Difference between revisions of "Excision of pheochromocytoma"

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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = Arterial line
| lines_access = Large bore IV
Additional large-bore PIVs<br/>
Arterial line
± Central venous catheter<br/>
± Central line
± Pulmonary Artery Catheter<br/>
± PA Catheter
± Epidural catheter (dependant upon approach)
± Epidural
| monitors = Standard Monitors
| monitors = Standard
Invasive blood pressure monitor<br/>
5-lead ECG
± Central venous catheter<br/>
Temperature
± Pulmonary Artery Catheter
ABP
± CVP
± PAP
| considerations_preoperative = Preoperative alpha-blockade
| considerations_preoperative = Preoperative alpha-blockade
| considerations_intraoperative = Rapid episodes of extreme hypertension
| considerations_intraoperative = Rapid episodes of extreme hypertension
Line 17: Line 19:
Hyperglycemia
Hyperglycemia
Hypovolemia
Hypovolemia
| considerations_postoperative = Residual hypertension  
| considerations_postoperative = Residual hypertension
Prolonged hypotension (requiring vasopressors)
Prolonged hypotension (requiring vasopressors)
Hyperglycemia/Hypoglycemia
Hyper/hypoglycemia
}}The '''excision of a pheochromocytoma''' is a variant of an [[adrenalectomy]], which is the removal of one or both adrenal glands. When the tumor being removed is a [[pheochromocytoma]], careful preoperative optimization and intraoperative management are required to ensure hemodynamic stability during the procedure.  
}}The '''excision of a pheochromocytoma''' is a variant of an [[adrenalectomy]], which is the removal of one or both adrenal glands. When the tumor being removed is a [[pheochromocytoma]], careful preoperative optimization and intraoperative management are required to ensure hemodynamic stability during the procedure.  


Surgical resection can be performed via open laparotomy, laparoscopic transabdominal, laparoscopic retroperitoneal, or single incision laparoscopic retroperitoneal approaches, each of which has different indications, advantages and disadvantages, as well as unique line and monitoring choices.  
Surgical resection can be performed via open laparotomy, laparoscopic transabdominal, laparoscopic retroperitoneal, or single incision laparoscopic retroperitoneal approaches, each of which has different indications, advantages and disadvantages, as well as unique line and monitoring choices.  


== Preoperative management ==
==Preoperative management==


=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
{| class="wikitable"
{| class="wikitable"
|+
|+
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|Cardiovascular
|Cardiovascular
|
|
* Evaluate history of chest pain, palpitations, arrhythmia and signs of heart failure
*Evaluate history of chest pain, palpitations, arrhythmia and signs of heart failure
* Patients may require EKG or echocardiography
*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|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|via=}}</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|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|via=}}</ref>
*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|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|via=}}</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|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|via=}}</ref>
|-
|-
|Respiratory
|Pulmonary
|
|
* Classify obstructive or restrictive lung disease
*Classify obstructive or restrictive lung disease
|-
|-
|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 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
*Evaluate fluid status as patients are often hypovolemic from catecholamine excess
|-
|-
|Endocrine
|Endocrine
|
|
* Patients may be functionally hyperglycemic due to excessive catecholamine release
*Patients may be functionally hyperglycemic due to excessive catecholamine release
|}
|}


=== Labs and studies ===
===Labs and studies===


* ± electrocardiogram to investigate palpitations, arrhythmia, cardiac ischemia, bundle branch block, or left ventricular hypertrophy
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
* ± Echocardiogram to assess signs of heart failure, Takotsubo cardiomyopathy, or to diagnose cardiac paragangliomas
* Capillary glucose to test temporary insulin resistance
*Capillary glucose to test temporary insulin resistance
*CBC to assess baseline hemoglobin and platelet values
*CMP to identify electrolyte abnormalities such as hypernatremia or hypokalemia
*Plasma metanephrines (Normetanephrine, Norepinephrine, Epinephrine , Dopamine)


=== 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
* Infusion manifold with high rate carrier
* Vasopressor infusion (typically non-direct sympathomimetics such as vasopressin)
*Vasopressor infusion (typically non-direct sympathomimetics such as vasopressin)
* Direct vasodilator infusion
*Direct vasodilator infusion
* ± insulin infusion to treat hyperglycemia
Insulin infusion to treat hyperglycemia
* Diluted push syringes of vasodilators and vasopressors to adjust blood pressure with sudden changes to blood pressure during catecholamine surges during induction and tumor manipulation.  
*Diluted push syringes of vasodilators and vasopressors to adjust blood pressure with sudden changes to blood pressure during catecholamine surges during induction and tumor manipulation.


=== 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. -->===
'''<u>Perioperative α-blockade</u>''': α-blockade continues to be a staple medication therapy for 10-14 days prior to pheochromocytoma excision
'''<u>Perioperative α-blockade</u>''': α-blockade continues to be a staple medication therapy for 10-14 days prior to pheochromocytoma excision  


* Choice between Irreversible non-selective α-blockade (Phenoxybenzamine) or non-selective α-blockade (Doxazosin, Prazosin, and Terazosin)
*Choice between Irreversible non-selective α-blockade (Phenoxybenzamine) or non-selective α-blockade (Doxazosin, Prazosin, and Terazosin)
* α-blockade blockade adequacy was originally described by the Roizen Criteria<ref>{{Cite journal|last=Roizen|first=M.F.|last2=Horrigan|first2=R.W.|last3=Koike|first3=M.|last4=Eger|first4=E.I.|last5=Mulroy|first5=M.F.|last6=Frazer|first6=B.|last7=Simmons|first7=A.|last8=Hunt|first8=T.K.|last9=Thomas|first9=C.|last10=Tyrell|first10=B.|date=1982-09-01|title=A PROSPECTIVE RANDOMIZED TRIAL OF FOUR ANESTHETIC TECHNIQUES FOR RESECTION OF PHEOCHROMOCYTOMA|url=https://doi.org/10.1097/00000542-198209001-00043|journal=Anesthesiology|volume=57|issue=3|pages=A43–A43|doi=10.1097/00000542-198209001-00043|issn=0003-3022|via=}}</ref>:
*α-blockade blockade adequacy was originally described by the Roizen Criteria<ref>{{Cite journal|last=Roizen|first=M.F.|last2=Horrigan|first2=R.W.|last3=Koike|first3=M.|last4=Eger|first4=E.I.|last5=Mulroy|first5=M.F.|last6=Frazer|first6=B.|last7=Simmons|first7=A.|last8=Hunt|first8=T.K.|last9=Thomas|first9=C.|last10=Tyrell|first10=B.|date=1982-09-01|title=A PROSPECTIVE RANDOMIZED TRIAL OF FOUR ANESTHETIC TECHNIQUES FOR RESECTION OF PHEOCHROMOCYTOMA|url=https://doi.org/10.1097/00000542-198209001-00043|journal=Anesthesiology|volume=57|issue=3|pages=A43–A43|doi=10.1097/00000542-198209001-00043|issn=0003-3022|via=}}</ref>:
*# Blood pressures < 160/90 for 24 hours prior to surgery
*#Blood pressures < 160/90 for 24 hours prior to surgery
*# Absence of orthostatic hypotension
*#Absence of orthostatic hypotension
*# Absence of ST or T-wave changes prior to surgery
*#Absence of ST or T-wave changes prior to surgery
*# No more than 5 premature ventricular contractions in a minute.
*#No more than 5 premature ventricular contractions in a minute.
* However, several centers have recently abandoned these strict criteria, given it's largely inpatient applications, and use a combination of symptoms of orthostatic hypotension, blood pressures, and duration of α-blockade to guide block adequacy.
*However, several centers have recently abandoned these strict criteria, given it's largely inpatient applications, and use a combination of symptoms of orthostatic hypotension, blood pressures, and duration of α-blockade to guide block adequacy.
* As titration of α-blockade increases prior to surgery, patients will typically exhibit tachycardia. At this time β-blockade or calcium-channel blockade may be introduced. It is still recommended to introduce β-blockade only after several days of α-blockade titration to avoid unopposed α-agonism from the circulating catecholamines, which may cause extreme hypertensive episodes for the patient.
*As titration of α-blockade increases prior to surgery, patients will typically exhibit tachycardia. At this time β-blockade or calcium-channel blockade may be introduced. It is still recommended to introduce β-blockade only after several days of α-blockade titration to avoid unopposed α-agonism from the circulating catecholamines, which may cause extreme hypertensive episodes for the patient.


'''<u>Pre-Operative anxiolysis and analgesia</u>''':
'''<u>Pre-Operative anxiolysis and analgesia</u>''':  


* Catecholamine surges can occur with any noxious stimuli such as laryngoscopy, positive pressure ventilation, or abdominal insufflation. Preoperative anxiolysis and analgesia is useful to prevent catecholamine surges during these episodes.
*Catecholamine surges can occur with any noxious stimuli such as laryngoscopy, positive pressure ventilation, or abdominal insufflation. Preoperative anxiolysis and analgesia is useful to prevent catecholamine surges during these episodes.




'''<u>Early Fluid Resuscitation:</u>'''
'''<u>Early Fluid Resuscitation:</u>'''


* Patients are often intravascularly dry due to excessive catecholamines. Early infusion of fluid to establish euvolemia prior to the clamp of the adrenal vein is advisable.  
*Patients are often intravascularly dry due to excessive catecholamines. Early infusion of fluid to establish euvolemia prior to the clamp of the adrenal vein is advisable.
* Without proper resuscitation during the day-of-surgery or early intraoperative period, patients may exhibit drastic hypotension once the pheochromocytoma is removed.  
*Without proper resuscitation during the day-of-surgery or early intraoperative period, patients may exhibit drastic hypotension once the pheochromocytoma is removed.


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===


* Epidural analgesia may be useful for patients undergoing open laparotomy approach for pheochromocytoma excision
*Epidural analgesia may be useful for patients undergoing open laparotomy approach for pheochromocytoma excision


== Intraoperative management ==
==Intraoperative management==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===


* Standard monitors
*Standard monitors
* Arterial line for immediate blood pressure management and electrolyte sampling
*Arterial line for immediate blood pressure management and electrolyte sampling
* +/- Central Venous Catheter (CVC) for vasoactive drug infusions (some specialized centers are moving away from CVC insertion)
*+/- Central Venous Catheter (CVC) for vasoactive drug infusions (some specialized centers are moving away from CVC insertion)
* +/- Pulmonary artery catheter for severe heart failure or pulmonary hypertension
*+/- Pulmonary artery catheter for severe heart failure or pulmonary hypertension
* Foley catheter to monitor fluid status  
*Foley catheter to monitor fluid status


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===  


* Endotracheal tube (consider armored ETT for prone position)
*Endotracheal tube (consider armored ETT for prone position)


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


* Supine for open laparotomy or combined procedures for multiple endocrine neoplasia presentations
* Supine for open laparotomy or combined procedures for multiple endocrine neoplasia presentations
* Lateral  for transabdominal laparoscopic approach
*Lateral  for transabdominal laparoscopic approach
* Prone for retroperitoneal laparoscopic approach
*Prone for retroperitoneal laparoscopic approach


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===


* Consider pre-induction arterial line as catecholamine surge can occur during mask ventilation and intubation.
*Consider pre-induction arterial line as catecholamine surge can occur during mask ventilation and intubation.  
** Some centers describe a conducting a phenylephrine titration prior to induction to test the adequacy of  α-blockade<ref>{{Cite journal|last=Saksa|first=Dane|last2=Shuch|first2=Brian|last3=Donahue|first3=Timothy|last4=Cusumano|first4=Lucas|last5=Yu|first5=Run|last6=Alapag|first6=Catharina|last7=Kamdar|first7=Nirav|date=2021-01-14|title=Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report|url=https://pubmed.ncbi.nlm.nih.gov/33512909|journal=A&A Practice|volume=15|issue=1|pages=e01378|doi=10.1213/XAA.0000000000001378|issn=2575-3126|pmid=33512909}}</ref>
**Some centers describe a conducting a phenylephrine titration prior to induction to test the adequacy of  α-blockade<ref>{{Cite journal|last=Saksa|first=Dane|last2=Shuch|first2=Brian|last3=Donahue|first3=Timothy|last4=Cusumano|first4=Lucas|last5=Yu|first5=Run|last6=Alapag|first6=Catharina|last7=Kamdar|first7=Nirav|date=2021-01-14|title=Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report|url=https://pubmed.ncbi.nlm.nih.gov/33512909|journal=A&A Practice|volume=15|issue=1|pages=e01378|doi=10.1213/XAA.0000000000001378|issn=2575-3126|pmid=33512909}}</ref>
* Catecholamine surges can occur during the following intraoperative periods<ref>{{Cite journal|last=Joris|first=J. L.|last2=Hamoir|first2=E. E.|last3=Hartstein|first3=G. M.|last4=Meurisse|first4=M. R.|last5=Hubert|first5=B. M.|last6=Charlier|first6=C. J.|last7=Lamy|first7=M. L.|date=1999|title=Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma|url=https://pubmed.ncbi.nlm.nih.gov/9895059|journal=Anesthesia and Analgesia|volume=88|issue=1|pages=16–21|doi=10.1097/00000539-199901000-00004|issn=0003-2999|pmid=9895059|via=}}</ref>: intubation < Positioning < Insufflation < tumor manipulation
*Catecholamine surges can occur during the following intraoperative periods<ref>{{Cite journal|last=Joris|first=J. L.|last2=Hamoir|first2=E. E.|last3=Hartstein|first3=G. M.|last4=Meurisse|first4=M. R.|last5=Hubert|first5=B. M.|last6=Charlier|first6=C. J.|last7=Lamy|first7=M. L.|date=1999|title=Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma|url=https://pubmed.ncbi.nlm.nih.gov/9895059|journal=Anesthesia and Analgesia|volume=88|issue=1|pages=16–21|doi=10.1097/00000539-199901000-00004|issn=0003-2999|pmid=9895059|via=}}</ref>: intubation < Positioning < Insufflation < tumor manipulation
* Treat and control hypertension prior to adrenal vein ligation.  
*Treat and control hypertension prior to adrenal vein ligation.  
** Start with vasodilators (nitroprusside, nitroglycerine, nicardipine, clevidipine) and then supplement with short-acting beta-blockade (esmolol)
**Start with vasodilators (nitroprusside, nitroglycerine, nicardipine, clevidipine) and then supplement with short-acting beta-blockade (esmolol)
* Surgery team should communicate with anesthesia team when the adrenal vein has been identified and prior to clamping
*Surgery team should communicate with anesthesia team when the adrenal vein has been identified and prior to clamping
** Anesthesia team should load patients with fluid prior to adrenal vein identification
**Anesthesia team should load patients with fluid prior to adrenal vein identification
** Increase vasopressor support (i.e. vasopressin) to prevent sudden loss of blood pressure after ligation of adrenal vein. Titrate down vasodilators at this time.  
**Increase vasopressor support (i.e. vasopressin) to prevent sudden loss of blood pressure after ligation of adrenal vein. Titrate down vasodilators at this time.
* Anticipate sudden drops of blood pressure after adrenal vein clamping. Such changes can induce cardiac collapse.  
*Anticipate sudden drops of blood pressure after adrenal vein clamping. Such changes can induce cardiac collapse.  
** Support blood pressure with vasopressors (i.e. vasopressin)
**Support blood pressure with vasopressors (i.e. vasopressin)


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===


* Extubation after case completion is customary
*Extubation after case completion is customary


== Postoperative management ==
==Postoperative management==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===


* Many centers still admit all pheochromocytoma patients to the intensive care units.  
*Many centers still admit all pheochromocytoma patients to the intensive care units.  
** A percentage of patients will require vasopressor support after surgical completion until fluid shifts and physiology equilibrates
**A percentage of patients will require vasopressor support after surgical completion until fluid shifts and physiology equilibrates
** A small population of patients will continue to have circulating catecholamines for several hours and may require a few hours of vasodilation  
**A small population of patients will continue to have circulating catecholamines for several hours and may require a few hours of vasodilation
* Specialty centers are able to titrate all vasopressors off by the end of the case and patients can be admitted into the PACU
*Specialty centers are able to titrate all vasopressors off by the end of the case and patients can be admitted into the PACU
* With diabetics, the sudden withdrawal of catecholamines can precipitate sudden hypoglycemia - particularly in patients on insulin drips intraoperatively
*With diabetics, the sudden withdrawal of catecholamines can precipitate sudden hypoglycemia - particularly in patients on insulin drips intraoperatively


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===


* Open laparotomy may require epidural pain control
*Open laparotomy may require epidural pain control. Extreme caution must be utilized in epidural dosing as hemodynamic changes can occur rapidly during surgery. Frequently the epidural is placed preoperatively and not utilized until hemodynamic stability with the tumor removed is achieved.
* Laparoscopic and particularly single-incision retroperitoneal support rarely require epidural pain management. Pain can be controlled using IV and PO pain medications.  
*Laparoscopic and particularly single-incision retroperitoneal support rarely require epidural pain management. Pain can be controlled using IV and PO pain medications.


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===  


* Sudden, wide, blood pressure changes can cause cardiac ischemia, cardiovascular collapse and ischemic or hemorrhagic stroke
*Sudden, wide, blood pressure changes can cause cardiac ischemia, cardiovascular collapse and ischemic or hemorrhagic stroke
* With diabetics, the sudden withdrawal of catecholamines can precipitate sudden <u>hypoglycemia</u> - particularly in patients on intraoperative insulin drips. Monitor post-operative glucose carefully.  
*With diabetics, the sudden withdrawal of catecholamines can precipitate sudden <u>hypoglycemia</u> - particularly in patients on intraoperative insulin drips. Monitor post-operative glucose carefully.


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==


{| class="wikitable"
{| class="wikitable"
Line 168: Line 173:
|'''Position'''
|'''Position'''
|Supine
|Supine
|Lateral
| Lateral
|Prone  
|Prone
|Prone and half jackknife position (praying position)
|Prone and half jackknife position (praying position)
|-
|-
|'''Surgical time'''
|'''Surgical time'''
|4-6 hrs
|4-6 hrs  
|3-5 hrs
|3-5 hrs
|1.5 hrs
|1.5 hrs
Line 187: Line 192:
|PACU or ICU
|PACU or ICU
|PACU or ICU
|PACU or ICU
|PACU  
|PACU
|PACU
|PACU
|-
|-
|'''Pain management'''
|'''Pain management'''
|
|Epidural
|Oral and IV pain medications
|Oral and IV pain medications
|Oral pain medications
|Oral pain medications
Line 215: Line 220:
|}
|}


== Outcomes ==
==Outcomes==
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. 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|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|via=}}</ref>.
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. 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|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|via=}}</ref>.


== References ==
==References==


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]

Latest revision as of 01:42, 30 May 2022

Excision of pheochromocytoma
Anesthesia type

General

Airway

ETT

Lines and access

Large bore IV Arterial line ± Central line ± PA Catheter ± Epidural

Monitors

Standard 5-lead ECG Temperature ABP ± CVP ± PAP

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) Hyper/hypoglycemia

Article quality
Editor rating
Comprehensive
User likes
0

The excision of a pheochromocytoma is a variant of an adrenalectomy, which is the removal of one or both adrenal glands. When the tumor being removed is a pheochromocytoma, careful preoperative optimization and intraoperative management are required to ensure hemodynamic stability during the procedure.

Surgical resection can be performed via open laparotomy, laparoscopic transabdominal, laparoscopic retroperitoneal, or single incision laparoscopic retroperitoneal approaches, each of which has different indications, advantages and disadvantages, as well as unique line and monitoring choices.

Preoperative management

Patient evaluation

System Considerations
Neurologic
  • Investigate headaches and fatigue
Cardiovascular
  • Evaluate history of chest pain, palpitations, arrhythmia and signs of heart failure
  • Patients may require EKG or echocardiography
  • Patients may present with catecholamine-induced, Takotsubo, or dilated cardiomyopathy[1][2]
Pulmonary
  • Classify obstructive or restrictive lung disease
Renal
  • Evaluate electrolyte disturbances[3]
  • Evaluate fluid status as patients are often hypovolemic from catecholamine excess
Endocrine
  • Patients may be functionally hyperglycemic due to excessive catecholamine release

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
  • CBC to assess baseline hemoglobin and platelet values
  • CMP to identify electrolyte abnormalities such as hypernatremia or hypokalemia
  • Plasma metanephrines (Normetanephrine, Norepinephrine, Epinephrine , Dopamine)

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
  • Diluted push syringes of vasodilators and vasopressors to adjust blood pressure with sudden changes to blood pressure during catecholamine surges during induction and tumor manipulation.

Patient preparation and premedication

Perioperative α-blockade: α-blockade continues to be a staple medication therapy for 10-14 days prior to pheochromocytoma excision

  • Choice between Irreversible non-selective α-blockade (Phenoxybenzamine) or non-selective α-blockade (Doxazosin, Prazosin, and Terazosin)
  • α-blockade blockade adequacy was originally described by the Roizen Criteria[4]:
    1. Blood pressures < 160/90 for 24 hours prior to surgery
    2. Absence of orthostatic hypotension
    3. Absence of ST or T-wave changes prior to surgery
    4. No more than 5 premature ventricular contractions in a minute.
  • However, several centers have recently abandoned these strict criteria, given it's largely inpatient applications, and use a combination of symptoms of orthostatic hypotension, blood pressures, and duration of α-blockade to guide block adequacy.
  • As titration of α-blockade increases prior to surgery, patients will typically exhibit tachycardia. At this time β-blockade or calcium-channel blockade may be introduced. It is still recommended to introduce β-blockade only after several days of α-blockade titration to avoid unopposed α-agonism from the circulating catecholamines, which may cause extreme hypertensive episodes for the patient.

Pre-Operative anxiolysis and analgesia:

  • Catecholamine surges can occur with any noxious stimuli such as laryngoscopy, positive pressure ventilation, or abdominal insufflation. Preoperative anxiolysis and analgesia is useful to prevent catecholamine surges during these episodes.


Early Fluid Resuscitation:

  • Patients are often intravascularly dry due to excessive catecholamines. Early infusion of fluid to establish euvolemia prior to the clamp of the adrenal vein is advisable.
  • Without proper resuscitation during the day-of-surgery or early intraoperative period, patients may exhibit drastic hypotension once the pheochromocytoma is removed.

Regional and neuraxial techniques

  • Epidural analgesia may be useful for patients undergoing open laparotomy approach for pheochromocytoma excision

Intraoperative management

Monitoring and access

  • Standard monitors
  • Arterial line for immediate blood pressure management and electrolyte sampling
  • +/- Central Venous Catheter (CVC) for vasoactive drug infusions (some specialized centers are moving away from CVC insertion)
  • +/- Pulmonary artery catheter for severe heart failure or pulmonary hypertension
  • Foley catheter to monitor fluid status

Induction and airway management

  • Endotracheal tube (consider armored ETT for prone position)

Positioning

  • Supine for open laparotomy or combined procedures for multiple endocrine neoplasia presentations
  • Lateral for transabdominal laparoscopic approach
  • Prone for retroperitoneal laparoscopic approach

Maintenance and surgical considerations

  • Consider pre-induction arterial line as catecholamine surge can occur during mask ventilation and intubation.
    • Some centers describe a conducting a phenylephrine titration prior to induction to test the adequacy of α-blockade[5]
  • Catecholamine surges can occur during the following intraoperative periods[6]: intubation < Positioning < Insufflation < tumor manipulation
  • Treat and control hypertension prior to adrenal vein ligation.
    • Start with vasodilators (nitroprusside, nitroglycerine, nicardipine, clevidipine) and then supplement with short-acting beta-blockade (esmolol)
  • Surgery team should communicate with anesthesia team when the adrenal vein has been identified and prior to clamping
    • Anesthesia team should load patients with fluid prior to adrenal vein identification
    • Increase vasopressor support (i.e. vasopressin) to prevent sudden loss of blood pressure after ligation of adrenal vein. Titrate down vasodilators at this time.
  • Anticipate sudden drops of blood pressure after adrenal vein clamping. Such changes can induce cardiac collapse.
    • Support blood pressure with vasopressors (i.e. vasopressin)

Emergence

  • Extubation after case completion is customary

Postoperative management

Disposition

  • Many centers still admit all pheochromocytoma patients to the intensive care units.
    • A percentage of patients will require vasopressor support after surgical completion until fluid shifts and physiology equilibrates
    • A small population of patients will continue to have circulating catecholamines for several hours and may require a few hours of vasodilation
  • Specialty centers are able to titrate all vasopressors off by the end of the case and patients can be admitted into the PACU
  • With diabetics, the sudden withdrawal of catecholamines can precipitate sudden hypoglycemia - particularly in patients on insulin drips intraoperatively

Pain management

  • Open laparotomy may require epidural pain control. Extreme caution must be utilized in epidural dosing as hemodynamic changes can occur rapidly during surgery. Frequently the epidural is placed preoperatively and not utilized until hemodynamic stability with the tumor removed is achieved.
  • Laparoscopic and particularly single-incision retroperitoneal support rarely require epidural pain management. Pain can be controlled using IV and PO pain medications.

Potential complications

  • Sudden, wide, blood pressure changes can cause cardiac ischemia, cardiovascular collapse and ischemic or hemorrhagic stroke
  • With diabetics, the sudden withdrawal of catecholamines can precipitate sudden hypoglycemia - particularly in patients on intraoperative insulin drips. Monitor post-operative glucose carefully.

Procedure variants

Open Laparotomy Transabdominal

Laparoscopic

Retroperitoneal

Laparoscopic

Single-Incision Retroperitoneal

Laparoscopic[7]

Position Supine Lateral Prone Prone and half jackknife position (praying position)
Surgical time 4-6 hrs 3-5 hrs 1.5 hrs 1.6 hrs
EBL 5 mL 5 mL
Postoperative disposition PACU or ICU PACU or ICU PACU PACU
Pain management Epidural Oral and IV pain medications Oral pain medications Oral pain medications (76%)
Potential complications Subcutaneous emphysema Subcutaneous emphysema
Length of Stay 1.4 days 1.1 days[8]
Other considerations High Insufflation pressures (20-30mmHg)

Outcomes

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. 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[9].

References

  1. Prejbisz, Aleksander; Lenders, Jacques W.M.; Eisenhofer, Graeme; Januszewicz, Andrzej (2011). "Cardiovascular manifestations of phaeochromocytoma". Journal of Hypertension. 29 (11): 2049–2060. doi:10.1097/HJH.0b013e32834a4ce9. ISSN 0263-6352.
  2. Gu, Yu Wei; Poste, Jennifer; Kunal, Mehta; Schwarcz, Monica; Weiss, Irene (2017). "Cardiovascular Manifestations of Pheochromocytoma". Cardiology in Review. 25 (5): 215–222. doi:10.1097/CRD.0000000000000141. ISSN 1061-5377.
  3. 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.
  4. Roizen, M.F.; Horrigan, R.W.; Koike, M.; Eger, E.I.; Mulroy, M.F.; Frazer, B.; Simmons, A.; Hunt, T.K.; Thomas, C.; Tyrell, B. (1982-09-01). "A PROSPECTIVE RANDOMIZED TRIAL OF FOUR ANESTHETIC TECHNIQUES FOR RESECTION OF PHEOCHROMOCYTOMA". Anesthesiology. 57 (3): A43–A43. doi:10.1097/00000542-198209001-00043. ISSN 0003-3022.
  5. Saksa, Dane; Shuch, Brian; Donahue, Timothy; Cusumano, Lucas; Yu, Run; Alapag, Catharina; Kamdar, Nirav (2021-01-14). "Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report". A&A Practice. 15 (1): e01378. doi:10.1213/XAA.0000000000001378. ISSN 2575-3126. PMID 33512909.
  6. Joris, J. L.; Hamoir, E. E.; Hartstein, G. M.; Meurisse, M. R.; Hubert, B. M.; Charlier, C. J.; Lamy, M. L. (1999). "Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma". Anesthesia and Analgesia. 88 (1): 16–21. doi:10.1097/00000539-199901000-00004. ISSN 0003-2999. PMID 9895059.
  7. Sho, Shonan; Yeh, Michael W.; Li, Ning; Livhits, Masha J. (2017). "Single-incision retroperitoneoscopic adrenalectomy: a North American experience". Surgical Endoscopy. 31 (7): 3014–3019. doi:10.1007/s00464-016-5325-8. ISSN 0930-2794.
  8. Sho, Shonan; Yeh, Michael W.; Li, Ning; Livhits, Masha J. (2017). "Single-incision retroperitoneoscopic adrenalectomy: a North American experience". Surgical Endoscopy. 31 (7): 3014–3019. doi:10.1007/s00464-016-5325-8. ISSN 0930-2794.
  9. Shen, Wen T.; Grogan, Raymon; Vriens, Menno; Clark, Orlo H.; Duh, Quan-Yang (2010). "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.