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This article describes and illustrates the process of nail regeneration and suggests specific management for acute nail bed injuries. The management consists of direct, nail matrix repair and nail matrix split grafting. Postoperative care following nail bed injuries is also discussed.

Cavernous hemangioma is the most common benign tumor of the liver. Eighteen patients were studied by both computed tomography (CT) and angiography. The angiographic features were classic, consisting of normal hepatic arteries, no tumor vessels, and densely stained blood-filled spaces producing a "cotton-wool" appearance. Before contrast infusion, CT scans showed roughly spherical, well-demarcated low-density masses; afterward there was a peripheral zone of enhancement which varied in thickness and sometimes had a corrugated inner margin, though the center remained low in density and the overall size of the lesion did not change. The authors feel that the CT findings are characteristic and that in some cases angiography is unnecessary.

Thirteen patients were studied during two hours of anaesthesia for abdmonial operations and for an hour post-operatively. Serial venous blood samples were taken for determination of plasma total and ionized calcium, acid-base variables, Na, K, Mg, PO4 total proteins and parathyroid hormone. One group of patients received 5 per cent dextrose/water and the other 5 per cent dextrose in Ringer's solution, at 250 ml per hour. Total and ionized calcium levels decreased toward the end of operation and an hour later, associated with respiratory alkalosis. Parathyroid hormone increased at the end of operation, as an effect of the decreased ionized calcium. The general effect was mild haemodilution with all the other electrolytes decreasing, as did total protein concentration.

The authors reviewed 23 cases of focal nodular hyperplasia and 13 cases of hepatic adenoma, all of which were confirmed pathologically. All solitary masses that exhibited normal or increased uptake of technetium 99m-sulfur colloid were shown to be hyperplasia; while previous criteria such as a central blood supply on angiograms or a central scar on computed tomography (CT) or ultrasound (US) scans were helpful, they were relatively infrequent. A mass that was slightly hypodense and homogeneous on a CT or US scan and highly vascular with an intense capillary stain on an angiogram was almost always hyperplasia. Acute hemorrhage within a focal hepatic tumor was common in adenoma but did not occur in hyperplasia.

1. CT and sonography are helpful in distinguishing between an obstructing lesion and hepatocellular disease as the cause of jaundice. 2. CT and sonography can demonstrate the level and extent of an obstructing lesion, and can define its nature if a mass more than 1-2 cm is present; sonography is usually the preferred screening study because of its availability, relatively low cost and lack of radiation hazard. 3. PTC or ERCP is useful in the evaluation of jaundice when sonography and CT are equivocal, fail to provide information necessary to establish proper therapy, or are at variance with the clinical impression of obstructive jaundice; in addition to defining obstructions these techniques can detect atrophy, sequestra, stones, abscesses, fistulas, primary sclerosing cholangitis, etc. 4. PBD offers an expedient alternative to surgical decompression in patients with obstructive jaundice, since most cancers that cause biliary obstruction are not resectable for cure at the time of diagnosis.

The pathologic features, clinical presentation and natural history of hepatocellular carcinoma (HCC) developing in the noncirrhotic liver were studied in 61 patients against a background of 63 patients seen concurrently with HCC complicating cirrhosis. Noncirrhotic HCC had a bimodal age distribution, with females predominating the first age-clustering (10-50 years) and males predominating the second age-clustering (50-90 years). Cirrhotic HCC had a unimodal age distribution (40-90 years) with male dominance throughout. Estrogen exposure was noted in 57% of the noncirrhotic HCC women overall and in 80% of those in the younger age-clustering. The majority of noncirrhotic HCC presented with a single hepatic mass or a dominant primary with satellite lesions in contrast to the usual multinodular or diffuse disease seen with cirrhosis. Twenty-nine noncirrhotic patients survived complete resection of disease limited to the liver and exhibited a median survival of 2.7 years with a 5-year survival of 25%. Low histologic grade, minimal necrosis, and the absence of hemoperitoneum, hepatomegaly, and adjacent organ involvement were all favorable prognostic variable. Patients with metastatic or locally unresectable noncirrhotic HCC had a median survival of 9 months, and 24% survived in excess of 2 years. This survival experience is significantly more favorable than cirrhotic HCC patients, who had only a 1.2-month median and a 3% 2-year survival. Low histologic grade, mild mitotic activity and the presence of some fibrosis within the specimen were associated with a favorable outcome in advanced noncirrhotic HCC. The favorable prognosis and heterogeneous composition of the noncirrhotic, when compared to the cirrhotic HCC cohort, may be important considerations in the design and evaluation of future clinical trials.

To investigate further an apparent relationship between chronic ulcerative and granulomatous colitis and pantothenic acid deficiency, colonic tissues obtained at the time of colectomy in 29 patients with these disorders were assayed for pantothenic acid and for coenzyme A (CoA) activity. For comparison, normal colonic tissues free of pathological lesions were obtained from 31 patients having colectomy for carcinoma or diverticulitis. Plasma, red blood cells, and colonic mucosa were assayed microbiologically for free and total pantothenic acid. The activity of CoA in colonic mucosa was determined by assaying the acetylation of sulfanilamide. Concentrations of free, bound, and total pantothenic acid in blood and in colonic mucosa did not differ between the two groups of patients. Bound pantothenic acid increased linearly with total pantothenic acid. Colonic mucosa concentrated free pantothenic acid to about 50 times the level of blood, and pantothenic acid in red cells was similar to the concentration in plasma. Compared to normal gut mucosa, CoA activity was markedly low in mucosa from patients with chronic ulcerative or granulomatous disease despite the presence of normal amounts of free and bound pantothenic acid. A block in the conversion of bound pantothenic acid to CoA in diseased mucosa is suggested.

The records of all patients who underwent pylorus-preserving pancreatic resection (29 subtotal and 4 total pancreatectomies) during a 10-year period at the Mayo Clinic were reviewed. Thirty-day operative mortality was 6%. Early postoperative morbidity occurred in 45% of patients and necessitated reoperation in four patients. One patient had a hemorrhage from a marginal ulcer in the early postoperative period. The incidence of late postoperative morbidity was 18%. Marginal ulcers developed in the late postoperative period in three additional patients, for an overall incidence of 13%. One patient underwent vagotomy and pyloroplasty because of intractable bleeding 2 years after initial operation. The 29 patients who underwent pylorus-preserving pancreatoduodenectomy (PPW) were compared (retrospectively) with 200 patients who had undergone standard pancreatoduodenectomy (Whipple operation) during the same 10-year period. The overall incidences of marginal ulcer were 10% in the PPW group and 5% in the Whipple group; the incidences of delayed gastric emptying were similar in these groups. We believe that caution is warranted in the use of PPW, as yet an unproved procedure.

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.

Nuclear deoxyribonucleic acid (DNA) ploidy studies of paraffin-embedded archival tumor specimen blocks were performed by flow cytometry on extracted nuclei from 101 surgically resected hepatic metastases from colorectal cancer. In 28 patients, the corresponding primary carcinoma of the metastases was also studied. Tumor clinicopathology and clinical course of the patients were reviewed. Preparation of paraffin-embedded tissue specimens was performed by the technique of Hedley et al. and stained with propidium iodide according to the method of Vindelov et al. Eighty-eight of 101 metastatic tumors and 26 of 28 primary tumors yielded evaluable DNA histograms. Twenty-six metastases showed a DNA diploid pattern, 25 showed a significantly increased 4C peak (DNA tetraploid/polyploid), and 37 had a DNA aneuploid peak. Ploidy pattern was constant between primary and metastases in 84.6% of tumors. No significant relationship between host and tumor characteristics and ploidy pattern was found except for a correlation between grade 3 metastases and DNA aneuploid. Survival of patients with DNA aneuploid metastases was significantly less than that of patients with DNA diploid metastases (p = 0.03). However, among DNA nondiploid metastases, survival was significantly less for low DNA index metastases (less than or equal to 1.5) than for high DNA index (greater than 1.5) metastases (p less than 0.05). Flow cytometric DNA ploidy measurements may have prognostic value for patients with resected hepatic metastases from colorectal carcinoma.

The surgical management of 29 adults with choledochal cysts is reviewed with emphasis on clinicopathologic features, long-term postoperative results (mean 9.1 years), and factors affecting outcome. Clinical symptoms were characterized by abdominal pain, jaundice, and cholangitis. Coexistent hepatobiliary pathologic findings were more complex and frequent than those that occur in children and included cystolithiasis or cholelithiasis, pancreatitis, malignancy, cirrhosis with portal hypertension, and intrahepatic abscess. Associated pathologic findings and cyst type (type I-22, II-1, III-2, IVA-4) determined the operative approach. In patients with type I or IVA cysts, results of cyst excision were excellent in five of seven patients but results of cystenterostomy were excellent in only seven of 19 patients. The high prevalence of pancreatitis (33%) and cyst-associated malignancy (28%) were major causes of treatment failure. Cyst excision with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice for adults to eliminate pancreatitis by pancreaticobiliary disconnection and possibly to reduce the risk of malignancy.

Most cancers of the hepatobiliary system will have grown beyond the limits of curative resection by the time they become clinically evident. This reality has fostered therapeutic nihilism, and most physicians and surgeons in their pessimism have failed to study the early modes of spread of these tumors--patterns of growth that are relevant to proper treatment of those patients who do have lesions that can be removed with hope of achieving a cure. Moreover, anatomic and technical complexities may beget surgical reluctance in the management of potentially curable lesions. Therefore, this review is offered for orientation and perspective for those who would hope to offer optimal treatment for patients who have primary cancers of the liver, gallbladder, or biliary ducts. The review includes considerations of (1) surgical anatomy, (2) modes of spread, (3) assessment of resectability, (4) surgical technique, and (5) results of operative treatment in relation to "curative" resection. Also offered are some guides to palliative surgical management of tumors that have reached the hepatic hilus.

Cancer may arise from any of the great variety of cells that comprise the liver, and each type of cell may be incited to malignant change in a variety of ways [1]. Therefore, the spectrum of primary hepatic malignancies that may or may not be resectable is so broad as to preclude generalizations about therapy.

To further define the clinicopathologic features and determinants of survival, we reviewed the cases of 110 patients with primary hepatic malignancy managed surgically between 1975 and 1986. Presenting signs of symptoms were pain (57%), fatigue (48%), abdominal mass (40%), and weight loss (33%). Twenty-six percent of patients had a history of hepatitis or cirrhosis. Histopathologically, tumors were hepatocarcinoma (72%), fibrolamellar variant (7%), cholangiocarcinoma (9%), mixed (7%), and other (5%). Resectability rate with curative intention was 67%. Exploration and biopsy alone was performed in 27% and palliative resection in 6%. Hospital mortality was 9%, and serious morbidity was 22%. Perioperative morbidity and mortality were significantly associated with operative blood loss. Median survival was 12.6 months, with a 5-year survival of 18%. Median survival after curative resection was 22.8 months, and 5-year survival was 27%. Univariate analysis showed that female sex, normal performance status, well-differentiated tumor, and curative resection were associated with increased survival; cholangiocarcinoma, nodal metastases, cirrhosis, hypocalcemia, prolonged prothrombin time, and increased serum transaminase and alkaline phosphatase were associated with decreased survival. Cox multivariate analysis showed that curative resection, normal performance status, and well-differentiated tumors were associated with increased survival, and prolonged prothrombin time and hypocalcemia were associated with decreased survival.

Based on strict predefined histologic criteria, we identified 23 patients with hepatic adenoma and 41 patients with focal nodular hyperplasia seen at this institution between 1961 and 1980. Patients with hepatic adenoma were young and 91% were female. When a reliable history was available, 89% had used oral contraceptives; 53% presented acutely or with pain. Eleven of 11 radionuclide scans were abnormal; 15 of 15 angiograms showed a hypervascular mass with 7 of 15 showing areas of hypovascularity. Eighteen resections were performed with one operative death. Two tumors contained areas of unequivocal hepatocellular carcinoma. Fifteen of 18 patients followed for 82 +/- 11 mo were living and well and had discontinued oral contraceptives. Focal nodular hyperplasia patients were older, 88% were female, and 58% had used oral contraceptives. Their lesions were discovered accidentally. Seven of 12 radionuclide scans demonstrated voids, while 13 of 13 angiograms showed hypervascular lesions with no areas of hypovascularity. Seventeen tumors were resected. Twenty-three of 24 patients followed for 45 +/- 7 mo were living and well. One died of nonhepatic causes. Based on the findings of this review, we believe that if the clinical suspicion of hepatic adenoma or focal nodular hyperplasia is strong, elective laparotomy for diagnosis is usually the best approach. Hepatic adenoma should be resected if technically feasible. Intraoperative wedge biopsy is appropriate for focal nodular hyperplasia.

Radical pancreatoduodenectomy, or Whipple's procedure, has gradually fallen into disrepute during the past decade. This loss of popularity has resulted from excessive postoperative mortality and morbidity due to inherent technical difficulties, the dismal long-term survival when the procedure is done for adenocarcinoma of the pancreas, and the current enthusiasm for total pancreatectomy. Our objective was to assess the technical aspects of the Whipple procedure as they relate to subsequent morbidity and mortality. Conclusions are drawn from the evaluation of 146 consecutive patients who underwent this procedure between 1970 and 1979 for either benign (10 patients) or malignant (136 patients) diseases of the pancreas and periampullary region. The postoperative mortality was 4.1%. Significant morbidity occurred in 34% of patients, and early reoperation was required in 7.5% of these patients. The median postoperative hospital stay was 19 days. The relatively low postoperative mortality indicates that inherent technical difficulties of the Whipple procedure can be overcome and supports its continued use in carefully selected patients. The persistent high morbidity and the rather poor long-term results following treatment of certain pancreatic malignancies place individual surgical judgment and technical expertise at a premium when ever this classic operation is contemplated.

The charts of 55 patients with clinical and surgical evidence of pancreatitis, secondary to gallstones, were reviewed. Patients with a history of high alcoholic intake were excluded. Gallstones were retrieved from all patients, 18 (33%) of whom had choledocholithiasis. Severe pancreatitis with extensive fat necrosis was documented during surgery in 27 patients (49%). We found an inverse relationship between the preoperative serum amylase levels and the severity of pancreatitis. Cholecystectomy was performed in 53 patients (96%). The operative mortality rate was 5.5%, and severe postoperative complications developed in five patients (9%). The follow-up period ranged from two to 24 years, and 39 of the patients in the follow-up evaluation remained completely asymptomatic postoperatively.

Five-year survival after resection of hepatic metastases from colorectal cancer is 25%. Although resection palliates some patients who do not live that long, 50% of patients so treated are not helped at all. Until ignorance of a cancer's real stage is resolved by improved techniques, the evaluation and choice of therapy can be based only upon knowledge of the natural history of untreated metastases and determinants of prognosis derived from treated patients. Analysis of the survival rates of 252 patients who had biopsy proven, unresected hepatic metastases that were the only evidence of residual disease shows the extent to which natural history, rather than resection, may determine length of survival-- and indicates the need for critical analysis of 2- and 3-year survival rates reported after any therapy. Study of 141 patients who had hepatic metastases resected shows that the stage of the primary lesion, being female, and the absence of extrahepatic metastases are significant determinants of favorable prognosis after resection of hepatic metastases.

Proximal gastric vagotomy was performed in 223 patients with chronic duodenal ulceration between 1973 and 1977. The follow-up ranged from 6 to 78 months with a mean of 39 months. There was no operative mortality. Adverse postoperative sequelae, including delayed gastric emptying, dumping, diarrhea, and reflux gastritis, were seen in less than 3% of patients. Ulcers recurred in 11 patients (4.9%). We conclude that proximal gastric vagotomy is an effective, safe, and satisfactory operation for chronic duodenal ulcer over the short term.

In this review of the surgical experience with pancreatitis, 55 patients had acute relapsing pancreatitis associated with gallstones and 47 had chronic pancreatitis of alcoholic, idiopathic, or familial causation. The severity of pancreatitis associated with gallstones could not be correlated with results of preoperative biochemical tests; only one-third of patients were found to have stones within the biliary ductal system; and postoperative mortality (5%) could not be correlated with the severity of pancreatic inflammation or the timing of surgical intervention. Postoperative observations have revealed that all but four of the patients have remained asymptomatic. With regard to the patients with alcoholic, idiopathic, or familial disease who had significant pancreatic ductal dilatation or obstruction, ductal drainage procedures with or without resection benefited 80%. In the absence of ductal dilatation or obstruction, major resective surgery benefited 50% of patients. Continuing alcohol abuse limited the effectiveness of any operative procedure, and diabetes occurred more often after major resective procedures.

The use of temporary inflatable implants to generate expanded skin flaps in the upper extremity is a useful reconstructive technique. Applications, technique, and complications are discussed and emphasized with case reports.

We reexamined our experience with the surgical and medical management of 53 patients with Zollinger-Ellison syndrome due to gastrinoma during the past decade. Surgical "cure" (defined here as resection of all identifiable tumor with normalization of serum gastrin and gastric secretory variables) appeared possible in 7 patients (of 44 explored, or 16%). Five of the 7 "cured" patients had duodenal wall tumors. Currently, these 7 receive no therapy, and none has apparent metastasis or multiple endocrine neoplasia, type 1. Excluding patients who have metastasis or multiple endocrine neoplasia, type 1 by preoperative screening would have increased the relative chance of surgical "cure" from 16% to 20% (7 of 35). Patients with unresectable or recurrent gastrinomas had a much worse prognosis than did patients whose tumors did not recur after resection or patients with a negative laparotomy. In any case, therapy with H2-receptor antagonists offered a satisfactory fallback position for management of gastric hypersecretion and its consequences. Adequate control by their use was achieved in 16 of 18 patients who were followed up an average of 28.9 mo (range 7-59 mo) without major side effects. Total gastrectomy, while undoubtedly the most effective therapy of gastric hypersecretion, is not free of significant sequelae, as evidenced by long-term follow-up of 18 gastrectomized patients. We concluded that (a) patients with Zollinger-Ellison syndrome without multiple endocrine neoplasia, type 1 or metastasis should undergo exploratory laparotomy and potential resection of identifiable gastrinomas, (b) chronic therapy with H2-receptor antagonists is preferable to total gastrectomy and satisfactory control may be achieved in most patients, and (c) tumor death is currently the major threat to survival for patients with unresectable gastrinomas, particularly nonmultiple endocrine neoplasia, type 1.

• We studied 141 patients who had resection of hepatic metastases from colorectal cancer, considering all such lesions removed between 1948 and 1982. The study involved extended observations of patients described previously. Also included were 21 patients who had wedge resections of small metastases done since 1976, who, therefore, did not qualify for analysis of major hepatic resections reported recently (1980 and 1983). The overall five-year survival rate was 25%, significantly higher than that of a group of historical controls who had resectable metastases that were not removed. The size and nature of our extended sample allowed identification of some determinants of favorable prognosis: Dukes' stage of the primary lesion, absence of extrahepatic metastases, and being female. Contrary to our earlier observations, this study justified removal of some multiple hepatic metastases. ( Arch Surg 1984;119:647-651)