Results and conclusion (351
words):
Shortly after the surgery commenced, the patient abruptly developed a
hypertensive crisis, with a peak blood pressure of 210/95 mmHg and
requiring the administration of 0.5 mg of nicardipine. The surgery then
went ahead. During the manipulation of a 5-cm left pararenal lump, the
patient abruptly developed another hypertensive crisis of up to
210/80 mmHg, which was not controlled by the titration of 0.5%
bupivacaine in the epidural catheter and which required the titration of
nicardipine and an increasing minimum alveolar concentration of
sevoflurane. Because of the circumstances, a paraganglioma was
suspected. The left nephrectomy was quickly completed, and the patient
then experienced severe hypotension, requiring norepinephrine up to
35 µg/min. Mean arterial pressure remained below 60 mmHg, requiring
phenylephrine and adrenaline up to 40 µg in conjunction with aggressive
filling. Blood pressure normalised after 40 minutes while continuous
high doses of norepinephrine were maintained. Due to the haemodynamic
instability, the surgeon ordered frozen section biopsies, which
confirmed an unsuspected peri-renal paraganglioma. (Figure 3) An
intra-aortic-caval lymph node dissection was also performed for tissue
samples.
The right nephrectomy proceeded uneventfully. Blood loss was estimated
at 700 ml. The abdomen was closed, and the patient was transferred to
the intensive care unit, sedated and intubated.
No organ failure occurred during the patient’s intensive care unit stay.
On day 1, she was weaned off aminergic support and successfully
extubated. On day 7, she presented with an occlusion of the
arteriovenous fistula. Surgical unblocking was performed under local
anaesthesia and sedation with propofol, with no complications. No other
postoperative complications were noted. The patient spent a further 22
uneventful days in the Department of Visceral Surgery. She was
discharged home from the hospital and returned for dialysis three times
a week. Unexpectedly, the definitive pathology report revealed a 13-cm
metastasis of the previously diagnosed myxoid liposarcoma on the right
side. The lymph node dissection showed 7 negative nodes and a second
0.4-cm paraganglioma.
On day 25, the patient went home with follow-up appointments at the
Nephrology and Oncology outpatient clinics. Due to the patient’s
metastatic state, the whole transplantation project was put under
review.