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Background: Colorectal cancer is one of the most frequent cancers in the Western world. Systematic surveillance after curative resection is common practice in Norway. The article presents the scientific grounds for surveillance in general, and for the Norwegian guidelines in particular., Material and Method: The basis for the study is literature on updated meta-analyses, randomized studies and reviews from 2002 to April 2007 (retrieved from Medline), and an evaluation of own experience with the national guidelines for follow-up., Results and Interpretation: Meta-analyses indicate better overall survival with systematic surveillance after curative resection for colorectal cancer, but the scientific evidence remains uncertain. Clinical practice varies from the setup in randomized trials and direct comparison is difficult. The exact factors associated with better survival remain unclear. The Norwegian surveillance routines contribute to diagnosing about 10 % of all patients with recurrent disease while they are still asymptomatic and amenable to secondary curative surgery. Systematic surveillance after curative resection for colorectal cancer is time-consuming and costly, and secondary curative surgery is only possible in a small proportion of the patients. Realistic and adequate information on what the surveillance can offer is an important part of optimal care. Several large ongoing international studies will shed new light on the usefulness of systematic surveillance.

Background: Colorectal cancer is a genetic disease for which the adenoma-carcinoma-sequence has served as a teaching model. This article presents an update on carcinogenesis and classification, according to the increased understanding of precursors and the improved insight into molecular biological mechanisms., Material and Methods: Literature from 1.1 2002 to 15.7 2007 was reviewed from PubMed by using the search words "colorectal cancer" matched with MeSH-terms "genetic instability", "epigenetic", "molecular classification", "crypt", "apoptosis", "proliferation" and "carcinogenesis". Focus is based on recent reviews (including systematic reviews), and selected original papers., Results and Interpretation: Colorectal cancer develops in the stem cells of the crypts through deregulated molecular mechanisms such as the Wnt-pathway, which lead to increased proliferation, lack of differentiation and loss of apoptosis. Precursors, such as the aberrant crypt foci, have potential as early biomarkers, but consensus lacks for their clinical utility. Assumed "innocent" polyps, such as serrated adenomas, appear to play a larger role than previously expected, mainly through epigenetics (CpG Island Methylator Phenotype; CIMP) and microsatellite instability (MSI). Three main pathways occur in the colorectal carcinogenesis (chromosomal instability [CIN] , MSI and CIMP), of which CIN represents the major part. These pathways have distinct clinical, pathological, and genetic characteristics, which can be used for molecular classification for improved diagnostics, prognosis and treatment.

Background: The epidemiology of trauma deaths in Europe is less than well investigated. Thus, our goal was to study the contemporary patterns of trauma deaths within a defined population with an exceptionally high trauma autopsy rate., Methods: This was a retrospective evaluation of 260 consecutive trauma autopsies for which we collected demographic, pre-hospital and in-hospital data. Patients were analyzed for injury severity by standard scoring systems (Abbreviated Injury Scale [AIS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]), and the Trauma and Injury Severity Scale [TRISS] methodology., Results: The fatal trauma incidence was 10.0 per 100,000 inhabitants (17.4 per 100,000 age-adjusted > or = 55 years). Blunt mechanism (87%), male gender (75%), and pre-hospital deaths (52%) predominated. Median ISS was 38 (range: 4-75). Younger patients (<55 years) who died in the hospital were more often hypotensive (SBP < 90 mmHg; p = 0.001), in respiratory distress (RR < 10/min, or > 29/min; p < 0.0001), and had deranged neurology on admission (Glasgow Coma Score [GCS] < or = 8; p < 0.0001), compared to those > or = 55 years. Causes of death were central nervous system (CNS) injuries (67%), exsanguination (25%), and multiorgan failure (8%). The temporal death distribution is model-dependent and can be visualized in unimodal, bimodal, or trimodal patterns. Age increased (r = 0.43) and ISS decreased (r = -0.52) with longer time from injury to death (p < 0.001). Mean age of the trauma patients who died increased by almost a decade during the study period (from mean 41.7 +/- 24.2 years to mean 50.5 +/- 25.4 years; p = 0.04). The pre-hospital:in-hospital death ratio shifted from 1.5 to 0.75 (p < 0.007)., Conclusions: While pre-hospital and early deaths still predominate, an increasing proportion succumb after arrival in hospital. Focus on injury prevention is imperative, particularly for brain injuries. Although hemorrhage and multiorgan failure deaths have decreased, they do still occur. Redirected attention and focus on the geriatric trauma population is mandated.

Background: Bile duct cysts (BDC) are rare, of uncertain origin, and occur most often in young females of Asian descent. Increasingly, BDCs are reported in the Western population, often with coexistent biliary tract cancer., Methods: The PubMed and Medline literature databases were searched for pertinent publications regarding the clinical association and molecular biological development of cancerogenesis in BDC. Reports from the last two decades were emphasized., Results: Cancer is found in 10-30% of adults with BDC. The cancer-risk is low in childhood (<1% in the first decade), and shows a clear increase with age. Cholangiocarcinoma is the most common malignancy in BDC, and represents a 20- to 30-fold risk compared to the general population. The mean age of malignancy in BDC is 32 years (about two decades earlier than in the general population). Type I and type IV cysts show a higher cancer incidence, even after cyst excision. Pathological findings strongly suggest a hyperplasia-dysplasia-carcinoma sequence in carcinogenesis of pancreatico-biliary maljunction (PBM). Reflux of pancreatic enzymes, amylase, bile stasis, and an increased intraductal concentration of bile acids contribute to proliferative activity of bile acids in BDC. While microsatellite instability, k-ras mutations, expression of COX-2 and bcl-2, and increased telomerase activity seem to occur early; involvement of cyclin D1, beta-catenin, DPC-4/Smad4 and p53 appear later in carcinogenesis., Conclusion: Increased molecular knowledge substantiates the clinically related cancer-risk in BDC. Surgery remains the golden standard for treatment, relieves patients from associated complications, and interrupts the cancerous potential in BDC.

Emergency department thoracotomy (EDT) may serve as a life-saving tool when performed for the right indications, in selected patients, and in the hands of a trained surgeon. Critically injured patients 'in extremis' arrive at an increasing rate in the trauma bay, as an effect of improved pre-hospital trauma systems and rapid transport. Any patient in near, or full cardiovascular shock prompts the trauma surgeon to rapidly perform a thoracotomy. The EDT procedure is managed best by surgeons familiar with, and experienced in, penetrating cardiothoracic injuries. However, the geographical differences in trauma epidemiology lends no, or only scarce, experience with this procedure in most European trauma centres. Consequently, mandatory training is imperative for success. The rationale for performing an EDT is to: (I) resuscitate the agonal patient with penetrating cardiothoracic injuries; (II) release cardiac tamponade by evacuation of pericardial blood; (III) immediately control hemorrhage and repair cardiac or pulmonary injury; (IV) perform open cardiac massage; and (V) place a thoracic aortic cross-clamp to redistribute the remaining blood volume, and perfuse the carotids and coronary arteries. The prevalence rates of blood-borne viruses reported in critically injured patients in the USA (10-20%) exceed the prevalence in the Nordic countries (HIV prevalence < 1% in general population). However, risk is not negligible and mandated universal precautions are needed. The literature is rich in series describing the use of EDT, however, the best evidence is derived from a few prospective trials. EDT saves about one in every five patients with isolated penetrating cardiac injury, while > 98% die after blunt injury. Based on an updated review of the current available literature, this paper presents the current evidence regarding the rationale, risk, and outcomes for employing EDT in the field of trauma surgery.

Microsatellite instability (MSI) is a genetic feature of colorectal cancer (CRC) associated with peculiar clinicopathological features and improved prognosis. It is demonstrated in >90% of patients with hereditary non-polyposis colorectal cancer (HNPCC) in which DNA mismatch repair (MMR) defects are the cause of MSI. HNPCC develop at a young age, and patients are at increased risk for additional cancers (e.g. endometrial, stomach, or biliary tract cancer). MSI is found in 15-20% of sporadic CRC, often based on epigenetic silencing (i.e. MLH1). The prognostic and predictive value of MSI is not yet fully elucidated, although improved survival in MSI is suggested. Distinguishing sporadic MSI from HNPCC is at present guided by the combination of familial history, immunohistochemistry, and genotyping of MMR genes (MLH1, MSH2, MSH6, and PMS2). The efficiency and accuracy of MSI testing is evolving, with more knowledge achieved concerning multipopulation polymorphisms, selection of markers (e.g. quasimonomorphic vs. dinucleotides), and more time-efficient panels (e.g. not requiring normal/germline DNA match). The role of distinct genetic features, such as BRAF V600E mutations often found in sporadic MSI but not in HNPCC, may further improve future test algorithms. The present knowledge and controversies pertaining to molecular testing of MSI and MMR defects in CRC are presented., (Copyright 2007 S. Karger AG, Basel.)

Apolipoprotein D (ApoD) is a small glycoprotein of 24 kD, and a member of the lipocalin family. ApoD exerts several intracellular mechanistic roles, especially ligand binding. Some putative ligands are arachidonic acid, progesterone, and tamoxifen. It probably has a binding/reservoir function of these ligands in the cytoplasm. Furthermore, ApoD has features compatible with endosomal trafficking, proteolytic activity and interactions in cellular signal pathways. ApoD inhibits translocation of phosphorylated MAPK into the nucleus. Moreover, ApoD is associated with reduced proliferative activity of cancer cells, and is abundantly raised in senescent cells. In breast cancer, ApoD expression is associated with favourable histology and clinical stage, whereas in adjacent tumour stroma ApoD expression is a marker of adverse prognosis. Oestrogen receptor expression in breast cancer is inversely related to ApoD expression. Therefore, a combined oestrogen receptor positivity/ApoD positivity, could reflect a non-functional oestrogen receptor pathway, and this subset of breast cancer patients does not react to adjuvant tamoxifen treatment. The triangular relationship between oestrogen receptor, tamoxifen and ApoD should be further explored.

Objective: Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital., Methods: Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (Ps) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase., Results: Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>or=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median Ps of 4.4%, range 0-89.5%). Males had significantly lower RTS and Ps (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (Ps) of 51 and 89%), one in a third trimester pregnancy., Conclusion: Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention.

Background: Benign peritoneal cystic mesothelioma (BPCM) is a rare tumor of unknown origin, most frequently encountered in women of reproductive age. Etiology is unknown; definitions and terminology are confusing, and preoperative diagnosis is difficult. Several differential diagnoses must be considered., Methods: Based on our own clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance., Results: Current literature on BPCM is mostly based on small case reports. Complete surgical resection is recommended if possible. Nevertheless, recurrent disease is not uncommon. Clinical positive effects of various adjuvant medical treatments remain to be shown., Conclusions: Lack of consistent definitions, various treatment approaches, and mostly short follow-up times make it difficult to draw any firm conclusions from published reports. The natural history of this rare disease is less than well clarified. When possible, in an individual patient, surgical resection with curative intent seems to be the treatment of choice.

Background: Pancreatic adenocarcinoma is a relatively frequent cancer with an extremely poor prognosis. Until recently, the natural history of pancreatic adenocarcinoma has not been possible to study, but the identification of precursor lesions (pancreatic intraepithelial neoplasia, PanIN) has lead to a better understanding of the stepwise morphological and genetic alterations involved in the development of invasive adenocarcinoma., Material and Methods: Relevant literature from the period of 1996-2005 was found by searching the Medline database, combining the terms "pancreas", "cancer", "PanIN" and "neoplasia". Principal original and review papers were extracted and used as background for a presentation of the PanIN cancer progression model., Results and Interpretation: PanINs are established as designation of histological precursor lesions to pancreatic adenocarcinoma. PanIN grade I to III represent stepwise morphological alterations in the pancreatic ductal epithelium, from early neoplasia (PanIN I and II), via carcinoma in situ (PanIN III) to the development of invasive ductal adenocarcinoma. This model allows for the investigation of sequential molecular changes such as activation of oncogenes and inactivation of tumour suppressor genes. Increased knowledge about pancreatic carcinogenesis may pave the way for prevention strategies, early detection, and new treatment options, thus ultimately improving the prognosis of the patients.

The understanding of peptic ulcer disease (PUD) etiology, and improvements in treatment during the last two decades, has dramatically decreased the once so frequently performed procedures for PUD and its complications. Benign gastric outlet obstruction may, however, still require operative intervention when non-operative treatment fails. Today, surgeons in training, and even practicing surgeons, may have limited operative experience with procedures required to alleviate an obstructed pylorus. Our aim of this paper is to review the techniques (the Heineke-Mikulicz and Finney pyloroplasties, and modifications) and indications for pyloroplasty in the modern surgical era.

Background/purpose: The aim of this study was to present the current experience and evidence relating to surgical evaluation and management of nonrenal genitourinary presentation in children with Henoch-Schönlein purpura (HSP). Henoch-Schönlein purpura is the most common systemic vasculitis in childhood. Presenting symptoms include a rash, arthralgia, abdominal pain, and, frequently, renal involvement. Genitourinary symptoms are infrequently reported; however, surgical evaluation is often required., Methods: A MEDLINE literature search of the last 3 decades was conducted using the terms Henoch-Schönlein purpura in combination with acute scrotum or genitourinary, genital, or related symptoms as the keywords. Reference lists of retrieved articles were reviewed for further relevant articles. Case reports were included when no larger case series were found. Articles of foreign language were included if abstracts proved sufficient information., Results: Genitourinary manifestations are mainly anecdotally reported. Scrotal pain and swelling were the most frequent nonrenal genitourinary symptoms reported in children with HSP, occurring in about 13% of boys evaluated for HSP. No prospective, population-based reports on genitourinary manifestations in HSP were found, thus making estimation of the true incidence difficult., Conclusions: A wide variety of nonrenal genitourinary pathology may be expected by surgical evaluation of patients with HSP. Most cases are self-limited in nature. Scrotal symptoms are frequent, but testicular torsion is highly unlikely when the diagnosis of HSP is established. Clinical vigilance should be paid to patients with possible obstructive ureteritis, for whom prompt surgical intervention may be indicated.

Background: Appendiceal neoplasms are rare. Patients may present with clinical symptoms suggestive of "acute appendicitis" or other unspecific abdominal complaints. An appendiceal mucinous neoplasia is sometimes diagnosed during a laparotomy performed on another indication. Frequently, the condition remains undiagnosed until the pathologists' examination., Materials and Methods: We present the case of a 49-year-old woman who presented with symptoms suggestive of acute appendicitis. An appendectomy was performed. The appendectomy specimen revealed a mucinous cystadenoma with a diverticulum in the appendix. The case is discussed in the light of the current literature., Results and Interpretation: Appendiceal tumours account for less than 0.4% of neoplasias in the gastrointestinal tract and are found in less than 1% of appendectomies. Mucinous lesions ("mucocele") are classified as mucosal hyperplasia, mucinous cystadenoma, or mucinous cystadenocarcinoma. However, there are reports of great variability in the biological behavior, especially concerning the development of pseudomyxoma peritonei. No current consensus exists as to diagnostic criteria or treatment. A radically removed appendix is curative in most cases of mucinous cystadenoma, whereas right hemicolectomy should be considered for patients with malignant mucinous lesions of the appendix.

An acute scrotum is a potential urologic emergency and requires urgent evaluation in order to rule out conditions that need immediate surgical management. The most important condition to rule out is torsion of the testis. In cases of less emergency, a wide variety of differentials may be considered. Scrotal pain or swelling may occur in 10 to 15% of boys with Henoch-Schönlein purpura. We present the case of a 19-year-old boy who had intermittent scrotal pain of two weeks' duration with acute exacerbation prior to admission. The clinical examination gave no specific results. A regular and Doppler sonographic scan showed no evidence of testicular affection. The patient was observed in hospital. Two years earlier he had present with abdominal cramps, rectal bleeding, duodenitis, proteinuria and a purpuric rash, suggestive of Henoch-Schönlein purpura; IgA-nephritis was proven after a renal biopsy. As all other differentials had been ruled out, we concluded that Henoch-Schönlein syndrome was the cause of the recurrent scrotal pain in our patient.

Background: Hurler's syndrome is a rare congenital metabolic disorder and is inevitably lethal when untreated. The presenting symptoms are usually vague, resembling those found in otherwise healthy children., Material and Methods: We present a patient with Hurler's syndrome and discuss the unspecific clinical signs and symptoms seen in these patients based on a review of relevant literature., Results: A two-months-old infant boy was operated for a rightsided inguinal hernia. The anaesthesiologist had difficulty intubating the patient. During the following months the patient had a severe allergic reaction to vaccination, chronic rhinitis with recurrent upper airway infections, and diarrhoea and vomiting. Eventually, failure to gain weight, and psychomotoric delay led to a thorough clinical investigation. Extensive X-ray diagnostics and analysis of urine and serum concluded with Hurler's syndrome., Interpretation: Clinical vigilance is needed in the diagnosis of Hurler's syndrome. Early symptoms, such as rhinitis and hernia, are vague and unspecific. Radiological features, such as broad costae or gibbus, are helpful in obtaining the diagnosis. Decreased level of alpha-L-iduronidase in serum confirms the diagnosis of Hurler's syndrome. Patients tend to be treated symptomatically before the eventual diagnosis of this syndrome.