Difference between revisions of "Excision of pheochromocytoma"
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Nirav Kamdar (talk | contribs) (Citations and preoperative management tables and laboratory studies.) |
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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. | Pheochromocytoma is a rare neuroendocrine disease of the adrenal gland where catecholamine-secreting tumors cause hypertension. Pheochromocytoma is present in 0.05%<ref>{{Cite journal|last=Lo|first=Chung-Yau|last2=Lam|first2=King-Yin|last3=Wat|first3=Ming-Sun|last4=Lam|first4=Karen S.|date=2000-03-01|title=Adrenal pheochromocytoma remains a frequently overlooked diagnosis|url=https://www.americanjournalofsurgery.com/article/S0002-9610(00)00296-8/abstract|journal=The American Journal of Surgery|language=English|volume=179|issue=3|pages=212–215|doi=10.1016/S0002-9610(00)00296-8|issn=0002-9610|pmid=10827323}}</ref> - 0.2%<ref>{{Cite book|last=Yeh|first=Michael|url=https://www.worldcat.org/oclc/1235959889|title=Sabiston textbook of surgery : the biological basis of modern surgical practice|last2=Livhits|first2=Masha|last3=Duh|first3=Quan-Yang|date=2022|publisher=|others=Courtney M., Jr. Townsend, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox, David C. Sabiston|year=|isbn=978-0-323-64064-0|edition=Twenty-first edition|location=St. Louis, Missour|pages=|chapter=The Adrenal Glands|oclc=1235959889}}</ref> 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)<ref>{{Cite journal|last=Peramunage|first=Dasun|last2=Nikravan|first2=Sara|date=2020-03-01|title=Anesthesia for Endocrine Emergencies|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(19)30088-6/abstract|journal=Anesthesiology Clinics|language=English|volume=38|issue=1|pages=149–163|doi=10.1016/j.anclin.2019.10.006|issn=1932-2275|pmid=32008649}}</ref>. 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 transabdominal; and (3) laparoscopic retroperitoneal. Each approach has different indications, advantages and disadvantages, as well as unique line and monitoring choices. | 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 transabdominal; and (3) laparoscopic retroperitoneal. Each approach has different indications, advantages and disadvantages, as well as unique line and monitoring choices. The largest North American series published about pheochromocytoma excision described 108 cases, where 90% were conducted laparoscopically, and the perioperative morbidity rate was 13% without a single mortality<ref>{{Cite journal|last=Shen|first=Wen T.|last2=Grogan|first2=Raymon|last3=Vriens|first3=Menno|last4=Clark|first4=Orlo H.|last5=Duh|first5=Quan-Yang|date=2010-09|title=One hundred two patients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy|url=https://pubmed.ncbi.nlm.nih.gov/20855761|journal=Archives of Surgery (Chicago, Ill.: 1960)|volume=145|issue=9|pages=893–897|doi=10.1001/archsurg.2010.159|issn=1538-3644|pmid=20855761}}</ref>. | ||
{{Infobox surgical case reference | {{Infobox surgical case reference | ||
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|Neurologic | |Neurologic | ||
| | | | ||
* Investigate headaches and fatigue | |||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | | | ||
* Evaluate history of chest pain, palpitations, arrythmia and signs of heart failure | |||
* Patients may require EKG or echocardiography | |||
* Patients may present with catecholamine-induced, Takotsubo, or dilated cardiomyopathy<ref>{{Cite journal|last=Prejbisz|first=Aleksander|last2=Lenders|first2=Jacques W.M.|last3=Eisenhofer|first3=Graeme|last4=Januszewicz|first4=Andrzej|date=2011-11-XX|title=Cardiovascular manifestations of phaeochromocytoma|url=https://journals.lww.com/00004872-201111000-00001|journal=Journal of Hypertension|language=en|volume=29|issue=11|pages=2049–2060|doi=10.1097/HJH.0b013e32834a4ce9|issn=0263-6352}}</ref><ref>{{Cite journal|last=Gu|first=Yu Wei|last2=Poste|first2=Jennifer|last3=Kunal|first3=Mehta|last4=Schwarcz|first4=Monica|last5=Weiss|first5=Irene|date=2017-09-XX|title=Cardiovascular Manifestations of Pheochromocytoma|url=https://journals.lww.com/00045415-201709000-00004|journal=Cardiology in Review|language=en|volume=25|issue=5|pages=215–222|doi=10.1097/CRD.0000000000000141|issn=1061-5377}}</ref> | |||
|- | |- | ||
|Respiratory | |Respiratory | ||
| | | | ||
* Classify obstructive or restrictive lung disease | |||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
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|Renal | |Renal | ||
| | | | ||
* Evaluate electrolyte disturbances<ref>{{Cite journal|last=Peramunage|first=Dasun|last2=Nikravan|first2=Sara|date=2020-03-01|title=Anesthesia for Endocrine Emergencies|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(19)30088-6/abstract|journal=Anesthesiology Clinics|language=English|volume=38|issue=1|pages=149–163|doi=10.1016/j.anclin.2019.10.006|issn=1932-2275|pmid=32008649}}</ref> | |||
* Evaluate fluid status as patients are often hypovolemic from catecholamine excess | |||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | | | ||
* Patients may be functionally hyperglycemic due to excessive catacholamine release | |||
|- | |- | ||
|Other | |Other | ||
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|} | |} | ||
=== Labs and studies | === Labs and studies === | ||
* +/ - electrocardiogram to investigate palpitations, arrhythmia, cardiac ischemia, bundle branch block, or left ventricular hypertrophy | |||
* +/- echocardiogram to assess signs of heart failure, Takotsubo cardiomyopathy, or to diagnose cardiac paragangliomas | |||
* Capillary glucose to test temporary insulin resistance | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
Infusion manifold with high rate carrier | |||
Vasopressor infusion (typically non-direct sympathomimetics such as vasopressin) | |||
Direct vasodilator infusion | |||
+/- insulin infusion to treat hyperglycemia | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === |
Revision as of 14:48, 1 May 2021
Pheochromocytoma is a rare neuroendocrine disease of the adrenal gland where catecholamine-secreting tumors cause hypertension. Pheochromocytoma is present in 0.05%[1] - 0.2%[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)[3]. 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 transabdominal; and (3) laparoscopic retroperitoneal. Each approach has different indications, advantages and disadvantages, as well as unique line and monitoring choices. The largest North American series published about pheochromocytoma excision described 108 cases, where 90% were conducted laparoscopically, and the perioperative morbidity rate was 13% without a single mortality[4].
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 | |
Editor rating | |
User likes | 0 |
Preoperative management
Patient evaluation
System | Considerations |
---|---|
Neurologic |
|
Cardiovascular | |
Respiratory |
|
Gastrointestinal | |
Hematologic | |
Renal |
|
Endocrine |
|
Other |
Labs and studies
- +/ - electrocardiogram to investigate palpitations, arrhythmia, cardiac ischemia, bundle branch block, or left ventricular hypertrophy
- +/- echocardiogram to assess signs of heart failure, Takotsubo cardiomyopathy, or to diagnose cardiac paragangliomas
- Capillary glucose to test temporary insulin resistance
Operating room setup
Infusion manifold with high rate carrier
Vasopressor infusion (typically non-direct sympathomimetics such as vasopressin)
Direct vasodilator infusion
+/- insulin infusion to treat hyperglycemia
Patient preparation and premedication
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
Open Laparotomy | Transabdominal
Laparoscopic |
Retroperitoneal
Laparoscopic | |
---|---|---|---|
Unique considerations | High Insufflation pressures (20-30mmHg) | ||
Position | Supine | Lateral | Prone |
Surgical time | 4-6 hrs | 3-5 hrs | 1.5 hrs |
EBL | 60-100mL | ||
Postoperative disposition | PACU or ICU | PACU or ICU | PACU |
Pain management | Epidural | Oral and IV pain medications | Oral pain medications |
Potential complications | Subcutaneous emphysema |
References
- ↑ Lo, Chung-Yau; Lam, King-Yin; Wat, Ming-Sun; Lam, Karen S. (2000-03-01). "Adrenal pheochromocytoma remains a frequently overlooked diagnosis". The American Journal of Surgery. 179 (3): 212–215. doi:10.1016/S0002-9610(00)00296-8. ISSN 0002-9610. PMID 10827323.
- ↑ Yeh, Michael; Livhits, Masha; Duh, Quan-Yang (2022). "The Adrenal Glands". Sabiston textbook of surgery : the biological basis of modern surgical practice. Courtney M., Jr. Townsend, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox, David C. Sabiston (Twenty-first edition ed.). St. Louis, Missour. ISBN 978-0-323-64064-0. OCLC 1235959889.
|edition=
has extra text (help) - ↑ Peramunage, Dasun; Nikravan, Sara (2020-03-01). "Anesthesia for Endocrine Emergencies". Anesthesiology Clinics. 38 (1): 149–163. doi:10.1016/j.anclin.2019.10.006. ISSN 1932-2275. PMID 32008649.
- ↑ Shen, Wen T.; Grogan, Raymon; Vriens, Menno; Clark, Orlo H.; Duh, Quan-Yang (2010-09). "One hundred two patients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy". Archives of Surgery (Chicago, Ill.: 1960). 145 (9): 893–897. doi:10.1001/archsurg.2010.159. ISSN 1538-3644. PMID 20855761. Check date values in:
|date=
(help) - ↑ Prejbisz, Aleksander; Lenders, Jacques W.M.; Eisenhofer, Graeme; Januszewicz, Andrzej (2011-11-XX). "Cardiovascular manifestations of phaeochromocytoma". Journal of Hypertension. 29 (11): 2049–2060. doi:10.1097/HJH.0b013e32834a4ce9. ISSN 0263-6352. Check date values in:
|date=
(help) - ↑ Gu, Yu Wei; Poste, Jennifer; Kunal, Mehta; Schwarcz, Monica; Weiss, Irene (2017-09-XX). "Cardiovascular Manifestations of Pheochromocytoma". Cardiology in Review. 25 (5): 215–222. doi:10.1097/CRD.0000000000000141. ISSN 1061-5377. Check date values in:
|date=
(help) - ↑ Peramunage, Dasun; Nikravan, Sara (2020-03-01). "Anesthesia for Endocrine Emergencies". Anesthesiology Clinics. 38 (1): 149–163. doi:10.1016/j.anclin.2019.10.006. ISSN 1932-2275. PMID 32008649.