Platelets interact with tumor cells and promote metastasis. The importance of platelets in posttransplant hepatocellular carcinoma (HCC) recurrence is unclear. Thus, we aimed to evaluate the association between preoperative platelet count (PLT) and HCC recurrence after living donor liver transplantation. Of 359 recipients of livers from living donors for HCC, 209 of 240 patients who had preoperative PLT £ 75 3 10 9 /L were matched with 97 of 119 patients who had preoperative PLT >75 3 10 9 /L using propensity score matching, with an unfixed matching ratio based on factors such as tumor biology. The cutoff value of 75 3 10 9 /L was set based on optimum stratification analysis. Survival analysis was performed with death as a competing risk event. The primary outcome was overall HCC recurrence. The median follow-up time was 59 months. Before matching, recurrence probability at 1, 2, and 5 years after transplantation was 4.7%, 9.2%, and 11.3% for the low platelet group and 14.5%, 23.0%, and 30.5% for the high platelet group. Recurrence risk was significantly greater in the high platelet group in both univariate (hazard ratio [HR] 5 3.09; 95% confidence interval [CI], 1.86-5.14; P < 0.001) and multivariate analyses (HR 5 2.10; 95% CI, 1.23-3.60; P 5 0.007). In the matched analysis, recurrence risk was also greater in the high platelet group in both univariate (HR 5 2.33; 95% CI, 1.36-4.01; P 5 0.002) and multivariate analyses (HR 5 1.90; 95% CI, 1.02-3.54; P 5 0.04). Preoperative PLT had no interaction with the Milan criteria, alpha-fetoprotein level, Edmonson grade, microvascular invasion, or intrahepatic metastasis. Incorporation of preoperative PLT into the Milan criteria significantly improved predictive power. Inflammation-based scores including neutrophil-tolymphocyte ratio, platelet-to-lymphocyte ratio, and the inflammation-based index did not show superiority to preoperative PLT in predicting HCC recurrence. In conclusion, preoperative PLT appears to be an important host factor affecting HCC recurrence after living donor liver transplantation.Liver Transplantation 24 44-55 2018 AASLD. Liver transplantation is a well-established therapeutic option for treatment of hepatocellular carcinoma (HCC), addressing both underlying liver disease, which is considered a premalignant lesion, and tumor burden. However, many recipients experience tumor recurrence and recurrent HCC is a major cause of death. Thus, better understanding of the contributing factors for HCC metastasis will help improve liver transplant outcome. (1,2) The platelet is the primary cell for hemostasis and tissue repair, (3) but extensive experimental evidence has also illuminated the involvement of platelets in tumor growth and metastasis. (4)(5)(6) Clinical evidence has demonstrated an association between higher platelet counts (PLTs) and shorter survival time and increased recurrence after treatment in various solid tumors. (7) In terms of HCC, a retrospective analysis using a large database of biopsy-proven HCC patients reported a positive Abbrevi...

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Background: We evaluated whether the surgical pleth index (SPI) following surgical incision was related to postoperative pain and opioid consumption. Methods: This prospective observational study was performed in 50 patients undergoing laparotomy under sevoflurane-based general anesthesia. We recorded the highest SPI during surgical incision. The postoperative pain with a numerical rating scale (NRS) and opioid consumption during postoperative 24 h were compared in patients who showed SPI over 50 (Group H) or 20-50 (Group L). The relationship between postoperative opioid consumption and SPI values (pre-incision, post-incision SPI value, change of SPI value, and post-incision SPI minus pre-incision SPI) was evaluated using receiver-operating characteristic analysis. Results: The mean of the highest SPI value during surgical incision was 56 (SD, 12; range, 26-85). Twenty-nine (63%) patients were included in Group H and 17 (37%) patients in Group L. There was a significant difference in NRS during recovery room stay and on postoperative 24 h in two groups (5 [5, 6] vs 7 [6, 8], p=0.007 and 3.5 [3, 5] vs 5 [5,6], p=0.006, Group L vs Group H). Group H used higher fentanyl via patient control analgesia during postoperative 24 h (573 (253) µg vs 817 (305) µg, p=0.008). A change of pre-incision and post-incision SPI value of 23, which showed the highest sensitivity (67%) and specificity (68%), was defined post hoc as the cutoff for fentanyl consumption during postoperative 24 h ≥1000 µg. Conclusion: Our finding suggests that the SPI response to nociceptive stimuli during surgery is closely related to the degree of patient postoperative pain and opioid requirements. This information may be used to provide proper intraoperative analgesia and individual postoperative pain management.

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Background: We evaluated the pulmonary effects of two ventilator-driven alveolar recruitment maneuver (ARM) methods during laparoscopic surgery. Methods: Sixty-four patients undergoing robotic prostatectomy were randomized into two groups: incrementally increasing positive end-expiratory pressure in a stepwise manner (PEEP group) versus tidal volume (VT group). We performed each ARM after induction of anesthesia in the supine position (T1), after pneumoperitoneum in the Trendelenburg position (T2), and after peritoneum desufflation in the supine position (T3). The primary outcome was change in end-expiratory lung impedance (EELI) before and 5 min after ARM at T3, measured by electrical impedance tomography. Results: The PEEP group showed significantly higher increasing EELI 5 min after ARM than the VT group at T1 and T3 (median [IQR] 460 [180,800] vs. 200 [80,315], p = 0.002 and 280 [170,420] vs. 95 [55,175], p = 0.004, respectively; PEEP group vs. VT group). The PEEP group showed significantly higher lung compliance and lower driving pressure at T1 and T3. However, there was no significant difference in EELI change, lung compliance, or driving pressure after ARM at T2. Conclusion: The ventilator-driven ARM by the increasing PEEP method led to greater improvements in lung compliance at the end of laparoscopic surgery than the increasing VT method.