Excision of pheochromocytoma

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Revision as of 14:29, 1 May 2021 by Nirav Kamdar (talk | contribs) (Updated variant table.)

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 transabdominal; and (3) laparoscopic retroperitoneal. Each approach has different indications, advantages and disadvantages, as well as 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
Editor rating
Comprehensive
User likes
0

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

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