In an attempt to attain the best possible delimitation of all the problems posed today by benign diseases of the esophagus, 181 authors each agreed to answer one or more of 210 questions that had been drawn up on the subject. These questions, each one deliberately limited and difficult, mostly concerned reflux esophagitis: its natural history, the means of its diagnosis, all existing treatments, and its eventual degeneration. The authors approached are today's most reputed specialists in the fields of epidemiology, gastroenterology, endoscopy, pathology, and surgery of esophageal diseases. The authors were all assigned one or more questions in their own field, none of which was simple: all did their best to synthesize in their replies their own experience on the precise point under review and included all the most useful bibliographical references on the topic. The book is thus the result of an original, individual approach to try to pinpoint the heart of a problem. The 210 answers succeed one another in logical progression according to the different diagnostic and therapeutic stages, specifying, at each step, the degree of precision sought. Consequently, the reader has at his disposal an exceptional synthesis of facts and concepts. Opening the book at random he will find at once the detail he is looking for, the professional opinion he is lacking, or the development of a question he had perhaps not yet asked himself.

When one deals with cancer, the hepatobiliary malignancies present a chal lenge to the oncologists that can be characterized as a series of unsolved clinical and biological dilemmas. Liver metastases from colorectal and other gastrointestinal malignancies, hepatocellular carcinoma, cholangiocar cinoma, and gall bladder cancer present an array of problems but have two features in common. These are high morbidity and mortality with an overall poor result from treatment. Why is it that hepatobiliary cancer carries with it such a dismal prognosis? First of all, these diseases present, for the most part, in an advanced state. To this point in time the oncologist has had no help from early diagnosis or screening. Only the occasional patient followed by ultrasound or a tumor marker has the disease diagnosed in an asymptomatic state. By the time these diseases become symptomatic, curative treatment options have usually disappeared. Evolution has placed the liver in a protected position in order to avoid injury to the soft parenchyma. As with many other internal organs, the nerve supply is extremely limited. These two anatomic features result in a great lack of early warning signs of cancer.

Recent developments have favourably and extensively altered general surgical practice. As editor I have happily been able to select certain topics of new and major interest for detailed discussion and have thus had the opportunity to collect these authoritative submissions within the covers of one text. The range of topics is broad. Endoscopy has changed the nature of both investigation and treatment of much gastrointestinal disease and the therapeutic uses of endoscopy continue to grow. That sophisticated new tool of the radiologist, computerized axial tomography, has revolu tionized the diagnosis of intra-abdominal disease, very often permitting precise localization of hitherto occult disease, and, as might be expect ed, it has become helpful in determining both the nature and extent of surgical and other therapy. Although an invasive procedure, intra abdominal angiography has similarly come of age as a means of localiz ing gastrointestinal haemorrhage and controlling such bleeding. Unfortunately, intra-abdominal malignancy continues to be a major source of concern to the general surgeon and the discovery that such tumours are associated with unusual markers, termed oncofetal anti gens, suggests that early diagnosis and early detection of recurrence may yet be feasible. Adjuvant or post-surgical therapy is an exciting de velopment in terms of prolonging the disease-free interval in women with breast cancer limited to regional lymph nodes. Equally efficacious therapy is not yet available for patients with gastrointestinal cancer, highlighting the need for more specific drugs and drug combinations."

Although the number of published papers on traumatic hip disloca tion in childhood is large, our actual current knowledge on this inju ry in this age group is still full of obscure points and unsolved prob lems. Luxation of the hip of traumatic origin in children is infrequent, and the small number of cases reported by authors and institutions, as well as the usually short follow-up in many cases, are responsible for the many doubts and questions, especially related to complications and outcome following the injury. Consequently the treatment, especially the postreduction management, has not been adequately defined. Dr. Antonio Barquet has made the great effort to analyze the ex perience gained from 38 cases in Uruguay and to review more than 500 references related to the subject, covering more than 1400 cases. He began to study this topic in 1976. It was the subject of his postgraduate monograph in 1979, which was followed by a statisti cal analysis of the major complication, i. e., avascular necrosis of the proximal femoral extremity, which was presented as his doctoral thesis in 1981. In addition, he has published numerous papers deal ing with several aspects of traumatic hip dislocation in children."

Inflammatory dieseases of the pancreas occur with increasing incidence in western industrialized countries. This volume deals with all aspects of CHRONIC PANCREATITIS including epidemiology, etiology, morphology and pathophysiology, dia- gnostic imaging as well as conservative and operative treat- ment. Very recent data based on experimental and clinical research projects are presented. The contributions have all been written by a team of internationally well recognized authorities in the various fields involved. Topics of parti- cular interest include feed-back regulation, new aspects of conservative and interventional treatment as well as modern surgical approaches including organ-preserving procedures.

Material for this book was gathered in the early 1980's in Manchester, where a higher incidence than usual of complications in the gastro-intestinal and urinary tract was observed. Part I describes the principles and methods of radiotherapy for pelvic tumours, pathological features and radiological analysis of bowel and urinary tract changes. Parts II and III are devoted to clinical assessment and management, where the need for a multi-diciplinary approach is emphasized.

This volume provides in a conveniently accessible package a comprehensive collection of accurate and timely information on the management of patients with diarrhea, both in pediatric age and in the adult. As medical knowledge has recently expanded in this area, this volume is full of new practical, clinically useful material for the busy clinician. Illustrations are emphasized to permit rapid acquisition of practical information that is not readily available in the major texts. Each chapter is concise, concentrating on "clinical pearls," and new advances in diagnostic and therapeutic technology. Each chapter discusses the relative costs of diagnostic and therapeutic options to permit financial considerations to be taken into account in the decision making process. Additional unique features include, summaries of key points, recommendations, and indications for requesting GI subspecialty consultation. Providing a comprehensive but practical overview of the issues surrounding the diarrheal diseases, this volume will prove of great value and utility to gastroenterologists, surgeons, internists, primary care physicians.

In 1988 we presented our Guide to Bone Marrow Transplan tation. The reception has been enthusiastic and we have re ceived a flood of critical comments, suggestions and requests to provide an update in due time. Although several books on marrow transplantation have recently been published, their scope and goal have generally been different. Hence, we have decided to prepare a second edition of the Guide. Our aim was to maintain a short, concise text which never theless would incorporate changes that have occurred over the past four or five years. We have streamlined the description of pretransplant considerations, by condensing two sections into one (Treatment Planning and Timing of Transplantation). This also facilitated the review of controversial indications for marrow transplantation, for example in patients with acute myelogenous leukemia in first chemotherapy-induced remission. We have updated the chapter dealing with conditioning regimens and have expanded the section on donor selection, in particular in regard to the current level of tissue typing and the identification of unrelated volunteer donors. In the chapter on collection, processing, and infusion of marrow, we have incorporated recent developments, for example, the use of closed systems for marrow harvesting and processing and the use of solid phase separation of stem cells."

This book reviews the most recent developments in the patho- physiology and therapy of ventilatory failure. It contains contributions by twenty-five internationally recognized aut- horities on respiratory muscle function and investigators actively contributing to our knowledge of the cause, diagno- sis and therapy of ventilatory failure. Of particular inter- estare the descriptions of new modalities of partial and complete ventilatory assistance as well as new knowledge re- garding ventilatory control and fatigue during stressful breathing. The reader will find here a state-of-the-art re- view of the latest research and practical applications in this most critical area of intensive care medicine.

Besides the mortality rate the value of an operative procedure is measured against the incidence and the degree of undesirable postoperative sequelae. In the surgical treatment of gastroduo denal ulcerations vagotomy is now competing with the success fully established resection therapy. Since this latter method has been further developed during the last years and late results are rare, a comparison between both types of operation is difficult. Meritoriously, the authors have tried to perform a comprehensive analysis. Due to the complexity of postoperative syndromes the diagnostic procedure and treatment can be successful only after integrated cooperation by gastroenterologists and surgeons. This is documented by the current monograph which originates from a cooperation of several years and an active exchange of scientific will facilitate the indica and practical experience. The monograph tion for the primary surgical procedure by critical confrontation of the postoperative syndromes and provide advice in treating postoperative complaints. We hope that the monograph will have the expected impact, which means the spreading of the actual knowledge of post gastrectomy and postvagotomy syndromes.

Controlled and predictable interference with hormonal feed- back mechanisms has become a major direction of preclinical and clinical research. There is a steadily increasing number of hormonal pep tides detected and characterized that are re- sponsible for endo-, para-, and autocrine cellular actions. Naturally, these peptides have been studied with regard to their cell growth stimulatory action and, in parallel, the re- spective antagonists are being investigated in terms of their antiproliferative (antineoplastic) function. Among the numerous pep tides of interest in this respect, somatostatin (somatotropin release inhibitory factor) and bombesin antagonizing factors have been the topic of inten- sive research during recent years. No presentation of the role of pep tides in oncology would be complete without a compre- hensive treatise of their physiological, preclinical and clinical functions in the context of their antineoplastic mechanism of action. Somatostatin and its various short- and long-acting analogs have the unique feature of suppressing and inhibiting a wide range of cellular processes including cell proliferation. Recep- tors for these peptides, which belong in a wider sense to the family of neuropeptides or neurotransmitters, are widely dis- tributed, a feature which is not in keeping with the general view of a growth hormone regulatory system. Thus, these substances are found in the gut in a variety of endocrine and exocrine glands including breast, pancreas, and prostate, and in the nervous system.

One out of every two men over eigthy suffers from carcinoma of the prostate.It is discovered incidentally in many patients with an alleged benign prostatic hyperplasia. In treating patients, the authors make clear that primary radical prostatectomy is preferred over transurethral resection due to the lower complication rate.

Rapid developments in this successful diagnostic and operative technique have called for a new edition of "Arthroscopy of the Knee Joint." This second edition has been completely revised and retains very little material from the first edition. The diagnostic section has been considerably expanded and elucidated and the operative section adapted to modern technology. The first part of the book presents the external conditions and pre-requisites for diagnostic arthroscopy. The endoscopic anatomy and pathology of the knee joint are covered in detail. Particular emphasis is placed on practical hints for accurate arthroscopic procedures. The second part then discusses operative techniques. The reader discovers step-by-step how and which pathological findings should, in the author's opinion, be treated. Here, too, the problems and possible complications of arthroscopic surgery relevant to the individual techniques are dealt with in detail. Equipped with this book, the reader will be thoroughly informed on all current arthroscopic methods and possibilities.

It is now more than 40 years since Drs. Wild and Reid published their first experience with rectal ultrasonography from the Surgery Department at the University of Minnesota. Professor Owen H. Wangen steen, in whose laboratory the studies were carried out, recognized at that time the need for early detection in the treatment of cancer. Technical improvements over the past 20 years have made endoscopy the procedure of choice for examination of the hollow organs of the genital, urinary and gastrointestinal tracts. The simultaneous development of endosonography has had an equally dramatic impact on the practice of medicine and surgery. The technology has been demonstrated to be helpful in both benign and malignant conditions. One of the so-called benign conditions of the anorectum is fistula-in-ano. Fistula surgery has always relied on excellent anatomic delineation of the intramuscular tracts. There is hope that adaptation of ultrasonographic technology will aid in the surgical management of this malady. Clearly, rectal ultrasonography has considerable potential in the management of rectal carcinoma. Accuracy rates in the range of 90% for the depth of neoplastic invasion have been reported. This ability for accurate assessment will undoubtedly lead to a better definition of the population of patients that can be managed by local therapeutic means.

For the first time four crucial aspects of gastrointestinal endoscopy are combined in a single text. Drugs for sedation and monitoring of the patient are addressed with particular reference to safety issues and comfort and acceptability for the patient. Resource management and health economic techniques are applied to endoscopy to determine quality and outcome. Problems of negligence and informed consent form the basis of a medico-legal examination of endoscopic practices.

Since the small bowel except the duodenum and (1961), Pygott et al. (1960), Gianturco (1967) terminal ileum is largely inaccessible during en- and Bilbao et al. (1967). doscopic examination, radiology of the small Sellink, however, was really responsible for bowel attains special significance as a diagnostic the widespread recognition of enteroclysis method. Owing to the length and position of (1971, 1974, 1976). In spite of the increasing this organ, good images are difficult to obtain. popularity of this method, the necessity for sub- Furthermore, the considerable variation oftran- stituting this apparently viable method for the sit time, unpredictable response of the contrast peroral examination is still equivocal (Rabe medium, and superimposition with the filled etal. 1981; Fried etal. 1981; Maglinte etal. loops make small bowel radiology difficult. As 1982; Ott et al. 1985). Comparisons of both methods, however, (Fleckenstein and Pedersen a result, few radiologists specialize in this field. With the exception of Crohn's disease, disorders 1975; Sanders and Ho 1976; Ekberg 1977; Val- lance 1980) have confirmed the superiority of of the small bowel are relatively rare. Thus, not many clinicians and radiologists are interested enteroclysis. It achieves a high accuracy (Antes in the small intestine. and Lissner 1983).

This work is derived from the International Symposium on Advanced Laparo-Endoscopic Surgery, reknowned for being a comprehensive program that brings together international leaders in the field to discuss the current state of practice, the emerging possibilities and the future directions for research. The program focuses on the experiences in large series which have set the standard of practice and won acceptance for laparo-endoscopic surgery in recent years; the panelists and lecturers span the field from concept to realization. The program also addresses the evaluation process by which innovations should be judged in the interest of safety, clinical efficacy and cost effectiveness to improve the delivery of surgical care in the world. The symposium clebrates the firm establishment of laparo-endoscopic surgery and the promise of the future. Together, members of the panel outline future innovations that will change the practice of laparoscopic surgery, showcasing the future of robotics, virtual reality, telesurgery, needlescopic surgery, minimally-invasive breast surgery, cryotherapy and live donor nephrectomy.Highlights include contributions by John Hunter (Endo-Gastric Surgery), Dana Anderson (Repair Common Bile Duct Injury), Jack Jackimowicz (European Laparoscopic Hernia Multi-Institutional Study), Alfred Cuschieri and John Flowers (Role of Clinical Trial for New Procedures).

Gastric cancer has been one of the great malignant scourges affecting man kind for as long as medical records have been kept. Until operative resection pioneered by Bilroth and others became available, no effective treatment was feasible and death from cancer was virtually inevitable. Even with resection by total gastrectomy, the chances of tumor eradication remained small. Over recent years, however, the situation has been changing. Some changes have resulted from better understanding of the disease, early detec tion, and better management techniques with applied clinical research, but the reasons for other changes are poorly understood. For example, the incidence of gastric cancer is decreasing, especially in westernized societies, where it has fallen from one of the most common cancers to no longer being in the top five causes of cancer death. Still it remains the number one killer of adult males in Japan and Korea. Whether the reduced incidence in western societies is a result of dietary changes or methods of food preservation, or some other reason, is as yet uncertain. Improvements in outcome have been reported from mass screening and early detection; more refined techniques of establishing early diagnosis, tumor type, and tumor extent; more radical surgical resection; and resection at earlier stages of disease."

The use oflasers in clinical practice is increasing rapidly, both in the definitive treatment of disease and in the palliation of symp toms. Consequently, this sixth contribution to the Bloomsbury Series in Clinical Science is particularly timely. It opens with an introduction to the basic physics of lasers and then focuses on the current use of lasers in urological practice, and concludes by reflecting on their potential for the future. Edited, and with several contributions by Tom McNicholas, the book also contains contributions from a number of workers at the National Medical Laser Centre in University College Hos pital. London. Given their ever widening application, there can be little doubt that lasers will be a subject the series will return to again. To date, the series has been concerned with a wide range of topics of fundamental importance in clinical science. It has now gained momentum and future titles continue to reflect its wide sphere of interest. As Series Editor, I would welcome suggestions from readers of topics and issues that could usefully be addressed in the series.

The European School of Oncology came into existence to respond to a need for informa tion, education and training in the field of the diagnosis and treatment of cancer. There are two main reasons why such an initiative was considered necessary. Firstly, the teaching of oncology requires a rigorously multidisciplinary approach wh ich is difficult for the Univer sities to put into practice since their system is mainly disciplinary orientated. Secondly, the rate of technological development that impinges on the diagnosis and treatment of cancer has been so rapid that it is not an easy task for medical faculties to adapt their curricula flexibly. With its residential courses for organ pathologies and the seminars on new techniques (laser, monocional antibodies, imaging techniques etc.) or on the principal therapeutic controversies (conservative or mutilating surgery, primary or adjuvant chemotherapy, radiotherapy alone or integrated), it is the ambition of the European School of Oncology to fill a cultural and scientific gap and, thereby, create a bridge between the University and Industry and between these two and daily medical practice. One of the more recent initiatives of ESO has been the institution of permanent study groups, also called task forces, where a limited number of leading experts are invited to meet once a year with the aim of defining the state of the art and possibly reaching a consensus on future developments in specific fields of oncology.

H.-J. Senn Adjuvant Chemotherapy (ACT) of breast cancer has now emerged as one of the controversial su):>jects in clinical and also experimental oncology. Driven by growing frustration about stagnating cure rates in breast cancer [1,4] and stimulated by elegant demonstration of highly curative effects of adjuvant systemic therapy in animal models [6, 11] and in several childhood neoplasias [15], researchers introduced ACT to the primary treatment of breast cancer with great hope some 15 years ago. After a first wave of isolated "historic" trials with generally limited but in one case remarkable success [5, 9], a second generation of ACT studies was initiated by NSABP investigators and oncology centers in Europe [2, 6, 13]. These trials were well conducted statistically and diagnostically, and all in the early 1970s included a surgical control arm. Early and intermediate beneficial effects on relapse-free survival (RFS) after 2-3 years median observation time then prompted a whole series of ACT studies in breast cancer. These "third-gener ation" studies usually regarded some positive influence of ACT as a given fact, dropping surgical control regimens and comparing different ACT regimens, hopefully in a prospective, randomized way 1984 Fig. 1. The mushrooming of adjuvant studies in breast cancer XII Introduction [reviews in 3, 14]. The "mushrooming" of ACT studies in breast cancer during the last 10 and especially 5 years is demonstrated in Fig. 1, and it gets really cumbersome even for the insider to keep on top of the multitude of sometimes conflicting data.

The examination of the human fallopian tubes was, until recently, restricted to observations on gross anatomical disposition and tubal patency. These studies, for decades, were the domain of doctors and physiologists whose primary interest was population control and family planning, funded largely by organisations and agencies seek ing alternatives to steroidal contraceptives. For a "worrying" but short period after the birth of Louise Brown in 1978 as the conse quence of successful in-vitro fertilisation and embryo transfer, the fallopian tube was considered to be "dispensable" given that the metabolic milieu in which human fertilisation takes place could be effortlessly reproduced in a Petri dish, in in-vitro fertilisation procedures. However, a number of factors have acted together to renew in terest in the fallopian tube, namely new techniques in cell biology, microinstrument developments (in particular in imaging), an inter disciplinary transfer of skills from interventional radiology and car diology to gynaecology, the surgeon's wish to improve surgical tech niques, and better techniques to monitor early pregnancy. These factors have led surgeons to develop the new diagnostic and ther apeutic strategies and techniques listed here. This volume contains contributions from the majority of keynote speakers at a conference held in London in April 1992 from which its title is derived. Better diagnostic procedures should lead to the implementation of rational effective treatments.

The most meaningful reward to clinicians and researchers is the absence of recurrent malignancy in their patients. While in some patients the disease will be cured by resection alone, in other similarly staged cases the disease will recur despite adequate loco regional and systemic therapies. Hence, risk assessment is a complex issue with many related or unrelated prognostic factors determining outcome. The purpose of this volume is to review some of the most relevant prognostic factors of newly diagnosed breast cancer, focusing on fea tures determining the magnitude of risk. The ultimate value of establishing the significance of each prognostic factor in a given patient will be the resulting ability to plan individu alized therapies for patients at different risk of recurrence at the time of diagnosis. To secure the maximum benefit for high-risk patients, while avoiding undue toxicity in those with low-risk lesions, a well-integrated analysis of all known prognostic factors will be essential in the early postdiagnos tic period. In addition to well-established staging criteria such as axillary nodes, tumor size, receptors, scanning and radiographic examinations, the more sophisticated labora tory techniques, as discussed by several authors herein, will playa crucial role in risk assessment. Most of them, - ploidy determination, oncogenes, tumor markers, monoclonal anti bodies, growth factors, etc. -are presently available in only a minority of treatment centers.

The roentgenologic visualization of excretory ducts of a secreting organ is a longe-stablished diagnostic method in roentgenology. For a long time, radiologists have felt the need to establish a method for filling the excretory duct system of the pancreas with contrast material, in the way that intravenous retrograde urography is used to diagnose pathologic changes such as displacement of the renal collecting system or of the urethra. This need to establish a method became more urgent the more the pancreas resisted conventional roentgenologic clinical di- agnostic methods. From time to time in peroperative or postoperative cholangiography mostly incomplete reflux into the pancreatic duct in 10-14% was observed (Stiller, 1948; San Julian und Pascual y Megias, 1952; Wapshaw, 1955; Bergkvist und Seldinger, 1957). However, there was no possibility of obtaining reliable and complete opacification of the pancreatic duct. Peroperative Pancreaticography It was in 1951 when Leger and Arway achieved this goal, though only by surgery. It should be mentioned that, when performing their first peroperative examination, these French surgeons already had the impression, that cannulation of the pancreatic duct was easier than cannulation of the common bile duct. This observation has been con- firmed by hundreds of examinations after ERPC had been established for several years; however, up till now this phenomenon has not been sufficiently explained. During the following years, peroperative pancreaticography develop- ed into a routine examination, above all by Doubilet et al.

Obstetric fistula is as old as mankind. While the incidence has diminished progressively with better health care in Western societies, the situation has changed little in many developing countries. Fistulae of pelvic organs, often monstrous defects, still are a major complication of child-birth causing misery to uncounted young women, and if they cannot find help in one of the very few hospitals with trained specialists, they became urological cripples losing everything: family, home and job. The magnitude of the problem is illustrated by some figures given by Reginald and Catherine Hamlin-about 700 fistula patients treated each year-a total of over 10,000 cases operated upon in their fistula hospital in Addis Ababa, Ethio pia. Most of these injuries could be prevented by better health care at the village level as some studies have shown conclusively. The incidence of fistula is an indicator of the standard of health and obstetrical care. The author of this book-Obstetric Fistula-is an internationally known Australian gynaecologist who for many years has been interested in all aspects of gynaecological urology, especially urinary stress inconti nence, other forms of involuntary loss of urine, and associated gynaeco logical conditions. He has devised a number of new operations to treat pelvic defects. Robert Zacharin's interest in obstetric fistula was a con sequence of his surgical activity in developing countries."