Surgical ‘damage control’ treatment of a large retroperitoneal liposarcoma encasing a horseshoe kidney

Damage control is a surgical strategy for severely compromised trauma patients based on speed control of life-threatening injuries that aims to rapidly resuscitate patients in an intensive care unit (ICU). We report on the use of such therapeutic strategy in a patient affected by a retroperitoneal sarcoma concomitant to a horseshoe kidney, a relatively rare anatomical malformation.


Introduction
Retroperitoneal soft tissue sarcomas (RPS) are rare mesenchymal tumours, their incidence being about 10% of all soft tissue sarcomas, which together constitute less than 1% of all malignant neoplasms [1]. Surgery is the principal mode of therapy and offers the most favourable prognosis after complete resection [2][3][4]. Complete resection is, however, often problematic to perform because of the large size of the tumour at the time of diagnosis, the difficult, deep-seated central location and common infiltration to adjacent organs.
We report a single, exceptional case of a patient affected by retroperitoneal liposarcoma, observed, diagnosed and treated in our department with a combined strategy of extreme surgery and damage control.

Clinical case
A 67-year-old male was hospitalized on 26 September 2007 because of a large, paucisymptomatic retroperitoneal tumour. The patient had been presenting progressive abdominal swelling, weight loss and asthenia for three months.
On 28 September 2007, at 9.00, a multi-sliced chest and whole abdomen CT scan was performed, both during early and late arterial phases as well as venous phase, for an evaluation of the vessels in view of surgery (Figures 1-5).
On 28 September 2007, at 14.30, the patient underwent surgery comprising:

2.
Radical removal of the mass that was separated with difficulty from the horseshoe kidney (the separation was aided by the presence of ureteral stents and by an intra-operative echogram) with binding of one of the three main renal arteries and of the left inferior polar artery (after confirming their transit inside the mass).

3.
During surgery the patient suffered heavy blood loss (22 l of blood) with inadequate haemostasis because of heavy bleeding, requiring splenectomy in an attempt to control the haemorrhage.

5.
The surgical procedure ended at 19.30.
The patient was transferred to the ICU for 14 hours, where he underwent: 1.
heating with a thermal blanket; 2. correction of metabolic acidosis;

4.
transfusion of three pools of platelets, 27 units of fresh plasma and no clotting factors.
On 29 September 2007, at 9.00, the patient (intubated and ventilated) was haemodynamically stable with normal diuresis. After angiography, he underwent second-look surgery with haemostasis and packing removal.
On 29 September 2007, at 9.30, an angiography was performed and no sites of major bleeding were detected (Figures 7-9).
2. Haemorrhaging sites were cauterized with argon and infusion of plasma achieving good control of bleeding.
3. The abdominal wall was sutured and two draining tubes were positioned.
His ureteral stents were removed after five days, and he required mechanical respiratory support for 10 days due to mild ARDS.
The patient left our ICU after 19 days.