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

Amount, activity and localisation of bleeding, as well as patient-specific risk factors were used to define a group of patients at risk who were treated electively early by surgical intervention, within the first 24-36 hours after onset of the primary bleeding. 147 patients were included in the study between 1982 and 1988, a bleeding gastric ulcer being present in 67 (46%), a bleeding prepyloric ulcer in 14 (9%), and a bleeding duodenal ulcer in 66 (45%). 135 (92%) patients had a bleeding activity of I and II in Forrest's classification. 94 patients were in the at risk group and underwent early selective surgical treatment. During the period of study 13 patients (8.8%) died, with a drastic reduction in mortality rate during the 1982-1988 period from 20 to 0%. Stoppage of bleeding was the aim of operative intervention; treatment of the ulcerative condition was undertaken in only 43%. Reduction of the mortality rate to zero is ascribed to the early treatment concept.

Obere gastrointestinale Ulcusblutung - Letalitätssenkung durch früh-elektive chirurgische Therapie von Risikopatienten

The rare case of a 63-year-old male diagnosed with pneumatosis cystoides intestinalis coli is presented and discussed The patient was found to have an unsymptomatic pneumoperitoneum on plain chest x-ray The results of a contrast enema, computed tomography scan, and laparoscopy are presented The patient had an uneventful hospital course without any specific therapy Causes and possible therapeutic options are discussed

Pneumatosis cystoides intestinalis coli.

Zwischen 1982 und 1991 wurden 795 Patienten wegen eines Magenkarzinoms operiert (Resektionsrate 88,3%; R 0-Resektionen 72,5%; Gastrektomieanteil 73%). Die Komplikationsrate betrug 28,6% bei einer 30-Tage-Letalitat von 2,8% und 90-Tage-Letalitat von 9,5%. Die univariate Analyse ergab signifikante prognostische Unterschiede in Abhangigkeit von Tumorlokalisation und -durchmesser, pTNM-Kategorie, UICC-Stadium, Grading, R-Klassifikation, Anzahl befallener LK, LK-Quotient und Art des Resektionsverfahrens. Alter, Geschlecht, Borrmann- und Lauren-Kiassifikation waren ohne Einflus. Die multivariate Analyse (Cox-Modell) ergab als unabhangige und hoch signifikante Prognosefaktoren (relatives Risiko): nodularer Status (5,72), Fernmetastasen (2,71), R-Klassifikation (2,55), Tiefeninfiltration (1,75), Tumordurchmesser (2,80), Resektionausmas (1,80), Quotient befallene/entnommene Lymphknoten ≤ 0,2 (1,66).

Prognosefaktoren beim Magenkarzinom. Ergebnisse einer uni- und multivariaten Analyse

A new technique for laparoscopic cholecystectomy is described which regards as far as possible the conventional approach to cholecystectomy. Positioning of the operating team is identical to normal cholecystectomy, and the surgeon is able to use both hands to operate since the camera is handled by the assistant. Dissection of the infundibulum is performed in the socalled "tease-and-tear" technique. The peritoneal layer is opened by coagulation. The cystic duct and artery are bluntly dissected by a commercially available dissector. Fat and connective tissue are gently torn off from both structures. After closure of cystic duct and artery by clips, the gallbladder is cut out by thermocoagulation. 178 operations were performed by 8 surgeons; mean duration of the operation was 60 min. A change to open cholecystectomy was necessary in 2.5%. Three complications occurred, requiring reoperation in one case of insufficiency of the cystic duct and another one with intestinal perforation. In the third case, bile leakage from an aberrant bile-duct occurred but dried up spontaneously after a few days. No death occurred nor were there any lesions of the common bile-duct. Conclusively, this new technique seems to be safe and simple to teach due to its approximity to the conventional technique and is recommended as a standard procedure.

Technik der laparoskopischen Cholezystektomie

In a retrospective analysis the risks were assessed of transthoracic oesophagectomy with mediastinectomy and regional lymphadenectomy followed 48-72 hours later by an abdomino-cervical operation with supra-pancreatic lymphadenectomy, retrosternal gastric interposition and cervical oesophageal stump anastomosis. Results in this group of 37 patients were compared with those in a group of 42 patients who had undergone a transmediastinal oesophagectomy (without thoracotomy) and immediate reconstruction. The 30-day death rate was 8.1% in the former (group I) and 7.1% in the latter (group II), total hospital death rate 10.8% and 11.9%, respectively. The complication rate was similar in the two groups, as was the recorded operative stress. The results indicate that the risk of an oncologically indicated oesophagectomy with regional lymphadenectomy is no greater than that of a palliative transmediastinal oesophagectomy.

J. R. Siewert

Papers

Obere gastrointestinale Ulcusblutung - Letalitätssenkung durch früh-elektive chirurgische Therapie von Risikopatienten

Pneumatosis cystoides intestinalis coli.

Prognosefaktoren beim Magenkarzinom. Ergebnisse einer uni- und multivariaten Analyse

Technik der laparoskopischen Cholezystektomie

[Esophageal carcinoma: transthoracic esophagectomy with regional lymphadenectomy and reconstruction with deferred priority].