Excision of pheochromocytoma

Pheochromocytoma is a rare neuroendocrine disease of the adrenal gland where catecholamine-secreting tumors cause hypertension. Pheochromocytoma is present in 0.05% - 0.2% of hypertensive individuals, the incidence of the disease presents equally between men and women with a distribution across age groups but peaks in between 40 and 50 years of age. The classic presentation of the disease is a triad of symptoms including headache, palpitations, diaphoresis with a documented clinical sign of hypertension (present in 90% of patients with pheochromocytoma). However, patients can often present with less definitive symptoms such as tremor, anxiety, flushing, weight loss, and hyperglycemia. While the majority of pheochromocytoma emerges from adrenal tumors, roughly 15-20% can be extra-adrenal in etiology.

During the early part of the 20th century, the perioperative mortality of this disease ranged between 26-50%. As surgery is curative in about 90% of presenting cases, the mortality has decreased to roughly 1% in specialized centers. Surgical resection can be approached in a variety of ways: (1) open laparotomy; (2) laparoscopic transperitoneal; and (3) laparoscopic retroperitoneal. Each approach has different indications, advantages and disadvantages, unique line and monitoring choices.

Excision of pheochromocytoma

Anesthesia type	General
Airway	ETT
Lines and access	Arterial line Additional large-bore PIVs +/- Central venous catheter +/- Pulmonary Artery Catheter +/- Epidural catheter (dependant upon approach)
Monitors	Stanford Monitors Invasive blood pressure monitor +/- Central venous catheter +/- Pulmonary Artery Catheter
Primary anesthetic considerations
Preoperative	Preoperative alpha-blockade
Intraoperative	Rapid episodes of extreme hypertension Severe hypotension after adrenal vein ligation Cardiovascular collapse Hyperglycemia Hypovolemia
Postoperative	Residual hypertension Prolonged hypotension (requiring vasopressors) Hyperglycemia/Hypoglycemia
Article quality
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Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Procedure variants

	Open Laparotomy	Transperitoneal Laparoscopic	Retroperitoneal Laparoscopic
Unique considerations			High Insufflation pressures (20-30mmHg)
Position	Supine	Lateral	Prone
Surgical time		3-5 hrs	1.5 hrs
EBL			60-100mL
Postoperative disposition			PACU
Pain management			Oral pain medications
Potential complications			Subcutaneous emphysema