT) with splenectomy., Patient Concerns: A 46-year-old female (blood type B+) with autoimmune hepatitis and hepatitis B carrier status underwent elective ABOi LDLT. The donor liver was from a 51-year-old male living donor (blood type A+). A splenectomy was performed without bleeding complications. Intraoperatively, the patients hemodynamic condition was acceptable, with no evidence of thromboembolism on transesophageal echocardiography (TEE)., Diagnosis: Postoperatively, her platelet count increased from 15.0 to 263.0 (× 109/L) and thromboelastographic parameters indicated hypercoagulable state. She suffered acute circulatory collapse, respiratory distress and, eventually, a decline in mental status. The attending physicians in the intensive care unit (ICU) immediately performed resuscitation., Interventions: The patient underwent emergency exploratory surgery. Intraoperatively, hypotension, bradycardia and arrhythmia developed, together with high central venous pressure. Assessment of cardiac structure and function using rescue TEE incidentally identified multiple, huge thromboembolic clots in the cardiac chambers; therefore, the patient underwent cardiac thromboembolectomy, including cardiopulmonary bypass with hypothermia therapy., Outcomes: Due to severe cardiac and respiratory distress, the patient required venoarterial extracorporeal membrane oxygenation (VAECMO) in the operating room and ICU. Despite continuous resuscitation in the ICU and maintenance of VAECMO, she suffered severe hypotension and massive bleeding that eventually led to death., Lessons: In patients with autoimmune hepatitis, risk factors for thromboembolism should be rigorously controlled during the peak period of reactive thrombocytosis after ABOi LDLT with splenectomy., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: This study was performed to determine the association between the serum level of antithrombin III (ATIII) level and the risk of acute kidney injury (AKI) in patients undergoing living-donor liver transplantation (LDLT)., Patients and Methods: A total of 591 patients undergoing LDLT were retrospectively investigated and 14 patients were excluded because of a history of kidney dysfunction or missing data; 577 patients were finally enrolled in the study. The study population was divided into normal and low ATIII groups. Data on all laboratory variables, including ATIII, were collected on the day before surgery., Results: After LDLT, 143 patients developed AKI (24.8%). A lower ATIII was independently associated with postoperative AKI along with preoperative (diabetes mellitus) and intraoperative (mean heart rate, hourly urine output) factors. Based on the standard cutoff for normal ATIII (<70%), the probability of AKI was 2.8-fold higher in the low ATIII group than in the normal ATIII group. In addition, patients with low ATIII received blood transfusion products during the operation and underwent longer duration mechanical ventilation., Conclusions: Preoperative ATIII measurement will help improve risk stratification for postoperative AKI development in patients undergoing LDLT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study investigated the optimal timing of analgesic transversus abdominis plane (TAP) block in the operating room for better recovery quality using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire in patients who had undergone open inguinal herniorrhaphy., Methods: This single-centre, prospective randomised controlled study included adult male patients who had an ASA physical status of I-II. A total of 80 patients were analysed. The patients were randomly assigned and classified into pre-incisional TAP (pre-TAP) block (n = 40) and post-incisional TAP (post-TAP) block (n = 40) groups. The quality of postoperative functional recovery and complications were compared between the two groups during 24 h postoperatively., Results: Preoperative findings of the two groups were comparable. The global QoR-40K score was higher in the pre-TAP group than in the post-TAP group. Among sub-dimensions, scores of physical comfort and pain were higher in the pre-TAP group than in the post-TAP group. In the post-anaesthesia care unit, the pre-TAP group showed lower pain scores than the post-TAP block group. There was no severe pain in the pre-TAP group, but two patients (5.0%) in the post-TAP block group suffered severe pain. The pre-TAP group required lower doses of IV rescue opioid in the PACU than the post-TAP group. All patients were discharged from hospital on postoperative day 1 without surgical complications., Conclusions: The timing of analgesic TAP block may be of clinical importance to prevent postoperative pain and to improve the quality of early patient recovery following open inguinal herniorrhaphy., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2020. Published by Elsevier Taiwan LLC.)

Objectives: We compared early recovery outcomes between living kidney donors who received total intravenous (IV) propofol versus inhalational desflurane during hand-assisted laparoscopic nephrectomy., Design: A single-centre, prospective randomised controlled trial., Setting: University hospital., Participants: Study participants were enrolled between October 2019 and February 2020. A total of 80 living donors were randomly assigned to an intravenous propofol group (n=40) or a desflurane group (n=40)., Intervention: Propofol group received intravenous propofol and desflurane group received desflurane, as a maintenance anaesthetic., Primary and Secondary Outcome Measures: The quality of postoperative functional recovery was primarily assessed using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire on postoperative day 1. Secondarily, ambulation, pain score, rescue analgesics, complications and total hospital stay were assessed postoperatively., Results: Our study population included 35 males and 45 females. The mean age was 46±13 years. The global QoR-40K score (161 (154-173) vs 152 (136-161) points, respectively, p=0.001) and all five subdimension scores (physical comfort, 49 (45-53) vs 45 (42-48) points, respectively, p=0.003; emotional state, 39 (37-41) vs 37 (33-41) points, respectively, p=0.005; psychological support, 30 (26-34) vs 28 (26-32) points, respectively, p=0.04; physical independence, 16 (11-18) vs 12 (8-14) points, respectively, p=0.004; and pain, 31 (28-33) vs 29 (25-31) points, respectively, p=0.021) were significantly higher in the intravenous propofol group than the desflurane group. The early ambulation success rate and numbers of early and total steps were higher, but the incidence of nausea/vomiting was lower, in the intravenous propofol group than the desflurane group. The total hospital stay after surgery was shorter in the intravenous propofol group than the desflurane group., Conclusions: Intravenous propofol may enhance the quality of postoperative recovery in comparison to desflurane in living kidney donors., Trial Registration Number: KCT0004365., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We investigated the impact of postreperfusion syndrome (PRS) on hyperglycemia occurrence and connecting (C) peptide release, which acts as a surrogate marker for insulin resistance, during the intraoperative period after graft reperfusion in patients undergoing living donor liver transplantation (LDLT) using propensity score (PS)-matching analysis., Patients and Methods: Medical records from 324 adult patients who underwent elective LDLT were retrospectively reviewed, and their data were analyzed according to PRS occurrence (PRS vs. non-PRS groups) using the PS-matching method. Intraoperative levels of blood glucose and C-peptide were measured through the arterial or venous line at each surgical phase. Hyperglycemia was defined as a peak glucose level >200 mg/dL, and normal plasma concentrations of C-peptide in the fasting state were taken to range between 0.5 and 2.0 ng/mL., Results: After PS matching, there were no significant differences in pre- and intra-operative recipient findings and donor-graft findings between groups. Although glucose and C-peptide levels continuously increased through the surgical phases in both groups, glucose and C-peptide levels during the neohepatic phase were significantly higher in the PRS group than in the non-PRS group, and larger changes in levels were observed between the preanhepatic and neohepatic phases. There were higher incidences of C-peptide levels >2.0 ng/mL and peak glucose levels >200 mg/dL in the neohepatic phase in patients with PRS than in those without. PRS adjusted for PS with or without exogenous insulin infusion was significantly associated with hyperglycemia occurrence during the neohepatic phase., Conclusions: Elucidating the association between PRS and hyperglycemia occurrence will help with establishing a standard protocol for intraoperative glycemic control in patients undergoing LDLT., Competing Interests: The authors have declared that no competing interests exist.

Background: We explored the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received intravenous patient-controlled analgesia (IV-PCA), rectus sheath bupivacaine block (RSB), or intrathecal morphine with bupivacaine block (ITMB)., Methods: This was a prospective, observational clinical trial. Patients were divided into three groups: IV-PCA (n = 30), RSB (n = 30), and ITMB (n = 30). Peak pain scores at rest and with coughing, cumulative IV-PCA drug consumption, the need for IV rescue opioids, and Quality of Recovery-15 (QoR-15) questionnaire scores collected on POD 1 were compared among the groups., Results: The preoperative and intraoperative findings were comparable among the groups; the ITMB group required the least remifentanil of all groups. During POD 1, the ITMB group reported lower levels of pain at rest and with coughing, compared with the other two groups. During POD 1, incidences of severe pain at rest (10.0% vs. 23.3% vs. 40.0%) and with coughing (16.7% vs. 36.7% vs. 66.7%) were the lowest in the ITMB group compared with the RSB and IV-PCA groups, respectively. After adjustment for age, body mass index, diabetes mellitus, hypertension, and intraoperative remifentanil infusion, severe pain at rest was 0.167-fold less common in the ITMB group than in the IV-PCA group, while pain with coughing was 0.1-fold lower in the ITMB group and 0.306-fold lower in the RSB group, compared with the IV-PCA group. The ITMB group required lower cumulative IV-PCA drug infusions and less IV rescue opioids, while exhibiting a better QoR-15 global score, compared with the other two groups. Complications (nausea and pruritus) were significantly more common in the ITMB group than in the other two groups; however, we noted no ITMB- or RSB-related anesthetic complications (respiratory depression, post-dural headache, nerve injury, or puncture site hematoma or infection), and all patients were assessed as Clavien-Dindo grade I or II during the hospital stay., Conclusion: Although ITMB induced complications of nausea and pruritus, this analgesic technique provided appropriate pain relief that enhanced patient perception related to early postoperative recovery., Trial Registration: Clinical Research Information Service, Republic of Korea, (approval number: KCT0005040 ) on May 20, 2020.

Objectives: We examine the association between vitamin B 12 level and risk for acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT)., Design: Retrospective observational cohort study., Setting: University hospital, from January 2009 to December 2018., Participants: A total of 591 patients who underwent elective LDLT were analysed in this study. Those with a preoperative history of kidney dysfunction, vitamin B 12 supplementation due to alcoholism, low vitamin B 12 (<200 pg/mL) or missing laboratory data were excluded., Primary and Secondary Outcome Measures: The population was classified into AKI and non-AKI groups according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, and associations between perioperative factors and AKI were analysed. After 1:1 propensity score (PS) matching, the association between high vitamin B 12 (>900 pg/mL) and postoperative AKI was evaluated., Results: Preoperative vitamin B 12 was higher in the AKI group. Potentially significant perioperative factors from univariate analyses were entered into multivariate analyses, including preoperative factors (vitamin B 12 , diabetes), intraoperative factors (hourly urine output) and donor graft fatty change in LDLT patients. PS matching analyses with adjustment using PS revealed that high serum vitamin B 12 (>900 pg/mL) was associated with risk for AKI, and the risk was 2.8-fold higher in patients with high vitamin B 12 than in those with normal vitamin B 12 . Higher vitamin B 12 was also related to a higher AKI stage. In addition, inflammatory factors (C reactive protein, white blood cells and albumin) were associated with vitamin B 12 level., Conclusions: Our study may improve the accuracy of predicting postoperative AKI by introducing preoperative vitamin B 12 into risk assessments for patients undergoing LDLT., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We compared the analgesic efficacy of a continuous suprascapular nerve block (C-SSNB) and a single-shot interscalene brachial plexus block (S-ISNB) for postoperative pain management in patients undergoing arthroscopic rotator cuff repair., Methods: A total of 118 patients undergoing arthroscopic rotator cuff repair were randomly allocated to the S-ISNB or C-SSNB groups. Postoperative pain was assessed using the visual analog scale (VAS) at 1, 2, 6, 12, and 24 h postoperatively. Supplemental analgesic use was recorded as total equianalgesic fentanyl consumption., Results: The C-SSNB group showed significantly higher VAS scores at 0-1 h and 1-2 h after the surgery than the S-ISNB group (4.9±2.2 versus 2.3±2.2; p<0.0001 and 4.8±2.1 versus 2.4±2.3; p<0.0001, respectively). The C-SSNB group showed significantly lower VAS scores at 6-12 h after the surgery than the S-ISNB group (4.1±1.8 versus. 5.0±2.5; p=0.031). The C-SSNB group required significantly higher doses of total equianalgesic fentanyl in the post-anesthesia care unit than the S-ISNB group (53.66±44.95 versus 5.93±18.25; p<0.0001). Total equianalgesic fentanyl in the ward and total equianalgesic fentanyl throughout the hospital period were similar between the groups (145.99±152.60 versus 206.13±178.79; p=0.052 and 199.72±165.50 versus 212.15±180.09; p=0.697, respectively)., Conclusion: C-SSNB was more effective than S-ISNB at 6-12 h after the surgery for postoperative analgesia after arthroscopic rotator cuff repair.

Rationale: Therapeutic hypothermia is an effective medical treatment for neurological recovery after cardiac arrest. Here, we describe a case of successful mild therapeutic hypothermia after cardiac arrest during living-donor liver transplantation., Patient Concerns: A 54-year-old woman with alcoholic liver cirrhosis was admitted for living-donor liver transplantation. Cardiac arrest occurred during the anhepatic phase. After cardiopulmonary resuscitation, spontaneous circulation returned, but the bispectral index level remained below 10 until the end of surgery., Diagnoses: Neurological injury caused by global cerebral hypoperfusion was suspected., Interventions: The patient was treated with mild therapeutic hypothermia for 24hours after resuscitation targeting a core body temperature of 34°C with surface cooling using ice bags., Outcomes: The patient recovered consciousness about 22 hours after the event. However, she showed symptoms of delirium even when discharged. At the 3-month follow-up exam, she showed no specific neurological complications. The transplanted liver showed no problems with regeneration., Lessons: Mild therapeutic hypothermia may be safely adopted in cases of cardiac arrest in liver transplant patients and is beneficial for neurological recovery.

Background: Enhancing postoperative recovery of the donor is important to encourage living kidney donation. We investigated the effects of anesthetic agents (intravenous [IV] propofol versus inhaled [IH] sevoflurane) on the quality of early recovery of healthy living kidney donors after hand-assisted laparoscopic nephrectomy (HALN) under analgesic intrathecal morphine injection., Methods: This single-center, prospective randomized controlled study enrolled 80 living donors undergoing HALN from October 2019 to June 2020 at Seoul St. Mary's Hospital. Donors were randomly assigned to the IV propofol group or IH sevoflurane group. To measure the quality of recovery, we used the Korean version of the Quality of Recovery-40 questionnaire (QoR-40 K) on postoperative day (POD) 1, and ambulation (success rate, number of footsteps) 6-12 h after surgery and on POD 1. The pain score for the wound site, IV opioid requirement, postoperative complications including incidences of nausea/vomiting, and length of in-hospital stay were also assessed., Results: The global QoR-40 K score and all subscale scores (physical comfort, emotional state, physical independence, psychological support, and pain) were significantly higher in the IV propofol group than in the IH sevoflurane group. The numbers of footsteps at all time points were also higher in the IV propofol group. Donors in the IV propofol group had a lower incidence of nausea/vomiting, and a shorter hospitalization period., Conclusions: Total IV anesthesia with propofol led to better early postoperative recovery than that associated with IH sevoflurane., Trial Registration: Clinical Research Information Service, Republic of Korea (approval number: KCT0004351 ) on October 18, 2019.

Background: We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT)., Case Presentation: A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO 2 insufflation and the head-up position. SpO 2 decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO 2 or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax., Conclusion: This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO 2 gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Purpose: Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes., Methods: Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient's clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database., Results: The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively)., Conclusion: ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Purpose: An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI., Methods: Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared., Results: AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9 mL/min/1.73 m 2 vs. - 1.4 mL/min/1.73 m 2 , p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group., Conclusions: Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.

Background: This study analyzed remnant kidney function recovery in living donors after laparoscopic nephrectomy to establish a risk stratification model for delayed recovery and further investigated clinically modifiable factors., Patients and Methods: This retrospective study included 366 adult living donors who underwent elective donation surgery between January 2017 and November 2019 at our hospital. ITMB was included as an analgesic component in the living donor strategy for early postoperative pain relief from November 2018 to November 2019 (n = 116). Kidney function was quantified based on the estimated glomerular filtration rate (eGFR), and delayed functional recovery of remnant kidney was defined as eGFR < 60 mL/min/1.73 m 2 on postoperative day (POD) 1 (n = 240)., Results: Multivariable analyses revealed that lower risk for development of eGFR < 60 mL/min/1.73 m 2 on POD 1 was associated with ITMB, female sex, younger age, and higher amount of hourly fluid infusion (area under the receiver operating characteristic curve = 0.783; 95% confidence interval = 0.734-0.832; p < 0.001). Propensity score (PS)-matching analyses showed that prevalence rates of eGFR < 60 mL/min/1.73 m 2 on PODs 1 and 7 were higher in the non-ITMB group than in the ITMB group. ITMB adjusted for PS was significantly associated with lower risk for development of eGFR < 60 mL/min/1.73 m 2 on POD 1 in PS-matched living donors. No living donors exhibited severe remnant kidney dysfunction and/or required renal replacement therapy at POD 7., Conclusions: We found an association between the analgesic impact of ITMB and better functional recovery of remnant kidney in living kidney donors. In addition, we propose a stratification model that predicts delayed functional recovery of remnant kidney in living donors: male sex, older age, non-ITMB, and lower hourly fluid infusion rate.

The aim of the present study was to investigate the role of intraoperative oxygen content on the development of early allograft dysfunction (EAD) in patients undergoing living donor liver transplantation (LDLT).This retrospective review included 452 adult patients who underwent elective LDLT. Our study population was classified into 2 groups: EAD and non-EAD. Arterial blood gas analysis was routinely performed 3 times during surgery: during the preanhepatic phase (ie, immediately after anesthetic induction); during the anhepatic phase (ie, at the onset of hepatic venous anastomosis); and during the neohepatic phase (ie, 1 hour after graft reperfusion). Arterial oxygen content (milliliters per deciliters) was derived using the following equation: (1.34 × hemoglobin [gram per deciliters] × SaO2 [%] × 0.01) + (0.0031 × PaO2 [mmHg]).The incidence of EAD occurrence was 13.1% (n = 59). Although oxygen contents at the preanhepatic phase were comparable between the 2 groups, the oxygen contents at the anhepatic and neohepatic phases were lower in the EAD group than in the non-EAD group. Patients with postoperative EAD had lower oxygen content immediately before and continuously after graft reperfusion, compared to patients without postoperative EAD. After the preanhepatic phase, oxygen content decreased in the EAD group but increased in the non-EAD group. The oxygen content and prevalence of normal oxygen content gradually increased during surgery in the non-EAD group, but not in the EAD group. Multivariable analysis revealed that oxygen content during the anhepatic phase and higher preoperative CRP levels were factors independently associated with the occurrence of EAD (area under the receiver-operating characteristic curve: 0.754; 95% confidence interval: 0.681-0.826; P < .001 in the model). Postoperatively, patients with EAD had a longer duration of hospitalization, higher incidences of acute kidney injury and infection, and experienced higher rates of patient mortality, compared to patients without EAD.Lower arterial oxygen concentration may negatively impact the functional recovery of the graft after LDLT, despite preserved hepatic vascular flow. Before graft reperfusion, the levels of oxygen content components, such as hemoglobin content, PaO2, and SaO2, should be regularly assessed and carefully maintained to ensure proper oxygen delivery into transplanted liver grafts.

Background: The enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection recommends balanced perioperative fluid therapy. According to recent guidelines, zero-balance fluid therapy is recommended in low-risk patients, and immediate correction of low urine output during surgery is discouraged. However, several reports have indicated an association of intraoperative oliguria with postoperative acute kidney injury (AKI). We investigated the impact of intraoperative oliguria in the colorectal ERAS setting on the incidence of postoperative AKI., Patients and Methods: From January 2017 to August 2019, a total of 453 patients underwent laparoscopic colorectal cancer resection with the ERAS protocol. Among them, 125 patients met the criteria for oliguria and were propensity score (PS) matched to 328 patients without intraoperative oliguria. After PS matching had been performed, 125 patients from each group were selected and the incidences of AKI were compared between the two groups. Postoperative kidney function and surgical outcomes were also evaluated., Results: The incidence of AKI was significantly higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (26.4% vs. 11.2%, respectively, P = 0.002). Also, the eGFR reduction on postoperative day 0 was significantly greater in the intraoperative oliguria than non-intraoperative oliguria group (-9.02 vs. -1.24 mL/min/1.73 m2 respectively, P < 0.001). In addition, the surgical complication rate was higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (18.4% vs. 9.6%, respectively, P = 0.045)., Conclusions: Despite the proven benefits of perioperative care with the ERAS protocol, caution is required in patients with intraoperative oliguria to prevent postoperative AKI. Further studies regarding appropriate management of intraoperative oliguria in association with long-term prognosis are needed in the colorectal ERAS setting., Competing Interests: The authors have declared that no competing interests exist.

Placing an esophageal temperature probe (ETP) in the optimal esophageal site is important in various anesthetic and critical care settings to accurately monitor the core temperature of a pediatric patient. However, no reported study has provided a formula to calculate the optimal insertion depth of ETP placement in children based on direct measurement of the optimal depth. The aim of this study was to develop a simple and reliable method to determine the optimal depth of ETP placement in children via their mouth. Using preoperative chest computed tomography scans, intraoperative chest X-rays, and the actual depth of ETP insertion, we measured the optimal depth of ETP placement retrospectively in 181 children aged 3-13 years who underwent minimally invasive repairs of the pectus excavatum and removal of a pectus bar. A linear regression analysis was performed to assess the correlation of the optimal depth of ETP placement with the children's age, weight, and height. The optimal depth of ETP placement had a greater correlation with height than with age or weight, and the best-fit equation was '0.180 × height + 6.749 (cm) (R 2  = 0.920).' We obtained three simplified formulae, which showed no statistically significant difference in predicting the optimal depth of ETP placement: height/6 + 8 (cm), height/5 + 4 (cm), and height/5 + 5 (cm). The optimal depth of ETP via children's mouths has a close correlation with height and can be calculated with a simple formula 'height/5 + 5 (cm)'.

Background: This study investigated perioperative clinical risk factors for early post-transplant bacteremia in patients undergoing living donor liver transplantation (LDLT). Additionally, postoperative outcomes were compared between patients with and without early post-transplant bacteremia., Methods: Clinical data of 610 adult patients who underwent elective LDLT between January 2009 and December 2018 at Seoul St. Mary's Hospital were retrospectively collected. The exclusion criteria included overt signs of infection within 1 month before surgery. A total of 596 adult patients were enrolled in this study. Based on the occurrence of a systemic bacterial infection after surgery, patients were classified into non-infected and infected groups., Results: The incidence of bacteremia at 1 month after LDLT was 9.7% (57 patients) and Enterococcus faecium (31.6%) was the most commonly cultured bacterium in the blood samples. Univariate analysis showed that preoperative psoas muscle index (PMI), model for end-stage disease score, utility of continuous renal replacement therapy (CRRT), ascites, C-reactive protein to albumin ratio, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, and sodium level, as well as intraoperative post-reperfusion syndrome, mean central venous pressure, requirement for packed red blood cells and fresh frozen plasma, hourly fluid infusion and urine output, and short-term postoperative early allograft dysfunction (EAD) were associated with the risk of early post-transplant bacteremia. Multivariate analysis revealed that PMI, the CRRT requirement, the NLR, and EAD were independently associated with the risk of early post-transplant bacteremia (area under the curve: 0.707; 95% confidence interval: 0.667-0.745; p < 0.001). The overall survival rate was better in the non-infected patient group. Among patients with bacteremia, anti-bacterial treatment was unable to resolve infection in 34 patients, resulting in an increased risk of patient mortality. Among the factors included in the model, EAD was significantly correlated with non-resolving infection., Conclusions: We propose a prognostic model to identify patients at high risk for a bloodstream bacterial infection; furthermore, our findings support the notion that skeletal muscle depletion, CRRT requirement, systemic inflammatory response, and delayed liver graft function are associated with a pathogenic vulnerability in cirrhotic patients who undergo LDLT.

Background: The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes., Methods: Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30 min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300 s - 1 ) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5 s - 1 ) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as > 13.0 cP at 300 s - 1 and diastolic blood hyperviscosity was defined as > 4.1 cP at 5 s - 1 ., Results: The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications., Conclusions: Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum., Trial Registration: Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.

Background. Acute kidney injury (AKI) is one of the common complications after living donor liver transplantation (LDLT) and is associated with increased mortality and morbidity. The prognostic nutritional index (PNI) has been used as a predictive model for postoperative complications. Here, we create a new predictive model based on the PNI and compared its predictive accuracy to other models in patients who underwent LDLT. Material and Methods: The data from 423 patients were collected retrospectively. The patients were dichotomized into the non-AKI and the AKI groups. Multivariate adjustment for significant postoperative variables based on univariate analysis was performed. A new predictive model was created using the results from logistic regression analysis, dubbed the modified-PNI model (mPNI). The area under the receiver operating characteristic curve (AUC) was generated to determine the diagnostic accuracy and cutoff value of individual models. The net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to investigate diagnostic improvement by the mPNI. Results: Fifty-four patients (12.7 %) were diagnosed with AKI within 1-week after LDLT. The mPNI had the highest predictive accuracy (AUC = 0.823). The model of end-stage liver disease (MELD) scores and PNI were 0.793 and 0.749, respectively, and the INR and serum bilirubin were 0.705 and 0.637, respectively. The differences in the AUCs were statistically significant among the mPNI, PNI, INR, and serum bilirubin. The cutoff value for mPNI was 8.7. The NRI was 10.4% and the IDI was 3.3%. Conclusions: The mPNI predicted AKI within 1-week better than other scoring systems in patients who underwent LDLT. The recommended cutoff value of mPNI is 8.7., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: This study was performed to determine the association between the ratio of C-reactive protein to albumin (CRP/ALB) and the risk of early allograft dysfunction (EAD) in patients undergoing living donor liver transplantation (LDLT)., Patients and Methods: A total of 588 adult patients undergoing LDLT were retrospectively investigated, after 22 were excluded because of signs of overt infection or history of ALB infusion. The study population was classified into high and low CRP/ALB ratio groups according to EAD. All laboratory variables, including CRP and ALB, had been collected on the day before surgery. A percentage value for the CRP/ALB ratio (%) was calculated as CRP/ALB × 100., Results: After LDLT, 83 patients (14.1%) suffered EAD occurrence. A higher CRP/ALB ratio was independently associated with risk of EAD, Model for End-stage Liver Disease score, fresh frozen plasma transfusion, and donor age. Based on a cutoff CRP/ALB ratio (i.e., > 20%), the probability of EAD was significantly (2-fold) higher in the high versus low CRP/ALB group. The predictive utility of CRP/ALB ratio for EAD was greater than those of other inflammatory markers. In addition, patients with a high CRP/ALB ratio had poorer survival than those with a low CRP/ALB ratio during the follow-up period., Conclusions: The easily calculated CRP/ALB ratio may allow estimation of the risk of EAD after LDLT and can provide additional information that may facilitate the estimation of a patient's overall condition., Competing Interests: The authors have declared that no competing interest exist.

The effects of hyperchloremia on kidney grafts have not been investigated in patients undergoing living-donor kidney transplantation (LDKT). In this study, data from 200 adult patients undergoing elective LDKT between January 2016 and December 2017 were analyzed after propensity score (PS) matching. The patients were allocated to hyperchloremia and non-hyperchloremia groups according to the occurrence of hyperchloremia (i.e., ≥110 mEq/L) immediately after surgery. Poor early graft recovery was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m 2 during the first 48 hours after surgery. After PS matching, no significant differences in perioperative recipient or donor graft parameters were observed between groups. Although the total amount of crystalloid fluid infused during surgery did not differ between groups, the proportions of main crystalloid fluid type used (i.e., 0.9% normal saline vs. Plasma Solution-A) did. The eGFR increased gradually during postoperative day (POD) 2 in both groups. However, the proportion of patients with eGFR > 60 mL/min/1.73 m 2 on POD 2 was higher in the non-hyperchloremia group than in the hyperchloremia group. In this PS-adjusted analysis, hyperchloremia was significantly associated with poor graft recovery on POD 2. In conclusion, exposure to hyperchloremia may have a negative impact on early graft recovery in LDKT.

Background: Patients on a waiting list for liver transplantation frequently show core muscle wasting, referred to as sarcopenia, which results in poor prognosis. To date, there has been a lack of research on the association between inflammation mediators, including cytokines, and loss of core muscle mass in cirrhotic patients scheduled for living donor liver transplantation (LDLT)., Methods: Cytokines in serum, such as interleukin (IL)-2, IL-6, IL-10, IL-12, IL-17, interferon-γ, and tumor necrosis factor (TNF)-α, were retrospectively investigated in 234 LDLT patients 1 day before surgery. The psoas muscle area was measured using abdominal computed tomography within 1 month before surgery and used to calculate the psoas muscle index (PMI = psoas muscle area/height 2 ). The study population was classified into 2 groups according to the interquartile range of PMI: a non-sarcopenia group (> 25th quartile) and a sarcopenia group (≤ 25th quartile) in each sex., Results: In both sexes, IL-10 and TNF-α levels were significantly higher in the sarcopenia group than the non-sarcopenia group. In a univariate analysis, male patients showed that serum IL-10 and TNF-α levels were potentially associated with sarcopenia. Serum TNF-α was independently associated with sarcopenia in a multivariate analysis. In female patients, TNF-α was significantly associated with sarcopenia in both univariate and multivariate analyses. Male patients with a PMI ≤ 25th quartile had significantly higher TNF-α levels than those in other quartile ranges, and female patients with a PMI ≤ 25th quartile had a significantly higher TNF-α level than those with a PMI > 75th quartile., Conclusions: Serum levels of TNF-α are inversely associated with skeletal muscle wasting in both male and female patients scheduled for LDLT., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The development of sarcopenia leads to adverse postoperative outcomes. However, no study has investigated perioperative loss in core muscle and the correlation between core muscle and residual liver volume in living donors for liver transplant., Patients and Methods: A total of 457 adult healthy donors who underwent a right lobe hepatectomy without the middle hepatic vein for elective liver transplant were retrospectively analyzed. Abdominal computed tomography was performed within 1 month before surgery and the first week and 3 months after the surgery. The average psoas muscle area between lumbar vertebrae 3 and 4 was measured and normalized by height squared (psoas muscle index [PMI] = psoas muscle area/height 2 ). The initial whole liver volume and remnant left lobe volume were measured on computed tomography images., Results: The study cohort included 279 men (61.1%) and 178 women (38.9%). The median preoperative PMIs were 420.9 mm 2 /m 2 (interquartile range, 360.6-487.0 mm 2 /m 2 ) in men and 280.9 mm 2 /m 2 (interquartile range, 243.5-318.7 mm 2 /m 2 ) in women. The PMIs in men and women significantly decreased during the first week after surgery, and gradually recovered to preoperative levels during the first 3 months after surgery. Based on the ratio between the remnant left lobe and initial whole liver volume (≥30%), the increase in remnant left lobe volume was not correlated with the decrease in PMI on postoperative day 7. A postoperative U-shaped recovery in the core muscles was present in both male and female donors, independent of the remnant liver ratio., Conclusions: Despite the requirements of partial liver regeneration and surgical wound repair, healthy donors did not suffer from sustained core muscle loss after surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Early extubation after liver transplantation is safe and accelerates patient recovery. Patients with end-stage liver disease undergo sarcopenic changes, and sarcopenia is associated with postoperative morbidity and mortality. We investigated the impact of core muscle mass on the feasibility of immediate extubation in the operating room (OR) after living donor liver transplantation (LDLT)., Methods: A total of 295 male adult LDLT patients were retrospectively reviewed between January 2011 and December 2017. In total, 40 patients were excluded due to emergency surgery or severe encephalopathy. A total of 255 male LDLT patients were analyzed in this study. According to the OR extubation criteria, the study population was classified into immediate and conventional extubation groups (39.6 vs. 60.4%). Psoas muscle area was estimated using abdominal computed tomography and normalized by height squared (psoas muscle index [PMI])., Results: There were no significant differences in OR extubation rates among the five attending transplant anesthesiologists. The preoperative PMI correlated with respiratory performance. The preoperative PMI was higher in the immediate extubation group than in the conventional extubation group. Potentially significant perioperative factors in the univariate analysis were entered into a multivariate analysis, in which preoperative PMI and intraoperative factors (i.e., continuous renal replacement therapy, significant post-reperfusion syndrome, and fresh frozen plasma transfusion) were associated with OR extubation. The duration of ventilator support and length of intensive care unit stay were shorter in the immediate extubation group than in the conventional extubation group, and the incidence of pneumonia and early allograft dysfunction were also lower in the immediate extubation group., Conclusions: Our study could improve the accuracy of predictions concerning immediate post-transplant extubation in the OR by introducing preoperative PMI into predictive models for patients who underwent elective LDLT.