Joseph E. Murray

Donor-site morbidity after harvesting rib and iliac bone.

Morbidity following 104 bone graft harvesting operations (60 iliac, 44 rib) in 72 patients is documented. Early morbidity of iliac donor sites was found, as expected, to be far greater than that of rib donor sites. However, long-term follow-up reveals that while hip symptoms largely resolve, a significant number of chest-wall sites cause persistent, unpleasant pain. Technical ways of minimizing problems are also discussed. When procuring an iliac graft, a lateral skin incision and a medial bony approach are used if possible. If full-thickness ilium is required, the crest should be left intact or raised and replaced as a trapdoor .

Successful Homotransplantation of the Human Kidney Between Identical Twins

○ A patient whose illness had begun with edema and hypertension was found to have suffered extreme atrophy of both kidneys. Because of the steady worsening of the condition and the appearance of uremia with other unfavorable prognostic signs, transplantation of one kidney from the patients healthy identical twin brother was undertaken. Preparations included collection of evidence of monozygosity and experimental transplantation of a skin graft from the twin. During the transfer of the healthy kidney it was totally ischemic for 82 minutes. Evidence of functional activity in the transplanted kidney was obtained. The hypertension persisted until the patients diseased kidneys were both removed. The homograft has survived for 11 months, and the marked clinical improvement in the patient has included disappearance of the signs of malignant hypertension.

Kidney transplantation between seven pairs of identical twins.

Kidney Transplantation Between Seven Pairs of Identical Twins JOSEPH MURRAY;JOHN MERRILL;J. HARRISON; Annals of Surgery

PROLONGED SURVIVAL OF SKIN HOMOGRAFTS IN UREMIC PATIENTS

In the studies by Hume el al.’ on the functional survival of renal homotransplants in patients with chronic renal insufficiency, it was observed that the period of homotransplant function in 4 of 9 recipients ranged from 5 to 25 weeks. The course of the renal homotransplant in the normal dog contrasts with this wide range and long duration of the period of functional survival of renal homotransplants in the uremic patient. Irrespective of the manner in which the donor and/or recipient have been modified, including procedures known to suppress antibody formation, functional survival of the renal homotransplant in the dog seldom exceeds 1 week. Since there has been no uniformly successful experimental counterpart of chronic renal insufficiency in the dog, no information is presently available on the renal homotransplant function in the dog under these circumstances. In man, when the recipient does not have a chronic renal insufficiency, as exemplified by the case of Michon et aE.,2 the renal homotransplant functions well for about 3 weeks and then ceases to function rather abruptly, with the homotransplant showing the same morphologic pattern of rejection seen in the dog. This pattern has been interpreted as a morphologic representation of an antigen-antibody reaction; the immune response of the recipient to the renal homotransplant is believed to be the basis for the rejection. A delayed rejection or prolonged acceptance, therefore, may well represent an impaired immune response. Homotransplantation studies by Dempster3 and Simonsen4 have established a close antigenic relationship between the kidney and the skin. Should this relationship apply in man, one would expect the uremic recipient, if the prolonged functional survival is a manifestation of an impaired immune response, likewise to show a prolonged survival of skin homografts. I t was on this basis that the study to be described was undertaken. The first group of patients studied had chronic renal insufficiency with uremia that ranged from 4 months to 6 years in duration (TABLE 1). It may be noted that a variety of chronic lesions is represented, with uremia a common denominator. Skin homografts were accompanied by skin autografts in each case. The grafts were approximately square with an area of 3 to 4 sq. cm. The bed of the recipient site was subcutaneous tissue, and the grafts were full thickness. Biopsies from the homograft and the autograft were obtained simultaneously. Tissues were fixed in buffered 10-per cent formalin and processed through a modified Bouin solution. Hematoxylin and eosin, periodic acid-Schiff, Verhoeff-van Gieson, reticulum, and Feulgen stains were used. TABLE 2 summarizes the data on the recipient, donor type of homograft, the time interval to biopsy, and the estimate of the degree of homograft survival. “Pure” refers to grafts obtained from normal donors, “cortisone” to grafts from

Kidney Transplantation in Modified Recipients

Kidney Transplantation in Modified Recipients Joseph Murray;John Merrill;Gustave Dammin;James Dealy;Guy Alexandre;J. Harrison; Annals of Surgery

Extracranial meningioma presenting as a tumor of the neck

Abstract 1. 1. A case is reported of extracranial meningioma without any evidence of intracranial component presenting as a tumor of the neck or parotid region. Origin of growth was presumably from the vicinity of the jugular foramen and possibly from the dural sheaths of the vagus or spinal accessory nerves. 2. 2. The literature on extracranial meningiomas, both primary and secondary, is reviewed. The rarity of origin from cranial nerve sheaths, other than optic, is pointed out.

Facial fractures in children: an analysis of 122 fractures in 109 patients

A retrospective study of 122 facial fractures in 109 children, under 16 years of age, is reported. The data are analyzed in terms of fracture type, sex, age, etiology, therapy, and complications.

Use of Demineralized Allogeneic Bone Implants for the Correction of Maxillocraniofacial Deformities

Two major problems in maxillocraniofacial surgery are the limited amount offresti autogenous bone, the standard material for bone grafting, and the resorption of the grafted bone. Experimental studies with demineralized, devitalized bone matrix have shown induction of endochondral ossification. Fifty-five demineralized allogeneic implants have been used in 44 patients over the past two years for a variety of congenital (n = 37) and acquired (n = 7) defects. The allogeneic bone was obtained from cadavers, prepared as powders, chips or blocks, and was demineralized. After having been sterilized by irradiation, they were used to augment contour, fill defects, or construct bone within soft tissue. Of implanted sites that could be evaluated by physical examination, 31 of 31 were solid by three months. By radiographic examination three of 19 were healed by three months, and an additional 11 were positive by six months. Induced bone was seen in four of four biopsy specimens. Infection occurred in four of 44 patients (9%), comparable with conventional grafts. Implant resorption occurred in four instances. Allogeneic demineralized implants offer several advantages over conventional bone grafting, such as avoidance of a harvesting operation, ease of manipulation, and potentially unlimited material in banked form. In addition, healing by induced osteogenesis may bypass the resorption seen with healing of mineral-containing grafts

Immunologic Rejection of Human Cancer Transplanted with a Renal Allograft

Abstract Metastatic carcinoma of the bronchus, inadvertently transferred to a patient when a kidney was transplanted from a cadaveric source, underwent immunologic rejection in the new host. This metastatic focus in and around the transplanted kidney did not appear until 18 months after the allograft was placed. When immunosuppressive therapy was discontinued, the previously functioning kidney was promptly rejected whereas tumor growth did not appear to be altered. After removal of the kidney, however, the residual cancer disappeared. The patient received a second kidney transplant nine months after removal of the first. There has been no evidence of further metastatic cancer despite resumption of a full program of immunosuppression.

Surgical management of fifty patients with kidney transplants including eighteen pairs of twins.

Abstract Surgical experience with fifty patients with kidney transplant has been discussed. The selection of the potential recipient and donor, the consideration of the donor, the preparation of the recipient, operative technics, postoperative management, complications and results have been presented.