Postoperative Acute Kidney Failure and Incision Skin Necrosis Caused by a Giant Retroperitoneal Paraganglioma
A 68-year-old man presented with a history of proteinuria lasting for one year. Upon abdominal examination, a giant fixed mass measuring 22 cm by 18 cm was discovered. Laboratory tests revealed severe proteinuria, with a measurement of 3.0 g/24 hours, and severe hypoalbuminemia, with a serum albumin level of 29 g/L (normal range: 40–55 g/L). The patient reported passing foamy urine for approximately one year, with symptoms worsening in the 20 days prior to hospital admission. Inflammatory and tumor markers were within normal limits, but contrast-enhanced computed tomography (CT) of the abdomen revealed a giant cystic solid neoplasm extending from the right upper quadrant of the retroperitoneum to the pelvis. The tumor surface exhibited strong enhancement due to a rich supply of blood vessels.
The presence of the tumor, along with the associated proteinuria and hypoalbuminemia, prompted the decision for surgical removal of the abdominal mass. The en-bloc resection of the mass was particularly challenging and resulted in transient intraoperative hypotension due to decompression of the inferior vena cava and minor bleeding from the hypervascularized tumor capsule. Postoperatively, the patient developed acute kidney failure, characterized by increased serum creatinine levels and severe oliguria, as well as partial necrosis of the surgical incision on the first postoperative day. Kidney function fully recovered after one month of hemodialysis, administered three times weekly for four hours each session. The necrotic incision skin was successfully replaced by healthy skin following two weeks of treatment with topical alprostadil, a vasodilation agent.
Histopathological evaluation of the resected mass confirmed the diagnosis of retroperitoneal paraganglioma, a rare neuroendocrine neoplasm originating from extra-adrenal chromaffin cells. These tumors typically produce neuropeptides such as catecholamines, grow rapidly, and may progress to distant metastasis. Surgical excision is currently the only curative treatment for retroperitoneal paragangliomas, as they appear to be resistant to radiochemotherapy.
At the three-month follow-up visit, the patient’s proteinuria had resolved, and the serum albumin level was nearly normal. These findings supported the initial interpretation that the proteinuria and hypoalbuminemia were tumor-related. The patient’s normal blood pressure was consistent with a nonfunctional paraganglioma. The development of postoperative acute kidney failure highlighted the importance of controlling decompression during the resection of a giant abdominal mass to maintain stable intraoperative hemodynamics. However, the root cause of the acute kidney injury might have been the preoperative proteinuria.
Postoperative ischemic necrosis of the skin surrounding the abdominal incision is an extremely rare surgical complication. The efficacy of vasodilator treatment suggested a cause-effect relationship between insufficient blood supply and the skin necrosis. The increased skin tension resulting from the presence of the tumor had severely compromised the blood supply to the abdominal wall. Aberrant vessels connecting the compressed skin and the tumor had been established, and the removal of the mass led to an acute postoperative reduction in blood circulation in the skin.
At the latest follow-up visit, 28 months post-surgery, the patient remained disease-free and was very satisfied with his health status. He provided informed consent for the publication of this case report.
This case underscores the complexity of managing giant retroperitoneal paragangliomas, particularly the challenges associated with surgical resection and the potential for severe postoperative complications such as acute kidney failure and skin necrosis. The successful outcomes in this case were attributed to prompt and appropriate management strategies, including hemodialysis for acute kidney failure and topical vasodilator therapy for skin necrosis. The findings from this case emphasize the importance of careful preoperative assessment, meticulous surgical technique, and vigilant postoperative care in the management of such rare and complex tumors.
doi.org/10.1097/CM9.0000000000000113
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