Left Retroperitoneal Space Research Articles

Giant aneurysm of the abdominal aorta

A 79-year-old man with a history of smoking, hypertension, chronic pulmonary disease, and nondisabling stroke was admitted to the emergency department due to loss of consciousness and diffuse abdominal pain. At admission, the patient was vigil but hypotensive (90/60 mm Hg) and tachycardic (107 bpm). Physical examination revealed a tender, pulsatile mass occupying the entire abdomen (A). His hemoglobin level was 6.5 g/dL. Computed tomographic angiography revealed a giant infrarenal aortic aneurysm with a maximum transverse diameter of 256 mm (B and C). A small layer of blood was visible in the left retroperitoneal space. Considerable displacement of the mesentery and left kidney was evident after postprocessing reconstruction (D). Anatomic constraints, which included a severely angulated, wide conical infrarenal neck, tortuous iliac arteries, and wide aortic lumen, precluded endovascular repair. The patient underwent emergency open repair through a transperitoneal midline approach. Temporary supraceliac aortic clamping was necessary for proximal control. After evacuation of the aneurysm sac content, an inlay aortoeaortic Dacron graft reconstruction was performed (E). Despite prolonged hospitalization due to respiratory complications and transient renal deterioration, the patient was discharged home after 39 days. The rupture risk of abdominal aortic aneurysms is intimately associated with the maximum diameter. However, other factors are known to influence the risk of rupture, and individual variability is considerable. Current recommendations advise repair for aneurysms >5.5 cm in diameter. For aneurysms >6 cm, the annual rupture risk exceeds 14%. Therefore, it is rare to encounter very large aneurysms (>10 cm); most would have previously ruptured or undergone repair. Unidentified protective factors for rupture possibly may allow aneurysms to occasionally grow insidiously to extreme dimensions. Although open repair may present significant technical difficulties, endovascular repair with current endovascular devices is frequently impossible due to anatomic limitations. To our knowledge, this case represents the largest abdominal aortic aneurysm ever reported.

Cystic local recurrence of renal cell carcinoma after laparoscopic radical nephrectomy in a hemodialysis patient

Although local recurrence of renal cell carcinoma after laparoscopic radical nephrectomy is sometimes reported, cystic local recurrence of renal cell carcinoma has rarely been reported. We report the case of a 59-year-old man with hemodialysis who developed cystic local recurrence of renal cell carcinoma accompanied by acquired cystic disease of the kidney in the retroperitoneal space after laparoscopic radical nephrectomy. A cystic tumor of 5.1 cm in diameter occurred in the left retroperitoneal space 15 months after left laparoscopic radical nephrectomy, and enlarged to 7.2 cm in diameter with enhanced mass along the wall of the cyst 36 months after surgery. The cystic tumor was removed and showed local recurrence of renal cell carcinoma on pathological examination.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis.

IntroductionOne of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion.AimWe are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method.Material and methodsWe performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy.ResultsThere were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days.ConclusionsMinimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Extrarenal Retroperitoneal Angiomyolipoma Mimicking Metastatic Melanoma

A 38-year-old man with melanoma of the right flank underwent a staging 18F-fluoro-2-deoxyglucose (FDG) PET/CT scan, which demonstrated a hypermetabolic extrarenal mass in the left retroperitoneal space, concerning for metastatic melanoma. However, surgical pathology demonstrated an angiomyolipoma (AML). Although AMLs can rarely occur in an extrarenal location, extrarenal retroperitoneal AMLs are exceptional. AMLs have variable imaging appearances on multiple imaging modalities, including FDG PET, and can confound accurate diagnosis when in an extrarenal location. This case demonstrates the only known FDG PET description of an extrarenal retroperitoneal AML and highlights the challenge in accurate diagnosis based on FDG PET findings.

Clinical Analysis of Childhood Pancreatoblastoma Arising From the Tail of the Pancreas

Pancreatoblastoma is a rare pancreatic tumor. In this study, 3 cases of childhood pancreatoblastoma that arise from the tail of the pancreas were reported. Abdominal pain and vomiting were observed in 1 case considering the huge size of the tumor. The other 2 patients, who were previously well, complained of a mass in the abdomen after a casual physical examination. Elevated serum α-fetoprotein levels were noted in all cases. Imaging findings indicated a well-defined heterogeneous large mass in the left retroperitoneal space. Exploratory laparotomy revealed a large mass, arising from the tail of the pancreas. Surgery alone with complete excision of the masses was performed. Immunohistochemical staining showed that only α-fetoprotein was positive in all cases. All of these 3 cases have a good outcome in the follow-up without adjuvant chemotherapy. These data suggest that the diagnosis of pancreatoblastoma is difficult and should be suspected at palpation of an abdominal mass. α-Fetoprotein may serve as a tumor marker for preoperative diagnosis and postoperative recurrence. Pancreatoblastoma arising from the tail of the pancreas is a curable tumor, and adjuvant chemotherapy may not be necessary if the tumor can be excised completely.

Spontaneous retroperitoneal hemorrhage after hemodialysis involving anticoagulant agents

In this paper, we described the symptoms and treatment of a patient with diabetic nephropathy accompanied by spontaneous retroperitoneal hemorrhage after hemodialysis. An elderly female patient with diabetic nephropathy presented with severe pain, numbness, and an increasing swelling in the left hip and left thigh after six sessions of hemodialysis involving the use of an antiplatelet drug and an anticoagulant agent. Her hemoglobin decreased to 46 g/L. An abdominal ultrasound showed a hematoma in the left retroperitoneal space, and computed tomography (CT) findings revealed a 6 cm × 8 cm × 10 cm hematoma in the left psoas muscle. After aggressive supportive therapy [the administration of packed red blood cell transfusion, carbazochrome sodium sulfonate injection, and continuous venovenous hemofiltration (CVVH)], the patient's vital signs stabilized and her hemoglobin increased to 86 g/L. Repeat CT showed that the hematoma had been partially absorbed after two weeks. Eventually, the patient was discharged with stable vital signs. Physicians should be aware of the possibility of spontaneous retroperitoneal hemorrhage, particularly in patients with diabetic nephropathy undergoing hemodialysis involving the use of anticoagulant agents.

Subcutaneous emphysema of the leg: Could be a fatal condition

Gas in the leg is not always a gas gangrene. Abdominal infection with gas forming organisms may spread to the thigh & leg. We report a case of critically ill patient who presented to the emergency department with features suggestive of septic arthritis of the left hip. Assessment and further intervention revealed subcutaneous emphysema of the leg secondary to an infection of a previously asymptomatic staghorn calculus. X-ray of the abdomen showed a left renal stone and gas in the soft tissue planes of the left retroperitoneal space while X-ray of the left femur showed gas in the soft tissue planes of the left hip region and whole thigh with no bony or joint abnormality. Such case has not been reported in English literature before. Physicians and surgeons should be aware of this condition that could be fatal but curable by early intervention.

A rare retroperitoneal schwannoma in a patient with neurofibromatosis Type 2.

Neurofibromatosis Type 2 (NF2) is a dominantly inherited tumour-prone disorder, characterized by the development of multiple schwannomas, meningiomas and ependymomas. Its prevalence is around 1:60 000. Vestibular schwannoma (VS) is the hallmark of NF2. Retroperitoneal schwannomas are expected to occur in only 3% of cases. We present the case of a large retroperitoneal schwannoma in a patient with NF2. A well-circumscribed heterogenic mass (9.5 × 4 × 4 cm) behind and under the left kidney and extending into the left retroperitoneal space was revealed during a lumbar and retroperitoneal space magnetic resonance imaging (MRI). Brain, orbits, cervical, thoracic and lumbar MRI revealed bilateral VS, multiple meningiomas as well as multiple schwannomas and ependymomas in the cervical, thoracic and lumbar spine. The retroperitoneal mass represents a schwannoma probably derived from an intercostal nerve. The patient underwent neurosurgical excision of the VS, and 3 months later, the patient's condition remained stable.

Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis

Because of major morbidity and mortality after open surgery in acute necrotic pancreatitis, an interest in minimally invasive necrosectomy approaches has increased. We report the results of a recently developed minimally invasive technique that we adopted in 2007. This article contains a retrospective analysis of cases and description of original retroperitoneoscopic necrosectomy technique. There were eight patients aged 25-58 years, who underwent retroperitoneoscopic pancreatic necrosectomy in the Center of Abdominal Surgery, Vilnius University Hospital Santariskiu Klinikos, between 2007 and 2009. All patients had at least 30% pancreatic necrosis with extensive retroperitoneal fluid collections on the left side, proved by CT scan. Operations were performed on the 21st-56th days of illness (median, 36th day). The mean postoperative hospital stay was 49 days (range, 14-99 days). All patients survived. Two patients underwent three additional procedures; two patients, one additional procedure due to remaining infected necrosis. Three patients had no requirement for additional procedures. One patient underwent laparotomy because of bleeding. We assume that minimally invasive techniques should be considered a first-choice surgical option in patients with acute necrotic pancreatitis, whenever it is possible. Pancreatic necrosis less than 30% with large fluid collections in the left retroperitoneal space facilitates employment of three-port retroperitoneoscopic necrosectomy.

Alveolar soft part sarcoma of the retro peritoneum

Alveolar Soft Part Sarcoma (ASPS), also called Alveolar Soft-Tissue Sarcoma, is a rare type of soft-tissue neoplasm with a poor long term prognosis. Such tumors originating in the retro peritoneal space are extremely rare. In this article we discuss a 34-year-old woman who was referred to our hospital with an increasing mass in her left lower abdomen. Ultrasonography and conventional Computed Tomography revealed a large hard mass occupying the left retroperitoneal space with a clear border. The pathological diagnosis was ASPS.

Malignant Triton tumor in the retroperitoneal space associated with neurofibromatosis type 1: a case study

We report an extremely rare case of malignant Triton tumor developing in the retroperitoneal space in a patient with neurofibromatosis type 1. A 21-year old man who had been diagnosed with neurofibromatosis type 1 was admitted to our hospital with the chief complaint of a palpable abdominal mass. Abdominal computed tomography revealed a huge heterogeneous tumor measuring approximately 17 cm in diameter occupying the left retroperitoneal space, and numerous metastatic lesions between the left psoas muscle and the left thigh with dissolution of the left hip joint. After the diagnosis of a retroperitoneal malignant neurogenic tumor, resection of the tumor with reconstruction of the abdominal aorta was conducted, followed by postoperative transarterial infusion chemotherapy. The histopathological diagnosis was malignant peripheral nerve sheath tumor with rhabdomyosarcomatous differentiation, namely malignant Triton tumor. Postoperative chemotherapy was in vain and the patient died 14 months after the surgery as a result of lung metastasis.

Haematuria and hydronephrosis caused by Castleman's disease.

A 16-year old man was referred with intermittent gross haematuria and left flank pain. On physical examination, there was a large mass in the left flank. Enhanced computed tomography demonstrated a 10 cm solid mass on the left retroperitoneal space compressing the renal pelvis and causing hydronephrosis on the left kidney. A few small lymph nodes were noted on the left para-aortic region (Figure ​(Figure1A1A and B). F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed a mildly hypermetabolic tumour in retroperitoneum with para-aortic lymph nodes. The mass was resected surgically. Operative findings showed a huge retroperitoneal mass and upward displacement of the left kidney and ureter by the mass. The histopathological diagnosis of the resected tissue revealed hyaline vascular type of Castleman's disease (CD) (Figure ​(Figure2).2). Histologically, lymphoid follicles showed marked vascular proliferation and hyalinization of their germinal centre. There was a tight concentric layering of lymphocytes at the periphery of the follicles, resulting in an onion skin appearance. CD is a rare lymphoproliferative disorder characterized by hyperplasia of lymphoid follicles and proliferation of lymphocytes. CD consists of unicentric Castleman's disease (UCD) and multicentric Castleman's disease (MCD). UCD is often a benign disorder not associated with human herpesvirus 8 (HHV-8) infection, while MCD is associated with HHV-8 infection and immunosuppression [1,2]. The patients with CD may have complications including infection, nephrotic syndrome and malignancy such as Kaposi's sarcoma, Hodgkin lymphoma and non-Hodgkin lymphoma [3,4]. Although Castleman's disease is a rare retroperitoneal tumour, we should always consider this tumour in the differential diagnosis of retroperitoneal mass associated with hydronephrosis and haematuria. Fig. 1 Contrast-enhanced computed tomography demonstrated a 10 cm solid mass on the left retroperitoneal space (arrow) (A) and severe hydronephrosis on the left kidney (arrow) (B). Fig. 2 Microscopic features are a typical pattern of hyaline-vascular Castleman's disease. The lymph node contains atrophic follicles with hyalinized vessels and concentric rings of lymphocytes. (H&E stain, × 200). Conflict of interest statement. None declared.

A Case of Renal Capsular Liposarcoma with Intracaval Fat Thrombus

A 58-yr-old woman was referred to our hospital for hematuria and a painless, rapidly growing abdominal mass. Computed tomography showed a rounded mass, 23×19cm in diameter, spread over the left retroperitoneal space. A thrombus was observed occupying the left renal vein until the vena cava. Total left nephrectomy with excision of the retroperitoneal mass was carried out. A cavotomy highlighted the intraluminal thrombus, which was easily detached with a forced Valsalva maneuver. The pathologic examination demonstrated a well-differentiated liposarcoma of the renal capsule with fat thrombus in the vena cava. At 24 mo follow-up, there was no evidence of recurrence.

Technique for repair of suprarenal and thoracoabdominal aortic aneurysms

Suprarenal and thoracoabdominal aortic aneurysms represent significant surgical challenges. For patients with associated aortic dissections, current endovascular technology has not been matured to address branch reconstructions that derive from separate lumens, making open surgical reconstruction the only proven method for repair. The required exposures of the thoracoabdominal aorta are expansive, and the extent of aortic replacement mandates efficient technique. Furthermore, a well-orchestrated team of surgeons, nurses, anesthesiologists, and perfusionists are all integral to achieving good outcomes and keeping operative courses tightly managed. Techniques to address extensive aneurysms of the thoracoabdominal aorta are reviewed in detail here, and videos are provided on The Journal website to show relevant anatomical features.

Infections After Simultaneous Pancreas and Kidney Transplantation: A Single-Center Experience

Simultaneous pancreas–kidney transplantation (SPKT) is now an accepted therapy for patients with insulin-dependent diabetes mellitus. However, SPKT has an high rate of morbidity and mortality, mainly for infection. From October 1986 to June 2008, in our center 54 patients (18 female; 36 male) affected by diabetes and end-stage renal disease underwent SPKT. The mean duration of diabetes mellitus was 25 ± 4 years. Only 4 patients had not been treated by dialysis before SPKT. Three operative techniques were used: duct injection ( n = 5), bladder diversion ( n = 14), and enteric diversion ( n = 39). The kidneys were always placed into the left retroperitoneal space. The pancreas was placed extraperitoneally in 5 patients. Thirty-four recipients are alive, including 30 with function of both grafts. Six patients died during the first year after transplantation. Infectious complications were the main cause of death in 3 subjects whereas 98 infections were diagnosed in 51 patients. All patients were treated with immunosuppressive agents: steroids associated with calcineurin inhibitors and mycophenolic acid, or azathioprine. Antibody induction was used in 41 patients with anti–interleukin-2 monoclonal antibody or antithymocyte globulin. We detected 41 episodes of cytomegalovirus infection: systemic ( n = 38), bladder ( n = 2), and duodenal ( n = 1). The 51 bacterial infections were systemic: ( n = 10); urinary tract: ( n = 22); pulmonary ( n = 11); wound ( n = 5); intestinal ( n = 3). The 5 fungal infections were gastrointestinal tract ( n = 3); and arteritis ( n = 2). Some patients experienced more than 1 type of infection. The predominant etiology of the systemic infections was bacterial. In conclusion, infectious complications were the main causes of morbidity after SPKT. An early diagnosis of infection, particularly fungal complications, is essential. We recommend administration of broad-spectrum prophylactic antibiotics, antifungals, and antiviral agents.

A Case of Retroperitoneal Mucinous Cystadenoma Treated Successfully by Laparoscopic Excision

A case of retroperitoneal mucinous cystadenoma treated laparoscopically is reported. A 26-year-old woman, who complained of abdominal fullness, was referred to us after a large intra-abdominal mass was discovered at her local hospital. Ultrasound and computed tomography showed a fluid-filled mass, 9 cm in diameter, in the left retroperitoneal space. Laparoscopic surgery was performed. We found a smooth and thin-walled cystic tumor that displaced the descending colon to the right and arose from the retroperitoneum, loosely adhering to the psoas muscle. We successfully extirpated the tumor laparoscopically. The surgical specimen consisted of a multilocular, red to yellowish-gray, cystic mass with a smooth, glistening external surface, and inner lining. The mass was filled with thin, yellowish fluid. The histologic diagnosis was benign mucinous cystadenoma. The postoperative course was uneventful, and the patient remains free of recurrence 15 months after surgery. Retroperitoneal mucinous cystadenoma is a rare entity, and the treatment of choice is surgical excision. Laparoscopic extirpation should be considered for the treatment of selected retroperitoneal cystic lesions.

Left retroperitoneal paraganglioma with enlarged ovarian vessels

A 40-year-old woman was suffering from a vague abdominal pain with presence of a mass in the left hypochondrium. Abdominal computed tomography showed a heterogenous enhancing mass in the left retroperitoneal space with absence of the left ovary. There were enlarged pelvic vessels supplying the mass, which was confirmed to be the left ovarian artery and vein on diagnostic angiography. A laparotomy was performed and histopathology examination showed a retroperitoneal paraganglioma.

Rupture of left common iliac artery aneurysm

A hypertensive 73-year-old man was found unconscious after cardiopulmonary arrest at his home and was brought to the emergency department by ambulance with cardiopulmonary resuscitation in progress. His Glasgow coma scale was 3, and there was no blood pressure. At the time, the hemoglobin value was 9.7 g/dL and the serum creatinine level was 2.0 mg/dL. Arterial blood gas analysis showed severe metabolic acidosis. The patient was resuscitated and underwent a rapid computed tomography (CT) scan. This detected a rupture of a left common iliac artery aneurysm (56 mm diameter), with a massive hematoma in the left retroperitoneal space (A, B). He was taken to the operating room, but on arrival had again lost his blood pressure despite fluid and blood resuscitation. In an attempt to obtain hemodynamic control, the descending thoracic aorta was rapidly clamped through a 5th right intercostal space thoracotomy. After the blood pressure returned, a laparotomy was performed. Bloody fluid was encountered in the peritoneal cavity, and the retroperitoneal space was filled with hematoma, consistent with rupture of the left common iliac artery. The patient died in the operating room before repair could be accomplished. Stent-graft treatment was not possible because it is not available in our institution. Subsequent three-dimensional CT (3D-CT) reconstruction demonstrated a bleeding mass from the left common iliac artery aneurysm that appeared as a “fireball” (C, Cover). The mortality rate of patients with ruptured abdominal aortic aneurysm arriving at hospital ranges from 32% to 70%, and in one study, the mortality rate increased to 90% if patients who died in transit or at home were included. Ruptured iliac aneurysms, although much less common, have a similar prognosis. The factors associated with a mortality rate are unconsciousness, low systolic blood pressure, cardiac arrest, low urine output, high serum creatinine levels, and signs of blood loss. In the present case, all these factors were present. The unusual appearance of the reconstructed 3-D CT scan was most likely associated with very rapid blood extravasation from the ruptured aneurysm.

後腹膜脱分化型脂肪肉腫の一例

A 64 year-old female visited our outpatient clinic with left dull flank pain. The ultrasonography and CT scans showed the large solid mass in 12 cm in maximum diameter, containing large area of fatty element, in the left retroperitoneal space. Under the diagnosis of retroperitoneum liposarcoma, the mass and left kidney was completely removed. Pathological examination revealed the dedifferentiated liposarcoma which contained the distinct two patterns of well differentiated lipoma and dedifferentiated fibrotic sarcomatoid tissue.

腎周囲組織より発生した悪性線維性組織球腫の1例

A 79-year-old man who had low grade fever and general malaise was referred to our hospital on January 27, 2004. Physical examination revealed a hard fixed painless mass, measuring 10 cm in the left abdomen. Sarcoma of retroperitoneal origin was suspected preoperatively by abdominal ultrasonogram, CT, MRI and Angiography. Extended surgical treatment including left nephrectomy was performed. The tumor was histologically diagnosed as storiform-pleomorphic malignant fibrous histiocytoma (MFH) arising from perirenal tissue. Although we recommended adjuvant therapy after the excision, the patient refused. After a follow-up period of 11 months, he developed local recurrence in the left retroperitoneal space, and external irradiation was performed. He died 21 months after the operation. To our knowledge, this is the 10th case of MFH arising from perirenal tissue in Japan.