J. Navratil The performance of operations on the heart and its replacement by a trans planted or artificial heart has been an age old dream of man. Rehn for example in an early attempt, in 1868 performed a closure of a heart wound after a thoracic puncture. At that time noone thought that this attempt was the beginning of cardiac surgery. The dream was partially realized when the replacement of the heart function by the heart-lungmachine became possible. Immediately following the first operations, cardiac surgeons and cardiologists saw with great enthusiasm that this machine could be an important tool for correcting congenital and non congenital heart diseases. However, the heart-lungmachine was soon seen to not be an optimal instrument for controlling cardiac failure after cardiopulmonary bypass or myocardial infarction. then arose for the development of mechanical assistance to the heart. Concepts The rollerpump was first designed for assisted circulation and could be applied clinically in 1962. A new concept of mechanical assistance to the heart was pro vided by the intra aortic balloon pump and later by the bypass ventricles. Use of the intra aortic balloon pump can reduce cardiac work by counterpulsation in accord with the natural ECG. The bypass ventricle can functionally replace the heart in series or parallel to the natural heart. The intra aortic balloon pump, now an established method, has reduced the number of patients who used to die from cardiac failure."

Ultrasonic surgical techniques were first used by Dr. Kelman in the 1960s to fragment cataracts through a 2-mm incision allowing for minimally invasive surgery. The results from this procedure stimulated the development of a larger, move powerful ultrasonic unit that was used in neurosurgery. This instrument allowed the neurosurgeon to selectively remove tumor tissue with decreased blood loss and tissue trauma. The ability now of ultrasonic equipment to selectively fragment, irrigate, and aspirate tissue with minimal coagulation effect spurred its rapid use in surgery on the liver, spleen, kidney, and other intra-abdominal organs. This instrument has been invaluable in ovarian cancer cytoreduction and intricate segmental organ resection. The newest technical developments include electro cautery capability built into the hand piece and extended hand pieces for laparoscopic surgery. The impetus for assembling this volume has been to provide an extensive review of the field of ultrasonic surgery as it has currently developed including principles, equipment features, and surgical tech niques. It is hoped that the information will be of use to physicians in training and surgeons in practice. The book takes a multidisciplinary approach with chapters authored by a diversity of subspecialists in gen eral surgery, urology, surgical oncology, and gynecologic oncology. Each chapter contains basic information on surgical techniques. Together, these chapters cover surgery of the GI tract, kidney, liver, and lower genital tract, and present a number of personal approaches."

All general surgeons, and especially hernia surgeons, will benefit from this book. It contains a complete update on the research and pathogenesis of the incisional hernia. The volume describes all important diagnostic and therapeutic procedures and evaluates the appropriate use of each procedure for each particular case. Pitfalls and unresolved issues are discussed in depth, and experts of international standing weigh in on each topic.

This volume has been written specifically for the practising clinician. All aspects of clinical transplantation have expanded enormously in recent years, but many of the doctors involved have received little or no tuition in immunology as medical students. The various chapters, written by physicians, surgeons, pathologists and immunologists present many of the currently important issues in transplantation and demonstrate that a basic undertaking of immunology is now essential in many areas of clinical practice. Perhaps this book will not only produce an increasing awareness of immunological technique but also and, more importantly, stimulate an abiding interest in this clinically relevant topic. Graeme R. Catto Aberdeen Royal Infirmary vii Series Editor's Note The modern clinician is expected to be the fount of all wisdom concerning conventional diagnosis and management relevant to his sphere of practice. In addition, he or she has the daunting task of comprehending and keeping pace with advances in basic science relevant to the pathogenesis of disease and ways in which these processes can be regulated or prevented. Immunology has grown from the era of antitoxins and serum sickness to a state where the study of many diverse cells and molecules has become integrated into a coherent scientific discipline with major implications for many common and crippling diseases prevalent throughout the world.

Surgical Diseases of the Spleen written and edited by internationally renowned scientists will be a masterpiece for any institution. It provides an updated multidisciplinary review of diseases of the spleen. Experts in the field have customed their chapters to further ease the readers understanding offering all the information needed to progress in this area. Different sections on basic concepts, specific splenic diseases and operative techniques cover new aspects in immunology, infectious, traumatic and neoplastic conditions.

Rectal cancer is a major killer. Most of those dying after curative surgery suffer from recurrent disease in the pelvis. Local recurrence is also the only site of failure in up to 50% of patients. A disturbing fact is that the local recurrence rate shows considerably surgeon-related variances. There is now strong evidence that optimizing surgical technique by adopting the principle of total mesorectal excision (TME) will reduce local failure rate, increase the use of sphincter-saving operations, and improve functional results. Surgeons applying this surgical principle will consistently achieve similarly low recurrence rates.

Where do you begin to look for a recent, authoritative article on the diagnosis or management of particular malignancy? The few general oncology textbooks are generally out of date. Single papers in specialized journals are informative but seldom comprehensive; these are more often preliminary reports on a very limited number of patients. Certain general journals frequently publish good in-depth reviews of cancer topics, and published symposium lectures are often the best overviews available. Unfortunately, these reviews and supplements appear sporadically, and the reader can never be sure when a topic of special interest will be covered. Cancer Treatment and Research is a series of authoritative volumes which aim to meet this need. It is an attempt to establish a critical mass of oncology literature covering virtually all oncology topics, revised frequently to keep the coverage up to date, easily available on a single library shelf or by a single personal subscription. We have approached the problem in the following fashion. First, by dividing the oncology literature into specific subdividions such as lung cancer, genitouri nary cancer, pediatric oncology, etc. Second, by asking eminent authorities in each of these areas to edit a volume on the specific topic on an annual or biannual basis. Each topic and tumor type is covered in a volume appearing frequently and predictably, discussing current diagnosis, staging, markers, all forms of treatment modalities, basic biology, and more."

J. E. Fischer, M.D. Professor Greep, ladies and gentlemen. It is a great pleasure for me and the participants to be present at this International Meeting of Parenteral Nutri tion. This meeting would not have been possible five years ago. At that time we were still arguing about central vs. peripheral routes, efficacy of the tech nique, and still getting accustomed to our ability to support patients nutri tionally. Within the last five years these discussions, which seem almost futile in retrospect, have been put aside. Both techniques, we know how, work quite well and have their own indications. Having become comfortable with the technique, it is now time to enter the second phase of parenteral nutrition, and that is the differentiation of the technique for the benefit of different patients. Over the next two days we will be discussing several problems which at the present time are central to the entire subject of parenteral nutrition. Is a fat calorie the same as a carbo hydrate calorie? What is the effect on protein metabolism of the fat calorie as opposed to the carbohydrate calorie? Are they equivalent? Are'there situations in which one is superior to the other? Perhaps we will find out tomorrow in the panel."

by Dr. Nathaniel R. Bronson, 11 This volume serves a two-fold purpose very nieely. For the ophthalmologist there is a presentation of the teehniques and results of ultrasonie examination of the eye and orbit. For the radiologist or general ultrasonographer the essential oeular anat- omy and pathology are deseribed with these findings. Unlike eon- ventional x-rays or statie general body ultrasonograms, the exami- nation of the eye by real-time ultrasonography must be done by an examiner with extensive personal knowledge of the eye and the orbit, both anatomieally and pathologieally. The student must realize that the Polaroid photographs ean only show an example of what was transiently seen, such as spot films taken during fturo- seopy. This is further eomplieated by the poor reproduetion by Polaroid films of the aetual gray sc ale seen during the examination. Considerable work has been done to prepare this text. The author has done elinieal ultrasonography of many eyes and presents the findings of his experienee. As in most fields of medieal diagnostie work this experienee is essential to aehieve the best results. The beginner in ophthalmie ultrasonography is eneouraged to work with known pathology. Fortunately, pathologie ehanges in the eye vii FOREWORD can frequently be seen with a slit lamp or an compared our ultrasonic diagnosis of orbital ophthalmoscope. For example, a known retinal masses with those of the same patient done on a detachment is an ideal case with which to start. CAT scanner.

New surgical techniques for the treatment of anal incontinence have given the increasing number of afflicted patients hope for a cure. Colorectal surgeons and more and more general surgeons are performing operations, yet until now they have not had a text that they can use as a reference work. The guidance and instruction that surgeons need are now available in this atlas. It describes every operation in technical detail, and the two-color illustrations clearly show the essential points of each procedure. The authors discuss thoroughly the indications for surgical treatment, its application to the individual patient, and post-operative care. The comprehensive scope of this book makes it a rich source of information for surgeons working outside highly specialized centers. For specialists, it is the only practical reference available on the subject.

This RRCR-conference-volume marks "number six" in a 20-year evolution of international conferences on the adjuvant therapy of primary breast cancer. Starting in 1978, a handful of some 80 en thusiastic breast cancer surgeons and oncologists, met in a se cluded mountain resort near st. Gallen in Eastern Switzerland, to exchange their early data of some pioneer trials on adjuvant sys temic therapy of early breast cancer, and to correlate their future research efforts to overcome the frustrating prognostic stagna tion of this dominant neoplastic disease in Western females dur ing the past decades. Repeated every 3-4 years, these St. Gallen International Conferences on Adjuvant Therapy of Primary Breast Cancer have continuously grown in numbers of partici pants and in normative, therapeutic influence by being published in major oncology journals 1-3], the last (6th) conference hav ing taken place from February 25-28, 1998 with more than 1800 attendees from over 50 countries worldwide. What is the fascination of adjuvant therapy in primary (early) breast cancer, and what has changed, during the last 3 years since March 1995, to justify another international gathering of this size, and of the world's leading experts in the field? There is no question, that providing even more effective care and designing appropriate recommendations for the multitudes of patients with so-called early breast cancer or at high risk of developing the disease, remain highly important public health goals."

One of the first applications of lasers was for surgery on the retina of the eye. That, and the evident analogy to the old dreams of powerful heat rays, led many to predict that lasers would quickly be used for all kinds of cutting and welding, including surgical applications. It was soon apparent that laser sur gery could be performed in ways that caused little bleeding. Nevertheless, other surgical applications have been slower to arrive. One difficulty has been the enormous range of possibilities provided by the many different kinds of lasers. Infrared, visible, and ultraviolet light beams each interact very differently with human tissues. Light pulses of enor mously great peak powers became available from lasers, but their effects dif fered in surprising ways from those obtained with continuous beams. That provided both opportunities (i.e., treating or removing a very thin surface layer without affecting the underlying tissue) and problems with undesired side effects. Moreover, techniques were needed to deliver a precisely con trolled amount of energy just where it was desired. Lasers also had to be engineered and manufactured with the desired power levels and a high reliability."

It gives us great pleasure to contribute a short introduction outstanding book. This comprehensive work provides an to this important volume. immense fund of information, and will be an invaluable The transplantation of thoracic organs - heart, heart source of knowledge to physicians, surgeons, and scientists lung, lung - is a field of surgery that is expanding annually. for many years to come. The use of mechanical assist devices and artificial hearts to support patients awaiting transplantation is also developing rapidly, and further advances in this field may eventually April 1990 Christiaan Barnard lead to a totally implantable device that will function Cape Town, South Africa successfully for many years. It is therefore timely that such a volume as this should be made available to those who wish to be brought up-to date with the current state of knowledge in these related fields. The editors have done us all a great service in bringing together experts in every aspect of heart and Nazih Zuhdi lung transplantation and replacement to contribute to this Oklahoma City, USA Xl Preface The fields of the transplantation and replacement of thoracic Refinements in bioengineering have enabled mechanical organs have expanded immensely since the first human assist devices and the total artificial heart to support patients to-human heart transplant was performed in 1967. This successfully until a suitable donor becomes available."

Cyclosporin has had a remarkable effect on clinical organ transplantation. Prior to its introduction, considerable advances had been made in the grafting of vital organs, particularly the kidney, heart and liver. In many developed countries, however, transplantation was not considered wo-rthwhile in terms of gain for the investment of resources. The improved results of kidney grafts following the use of cyclosporin has changed this attitude. For all types of organ transplantation, cyclosporin has resulted in an improvement of functional graft survival and has allowed a reduction in steroid dose and, in some cases, no steroids at all. It has permitted the first successful experimental transplantation of the heart and lungs in primate species by Reitz and colleagues and their results were applied directly to the clinic. It was largely due to the introduction of cyclosporin that the Washington Consensus Meeting on Liver Transplantation came to a favourable recommendation and the result has been the proliferation of units performing liver transplantation, approximately fifty in North America and another fifty in Europe, where previously there had been a handful. Having been involved in cyclosporin for organ grafting from the beginning, I have been able to witness these developments which have far exceeded my expectations once the nephrotoxicity of cyclosporin was demonstrated in man. It is fitting that Dr.

In recent years, a series of excellent textbooks have been published dealing with pathology of the thyroid gland. The present volume of CURRENT TOPICS IN PATHOLOGY provides further information for both pathologists and clinicians interested in the thyroid gland. The contributions deal with surgical pathology of the thyroid as well as with basic aspects of thyroid metabolism, hormone transport, and growth factors in thyroid cells. The topics covered in this book should mainly be considered as adjuncts to common textbooks on thyroid pathology. The contributions should help pathologists in their routine diagnosis and should stimulate further thyroid research.

The aim of computer-aided surgery (CAS) is to advance the utilization of computers in the development of new technologies for medical services. The Asian Conference on Computer Aided Surgery (ACCAS) series provides a forum for academic researchers, clinical scientists, surgeons, and industrial partners to exchange new ideas, techniques, and the latest developments in the field. The ACCAS brings together researchers from all fields related to medical activity visualization, simulation and modeling, virtual reality for CAS, image-guided diagnosis and therapies, CAS for minimally invasive intervention, medical robotics and instrumentation, surgical navigation, clinical application of CAS, telemedicine and telesurgery, and CAS education. The ACCAS is also interested in promoting collaboration among people from different disciplines and different countries in Asia and the world. This volume helps to achieve that goal and is a valuable resource for researchers and clinicians in the field.

Strain Measurement in Biomechanics will provide a valuable reference source for all research workers in biomechanics and biomaterials as well as orthopaedic manufacturers and orthopaedic surgeons.

For many years, patients who complained of prostatism had only a few treatment choices. The patient was either a candidate for an elective prostatectomy, or the operation was deferred until the patient became more symptomatic. The present text summarizes the multiple options which have become available to the practicing urologist. Minimally invasive techniques such as transurethral incision of the prostate, balloon dilatation, hyperthermia, laser therapy, and prostatic stents are described. Medical treatment with alpha-blockers, 5 alpha-reductase inhibitors, and flutamide are addressed by authors who have had extensive clinical experience with the use of these agents.

As recently as 20 years ago, ceramics were widely ignored as potential biomaterials. Interest in bioceramics has increased dramatically over the past decade to the point where it is anticipated they will be the materials of choice for many orthopedic, otologic, maxillofacial and dental applications during the decade of the '90s. Alumina ceramics are being used extensively as articulating comJ1onents in total joint prostheses because of Ithe materials low coefficient of friction and excellent wear resistances. Alumina ceramics are also being used in dental and maxillofacial applica tions because of the materials excellent biocompatibility. Because of its ability to chemically bond to bone, hydroxyapatite is rapidly becoming the material of choice for many dental and maxillofacial applications. For the past decade, one of the most widely researched topics in the field of orthopedics has been the clinical evaluation of joint prostheses based upon stabili zation via tissue ingrowth. It appears that the next generation of joint prostheses will be based upon direct chemically bonding to bone using hydroxyapatite, surface-active glass or surface-active glass ceramics coatings. Resorbable bioceramics are limited to temporary bone space fillers, periodontal pockets treatment and resorbable pharma ceutical delivery systems. Bioceramics is a comprehensive reference textbook covering the history of bio ceramics, present status of bioceramics, and prediction for future use of bioceramics. This book will serve as a major reference for students, as well as experienced bio material researchers. The book presents the state-of-the-art of bioceramics as of 1991."

R. Y.Calne Surgeons are transplanting kidneys in ever increasing numbers-more than 10000 renal allografts have now been reported to the Transplant Registry. With related donors 75% of grafted kidneys continued to function after 2 years, compared with 50% when the donors were unrelated. The therapeutic value is obvious, but the management is largely empirical and results have improved little in the past 5 years. The basic sciences related to tissue transplantation have advanced rapidly. New serological and tissue culture techniques and chemical analysis of antigens and anti bodies have produced complicated data that is almost incomprehensible to the non specialist. Mathematical treatment of genetic probabilities and of immunological kinetics are similarly difficult to follow for those not especially trained. There has always been a gulf between the practical clinician whose patients do not behave like inbred rodents and the biologist who likes carefully controlled experiments with easily observed results. Both realize, however, that predictable and safe control of rejection must involve close collaboration and co-operation between the laboratory and the clinic. Unfortwlately, the different nature of the work and the workers has widened the gap between them. The clinicians tend to improve their techniques and patient care, whilst the biologists seek clearer and more precisely deflned experi ments which lead them to use increasingly artiflcial experimental models."

Nutritional support of critically ill patients is a major treatment modality which will enhance recovery and shorten convalescence. New knowledge has emphasized that much of the organ dysfunction associated with sepsis and altered blood flow is related to oxidative injury. Specific nutrients are highly effective in counteracting these effects and their early administration may attenuate cellular damage and multi-organ failure. Patient outcome may also be enhanced by the route of feeding, administration of newer nutrient combinations, utilization of evolving methods of monitoring and the use of growth factors. This new knowledge has evolved to a new area of metabolic support which is addressed for the first time by a group of international experts. The topics presented and general conclusions are of major importance to the practitioners in this field, for they show, for the first time, a departure from the more traditional approaches of nutritional support in patients with life-threatening diseases.

Dermatosurgery cannot readily be therefore be to impart the knowledge assigned to anyone branch of medical that gives the dermatologist this free- science, and as with any borderline dom of choice. This involves the teach- case, this assignation is a matter of con- ing not only of the basic principles of troversy. Since the end of the last cen- dermatosurgery but also of the ability tury, the place of the subject in the field to discriminate according to the most of dermatology has been firmly estab- varied criteria. In this field, technical lished. This is hardly surprising, since knowledge, motivation, and enthusi- a number of specialists in dermatology asm are not enough; talent is also re- spent the first part of their professional quired. C. Moncorps was engaged in work life as surgeons: for example, E. Lang of Vienna, famous for his treatment of on a monograph on dermatosurgery lupus by plastic surgery; and K. Linser (unfortunately nowhere near comple- of Tiibingen, one of the originators of tion) at the time of his death. As a for- varicose-vein stripping. H. T. Schreus mer pupil and long-standing colleague and C. Moncorps were distinguished of his, it is particularly gratifying to me to see colleagues past and present con- members of a later generation of sur- gery-oriented dermatologists; the der- tinuing a tradition in their work.

Advances in breast cancer research, achieved through the progress of knowledge and development of new therapies, have been translated into improved quality of care for breast cancer patients. Clinical investigations and clinical trials have made the largest contribution to the body of knowledge that finds its way to the patient. Never before during the past decades of management of breast cancer has there been such a fruitful intellectual cross-fertilization of ideas among individuals involved in the generation of hypotheses, basic research, development of drugs and treatments, conduct of clinical trials, and statistical evaluation - the results of all of which are now translated into progress in clinical care. Even issues such as the quality of life of breast cancer patients, once the domain for few, are now being openly addressed by trials and discussed in a much broader forum. The IVth International Conference on the Adjuvant Therapy of Primary Breast Cancer, also known as the st. Gallen Conference, was again attended by more than 800 scientists and clinicians interested in this broad spectrum of breast cancer research and the interactions between such diverse fields of interest and specialties as cancer pathology, molecular biology, and psychosocial oncology. This volume collects findings and conclusions presented at the conference.

There has long been disagreement about various aspects of the structure and function of the "gatekeeper" (Greek pyloros, from pyle = gate and ouros = guard). In recent years the problem has often been mentioned in anatomy, physiology, gastroenterology, radiology and even in nuclear medicine. For instance, while referring to manometric and gastric emptying studies, Schu- urkes and van Nuenten (1984 ) pointed out that there was considerable contro- versy as to whether a true pyloric sphincter existed in most species, and espe- cially in man. According to Reeve (1981) many functional aspects of sphincters are poorly understood; the exact mechanism of control of the transfer of chyme from stomach to duodenum through the pylorus is still not clear. Malagelada (1983) states that controversy surrounds the motor activity and function of the antro- duodenal junction; there is disagreement as to whether the pylorus functions as or as an integral part of the distal antrum. Ehrlein et al. (1984) a separate unit reiterate that pyloric motility is poorly understood, and according to Funch- Jensen (1987) there are many unsolved questions. Malagelada (1990) states that the stomach performs multiple functions with a deceivingly simple anat- omy; this is regarded as the key to the investigator's frustration when trying to uncover its secrets. One source of the many controversies surrounding the pylorus may be species differences, according to Schulze-Delrieu et al. (1984).

The ultimate "consumer" of the data presented at conferences on the primary treatment of operable breast cancer is the patient, and when, as in this disease, the benefits of therapy are relatively mod est, the availability and interpretation of the data from trials be comes an issue of primary importance. The effects of present treat ment are in fact such that more patients relapse despite therapy than are estimated to benefit from it. It is, therefore, extremely dif ficult for the physician to recommend unequivocally one particular adjuvant treatment modality for the vast population of women with breast cancer. The interpretation of results from clinical research-oriented pro grams is constantly applied, however, in the treatment of breast cancer patients outside of clinical trials. From presented or publish ed data, many physicians extrapolate indications for the use of a given treatment regimen for their patients, perceiving it as the "best available therapy. " It is essential that the "best available therapy" be selected individually for each patient. However, considering the modest effect of treatment upon outcome, it is imperative that those who provide the data - those who are involved in both pa tient care and clinical research - make it known that the best cur rent treatment for the population of breast cancer patients is avail able within the framework of clinical trials. In this way not only present-day patients but also future ones will derive the greatest benefit.