1276

THE AMERICAN SURGEON

September 2011

Vol. 77

In the Treatment for Stomach cancer [SPIRITS] trial) reported that the median overall survival was significantly longer in patients assigned to S-1 plus cisplatin (13 months) than in those assigned to S-1 alone (11 months).3 From the result of the SPIRITS trial, S-1 plus cisplatin was recommended for the basic treatment of metastatic gastric cancer in Japan. Our study indicated that S-1-based chemotherapy followed by hepatectomy prolonged survival time compared with S-1-based chemotherapy alone. Kakeji et al.1 reported a hepatic resection rate of 17 to 38 per cent and the MST of patients was 12 to 34 months with a 5-year survival rate after hepatectomy of 18 to 42 per cent. A potentially curative hepatectomy may bring some hope of long-term survival for patients with hepatic metastasis. However, the reported survival rate after hepatectomy was rather unsatisfactory, because two thirds of the patients developed intrahepatic recurrence, and this high recurrence rate within 2 years of the surgery might suggest the presence of occult intrahepatic metastases even at the time of the hepatectomy. Thus, to avoid the possibility of intrahepatic recurrence or another type of recurrence after hepatectomy, we need to select the patients for hepatectomy. Thus, we started with S-1-based chemotherapy for patients with hepatic metastasis. During these chemotherapy periods (almost 6 months), patients who developed tumors in new regions or who showed enlargement of tumor size were excluded from hepatic resection. We believe that surgical resection may bring some hope of long-term survival for selected patients with hepatic recurrence from gastric cancer. Masahide Ikeguchi, Ph.D., M.D. Hiroaki Saito, Ph.D., M.D. Shigeru Tatebe, Ph.D., M.D. Toshiro Wakatsuki, Ph.D., M.D. Department of Surgery Division of Surgical Oncology Faculty of Medicine Tottori University Yonago, Japan
REFERENCES

Indication of Emergency Operation and Intensive Care for Cardiopulmonary Arrest Related with Gastrointestinal Perforation The survival rates of gastrointestinal perforation (GIP) have improved as the clinicopathological concept and practice guidelines for treating GIP, systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction syndrome have improved as well as organsupporting systems.1 However, we often encounter patients with GIP who have already fallen into septic shock or cardiopulmonary arrest (CPA). Patients with severe peritonitis with unstable circulatory dynamics just before the CPA in itself are difficult to save. Although we often hesitate to perform surgery for these patients, this choice means withdrawal and withholding, basically. We made a retrospective study of cases diagnosed with GIP from all CPA cases on arrival and just after arrival. We made a diagnosis of GIP based on findings in the operation and the autopsy, intestinal contents aspirated by abdominal paracentesis, and image findings of intraperitoneal free air with free fluid. Patients showing intraperitoneal free air without free fluid were excluded, whose intraperitoneal free air was often accompanied by pneumothorax and mediastinal emphysema. We used all information collected from arrival at the hospital to discharge. In patients with CPA just after arrival, we dealt with the duration from contact with the patients to arrival at the hospital as 0 minutes and substituted the initial rhythm with the rhythm at the CPA confirmation in the hospital. We examined the indication of resuscitation for CPA and the indication of surgery using the patients medical records. Statistical analysis was performed using a t test and chi-squared test. In our city, we established a unique system for the prehospital transfer of patients with CPA, who are transferred to the nearest of the selected 11 hospitals (12 since 2007), which received all patients with CPA regardless of the etiology, possibility for resuscitation, and any other reason except the predecision of transfer to a designated hospital. The data concerning CPA of these 11 hospitals can be population-based data, which considered a transportation network.2, 3 Of 12 subjects (four gastric, one duodenal, one small intestinal, four colorectal, and two unknown), four could not achieve return of spontaneous circulation (ROSC) (group unresuscitatable, group UR). The other eight patients could successfully achieve ROSC, four of whom were also able to undergo emergency surgery and be saved (operable group, group O), whereas the other four
Address correspondence and reprint requests to Yoshihiro Moriwaki, M.D., Ph.D., Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan. E-mail: qqc3@urahp. yokohama-cu.ac.jp.

1. Kakeji Y, Morita M, Maehara Y. Strategies for treating liver metastasis from gastric cancer. Surg Today 2010;40:28794. 2. Shirasaka T, Shimamato Y, Ohshimo H, et al. Development of a novel form of an oral 5-fluorouracil derivative (S-1) directed to the potentiation of the tumor selective cytotoxicity of 5-fluorouracil by two biochemical modulators. Anticancer Drugs 1996;7: 54857. 3. Koizumi W, Narahara H, Hara T, et al. S-1 plus cisplatin versus S-1 alone for first-line treatment of advanced gastric cancer (SPIRITS trial): a phase III trial. Lancet Oncol 2008;9:21521.

No. 9

BRIEF REPORTS

1277

FIG. 1.

The diagnostic precess and prognosis of the cases.

FIG. 2. The time interval of the cases among operable cases, unstable cases after ROSC, and unresuscitated cases; suspected collapse time (left), the time interval between the contact of emergency lifesaving technique with the patient (middle) and arrival to the hospital, and the time interval between arrival to the hospital to ROSC (right). ROSC, return of spontaneous circulation.

could not be transferred to the operating room because of a prolonged extremely unstable condition (inoperable group, group IO). In group O, two patients were CPA just after arrival, one of whom was discharged without neurological abnormality; and the other two patients were CPA on arrival, one of whom could partially communicate (Fig. 1). The mean estimated collapse time was 4.3, 14.0, and 10.5 minutes in groups O, IO, and UR, respectively (no statistical difference). In group O, three patients (75%) received surgery after less than 4 minutes of the collapse time (P < 0.01), and two (50%) survived. The mean duration from contact of patients with emergency services to arrival at the hospital was 4.3, 19.5, and 13.0 minutes in groups O, IO, and UR, respectively. The duration for group O tended to be shorter than those of the other two

groups. Of five patients in whom this duration was within 10 minutes, three patients were in group O, and two (40%) survived. The mean duration from arrival at the hospital to ROSC was 9.0 and 14.5 minutes in group O and group IO, respectively. There was a tendency toward the shorter time for patients in group O. All three patients in whom this duration was within 10 minutes were in group O (P < 0.01) and survived (P < 0.01). Of five patients whose initial rhythms were pulseless electrical activity (PEA), 60 per cent were in group O and 20 per cent were in group IO. Of six patients whose initial rhythms were asystole, 50 per cent were in groups IO and UR, and one patient whose initial rhythm was ventricular fibrillation was in group O. Two of three patients (67%) with PEA on arrival at the hospital were in group O, and the other patient was in group UR. One of eight patients (13%) with asystole on arrival at the hospital was in group O, four (50%) were in group IO, and three (37%) were in group UR (Fig. 2). It is not surprising that the time course (clock) from collapse and the etiology of the CPA are the most important predictors of CPA. The causative etiology of CPA from GIP include, as primary causes, severe peritonitis and septic shock and, as secondary causes, vomiting, airway obstruction, abdominal compartment syndrome, and cardiac ischemia. The patients conditions continue worsening after all without several treatments for both etiologies, even if we succeed in ROSC. The lifesaving possibility depends on the possibility of the treatment, including surgery for peritonitis and septic shock. The procedure of the operation disturbs the procedure of cardiopulmonary resuscitation (CPR), resulting in the decrease of the success rate of ROSC. During CPR, the systolic blood pressure is not beyond 60 to 80 mmHg and the average carotid pressure is not beyond 40 mmHg.4 We should do CPR blindly before ROSC for patients with GIP with CPA as poor candidates for surgery before ROSC, even if the cause of the CPA is recognized as GIP and the treatment for peritonitis potentially improves the unstable circulatory and metabolic condition. We should also confirm the information. The time interval from contact of emergency services with the patient to arrival at the hospital and from arrival at the hospital to ROSC must be accurately described. In patients with good functional recovery, the latter time interval was within 10 minutes, which seemed to be a good cutoff point for the indication of surgery. Based on this study, we conclude that life expectancies and the functional prognoses of GIP patients falling into CPA are considered to be poor but desirable, if the CPAs are witnessed, the time courses are clearly comprehensive and the estimated collapse times are less than 4 minutes, their initial rhythms are not asystole, and they successfully achieved ROSC within

1278

THE AMERICAN SURGEON

September 2011

Vol. 77

10 minutes after hospital arrival, when there are no factors indicating do not attempt to resuscitate. We should arrange accurate information in parallel with performing CPR, make a decision about the indication of surgery, and perform emergency surgery for them after or parallel to the treatment for CPA. Yoshihiro Moriwaki, M.D., Ph.D. Shinju Arata, Ph.D. Yoshio Tahara, Ph.D. Takayuki Kosuge, Ph.D. Hiroshi Toyoda, Ph.D. Masayuki Iwashita, Ph.D. Nobuyuki Harunari, Ph.D. Noriyuki Suzuki, Ph.D.

Critical Care and Emergency Center Yokohama City University Medical Center Yokohama, Japan
REFERENCES

1. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 2004;30:53655. 2. Moriwaki Y, Sugiyama M, Hayashi H, et al. Emergency medical service system in Yokohama, Japan. Annali Degli Ospedali San Camillo e Forlanini 2001;3:34456. 3. Moriwaki Y, Sugiyama M, Yamamoto T, et al. Outcomes from prehospital cardiac arrest in blunt trauma patients. World J Surg 2011;35:3442. 4. Paradis NA, Martin GB, Goetting MG, et al. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans: insights into mechanism. Circulation 1989;80:3618.

Copyright of American Surgeon is the property of Southeastern Surgical Congress and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.