A 45-year-old patient, with no personal history of interest except for occasional episodes of psychosis.
She suddenly presented with vomiting and general malaise without fever, cough or dyspnea, so she went to the emergency department where she was diagnosed with pneumonia and was admitted to hospital for antibiotic treatment.
The patient developed fever, progressive hypoxemia and oliguria 24 hours after admission and was admitted to the intensive care unit (ICU).
Upon admission to the ICU he had a respiratory rate greater than 40, oxygen saturation of 85% with reservoir, heart rate of 140 ppm, blood pressure 120/40 mmHg, temp-35o C. Physical examination showed no distal hemithorax.
Blood tests showed leukocytosis of 36400, Glucose: 266 mg/dL, Creatinine: 3.3 mg/dL, AST: 3127 U/L, ALT: 3139 U/L, Gam.
Gas: PH: 7,11.
PCO2: 41.
PO2: 44.
Saturation O2: 63.
Chest X-ray showed bilateral alveolar-interstitial infiltrate with right predominance.
Immediate intubation was performed and treatment with broad-spectrum antibiotics was initiated.
The patient presented with a multiorgan failure and in a new analytical right coronary artery the elevation of creatine phosphokinase and troponin was observed, so a transesophageal echocardiogram showed a mass in the upper lobe.
A computed tomography (CT) scan showed bilateral pleural effusion without pulmonary thromboembolism, dilatation and occupation of the intrahepatic inferior vena cava proximally reaching the right atrium and distally to the veins.
Hypodensity of the right suprahepatic vein compatible with secondary thrombosis and a right adrenal mass of 4 cm hypercapnia in close contact with the inferior vena cava.
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Having stabilized the patient was referred to the ICU of our center 4 days after admission, intubated and with multiorgan dysfunction, in order to plan surgical treatment.
Laboratory tests showed leukocytosis, AST: 165 IU/L, ALT: 1050 IU/L with normal ionogram and creatinine.
After evaluating the tests provided, given the severity of the condition, and since the imaging tests performed did not show distant metastases, emergency surgical treatment was proposed.
A bilateral subcostal laparatomy was performed at the same time as a longitudinal cystotomy.
Bilateral pleural effusion, slight pericardial effusion and heart with normal contraction in the thoracic cavity were observed, while laparotomy showed ischemia of segments 6 and 7 of the liver and right adrenal mass.
The General Surgery team performs anterior hepatectomy with intermittent Pringle maneuver, without turning the liver, sectioning the liver until it reaches the anterior face of the retrohepatic cavity.
Subsequently, the Urology team performs dissection of the right genital vein, ligation of the right genital vein, release of the renal vein and the anterior face of the right kidney after detaching the right colon.
The right adrenal gland is released, except for its superior and medial edge which is closely attached to the right wall of the vena cava.
The field for adrenal resection and right liver due to lack of cavotomy is exposed.
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Once this has been done, the Cardiac Surgery team performs extracorporeal circulation progressively lowering temperature up to 14oC esophageal level and rectally reaching 14oC. After performing cardiopulmonary bypass, the patient begins to maintain and maintain blood at 19oC.
This is when inferior cavotomy is performed at the adrenal level up to 2 cm of the diaphragm, right auriculotomy and removal of the tumor thrombus through the incision made in the inferior vena cava.
The right lateral wall of the vena cava was sectioned (from the adrenal vein to the right suprahepatic vein), extracting in block right liver with right suprahepatic and adrenal veins included in this patch, right adrenal gland and thrombus.
Thrombus rupture occurs at the level of the renal vein, so in a second time thrombus is extracted from the renal vein to iliac arteries.
Irrigation of the vena cava and right atrium was performed and, as no remnants of continuous thrombus or monofilament of the vena cava or right atrium were observed, vena cava and orejuela were closed separately.
Once this closure is performed, the patient is progressively reperfused and re-entry into extracorporeal circulation, re-warming the esophagus temperature and unclamping the aorta and perfusing the heart when reaching a temperature.
The onset of cardiac function allows the removal of extracorporeal circulation.
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Retroperitoneal and mediastinal drainages were placed in the right renal fossa.
During the intervention, 14 erythrocyte concentrates, 1200 ml plasma and 2 units platelets were transfused.
During the stay in the ICU an abdominal ultrasound is performed showing good permeability of the left hepatic venous system and vena cava.
Ten days later, the patient became conscious, oriented and cooperative, but presented weakness in the four limbs.
The patient remains in the ward for 20 days receiving passive and assisted generalised kinesiotherapy.
After a good evolution in mobility, the patient was discharged and no treatment was required except for low molecular weight heparin.
Pathology reports pheochromocytoma affecting the right adrenal gland with a larger diameter of 2 cm. The tumor is not encapsulated and extends outside the adrenal gland without affecting adjacent organs.
There is extensive tumor necrosis.
The adrenal gland does not show abnormalities.
The lymph nodes studied showed no tumor.
In the hepatic parenchyma there are extensive areas of centrilobular hemorrhage, with necrosis of hepatocytes without observing tumor cells in the fragments studied of the hepatic parenchyma.
Infrarenal thrombus, there is no evidence of tumour cells.
In the review carried out at 2 months, the patient was asymptomatic, performing active life and CT showed no lesions suggestive of tumor disease.
