Primary and metastasizing malignant carcinoma of the liv er represent a challenge to both the diagnostician and the therapist. For this reason, it appears a worthwhile task to review the current status of knowledge about the treatment of primary and metastasizing tumors of the liver. The ques tion is whether modem diagnostic methods and new thera peutic concepts can help to improve the prospects of treat ment. Of particular interest is the role played by therapeu tic procedures directly involving the liver. Thus, it is equally important to discuss the pathophysiological and pharmacological bases for a modem therapy concept as it is to consider diagnostic issues and possible definitions of stages of progression. Therapeutic concepts comprise sys temic therapy and organ-related therapeutic methods, in cluding surgical resection, changes in the blood supply, re gional selective chemotherapy, and other localized or regional, highly specialized forms of therapy. This survey of the various possibilities in the field is meant too to stimulate further scientific research, given that methods of treatment are as yet by no means stan dardized, but are still in the stage of clinical research, where experimental models can find an application. The only well-established operative procedure is surgery on the isolated liver tumor. In this area, specialized techniques and various intraoperative procedures are discussed. There is a wealth of information available on all the top ics covered."

A thorough knowledge of normal radiological anatomy is necessary for detection and evaluation of pathological changes. In pediatric radiology, normal anatomy and normal proportions of anatomical structures may differ considerably from the adult, and may vary during growth. Therefore, in pediatric radiology there is a multitude of measurements, that in the individual patient is important, but that for the radiologist is not meaningful or even possible to keep in mind. This holds true both for the experienced pediatric radiologist, and for those who practise pediatric radiology only occasionally. This volume is written for both categories. In the literature, normal values are calculated and presented in many different ways, that are not always easy to compare, or easy to use in daily work. Therefore, we have revised and recalculated the data given by authors, in order to present the statistical upper and lower normal limits as between plus and minus two standard deviations (+/- 2SD). This means that about 2% of a normal population will be assessed as abnormally large and around 2% abnormally small with respect to the parameter assessed. In this way, the presentation throughout the book is uniform, and hopefully easy to use. All figures have been redrawn and computed in an attempt to make them as clear as possible.

If a consecutive series of patients with lung cancer is followed up until the decision is made about therapy, it emerges that the role of surgery is quite small. Only a very limited proportion will ultimate ly qualify for rationally conceived surgical therapy; most patients are inoperable. In a series of 397 patients investigated at our hospi tal, 78% were inoperable on the basis of preoperative evaluation and a further 3% proved nonresectable at thoracotomy; therefore, only 19% were suitable for resection. On the other hand, surgery is still thought to offer the best, if not the only realistic chance of cure. The question "operable or not?" is therefore of vital importance for the individual patient. The answer to this crucial question must be based on valid guidelines for pa tient selection and preoperative evaluation, and it should be clearly defined what extent of resection is necessary in order to realize any curative intention. In 1972 a thorough analysis of the literature revealed that re section of bronchial carcinoma - although 40 years old - was being undertaken with very variable indications. There was hardly any systematic staging, and assessment of results was hampered by the fact that most communications in the literature were based on retrospective analysis.

Technical improvements over the past twenty years have made endos copy the procedure of choice for examination of the hollow organs of the genitourinary and gastrointestinal tracts. The development of electro surgical techniques, laser technology, injection therapy, and a wide variety of other modalities now allow the endoscopist to treat many problems that in the past required open surgery. The simultaneous development of transcutaneous abdominal sonography has had an equally dramatic impact on the practice of gastrointestinal and geni tourinary surgery. The marriage of these proven technologies, known as endoscopic sonography, provides an exciting new modality that promises to further revolutionize the diagnosis and management of many intraabdominal diseases. Endoscopic sonography opens new frontiers by overcoming the primary limitations of its parent technologies. Fiberoptic endoscopy is limited by the inability to see beyond the luminal surface, this is particularly important when considering neoplastic disease because depth of wall invasion is a key factor in determining treatment. The limiting factor in transcutaneous sonography is the distance between the transducer and the target organ. With endoscopic sonography, the transducer is placed in close proximity to the target organ. This allows the use of high frequency waves (greater than 5 MHz), which provide better tissue resolution and eliminates the image distortion caused by overlying structures.

This book has been conceived as a reference for all those who want to deepen their knowledge of technical details, design concept and interac tion of the individual modules of Zeiss operation microscopes. The sub jects of the book are classified in accordance with our intention. Special emphasis has been placed on practical hints for the user of opera tion microscopes to avoid operating errors. Parameters which are of para mount importance for surgeon and assistant such as PD and diopter set ting are therefore described in detail. The effects of wrong adjustments are indicated. The above statements also apply to the ample selection of acces sories for Zeiss operation microscopes. That is why much attention has been given to the accessories for co-observation and documentation. The most frequently used formulae are liste in the last chapter of the book, supplemented by nomograms which allow the reader to determine the most important data of a specific piece of microscope equipment without calculation. Our thanks are due to all those who assisted in preparing the manuscript, drawings and photographs, to Mrs. Ursula Gabler for making the English translation and Miss Helen Robertson for editing it, and last but not least to the Springer-Verlag for the most careful, qualified and excellent pro duction of the book."

The interrelated syndromes of shock and the adult respiratory distress to attract the attention of both clinical and syndrome (ARDS) continue laboratory scientists. This reflects both the size of the problem and its unresponsiveness to current lines of treatment. Doubtless, a greater appreciation of the underlying pathophysiological disturbances during the past two decades has led to appropriate action and increased survival in the early stages but once established these syndromes have remained remarkably immune to a wide spectrum of therapeutic modalities. This observation stresses the importance of prevention but also indicates the need for continued research into the nature of the established syndromes and the means whereby they may be reversed. Drs Kox and Bihari are to be congratulated on bringing together within the covers of this volume many of the acknowledged European experts in these two fields of investigation. Each author has provided an up-to-date account of his current experimental and clinical research, and their com bined contributions makes fascinating reading. Undoubtedly, these are exciting times in the development of understanding of shock and ARDS. Inevitably, more questions are raised than answers provided, but the accumulated knowledge presented here adds significantly to our under standing of this complex biological jigsaw. From this corporate endeavour will come the clinically useful developments of the future and with them the ultimate hope that the term 'refractory' shock may be finally removed from our vocabulary.

This monograph, which was more than five years in preparation, represents a very detailed account of pheochromocytoma, a tumor that is almost invariably lethal if untreated. In addition to its definitive presentation of the subject, this volume contains the most cur rent information regarding the diagnosis and management of pheochromocytoma. It is im portant to reemphasize the seriousness of diagnosing and treating pheochromocytoma with the aphorism of Esperson and Dahl Iversen that although a pheochromocytoma may be morphologically benign it is physio logically malignant (280) and with Aranow's characterization of this tumor as a "veritable pharmacological bomb" (20). If managed ap propriately by a highly skilled and profes sional "bomb squad," this tumor can be re moved and the patient cured in at least 90 percent of cases. The secret lies in first sus pecting and recognizing the patient who has and then offering the ex pheochromocytoma pert management such a patient requires. These facts more than justify this publication, since the internist, pediatrician, obstetrician, ophthalmologist, otolaryngologist, urologist, neurologist, surgeon, anesthesiologist, derma tologist, psychiatrist, radiologist, and also the dentist must be made acutely aware of the varied manifestations of this condition and of the pathologic entities which sometimes co- xiv Preface exist with pheochromocytoma. Furthermore, have included a large number of instructive they should have a thorough knowledge of the figures and have emphasized teaching tables."

Over the past few years, a wealth of new insights have been gained and put to use in basic gastrointestinal tumor research, including tumor suppressor genes, oncogenes, cell-cycle con- trol, apoptosis, adhesion receptors, signal transduction, and gene therapy. Similarly, progress has been made in preven- tion, molecular diagnosis, laparoscopic staging, and antibody- based immunotherapy, and new drugs such as thyrnidylate and topoisomerase I inhibitors have been developed espe- cially for the treatment of colorectal carcinoma. Despite this burgeoning of knowledge in both basic and clinical research, however, we have just begun to put these results into clinical practice. Therefore, the key goal of this volume is to bring together basic and clinical research findings so as to facilitate the translation of these advances into the clinical manage- ment of gastrointestinal tumors. We hope that this volume, which covers a broad spectrum of research and clinical medicine, will impart new insights and greater understanding to all those interested in the therapy of gastrointestinal tumors and will stimulate further scientific research. Berlin, January 1996 E. D. Kreuser P. M. Schlag Contents 1 I. Basic Research S. J. Meltzer The Molecular Biology of Esophageal Carcinoma 1 E. R. Greenberg Preventing Colorectal Cancer...9 M. Streit, R. Schmidt, R. U. Hi/genfeld, E. Thiel, and E. -D. Kreuser Adhesion Receptors in Malignant Transformation and Dissemination of Gastrointestinal Tumors...19 R. Kaiser, E. Thiel, and E. -D. Kreuser Human Gene Therapy in Gastrointestinal Diseases: In Vivo and In Vitro Approaches ...

This book is a unique work devoted to the subject of disordered defaecation. It contains chapters written by experts in the field of ano-rectal physiology and management of disordered defaecation. The various contributions present personal views and special clinical experience of individuals. There are some personal views which we felt should be commented upon and a few areas where the experience of others has been included into the text. For the sake of completeness of each chapter, a slight overlap in some cases was inevitable. We hope the book will serve as a useful collection of opinions on a subject which until recently has been largely ignored by the medical profession. The editors Major contributors H. O. ten Cate Hoedemaker Department of Surgery, University Hospital, Rijnsburgerweg 10,2333 AA Leiden, The Netherlands G. Coremans Department ofInternal Medicine, University Hospital Gasthuisberg, Here- straat 49, 3000 Leuven, Belgium S. Fasth Department of Surgery II, Sahlgrenska Hospital, S-413 45 G6teborg, Swe- den H. G. Gooszen Department of Surgery, University Hospital, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands J. A. Gruwez Department of General Surgery, University Hospitals KU, Brusselsestraat 63,3000 Leuven, Belgium M. M. Henry Department of Gastroenterology, Central Middlesex Hospital, Acton Lane, London NWlO 7NS, United Kingdom M. R. B. Keighley Department of Surgery, The General Hospital, Steelhouse Lane, Bir- mingham B4 6NH, United Kingdom J. H. C. Kuypers Department of Surgery, University Hospital St. Radboud, Geert Groote- plein Zuid 14,6500 HB Nijmegen, The Netherlands Ph. B.

The Medicines Act 1968 together with its delegated legislation comprehensively controls the manufacture, packaging, labelling, distribution and promotion of medicines for both human and animal use in the United Kingdom. It also controls the import and export of such medicines. It replaced a patchwork of controls which evolved over a century. Since its enactment, more than 150 items of delegated legislation (orders and regulations) have been made under its provisions and about 130 are still operative. The sheer physical bulk of this mass of material causes difficulty, not only in comprehension but also in finding the detail so often required. The situation is exacerbated by the fact that some pieces of legislation have been amended several times. My principal aim is to provide a reference book which contains all of the provisions of the Act and its various orders, regulations as amended to date. The material is arranged to facilitate the search for detail. In order to assist the reader in finding his way through this maze, Chaper 1 consists of a survey of the situation which existed before the Act came into being, together with a synopsis of the present controls. This should enable the reader to appreciate the changes which have occurred and how the system works.

The first edition of Surgery of the Hip Joint has had certain measures of success. Its cover won the Outstanding A ward for art at a publishers trade show. A year later it was translated into Spanish for exposure to the vast world of the Spanish speaking peoples. As I traveled through Europe, it was repeatedly a pleasant surprise to have the book recognized as an authoritative reference. This was a great tribute to the experts whose diligent efforts made it all possible. Apparently the book has stood the test of time to judge from the many inquiries and constructive comments made toward urging us on to write a second edition. It was not an easy task to gather another cadre of authorities to update our knowledge of the hip joint. People who have earned respected positions in their field are unavoidably burdened with a busy schedule, so a chapter in this text must be appreciated as coming from someone devoted to giving up some of his precious time for the sake of sharing his knowledge with peers and students. As we struggled along, it became obvious that the book should be divided into three volumes, because outdated concepts had to be scrapped if an up-to-date text were to be offered. Time passed so rapidly that total hip arthroplasties would not become stabilized because of a never-ending parade of implant designs with increasing bioengineering considerations.

For a long time, approximately since Oberlin and Guerin described the multifocal origin of pancreatic cancers and precancerous pancreatic lesions, no important study dealing with the entire subject of pancreatic cancer has been published in France and probably in the international literature. For some decades the knowl- edge acquired 40years or more ago was not improved appreciably, though the fre- quency ofthe disease started to increase in occidental countries. This has recently changed, and the progress ofthe medical sciences has spread to the pancreas. Although the surgical or medical prognosis of the most frequent form of pancreatic cancer, exocrine adenocarcinoma, remains very bad, recent studies have shown the multiplicityofits pathological forms, some being less severe so that curative surgery is possible. New experimental models, particularly in the hamster, and the use of carcinogenic drugs allow experimental studies on lesions similar to those in man. Oncologic immunology is still at its beginnings but shows promise for diagnosis and treatment. Though modem techniques of imaging - sonography, aspirative cytology, CT scan, endoscopic catheterism, arteriography, and maybe in the future nuclear magnetic resonance - have not yet significantly in- fluenced prognosis,they have made the diagnosis easierand more precocious. Yet in a diseasethat diffuses so rapidly to deep lymph nodes, it has not been proved whether early diagnosis can improve prognosis.

Preclinical experimental transplantation research that is based on microsurgical models in rats fulfills two indispensable conditions for modern organ transplanta tion research: Almost all organ grafts can be performed on the rat with an amount of technical effort that is still justifiable. Thus transplantation models that are analogous to human organ transplantation can be developed, tested, and evaluated. This fulfills a necessary condition from the standpoint of surgery. With the species rat, we have a great variety of genetically different inbred strains. From the immunological point of view this is an indispensable prerequisite for the investigation of preclinical transplantation models that can be expected to produce controllable, reproducible results. In vivo experimental results can be supplemented by and correlated to in vitro tests. Lately these experimental results are being greatly expanded and more precisely defined by the application of immunohistological methods that have been established recently in Kiel. In this book we hope to present a cross section of the microsurgical models in use today and of current immunological and immunohistological models. Furthermore, we wish to record the present state of microsurgical organ transplantation research and to show its relationship to the current state and development of clinical organ transplantation. A special aspect of our Kiel research group is the long-term, well-functioning, interdisciplinary cooperation between surgery, immunology, and pathology. Through this cooperation we attempt to provide an atmosphere in which theoretical and practical viewpoints can mutually influence each other."

There has been incredible progress over the last decade in therapeutic endoscopy. Such therapies are either easier now than ten years ago or are possible when previously they were inconceivable. These advances have depended upon major improvements in diagnostic endoscopy for different subspecialties. Simultaneously, a major innovation for therapeutics through endoscopes is the application of medical lasers. This book is written by renowned biophysicists and laser endoscopists of different sub specialties where the application of lasers has revolutionized medical care. In some cases treatments which were not previously possible are now routine. Laser palliation of obstructing tumors in different sub specialties is an example of this. In other cases, resective surgery is obviated by the application of lasers via endoscopy such as for the control of gastrointestinal bleeding. The authors of different medical or surgical subspecialties which use endoscopic lasers write about the pathology and clinical problems, their personal experience and results. However, they also emphasize their techniques of laser endoscopy through case examples, technical discussions, and colored illustrations. Their discussions will give the reader a better understanding about the role of laser treatment of different conditions compared to routine medical or surgical therapy. In several instances, randomized controlled trials involving medical lasers were discussed in this book because they fundamentally changed our understanding of common problems such as upper gastrointestinal bleeding. We predict continued progress in therapeutic endoscopy.

An International Conference on "Neurosurgical Training and Reserach" was held in Munich from October 6 - 9, 1996, under the auspices of the EANS, and organized by H.-J. Reulen and H.-J. Steiger. Experts from different countries and neurosurgical organizations have collected information on the present status of resident training in neurosurgery and the mechanisms involved with the training. Various aspects, the recruitment process, the criteria used for selection, the contents and structure of a program, the continuous quality control, exposition to the art of research, fellowships and subspeciality training, etc. have been covered. The present book contains this material and thus provides a unique and comprehensive source of information on the complex of modern neurosurgical training. " ... The beauty of this work is that it puts in one place the many varied aspects of a neurosurgical training program that one needs to be aware of ... should be required reading for the faculty of any academic training program as well as for others who may have a misconception of what residency training is ... an excellent book for any program director or active faculty member. It should be required reading for all faculty members before the next round of resident interviews ..." Neurosurgery "... well edited, published to a high standard and will naturally be of interest to those specifically involved in the areas of selection and training ... a useful text for aspirants to surgical training posts ..." British Journal of Neurosurgery

Bone Metastases brings together the many recent developments that are gradually improving the prospects for patients with secondary involvement of the skeleton in a primary cancer elsewhere. The morbidity from bone metastases is extensive, and the palliative and supportive treatment that sufferers require for many months or even years constitutes a major health problem. A multidisciplinary approach is essential since a variety of specialists are involved: radiation and medical oncologists, general and orthopaedic surgeons, general physicians, radiologists and nuclear medicine physicians, symptom control and terminal care specialists. The book's editors, themselves authorities in the fields of oncology and bone disease respectively, have brought together experts from all these disciplines to provide comprehensive coverage of metastatic bone disease. They cover the biology and pathophysiology, hypercalcaemia, imaging, assessment of response to treatment, types of treatment (systemic, radiotherapy, surgery), and symptomatic and supportive care. Particularly new approaches included are magnetic resonance imaging, the assessment of skeletal response and isotope therapy.

Endoscopic Sinus Surgery examines the surgical techniques for tackling nose and sinus disease. With the advent of multi-angled endoscopes, better optical instruments and imaging techniques, the impact of endoscopic sinus surgery has been greatly increased in recent years as it considers the problem at its root cause. The book combines a clear, practical text with extensive visual material and many colour illustrations. All aspects of functional endoscopic sinus surgery are covered including an assessment of the technique and a detailed account of both morbid and endos copic anatomy which are important to an understanding of the techniques involved. Post-operative care, complications (and how to avoid them) and radiology of the sinuses are also covered. This is an accessible and practical book for the novice which will broaden diagnostic skill and improve patient care. The many tips included will also aid established surgeons.

This volume describes a new direction in technological and biomedical developments for profoundly deaf individuals. The first section covers topics of tissue characteristics, such as responses to electrical stimulation and computer modelling of cochlea currents. Perception of acoustic signals, responses and behavioral pattern as well as psychophysical aspects are treated in the second part. Part III is addressed to perspectives and challenges of encoding schemes. Reports on studies of acoustic and electrical encoding of temporal information, speech features with cochlear implants as well as psychophysical and speech perceptual studies will allow further strategies for cochlea implants.

Posttraumatic cerebral contusions, lacerations and hematomas in the past could often only be suspected by clinical symptomatology and be visualized by angiography in a restricted manner, but they are now diag nosed with precision through CT and MRI; they remain in the limelight in our daily management of severe head injuries. Stalhammar's longlasting research in biomechanics is he re condensed in a concise review of the current knowledge in this field, thus providing the basis for our understanding of the parenchymal cerebral posttraumatic lesions. The neuropathological investigations and findings remain fundamental to the clinical features, and in this text there is the advantage that they were carried out and interpreted by a very experienced neurasurgeon, Ion Oprescu, who most regretfully died before the completion of this volume. The special morphological and clinical investigations by Nakamura, concerning diffuse brain injury, contribute to our necessary diagnosis and treatment of this phenomenon where, without grass visible lesions of cerebral tissue, a high mortality occurs. The clinical features, the princip1es of therapy and the outcome are described by Vigouroux and Guillermain, whose clinical study clearly demonstrates the limitations of all our efforts in severe brain injuries, in spite of decades of clinical experience and research."

Recent Advances in Coloproctology provides a thorough overview of modern developments in the surgical treatment of disorders of the lower intestine including ulcerative colitis/severe acute colitis, Crohn's disease, carcinomas, haemorrhoids and anal incontinence. Recognizing that the surgeon does not work in isolation, the book also integrates recent progress in imaging techniques for the anal canal and rectum, and highlights medico-legal considerations in separate chapters. Aimed at current practitioners and trainees, Recent Advances in Coloproctology discusses key concepts that will assist general surgeons and colorectal consultants in their management of patients with a broad spectrum of anorectal and colonic disorders. With a problem-oriented slant, this book is essential reading for all those with interest in coloproctology.

Modern surgical oncology is characterized by multimodal therapy. In recent years numerous therapeutic approaches of pre-, peri-, intra-and postoperative treatment have been in vestigated with regard to their use in combination with surgi cal intervention. It now is time to analyze and to define the state of our knowledge. For tumors of the gastrointestinal tract there are several encouraging therapeutic approaches, such as preop erative chemotherapy in esophageal and perioperative chemotherapy in colon cancer. For some special tumors, like anal carcinoma, we have clearly defined combined therapies which even now must be viewed as standard treatment. It is also time to demonstrate the results of several clini cal studies that have been conducted within the last few years that combined surgical efforts with pre- or postinter ventional chemotherapy or radiotherapy. It is necessary to evaluate whether these trials contribute to progress in onco logical therapy. The editors of this volume - surgeons at the university hospitals of Heidelberg and Zurich - must be given the mer it of achieving these goals. It was especially appropriate for the Department of Surgery in Heidelberg, in close coopera tion with the Comprehensive Cancer Center Heidelberg/ Mannheim, to prepare a review of our present knowledge of surgical oncology as it is in the tradition of attempting to combine different therapeutic approaches to cancer therapy.

The European School of Oncology came into existence to respond to a need for information, 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 multidiscipli nary approach which is difficult for the Universities 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, monoclonal 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 on cology."

Cancer is one of the major health problems of our time and liver cancer is responsible for over one million deaths per year world-wide, making it the fourth most common cause of death from cancer. Surgical resection of the tumour(s) is the treatment of choice and offers the only chance of prolonged survival. Yet the best attempts are often frustrated by either advanced or co-existent disease that renders the patient non-resectable. This book tackles the many options available to doctors and patients in an attempt to combat this desperate disease.

The result of a European-American co-operation, whose joint efforts have dramatically reduced the rate of recurrent groin hernia, burst abdomen and incisional hernia in patients.
The contributors to this updated volume are among the most renowned specialists in the field and here they present personal accounts of the once controversial techniques they have now perfected.
New sections have been added to include such revolutionary techniques as prosthetic mesh and laparoscopic surgery.