Gallbladder carcinoma producing alpha-fetoprotein.

Alpha-feto protein (AFP) is a clinically useful marker for hepatocellular carcinoma, hepatoblastoma, and nonseminomatous testicular tumors. Elevated serum AFP can also occur with tumors of the gastrointestinal tract, pancreas, lung, kidney, and urachus. Serum AFP can also be minimally elevated in nonmalignant conditions including acute and chronic hepatitis, cirrhosis, and pregnancy. Reports of gallbladder carcinoma that elaborate AFP are extremely rare, and almost all represent papillary carcinomas. Until now, there have been only two reports in the world literature that describe undifferentiated gallbladder carcinoma with elevated serum AFP. The authors present one case of undifferentiated gallbladder carcinoma and another case of poorly differentiated gallbladder carcinoma with increased serum AFP. In both cases, serum AFP was particularly useful in documenting metastatic recurrence of gallbladder carcinoma.

Exposure to Mycobacterium tuberculosis (MTB) in a renal transplant candidate: what further preoperative screening tests are available?

Despite negative preoperative screening for MTB, a renal candidate demonstrated active tuberculous lymphadenitis (TL) in a deep iliac node intraoperatively during living related renal transplantation. With intraoperative discovery of TL, both donor nephrectomy and renal transplant were aborted. The authors present this case of TL to discuss whether additional preoperative screening tests are available to document previous exposure to MTB in a renal transplant candidate. The diagnosis and treatment of MTB in patients on routine hemodialysis are reviewed. The authors review the operative case to emphasize that critical intraoperative measures must be taken to minimize operative and postoperative morbidity in the donor and recipient. Finally, the literature for current antibiotic regimens in the treatment of TL is reviewed.

Endoscopic biliary stent migration with small bowel perforation in a liver transplant recipient.

Intestinal perforation from a migrated biliary stent is a rare complication after endoscopic stent placement for benign biliary stricture. We provide the first description of stent migration and distal small-bowel perforation after stent placement for biliary anastomotic stricture in a liver transplant recipient. We review the current literature on the diagnosis and management of stent migration and intestinal perforation after endoscopic or percutaneous stent placement for benign and malignant biliary strictures. Early diagnosis and treatment of biliary stent migration and subsequent intestinal perforation are essential in transplant patients, in whom immunosuppression sometimes blunts signs and symptoms of intestinal perforation.

Pancreaticocystostomy revision for obstructive pancreatitis and pancreatic fistula after segmental pancreatic transplantation.

Combined kidney-pancreas transplantation is an effective surgical therapy for end-stage renal failure secondary to type I diabetes mellitus. However, obstructive pancreatitis and pancreaticocutaneous fistula remain significant postoperative complications unique to extraperitoneal segmental pancreatic transplantation. We present our experience with 13 patients (7 with obstructive pancreatitis and 6 with pancreaticocutaneous fistulae) after segmental extraperitoneal pancreatic transplantation, who subsequently underwent intraperitoneal reconstruction of the pancreaticocystostomy. This reconstruction was successful in 11 of 13 (85%) patients with minimal morbidity and no mortality. This intraperitoneal approach to reconstruction of the pancreaticocystostomy after segmental extraperitoneal pancreatic transplantation is a safe and effective means of graft salvage and this technique has not been described in the literature.

Permanent blindness after cyclosporine neurotoxicity in a kidney-pancreas transplant recipient.

Blindness is an extremely rare complication of cyclosporine neurotoxicity. In all 10 cases in the literature, this form of blindness is completely reversible with the reduction or withdrawal of cyclosporine. We describe the first case of sudden, complete, and permanent blindness within 36 h after administration of intravenous cyclosporine in a kidney-pancreas transplant recipient.

Rejection with duodenal rupture after solitary pancreas transplantation: an unusual cause of severe hematuria.

A common urologic complication after pancreas transplantation with bladder drainage is hematuria. However, hematuria is usually mild and self-limiting and rarely requires open surgical intervention. We report an unusual case of refractory hematuria that began 17 days after solitary pancreas transplantation due to severe rejection. The patient developed severe duodenal segment swelling with mucosal rupture that eventually required operative therapy. This case is illustrative of the diagnosis and management of gross hematuria after pancreas transplantation and demonstrates the limitations of cystoscopic techniques. This unusual complication must be considered in the differential diagnosis of refractory hematuria with pancreas allograft dysfunction and may represent a problem unique to solitary pancreas transplantation until better immunosuppressive strategies are available.