Tsunamasa Inou

Changes of bone remodeling immediately after parathyroidectomy for secondary hyperparathyroidism

BACKGROUND Successful parathyroidectomy for secondary hyperparathyroidism alleviates bone pain and is followed by the development of hypophosphatemia and hypocalcemia, as well as an increase in bone mineral density. An increase in osteoblast surface (Ob.S/BS) is not observed several months after surgery. In this study, we investigated early bone changes at 1 week after parathyroidectomy and the mechanism underlying an increase in bone mineral density. METHODS Fourteen patients with severe secondary hyperparathyroidism underwent iliac bone biopsy before and 1 week after parathyroidectomy. Changes in histomorphometric parameters, including osteoclast surface (Oc.S/BS), eroded surface (ES/BS), erosion depth (E.De), fibrosis volume (Fb.V/TV), Ob.S/BS, osteoid volume (OV/BV), osteoid surface (OS/BS), and osteoid thickness (O.Th), were investigated. Changes in texture of mineralized bone and osteoid seams were also investigated. RESULTS Oc.S/BS (P < 0.001), ES/BS (P < 0.01), and E.De (P < 0.001) decreased, but Fb.V/TV did not change at 1 week postoperatively. In particular, osteoclasts disappeared in almost all patients. Ob.S/BS (P < 0.001) increased, and cuboidal osteoblasts were proliferating on the trabecular surface where osteoclasts had existed before parathyroidectomy. As a result, newly developed osteoblasts coexisted with fibrous tissue after surgery. OV/BV (P < 0.005), OS/BS (P < 0.005), and O.Th (P < 0.005) increased, with lamellar osteoid volume showing a particular increase. Bone mineralization continued despite the low postoperative serum parathyroid hormone level. CONCLUSION A rapid decrease in serum parathyroid hormone level after parathyroidectomy appears to suppress bone resorption, as well as cause a transient marked increase in bone formation and an increase in normal lamellar osteoid seams.

Blood vessel repair utilizing a new plastic adhesive: Experimental and clinical studies

Summary Compared with Eastman 910 (90% alphamethyl-cyanoacrylate monomer), Aron Alpha S-2 (98% alpha-ethyl-cyanoacrylate monomer) elicited less tissue reaction on adventitia and less thrombus formation on intima and maintained its tensile strength in vivo over a much longer period of time. Aron Alpha A-2 was able to repair longitudinal vessel incisions without a single suture, resulting in 100 per cent patency in 24 vessels. This adhesive yielded a patency rate of 88.2 per cent (53/68) in end-to-end carotid artery anastomoses when used with three stay sutures without stent. This patency rate is as good as that of routine meticulous continuous suture. Wrapping, invagination and stay suture, all with stent, failed to surpass routine continuous suture in terms of resulting patency rate. Use of Aron Alpha S-2 made possible a speedy and yet bloodless operation in end-to-side anastomoses of 5 carotid arteries, end-to-end anastomoses of 18 external jugular veins and anchoring of 6 peeled intima. They were all patent at sacrifice 14 to 180 days after surgery, except 3 jugular veins complicated by bacterial contamination. Twenty-one patients underwent vascular surgery using plastic adhesives, Eastman 910 for one patient and Aron Alpha S-2 for 20 patients. More extensively described are six patients who required repair of diseased vessels. Aron Alpha S-2 was unable to restore the blood flow in a patient with bilateral occlusion of femoral arteries. In 20 other patients, vessel repairs with plastic adhesives were successful in reestablishing and maintaining blood flow.

Development of low-turnover bone diseases after parathyroidectomy and autotransplantation

Abstract Parathyroidectomy and immediate autotransplantation (PTX‐AT) has been shown to decrease bone pain and increase bone mineral density. However, adynamic bone disease (ABD) has been predicted to develop if the serum intact parathyroid hormone (i‐PTH) level remains lower than normal for a long period of time. Therefore, we investigated the bone histology of patients whose serum i‐PTH levels did not increase over 70 pg/mL for 1 year after PTX‐AT. Four chronic hemodialysis patients were investigated. The serum intact osteocalcin (i‐OC) level was measured and histomorphometry for cancellous bone was performed 1 year after the operation. Tetracycline hydrochloride was administered in the 12 weeks after PTX‐AT. The serum i‐PTH levels were 20.5 ± 15.0 pg/mL and i‐OC levels were 19.5 ± 0.9 ng/mL. Histomorphometric analyses showed the osteoclast surface to be 0.1% in two cases and 0% in the other two cases, the eroded surface was 7.7 ± 6.1%, and the fibrosis volume and osteoblast surface were 0% in all four cases. Osteoid volume, osteoid surface and osteoid thickness were lower in cases 1–3, but higher in case 4. All tetracycline labelings were in contact with the mineralization front in cases 1 and 3, but some were not in cases 2 and 4. Serum i‐PTH and i‐OC levels indicated that ABD developed in these four cases. Histomorphometric analyses revealed that ABD developed in case 1, while either ABD or low‐turnover osteomalacia developed in cases 2 and 4, and low‐turnover osteomalacia was observed in case 3 after PTX‐AT. In conclusion, i‐PTH should not be maintained at lower levels to avoid low‐turnover bone diseases.

Allotransplantation of the pancrease in dogs

Abstract En block transplantation of the pancreas and duodenum was performed in 30 pancreatectomized dogs, 10 of which served as a control group and the remaining 20 as the azathioprine group. The latter were orally administered (6 mg. per kilogram) azathioprine every day. The former group lived an average of 10 days; and the latter, 22 days. Rejection was a cause of death in 6 of the control group and in 6 of the azathioprine group. In 5 of these 12, however, the last fasting blood glucose level was over 150 mg. per deciliter, suggesting that hyperglycemia is not an initial sign of rejection but rather its terminal sign. Histological study revealed that acute rejection resembling acute pancreatitis was a phenomenon observed in the control group, while chronic rejection manifested by interstitial fibrosis was characteristic of the azathioprine group. Azathioprine is effective in suppressing the acute rejection process but is unable to prevent fibrotic process.

Manifestations of rejection of pancreaticoduodenal allografts.

Transplantation of pancreaticoduodenal allografts was done in 30 totally pancreatectomized dogs. Ten hosts served as a control group and the remaining 20 were treated with azathioprine for immuno-suppression. Excepting two hosts (one in each group) which died of anastomotic complications, the control hosts lived for 3–20 days (averaging 10 days) and the azathioprine-treated hosts for 7–63 days (averaging 22 days). In both groups, hyperglycemia occurred rarely and only after a preponderance of islets were destroyed by rejection; it was therefore considered a terminal event. Serum amylase increased sharply at the start of rejection in control hosts and decreased rapidly to the preoperative level once the initial phase of rejection had passed. In azathioprine-treated hosts, small retarded rises in serum amylase were observed. Histologically the rejection patterns in the allografts were either acute or chronic. A chronic rejection pattern was found only in such allografts as stayed for more than 3 weeks in azathioprine-treated hosts. In the transplanted pancreas, there was no difference between the resistance of acinar cells and that of islet cells against the hosts immunological attack. Different parts of the allograft showed different susceptibilities to the host reaction. The parenchyma of the pancreas and of the duodenum, as organs, succumbed readily to the immunological attack. Some lymph nodes were relatively resistant. Nerves and blood vessels maintained their histologic integrity longer than other tissues of the allograft.

Cross-reactive antibodies against human cultured B cells and bovine erythrocytes in human renal transplantation sera.

Sera of 58 recipients of renal allografts were studied for the presence of antibodies against cell cultures of human B lymphoid cell lines (B-LCL) and bovine erythrocytes (BRBC). Cytotoxic anti-B-LCL antibodies were found in 13% of the sera from recipients with the grafts and in 67% of the sera obtained after removal of the rejected grafts. Most of these sera also contained BRBC lysins of high titers. Absorption studies showed that the anti-B-LCL antibodies are directed against antigens shared by BRBC and that they can be absorbed with corresponding graft tissues. The specificity of BRBC lysins found in some of the transplantation sera was shown to be similar to that of Hanutziu-Deicher antibodies.

Vascular Changes in the Pancreaticoduodenal Allograft

* From the Second Department of Surgery, Tokyo University School of Medicine, 7-chome, Hongo, Bunkyo-ku, Tokyo, Japan. An allotransplanted organ is soon exposed to and attacked by the host’s immunologic reaction. Rapidly changing histologic features of the transplanted organ in the host environment have attracted an attention of many investigators. 1-4 Vascular changes in the transplanted organ are of vital importance in the graft rejection phenomenon because the graft vessel is the place where the host’s cytotoxic antibody5 first meets the graft antigen, and the host’s immature plasma cells make cytoplasmic continuity with the graft’s endothelial cells.’ Vascular changes in the allograft are of interest in comparison with polyarteritis nodosa,s lupus erythematodes and scleroderma which

Renal Allografts With Glomerulonephritic Change and Proteinuria

Eight cases of renal allografts with glomerulonephritic change and proteinuria were classified into three groups according to the morphological features of the glomerular lesions. Group I (3 cases): By light microscope, remarkable reduplication of glomerular basement membrane (GBM), widening of mesangial region, and slight increase in mesangial cells, were observed. Electron microscopy revealed thickening of subendothelial space by deposition of electron‐lucent material, mesangial interposition, and dense deposits in various regions (mainly in the subendothelial space). Group II (3 cases): By light microscope, crescent formation and reduplication of GBM were observed, while by electron microscope, changes of GBM similar to group I, but less remarkable, were seen. Group III (2 cases): Light microscope revealed spike formation in one case, but not in the other. With an electron microscope, subepithelial dense deposits were observed in both cases. Thickening of subendothelial space by deposition of electron‐lucent material was noted in one case, while thickening of lamina densa was observed in the other case. Morphological change caused by rejection was observed in all eight cases, with six cases showing massive proteinuria and the other two showing slight proteinuria.

Successful surgical treatment for hepatic encephalopathy caused by a pancreatic siphon: Report of a case

We report herein the case of a 39-year-old man with cirrhosis of the liver who developed hepatic encephalopathy and progressive diabetes caused by a pancreatic siphon after undergoing a distal splenorenal shunt (DSRS) for a variceal hemorrhage.Radiologic occlusion was judged to be inappropriate because of the extensive DSRS. The DSRS was surgically closed 6 years after the operation to restore portal perfusion. To alleviate the portal hypertension, splenectomy and gastric devascularization were performed, which proved successful, as the encephalopathy disappeared completely, the ammonia levels decreased, liver function improved, and the diabetes subsided. Our experience indicates that a small percentage of cirrhotic patients who undergo DSRS with longterm followup may develop various undesirable complications, although some of these patients benefit from a combination of surgical shunt occlusion, splenectomy, and gastric devascularization.