Background A regimen of epirubicin, cisplatin, and infused fluorouracil (ECF) improves survival among patients with incurable locally advanced or metastatic gastric adenocarcinoma. We assessed whether the addition of a perioperative regimen of ECF to surgery improves outcomes among patients with potentially curable gastric cancer. Methods We randomly assigned patients with resectable adenocarcinoma of the stomach, esophagogastric junction, or lower esophagus to either perioperative chemotherapy and surgery (250 patients) or surgery alone (253 patients). Chemotherapy consisted of three preoperative and three postoperative cycles of intravenous epirubicin (50 mg per square meter of body-surface area) and cisplatin (60 mg per square meter) on day 1, and a continuous intravenous infusion of fluorouracil (200 mg per square meter per day) for 21 days. The primary end point was overall survival. Results ECF-related adverse effects were similar to those previously reported among patients with advanced gastric cancer. Rates of postoperative complications were similar in the perioperative-chemotherapy group and the surgery group (46 percent and 45 percent, respectively), as were the numbers of deaths within 30 days after surgery. The resected tumors were significantly smaller and less advanced in the perioperative-chemotherapy group. With a median follow-up of four years, 149 patients in the perioperative-chemotherapy group and 170 in the surgery group had died. As compared with the surgery group, the perioperative-chemotherapy group had a higher likelihood of overall survival (hazard ratio for death, 0.75; 95 percent confidence interval, 0.60 to 0.93; P = 0.009; five-year survival rate, 36 percent vs. 23 percent) and of progression-free survival (hazard ratio for progression, 0.66; 95 percent confidence interval, 0.53 to 0.81; P<0.001). Conclusions In patients with operable gastric or lower esophageal adenocarcinomas, a perioperative regimen of ECF decreased tumor size and stage and significantly improved progression-free and overall survival. (Current Controlled Trials number, ISRCTN93793971.)

/pdf/perioperative-chemotherapy-versus-surgery-alone-for-5bm4upx1bz.pdf

Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer

https://www.chpso.org/sites/main/files/file-attachments/chest-2008-geerts-381s-453s.pdf

Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition)

Sepsis is the leading cause of death in critically ill patients in the United States. Yet the individual host response to septicemia is variable, depending on the patient's immune response, age, nutritional status, and coexisting conditions, as well as on the virulence of the organism and the size of the inoculum. This review examines evolving concepts of sepsis and discusses new and potential therapies. Recent clinical advances include therapy with activated protein C, stringent control of blood glucose, and early goal-directed therapy to treat cellular oxygen deficit. Future therapies may be focused on modulating the immune response in the light of the characteristics of the specific pathogen, the genetic profile of the patient, and the duration of the disease.

https://www.nejm.org/doi/pdf/10.1056/NEJMra021333

The pathophysiology and treatment of sepsis.

The purpose of this article is to review the status and limitations of anatomic tumor response metrics including the World Health Organization (WHO) criteria, the Response Evaluation Criteria in Solid Tumors (RECIST), and RECIST 1.1. This article also reviews qualitative and quantitative approaches to metabolic tumor response assessment with 18 F-FDG PET and proposes a draft framework for PET Response Criteria in Solid Tumors (PERCIST), version 1.0. Methods: PubMed searches, including searches for the terms RECIST, positron, WHO, FDG, cancer (including specific types), treatment response, region of interest, and derivative references, were performed. Abstracts and articles judged most relevant to the goals of this report were reviewed with emphasis on limitations and strengths of the anatomic and PET approaches to treatment response assessment. On the basis of these data and the authors’ experience, draft criteria were formulated for PET tumor response to treatment. Results: Approximately 3,000 potentially relevant references were screened. Anatomic imaging alone using standard WHO, RECIST, and RECIST 1.1 criteria is widely applied but still has

https://jnm.snmjournals.org/content/jnumed/50/Suppl_1/122S.full.pdf

From RECIST to PERCIST: Evolving Considerations for PET Response Criteria in Solid Tumors

Prevention of Venous Thromboembolism : The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

The prerequisites for a successful outcome after fundoplication are careful patient selection, good technique, and an understanding of the principles of antireflux surgery. The most important aspect of any such operation is the construction of a peri-esophageal ring around the gastro-esophageal junction buttressing the sphincter and, thus, neutralizing the gastric opening pressure. Accordingly, the operation has to comprise: 1) generous dissection around the gastric fundus to allow the formation of a "floppy" fundoplication; 2) construction of the cuff as short as possible (2 cm to 3 cm); and 3) proper fixation of the cuff at the correct site in the region of the lower esophageal sphincter. Adherence to these principles will avoid postoperative dysphagia or functional gastro-intestinal disorders and produce long-lasting reflux control in approximately 90% of patients at 10 years. Problems of hypercontinence may occasionally occur since gastro-esophageal reflux suppression is usually complete and any physiological reflux abolished. With the advent of modern drug treatment, the excellent results achieved by fundoplication need to be maintained despite fewer operations. Careful postoperative quality control including pH monitoring is therefore mandatory. The principle of periesophageal wrapping is likely to remain the cornerstone of antireflux surgery. Current techniques are, however, likely to evolve. One direction being investigated is laparoscopic fundoplication, rendering the procedure much less invasive.

Fundoplication: how to do it? Peri-esophageal wrapping as a therapeutic principal in gastro-esophageal reflux prevention.

Background:

Several studies have shown that the cytological detection of free peritoneal tumour cells (FPTCs) in patients with gastric cancer indicates the presence of metastatic disease. The immunocytochemical detection of FPTCs, especially in early-stage tumours, has not been examined comprehensively.



Method:

Peritoneal lavage was performed in 351 patients before curative resection of a gastric carcinoma between 1987 and 2001, and an adequate sample was obtained from 346 patients. FPTCs were detected immunocytochemically using Ber-EP4 antibody. Median follow-up time was 70 months.



Results:

FPTCs were detected in the lavage fluid of 74 patients (21·4 per cent) and correlated with increasing pathological tumour depth (pT) and lymph node (pN) status (P < 0·001). The 5-year overall survival of patients with FPTCs was significantly worse than that of patients without FPTCs (35 versus 71·9 per cent; P < 0·001). FPTCs were present in 14 (8·5 per cent) of 164 patients with stage IA or IB tumours. Although the detection of FPTCs had no prognostic significance for stage IA tumours, the presence of FPTCs in those with stage IB tumours was associated with a worse prognosis (P < 0·001). Multivariate analysis identified the presence of FPTCs as an independent prognostic factor in the whole cohort and in the stage IB subgroup.



Conclusion:

Detection of FPTCs is associated with poor prognosis even in patients with early-stage gastric cancer and should be used for risk-group stratification. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Free peritoneal tumour cells are an independent prognostic factor in curatively resected stage IB gastric carcinoma

The postoperative mortality after esophagectomy still remains a major factor influencing the prognosis of esophageal cancer and largely depends on the patient’s preoperative physiological status.

Risk analysis in esophageal surgery.

Surgery for the treatment of Zenker's diverticulum was performed at our institution in a total of 43 patients over 6 1/2 years. Cervical myotomy with diverticulectomy was performed in 32 of the patients and myotomy alone in 11. Mortality totaled 0%, with a reversible lesion of the recurrent nerve occurring in 7%. In 60% of the cases investigated preoperatively (N = 40), motility disorders of the upper esophageal sphincter (UES) could be demonstrated using manometry as well as with cineradiography in 92% of the patients. Follow-up studies in 39 of the cases 25 months (mean) postprocedure indicated 82% of the patients to be symptom-free, with the remaining 18% demonstrating a marked improvement. Postoperative manometry as well as cineradiography carried out in 12 patients revealed the presence of UES motility dyscoordination in 8% and 25%, respectively. There were, however, no signs of recurrence of the diverticulum. The high number of patients in our study group demonstrating motility disorders of the UES emphasizes the need for cervical myotomy as part of the surgical therapy for Zenker's diverticulum.

J. R. Siewert

Papers

Fundoplication: how to do it? Peri-esophageal wrapping as a therapeutic principal in gastro-esophageal reflux prevention.

Free peritoneal tumour cells are an independent prognostic factor in curatively resected stage IB gastric carcinoma

Risk analysis in esophageal surgery.

Surgical therapy of Zenker's diverticulum: low risk and high efficiency.

Praxis der Viszeralchirurgie