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Background: The ECF (Epirubcin/Cisplatin/5-fluorouracil) as first line therapy in metastatic gastric is the optimal therapeutic option but its complexity limits its utility in many communities. Methods: We investigated a more convenient modification of the standard approach, "5 days CIV 5-fluorouracil 1000mg/m2". A total of 115 patients with advanced and metastatic adenocarcinoma of the stomach and gastroesophageal cancer were reviewed retrospectively to compare the efficacy of modified ECF with the reference protocols FAM and ELF Results the number of patients in each regimen was 41 patients received modified ECF while 42 received ELF and 32 received FAM. The overall response rate was 36.5% with ECF, 16.6% with ELF, and 15.6% with FAM, with significant differences p=0.001. No one achieved a complete tumor remission. However, 4 patients with locally advanced stomach were able to have total gastrectomy in ECF arm only with p=0.000. Hematologic toxicities were more common in ECF p= 0.01. On the other hand, there was no significant difference in progression free survival or overall survival between the three regimens. Conclusion Modified ECF showed significant overall response than FAM and FLF. However survival benefit is very small. So we recommend using this regimen as neoadjuvant treatment.

Background: The ECF (Epirubcin/Cisplatin/5-fluorouracil) as first line therapy in metastatic gastric is the optimal therapeutic option but its complexity limits its utility in many communities. Methods: We investigated a more convenient modification of the standard approach, "5 days CIV 5-fluorouracil 1000mg/m2". A total of 115 patients with advanced and metastatic adenocarcinoma of the stomach and gastroesophageal cancer were reviewed retrospectively to compare the efficacy of modified ECF with the reference protocols FAM and ELF Results the number of patients in each regimen was 41 patients received modified ECF while 42 received ELF and 32 received FAM. The overall response rate was 36.5% with ECF, 16.6% with ELF, and 15.6% with FAM, with significant differences p=0.001. No one achieved a complete tumor remission. However, 4 patients with locally advanced stomach were able to have total gastrectomy in ECF arm only with p=0.000. Hematologic toxicities were more common in ECF p= 0.01. On the other hand, there was no significant difference in progression free survival or overall survival between the three regimens. Conclusion Modified ECF showed significant overall response than FAM and FLF. However survival benefit is very small. So we recommend using this regimen as neoadjuvant treatment.

Objectives: To assess the analgesic efficacy and tolerability of co-administration of pre-emptive single oral dose of sustained release morphine and sub- anesthetic ketamine infusion for modified radical mastectomy (MRM) with axillary evacuation. Methods: Sixty four adult female patients scheduled for MRM were divided to two groups, morphine group (n=32) received preoperative oral sustained release morphine tablet, 30 mg and placebo group (n=32) received placebo tablet. Both groups received preoperative ketamine bolus, 0.5 mg/kg followed by continuous infusion 0.1 mg/kg/h for 24 h postoperatively. VAS pain score, time to first analgesic request, 24 h analgesic consumption were reported. Results: The mean VAS pain score during movement was significantly decreased in morphine group in comparison to placebo group from 2 h till 72 h postoperatively, 2 h (2.87 ± 1.0 vs. 4.53 ± 1.67) mean difference (-1.67) (95% CI)-(2.38-0.95), 72 h (1.20 ± 0.76 vs. 1.83 ± 0.91) mean difference (-0.63) (95% CI)-(1.07-0.20) while the mean VAS pain score during rest was significantly decreased in morphine group in comparison to placebo group from 2 h till 24 h postoperatively, 2 h (2.03 ± 0.85 vs. 3.47 ± 0.93) mean difference (-1.33) (95% CI)-(1.78-0.90), 24 h (1.40 ± 0.72 vs. 1.77 ± 0.68) mean difference (-0.37) (95% CI)-(0.73-0.01). The median (IQ) time to first analgesic request was significantly delayed in morphine group in comparison to placebo group, 11.8 (9.7:14.2) h vs. 2.3 (2.1:2.5) h, (P0.001). The number (percentage) of patients required paracetamol in the first postoperative 24 h was significantly lower in morphine group in comparison to placebo group, 10 (33%) vs. 30 (100 %) (P0.001). Conclusion: Analgesic technique based on pre-emptive sustained release oral morphine and perioperative infusion of sub-anesthetic dose of ketamine provides satisfactory analgesia for patients undergoing MRM.

Objectives: To assess the analgesic efficacy and tolerability of co-administration of pre-emptive single oral dose of sustained release morphine and sub- anesthetic ketamine infusion for modified radical mastectomy (MRM) with axillary evacuation. Methods: Sixty four adult female patients scheduled for MRM were divided to two groups, morphine group (n=32) received preoperative oral sustained release morphine tablet, 30 mg and placebo group (n=32) received placebo tablet. Both groups received preoperative ketamine bolus, 0.5 mg/kg followed by continuous infusion 0.1 mg/kg/h for 24 h postoperatively. VAS pain score, time to first analgesic request, 24 h analgesic consumption were reported. Results: The mean VAS pain score during movement was significantly decreased in morphine group in comparison to placebo group from 2 h till 72 h postoperatively, 2 h (2.87 ± 1.0 vs. 4.53 ± 1.67) mean difference (-1.67) (95% CI)-(2.38-0.95), 72 h (1.20 ± 0.76 vs. 1.83 ± 0.91) mean difference (-0.63) (95% CI)-(1.07-0.20) while the mean VAS pain score during rest was significantly decreased in morphine group in comparison to placebo group from 2 h till 24 h postoperatively, 2 h (2.03 ± 0.85 vs. 3.47 ± 0.93) mean difference (-1.33) (95% CI)-(1.78-0.90), 24 h (1.40 ± 0.72 vs. 1.77 ± 0.68) mean difference (-0.37) (95% CI)-(0.73-0.01). The median (IQ) time to first analgesic request was significantly delayed in morphine group in comparison to placebo group, 11.8 (9.7:14.2) h vs. 2.3 (2.1:2.5) h, (P0.001). The number (percentage) of patients required paracetamol in the first postoperative 24 h was significantly lower in morphine group in comparison to placebo group, 10 (33%) vs. 30 (100 %) (P0.001). Conclusion: Analgesic technique based on pre-emptive sustained release oral morphine and perioperative infusion of sub-anesthetic dose of ketamine provides satisfactory analgesia for patients undergoing MRM.

Objectives: To assess the analgesic efficacy and tolerability of co-administration of pre-emptive single oral dose of sustained release morphine and sub- anesthetic ketamine infusion for modified radical mastectomy (MRM) with axillary evacuation. Methods: Sixty four adult female patients scheduled for MRM were divided to two groups, morphine group (n=32) received preoperative oral sustained release morphine tablet, 30 mg and placebo group (n=32) received placebo tablet. Both groups received preoperative ketamine bolus, 0.5 mg/kg followed by continuous infusion 0.1 mg/kg/h for 24 h postoperatively. VAS pain score, time to first analgesic request, 24 h analgesic consumption were reported. Results: The mean VAS pain score during movement was significantly decreased in morphine group in comparison to placebo group from 2 h till 72 h postoperatively, 2 h (2.87 ± 1.0 vs. 4.53 ± 1.67) mean difference (-1.67) (95% CI)-(2.38-0.95), 72 h (1.20 ± 0.76 vs. 1.83 ± 0.91) mean difference (-0.63) (95% CI)-(1.07-0.20) while the mean VAS pain score during rest was significantly decreased in morphine group in comparison to placebo group from 2 h till 24 h postoperatively, 2 h (2.03 ± 0.85 vs. 3.47 ± 0.93) mean difference (-1.33) (95% CI)-(1.78-0.90), 24 h (1.40 ± 0.72 vs. 1.77 ± 0.68) mean difference (-0.37) (95% CI)-(0.73-0.01). The median (IQ) time to first analgesic request was significantly delayed in morphine group in comparison to placebo group, 11.8 (9.7:14.2) h vs. 2.3 (2.1:2.5) h, (P0.001). The number (percentage) of patients required paracetamol in the first postoperative 24 h was significantly lower in morphine group in comparison to placebo group, 10 (33%) vs. 30 (100 %) (P0.001). Conclusion: Analgesic technique based on pre-emptive sustained release oral morphine and perioperative infusion of sub-anesthetic dose of ketamine provides satisfactory analgesia for patients undergoing MRM.

Objectives: To assess the analgesic efficacy and tolerability of co-administration of pre-emptive single oral dose of sustained release morphine and sub- anesthetic ketamine infusion for modified radical mastectomy (MRM) with axillary evacuation. Methods: Sixty four adult female patients scheduled for MRM were divided to two groups, morphine group (n=32) received preoperative oral sustained release morphine tablet, 30 mg and placebo group (n=32) received placebo tablet. Both groups received preoperative ketamine bolus, 0.5 mg/kg followed by continuous infusion 0.1 mg/kg/h for 24 h postoperatively. VAS pain score, time to first analgesic request, 24 h analgesic consumption were reported. Results: The mean VAS pain score during movement was significantly decreased in morphine group in comparison to placebo group from 2 h till 72 h postoperatively, 2 h (2.87 ± 1.0 vs. 4.53 ± 1.67) mean difference (-1.67) (95% CI)-(2.38-0.95), 72 h (1.20 ± 0.76 vs. 1.83 ± 0.91) mean difference (-0.63) (95% CI)-(1.07-0.20) while the mean VAS pain score during rest was significantly decreased in morphine group in comparison to placebo group from 2 h till 24 h postoperatively, 2 h (2.03 ± 0.85 vs. 3.47 ± 0.93) mean difference (-1.33) (95% CI)-(1.78-0.90), 24 h (1.40 ± 0.72 vs. 1.77 ± 0.68) mean difference (-0.37) (95% CI)-(0.73-0.01). The median (IQ) time to first analgesic request was significantly delayed in morphine group in comparison to placebo group, 11.8 (9.7:14.2) h vs. 2.3 (2.1:2.5) h, (P0.001). The number (percentage) of patients required paracetamol in the first postoperative 24 h was significantly lower in morphine group in comparison to placebo group, 10 (33%) vs. 30 (100 %) (P0.001). Conclusion: Analgesic technique based on pre-emptive sustained release oral morphine and perioperative infusion of sub-anesthetic dose of ketamine provides satisfactory analgesia for patients undergoing MRM.

Background and objectives Major abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery. Patients and methods One hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded. Results There was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group. Conclusion Perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.