Kazuhiko Onodera

Clinical study of therapeutic angiogenesis by autologous peripheral blood stem cell (PBSC) transplantation in 92 patients with critically ischemic limbs

Patients with critically ischemic limbs due to maintenance hemodialysis and diabetes are increasing in number markedly in Japan. The difficulty of treating critically ischemic limbs is well recognized. Despite active medication and surgical therapy, many critically ischemic limbs are amputated. Ninety-two patients with critically ischemic limbs were treated by transplantation of autologous peripheral blood stem cells (PBSCs). The stem cells were mobilized into the peripheral blood by administration of granulocyte colony stimulating factor (G-CSF). The mobilized mononuclear cells were separated by an apheresis technique using a centrifuge. The separated mononuclear cells contained approximately 4.0 × 107 CD34-positive cells. The collected cell suspension was divided into aliquots of 0.5–1.0 ml and transplanted into the muscle of ischemic limbs at 50–70 transplantation points. At 1.5 months after PBSC transplantation, a strong immunostaining of CD34-positive cells and factor VIII, as well as capillary formation, was observed in the muscles into which stems cells had been transplanted. In each patient tested, the serum vascular endothelial growth factor (VEGF) level increased after stem cell transplantation; the mean VEGF level increased by 176%. Of 11 diabetic patients (DM) who were not receiving hemodialysis (HD), there were no amputees regardless of their Fontaine classification. Of 19 patients in the HD(+)DM(−) category, there were no amputations in Fontaine stage I, II, and III patients, whereas three limbs and one toe were amputated in Fontaine stage IV patients. Of 13 patients in the HD(−)DM(+) category, none of the Fontaine stage I, II, or III patients underwent amputation, but six Fontaine stage IV patients underwent amputation. Of 49 patients in the HD(+)DM(+) category, 38 (78%) were classified as Fontaine stage IV, 71% (27/38) of whom had a toe or a limb amputated. In nine patients over 80 years of age, one toe and one limb were amputated. Nondiabetic, nondialyzed patients with ischemic limbs are strongly indicated for stem cell transplantation regardless of Fontaine classification. Therapeutic angiogenesis is effective for critically ischemic limbs resulting from hemodialysis and diabetes until Fontaine stage III, but is of limited effectiveness for stage IV cases.

Artificial liver support at present and in the future.

Liver failure is a fatal disease. Liver transplantation is the only established treatment for liver failure; however, donor shortages remain problematic. In the United States and Europe, artificial livers as a bridge to liver transplantation are being considered. In Japan, we have taken a different approach to the treatment of end-stage liver diseases because of the characteristics of the health-care insurance system, regulated by the government. Furthermore, cadaveric liver transplantations are unsuited to the social mores of Japanese culture. Practically speaking, we believe that plasma exchange (PE) and continuous hemodiafiltration (CHDF) are the most effective therapies for the treatment of liver failure, although randomized controlled studies are needed to determine their effects. Overall, we believe that the first line of treatment for liver failure should be PE and CHDF, and the second line should be bioartificial liver support. In the near future, we hope that both gene therapy and regenerative medicine will contribute to the development of a functional artificial liver.

Angiolipoma of the Colon with Right Lower Quadrant Abdominal Pain

Background/Aim: An angiolipoma is a common benign neoplasm with a characteristic vascular component that occurs in the subcutaneous tissue and rarely in the gastrointestinal tract. We report on a 69-year-old man with a submucosal angiolipoma in the cecum. Methods: This patient was treated with a laparoscopy-assisted ileocecostomy, and a side-to-side anastomosis was performed extracorporeally. Results: A light microscopic study supported the diagnosis of an angiolipoma of the colon. After 5 years of follow-up, the patient has no symptoms or signs of recurrence. Conclusion: The colonic angiolipoma was successfully removed using a minimally invasive laparoscopic technique.

Laparoscopic cholecystectomy from fundus downward.

Laparoscopic cholecystectomy from fundus downward (LCFD) is desirable when exposure of the cystic duct is difficult and hazardous. First the cystic duct and artery are exposed and clipped, and the artery is divided. Then removal of the gallbladder is started from fundus downward. After the gallbladder is dissected from the liver bed, the cystic duct is double clipped and divided. This approach affords better visualization of the cystic duct and common duct with less chance of common duct injury. Twenty-eight LCFDs were performed without complications, immediate or late. LCFD appears to be a safe procedure and does not compromise the retrograde method.

Papillary adenoma of the distal common bile duct.

Abstract: A 73-year-old man with a papillary adenoma located in the distal common bile duct is reported. He underwent pylorus-preserving pancreatoduodenectomy. The lesion in the common bile duct featured papillary proliferation of the epithelium and fibrous elements with diffuse infiltration by inflammatory cells. Positive staining for MIB-1 (Ki-67) and p53 was identified in the nuclei of the proliferative epithelium. These findings suggested the malignant potential of this lesion. Further progress in imaging diagnostic techniques should increase the frequency with which such lesions are discovered. Even now, if mural irregularities and defects are found in the extrahepatic biliary system, especially the distal common bile duct, the possibility of such borderline biliary adenoma should be taken into consideration when making a diagnosis.

The immuno-stimulant OK-432 enhances liver regeneration after 70% hepatectomy

The effect of reticuloendothelial system activation on hepatic regeneration after 70% hepatectomy was investigated. OK-432, a killed streptococcal preparation which increases reticuloendothelial system function, was administered to rats prior to 70% hepatectomy. Hepatic incorporation of 3H-thymidine 24 h after 70% hepatectomy was enhanced by OK-432 pretreatment. DNA synthesis was greater in pretreated than in control rats and correlated highly with reticuloendothelial system phagocytic activity prior to surgery. Methyl palmitate, which decreases reticuloendothelial system function, was administered to rats prior to 70% hepatectemy. Hepatic incorporation of 3H-thymidine 24 h after 70% hepatoctomy was significantly depressed by methylpalmitate-pretreatment. These data suggest that reticuloendothelial system plays a role in liver regeneration and that hepatocyte proliferation might be enhanced by protection from surgical stress and endotoxins with reticuloendothelial system stimulation by OK-432.

Effect of 70% partial hepatectomy on developmental expression of cytochrome P450 IVA1 within intrasplenically transplanted fetal hepatocytes from spontaneously hypertensive rats

Abstract Fetal hepatocytes were harvested at 20 days of gestation from spontaneously hypertensive rats (SHR) and then transplanted into recipient adult SHR spleens. Morphological examination of the recipient spleens revealed that after 4 weeks, large masses of hepatocytes were present in the red pulp, as well as cord-like structures. Immunochemical determinations revealed that cytochrome P450 IVA1 (cytochrome P450 LAω) could be detected without any prior induction. Cytochrome P450 LAω was detected in fetal hepatocyte microsomes from the spleens 6 weeks after fetal hepatocyte transplantation. Cytochrome P450 LAω and peroxisomal acyl CoA oxidase were expressed 6 weeks after transplantation in a 70% hepatectomized host. These results demonstrate that fetal hepatocytes can be successfully transplanted to the spleens of recipient hosts, and that fetal hepatocytes appear to grow and develop functional cytochrome P450 metabolizing systems.

A study of liver regeneration using fetal rat liver tissue transplanted into the spleen

The liver morphology of fetal hepatic tissue transplanted into an ectopic location was investigated over one year period. Fetal liver fragments prepared from a maternal rat on the 18th or 19th day of pregnancy were injected into the splenic parenchyma of syngeneic rats using a 21 gauge needle. Histologically, the fetal liver did not essentially show any apparent lobular architecture or cord structure. The transplanted fetal hepatic tissues survived and formed hepatic cords in the spleen instead of undergoing degeneration and necrosis. Three characteristic features became complete during the 4 weeks following transplantation, namely; clumps of hepatocytes with obvious hepatic cords and sinusoids, markedly proliferating bile ducts and proliferating individual hepatocytes. Macroscopic nodules of the hepatocytes on the spleen were seen at about 6 months after transplantation. When the differentiation of the transplanted fetal hepatic tissue was compared with the development of a normal neonatal liver after birth, it was delayed by only about one week, while there was no proliferation of bile ducts in the normal neonatal liver. This experimental model provides a useful system for investigating liver regeneration and the mechanism of cell growth.

Multilocational hepatocyte transplantation for treatment of congenital ascorbic acid deficiency rats

We attempted multilocational hepatocyte transplantation (HCTx) including hepatocyte-bearing polyurethane foam (PUF) to treat congenitally ascorbic acid (AsA) biosynthetic enzyme-deficient (ODS-od/od) rats. Hepatocytes isolated from the liver of congeneic rats were transplanted into the portal vein (Pv), spleen (Sp), omentum (Om), and mesentery (Ms). Hepatocyte-bearing PUF was transplanted into the Om and Ms. Experimental groups were divided into four groups (group I; Pv + Sp, group II; Pv + Sp + Om + Ms, group III; Pv + Sp + hepatocyte-bearing PUF, group IV; control). The average serum AsA level of the surviving rats in group II and III was significantly higher than that in group I 3 mo after HCTx. Histological examination showed small foci of surviving hepatocytes in the Om and Ms tissues and in the connective tissue in the PUF. ODS-od/od rats survived for a long time by multilocational HCTx.

Pravastatin-induced rhabdomyolysis and purpura fulminans in a patient with chronic renal failure

Highlights • Pravastatin monotherapy is associated with the potentially fatal side effect of rhabdomyolysis in a patient with chronic renal failure.• The pathogenesis of purpura fulminans with digital gangrene is unclear and thought to be related to the development of DIC.• We report an extremely rare case of pravastatin-induced rhabdomyolysis and purpura fulminans with DIC in a patient with CRF.• This is the first report of pravastatin monotherapy resulting in rhabdomyolysis of the multifidus muscle and purpura fulminans with DIC.