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

Ein wesentliches Anliegen der modernen Chirurgie muss die weitere Reduktion des Zugangstraumas sein, um die operative Behandlung fur den Patienten noch weniger belastend zu gestalten und nicht zuletzt auch materielle Ressourcen zu schonen. Die Einfuhrung der laparoskopischen Chirurgie ist ein Ausdruck dieser Bemuhungen. Um zu untersuchen in wieweit diese Zielsetzung bisher erreicht werden konnte, eignet sich der Vergleich von heute laparoskopisch standardmasig durchgefuhrten Eingriffen wie der Cholecystektomie, Fundoplicatio und Sigmaresektion bei Diverticulitis/Divertikulose mit den jeweiligen offenen Verfahren. Die Auswirkungen des kleineren Zugangs konnen anhand unterschiedlicher Parameter, wie Auswirkungen auf das Immunsystem, die Lungenfunktion sowie den postoperativen Schmerz, die Hospitalisationszeit und die Wiedererlangung der Arbeitsfahigkeit bzw. die Gesamtdauer der Rekonvaleszenz abgeschatzt werden. Hilfreich ist auch ein Vergleich der Auswirkungen auf die Lebensqualitat. Die Datenlage bzgl. der Auswirkungen auf die Immunfunktion ist nicht einheitlich. Insgesamt scheint die postoperative Entzundungsreaktion jedoch nach laparoskopischen Eingriffen geringer zu sein. Auser Zweifel steht eine geringere Beeintrachtigung der postoperativen Lungenfunktion, eine gunstigere Auswirkung auf den postoperativen Schmerz, sowie die kurzere Hospitalisationszeit und Dauer der Rekonvaleszenz. Dies druckt sich auch in einer Uberlegenheit der Lebensqualitatsmessungen aus, die sich aber erwartungsgemas im Laufe der Zeit nivelliert. Wirklich zum Tragen kommt der Vorteil des minimal-invasiven Vorgehens aber erst nach Uberwinden der Lernkurve und bei Eingriffen wegen gutartiger Grundkrankheit. Welche Rolle die Reduktion des Zugangstraumas kunftig in der onkologischen Chirurgie spielen wird, ist derzeit noch unklar.

[Reduction of surgical access trauma: reliable advantages].

BACKGROUND AND STUDY AIMS: In the past, there were long delays in the diagnosis of patients with cancer of the stomach or esophagus The objective of this study was to describe current delays in the diagnosis and treatment of gastric and esophageal adenocarcinoma and to compare the findings with those from an historical control population treated at the same institutions 10 years earlier PATIENTS AND METHODS: Patients with biopsy-proven gastric cancer or esophageal adenocarcinoma who were treated at two academic medical centers in Germany between April and October 2003 were consecutively screened for eligibility to take part in the study Medical charts for each patient were reviewed Additional data were obtained via structured interviews Main outcome measures were the total delay, and the delays related to patients themselves, to doctors, and to the hospital Data were compared with those from a historic control group assessed in 1993 RESULTS: The median total delay for patients with gastric cancer (n =104) was 35 months (range 03 - 296), and in patients with esophageal adenocarcinoma (n = 22) the total delay was significantly shorter (median 22 months, range 12 - 117; P< 005) Comparing these findings with those from an historic cohort of patients with gastric cancer (n = 100) revealed a significant decrease in the total delay (35 versus 80 months, P< 0001) CONCLUSIONS: The current findings indicate that delays in the diagnosis and treatment of gastric cancer have become significantly shorter within the last 10 years as our understanding of and ability to treat this form of cancer have improved

Delays in diagnosis and therapy of gastric cancer and esophageal adenocarcinoma.

The advance of endoscopic and laparoscopic techniques in recent years has prompted several groups throughout the world to investigate the possibilities for a minimally invasive approach to reconstruct a defective antireflux mechanism in patients with intractable gastro-esophgeal reflux disease. Prospective trials are needed to evaluate the long-term durability and efficiency of these procedures.

Minimally invasive antireflux procedures.

Gastroesophageal reflux disease (GERD) is one of the most frequent benign diseases of the gastrointestinal tract and in some cases the diagnosis may be very difficult. There are many diagnostic procedures but none of them could prove or definitely exclude the disease. The 24-h pH-monitoring is the “gold standard” for detection of gastroesophageal reflux and in many patients the reflux correlates with the GERD. The evaluation of a diagnostic method has to be done in a similar manner to the evaluation of therapeutic study (phase 1 to phase 4). For the definition of the “gold standard” for detection of a special diagnosis (e.g., the gastroesophageal reflux disease), the results of phase 3 studies for different methods had to be compared. The method with the best values for sensitivity and specificity is yet to be discovered. Until now, pH monitoring has been the gold standard for the diagnosis of GERD. However, there are many problems connected with using this method in clinical practice.

J. R. Siewert

Papers

[Reduction of surgical access trauma: reliable advantages].

Delays in diagnosis and therapy of gastric cancer and esophageal adenocarcinoma.

Minimally invasive antireflux procedures.

pH monitoring: the gold standard in detection of gastrointestinal reflux disease?

Does saving the pylorus in pancreatoduodenectomy for periampullary cancer have a value