Phaeochromocytoma--recent progress in its management

Primary perioperative haemodynamic effects of ß-receptor blockade in patients with catecholamine-secreting tumours

Introduction

Guidelines for the treatment of catecholamine-producing tumours strictly recommend starting ß-receptor blocking medication only after α-receptor blockade has been established. This recommendation is supported only by non-surgical case reports. However, in clinical practice ß-receptor blockade is often started before the diagnosis of a phaeochromocytoma is made. As we routinely treat patients with catecholamine-producing tumours without α-receptor blockade, our aim was to evaluate haemodynamic changes in such patients with and without ß-receptor blockade.

Methods

Perioperative blood pressure was assessed prospectively for all patients. The primary outcome was the highest pre-, intra-, and postoperative systolic blood pressure in patients with or without a ß-receptor blockade. Secondary outcomes were the incidence of intraoperative systolic blood pressure peaks >250 mm Hg and hypotensive episodes. Subsequently, a propensity score matching (PSM) analysis was performed.

Results

Out of 584 phaeochromocytoma and paraganglioma resections, 383 operations were performed without α-receptor blockade (including 84 with ß-receptor blockade). Before operation and intraoperatively, patients with ß-receptor blockade presented with higher systolic blood pressure (155 [25] and 207 [62] mm Hg) than patients without ß-receptor blockade (147 [24] and 183 [52] mm Hg; P=0.006 and P=0.001, respectively). Intraoperatively, patients with ß-receptor blockade demonstrated a higher incidence of hypotensive episodes (25% without vs 41% with ß-blockade; P<0.001). After propensity score matching no difference between the groups could be confirmed.

Conclusion

Overall, patients with isolated ß-receptor blockade developed higher blood pressure before operation and intraoperatively. After propensity score matching a difference could no longer be detected. Overall, ß-receptor blockade seems to be more a sign for severe disease than a risk factor for haemodynamic instability.

Preoperative α-blockade versus no blockade for pheochromocytoma-paraganglioma patients undergoing surgery: a systematic review and updated meta-analysis

BACKGROUND

Surgical resection of pheochromocytomas and paragangliomas (PPGLs) is associated with a significant risk of intraoperative hemodynamic instability and cardiovascular complications. α-blockade remains the routine preoperative medical preparation despite controversies over the lack of evidence. We presented an updated meta-analysis to ulteriorly evaluate the potential efficacy of preoperative α-blockade versus no blockade for PPGL patients undergoing surgery.

MATERIALS AND METHODS

Randomized and nonrandomized comparative studies assessing preoperative α-blockade for PPGL surgery in adults were identified through a systematic literature search via MEDLINE, Embase, Web of Science, and CENTRAL up to November 2022. Outcome data of intraoperative hemodynamic parameters and major postoperative events were extracted. Mean difference and risk ratio were synthesized as appropriate for each outcome to determine the cumulative effect size.

RESULTS

Fifteen nonrandomized studies involving 3542 patients were finally eligible. Intraoperatively, none of the analyzed hemodynamic parameters differed between patients with or without α-blockade: maximum and minimum systolic blood pressure, hypertensive and hypotensive hemodynamic instability episodes, and peak heart rate, subgroup analysis of normotensive PPGL patients yielded similar results with the overall effects. Postoperatively, α-blockade was associated with prolonged hypotension and vasopressor usage (risk ratio: 4.21, 95% CI: 1.17-15.18, P =0.03). ICU admission, length of stay, overall cardiovascular morbidity, and mortality were similar between the two groups.

CONCLUSIONS

Preoperative α-blockade ensured neither more stable intraoperative hemodynamics nor better perioperative outcome over no blockade for PPGL surgery. However, large-volume randomized controlled trials are still warranted to ascertain these findings.

Tips and Tricks in Laparoscopic Adrenalectomy for Pheochromocytoma. How We Do It

"Pheochromocytomas are rare neuroendocrine tumors that frequently have genetic involvement and can present a particular risk in terms of the anesthetic-surgical procedure. Current worldwide medical recommendations state that laparoscopic adrenalectomy is the conventional treatment for pheochromocytoma, however, the ideal surgical strategy is still being developed as specialized surgeons gain experience with these rare tumors. The study's purpose was to thoroughly evaluate our film library and identify the best surgical steps that represent our standardized procedure. We developed a comprehensive set of surgical critical strategies for either a left or right adrenalectomy, providing helpful advice on patient positioning, port placement, the adrenal gland approach, as well as other surgical methods specifically designed for tumor mobilization and dissection. The current paper aims to synthesize our clinical experience in terms of preoperative preparation, patient positioning, intraoperative complications, causes of conversion, and specimen extraction. The main conclusions concern both the best surgical approach and the importance of surgical experience in the clinical management of these rare tumor types. "

Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma-Paraganglioma Patients Undergoing Surgery: A Meta-Analysis

The main objective of this systematic review and meta-analysis was to review, assess and report on the studies that have evaluated selective alpha blockade (SAB) vs. non-selective alpha blockade (NSAB) therapy in patients undergoing surgery for pheochromocytomas and paragangliomas (PPGL). We performed a systematic search of electronic databases. A meta-analysis was conducted to examine the effectiveness of the two blockades. RevMan 5.3 was used for the meta-analysis. Of the eight articles that met the inclusion criteria, there was only one randomized control trial. Meta-analysis showed that there was no significant difference between the groups SAB and NSAB with regard to intra-operative systolic blood pressure (SBP) >160 mm Hg (relative risk (RR) 0.95 [95% CI 0.57, 1.56] P = 0·83) and intra-operative vasopressor requirement (RR 1.10 [95% CI 0.96, 1.26] P = 0·16). Meta-analysis revealed that there was a significant difference between the groups (SAB vs NSAB) with respect to post-operative vasopressor requirement (RR 1.66 [95% CI 1.0, 2.74] P = 0·05). There was no significant difference between the groups with respect to post-operative complications (RR 0.84 [95% CI 0.58, 1.22] P = 0·36). In conclusion, as patients blocked selectively may have a higher incidence of vasodilator requirement intra-operatively, NSAB offers some haemodynamic advantage over SAB. However, NSAB's real clinical benefit cannot be ascertained with the current studies as this difference did not result in any significant advantage over SAB with regard to morbidity or mortality.

Anesthetic challenges in bilateral pheochromocytoma with history of percutaneous transluminal coronary angioplasty (PTCA): A case report and literature review

Pheochromocytoma are catecholamine-producing neuroendocrine tumors that can be adrenal or extra-adrenal (paraganglioma) in origin. The mainstay of definitive therapy is surgical resection, and successful management depends on careful preoperative optimization, meticulous intraoperative and postoperative hemodynamic management.

A case report of an open aortic valve replacement followed by open adrenalectomy in a patient with symptomatic pheochromocytoma and critical aortic stenosis

Background

Pheochromocytoma is a rare medical condition caused by catecholamine-secreting tumor cells. Operative resection can be associated with significant hemodynamic fluctuations due to the nature of the tumor, as well as associated post-resection vasoplegia. To allow for cardiovascular recovery before surgery, patients require pre-operative alpha-adrenergic blockade, which would be limited in the setting of co-existent severe aortic stenosis. In this report, we describe a patient with severe aortic stenosis and symptomatic pheochromocytoma.

Case presentation

A 51-year-old man with severe aortic stenosis (valve area 0.8 cm²) was found to have a highly active 4 × 4 cm left adrenal pheochromocytoma. Alpha-adrenergic blockade for his pheochromocytoma was limited by syncope in the setting of his aortic stenosis. Open aortic valve replacement (AVR) was performed, followed by adrenalectomy the next day. The perioperative course for each surgical procedure was hemodynamically volatile, exacerbated by severe alcohol withdrawal. During the adrenalectomy, cardiogenic and vasoplegic shock developed immediately after securing the vascular supply to his tumor. This shock was refractory to vasopressin and methylene blue, but responded well to angiotensin II and epinephrine. After both surgeries were completed, his course was further complicated by severe ICU psychosis, ileus, fungal bacteremia, pneumonia/hypoxic respiratory failure and atrial fibrillation. He ultimately recovered and was discharged from the hospital after 38 days.

Conclusion

To our knowledge, this is the first report of surgical AVR and pheochromocytoma resection in a patient with critical aortic stenosis. The appropriate order and timing of surgeries when both these conditions co-exist remains controversial.

Perioperative Management of Pheochromocytoma: From a Dogmatic to a Tailored Approach

BACKGROUND

Perioperative management of pheochromocytoma (PCC) remains under debate.

METHODS

A bicentric retrospective study was conducted, including all patients who underwent laparoscopic adrenalectomy for PCC from 2000 to 2017. Patients were divided into two groups: Group 1 treated with alpha-blockade, and Group 2, without alfa-blockers. The primary end point was the major complication rate. The secondary end points were: the need for advanced intra-operative hemostasis, the admission to the intensive care unit (ICU), the length of stay (LOS), systolic (SBP), and diastolic blood pressure (DBP). Univariate and multivariate analysis was conducted. A p-value < 0.05 was considered statistically significant.

RESULTS

Major postoperative complications were similar (p = 0.49). Advanced hemostatic agents were 44.9% in Group 1 and 100% in Group 2 (p < 0.001). In Group 2, no patients were admitted to the ICU, while only 73.5% of Group 1 (p < 0.001) were admitted. The median length of stay was larger in Group 1 than in Group 2 (p = 0.026). At the induction, SBP was 130 mmHg in Group 1, and 115 mmHg (p < 0.001). The pre-surgery treatment was the only almost statistically significant variable at the multivariate analysis of DBP at the end of surgery.

CONCLUSION

The preoperative use of alfa-blockers should be considered not a dogma in PCC.

A Misleading Presentation of Pheochromocytoma in Pregnancy: A Case Report

Pheochromocytoma is a catecholamine-secreting adrenal tumor and also a rare cause of secondary hypertension in pregnancy. Its low prevalence, nonspecific clinical presentation, and symptoms similar to preeclampsia generate a diagnostic challenge during pregnancy. A 23-year-old hypertensive pregnant woman at 36th gestational week of her first pregnancy was admitted with severe hypertension (210/150 mmHg), headache and proteinuria that made us presume the case as severe preeclampsia. In spite of starting with maximum doses of antihypertensive medications like IV labetolol,and oral nifedipine, loading dose of an anticonvulsant drug, and IV magnesium sulphate, her symptoms persisted. Keeping in view the risks involved to mother and fetus, we delivered the baby by emergency cesarean section. In the postoperative period, along with severe uncontrolled hypertension, she developed tremors, palpitation, and sweating that all led us to further diagnostic workup for secondary causes of hypertension. Eventually, a diagnosis of pheochromocytoma was confirmed by abdominopelvic contrast- enhanced computed tomography and by increased 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid levels. Subsequently, adrenal suppression was achieved by a multidisciplinary approach, and then she underwent laparoscopic adrenalectomy. This case highlights the importance of maintaining a high index of suspicion and multidisciplinary approach while investigating secondary causes of hypertension in young women, thereby differentiating it from preeclampsia.

Perioperative management of pheocromocytoma/ paraganglioma: a comprehensive review

Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this condition and undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

A Comparison of Open and Laparoscopic Approaches to Adrenalectomy in Patients with Phaeochromocytoma

We compared the perioperative profiles of patients undergoing unilateral phaeochromocytoma resection performed by open adrenalectomy with those performed by laparoscopic adrenalectomy.

Data was collected prospectively on 24 patients (12 open, 12 laparoscopic). All patients underwent extensive preoperative medical preparation with phenoxybenzamine and β-blockers. The final preoperative dose of phenoxy-benzamine was similar in each group (laparoscopic 119±60 mg/day, open 100±25 mg/day).

Intraoperative haemodynamic instability was assessed by the requirement for therapeutic intervention. More haemodynamic instability was observed in the laparoscopic group but the differences were not statistically significant. Sodium nitroprusside use to treat hypertension (systolic blood pressure >180 mmHg) was more frequent and the duration of the infusions longer in the laparoscopic group; high dose β-blocker therapy with atenolol and/or esmolol to treat intraoperative tachycardia (heart rate >90) was also more frequent in the laparoscopic group. The small sample size of the study limited the ability to detect a true difference. Blood loss was greater in the open adrenalectomy group but the difference was not significant. The operating time was significantly longer (236±78 vs 147±47 min, P<0.01) but the duration of postoperative hospitalization was significantly shorter (5±2 vs 11±4 days, P<0.01) in the laparoscopic group. Postoperative complications were not significantly different. There were no perioperative deaths.

Overall, we observed more haemodynamic instability in patients undergoing laparoscopic resection but were unable to demonstrate a statistically significant difference. In our experience, laparoscopic adrenalectomy has the advantage of a shorter time to discharge from hospital.

Propranolol: A 50-Year Historical Perspective

Propranolol is a beta-adrenergic receptor antagonist that was developed by the British scientist Sir James Black primarily for the treatment of angina pectoris, more than 50 years ago. It was not long before several other cardiovascular as well as noncardiovascular therapeutic uses of propranolol were discovered. Propranolol soon became a powerful tool for physicians in the treatment of numerous conditions such as hypertension, cardiac arrhythmias, myocardial infarction, migraine, portal hypertension, anxiety, essential tremors, hyperthyroidism, and pheochromocytoma. Owing to its action at multiple receptor sites, propranolol exerts several central and peripheral effects and is therefore useful in various conditions. Right from reduction in postmyocardial mortality to control of anxiety in performers, propranolol plays an important role in a plethora of medical conditions. Interestingly, even today, newer indications of this age-old drug are being discovered. Moreover, propranolol treatment has been found to be cost-effective when compared to other corresponding treatment options for individual indications. In this article, we attempt to recount the journey of propranolol right from its inception to the present day.

Perioperative Management of Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors that produce and store catecholamines. Without adequate preparation, the release of excessive amounts of catecholamines, especially during anesthetic induction or during surgical removal, can produce life-threatening cardiovascular complications. This review focuses on the perioperative management of pheochromocytoma/paragangliomas, initially summarizing the clinical aspects of the disease and then highlighting the current evidence available for preoperative, intraoperative, and postoperative anesthetic management.

Phaeochromocytoma presenting with labile blood pressures following coronary artery bypass grafting

Pheochromocytomas have been reported prior to and during coronary artery bypass surgery. We present a patient with an undiagnosed pheochromocytoma who presented with labile hypertension following coronary artery bypass surgery. This case calls attention to the inclusion of an undiagnosed pheochromocytoma in the differential diagnosis for all patients who develop labile hypertension in the postoperative period following cardiac surgery.

Pheochromocytoma presenting as an acute coronary syndrome complicated by acute heart failure: The challenge of a great mimic

Pheochromocytoma is a rare neuroendocrine tumor with a highly variable clinical presentation. The serious and potentially lethal cardiovascular complications of these tumors are related to the effects of secreted catecholamines. We describe a case of a 50-year-old woman urgently admitted to our hospital because of symptoms and clinical and instrumental findings consistent with an acute coronary syndrome complicated by acute heart failure. Urgent coronary angiography showed normal coronary arteries. During her hospital stay, the recurrence of episodes characterized by a sudden increase in blood pressure, cold sweating, and nausea allowed us to hypothesize a pheochromocytoma. The diagnosis was confirmed by elevated levels of urinary catecholamines and by the finding of a left adrenal mass on magnetic resonance imaging. The patient underwent left adrenalectomy. Therefore, the initial diagnosis was critically reappraised and reviewed as a cardiac manifestation of a pheochromocytoma during catecholaminergic crisis.

An Emergency Department Approach to Drug Treatment of Hypertensive Urgency and Emergency

Patients who present with hypertensive urgency or emergency require immediate attention to assess the severity of illness. Guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure are available but do little to address the management of acute elevations in blood pressure. Various treatment options, both old and new, exist to manage these patients in the emergency department. Decisions on therapy are patient specific and depend on the underlying cause of elevated blood pressure. This article sets out to describe specific patient presentations and reviews current available options in the management of hypertensive urgencies and emergencies.

[Anesthetic management during pheochromocytoma surgery : Current strategies]

BACKGROUND

Surgery-related mortality in patients with pheochromocytoma or paraganglioma has dramatically decreased over the last few decades. This effect has often been attributed to perioperative α‑receptor blockade. However, this has never been tested in a randomized trial and many other changes have contributed to this improvement. At the same time α‑receptor blockade was introduced, short-acting and well controllable agents became available for intraoperative arterial blood pressure management. Subsequently, surgical techniques improved and led almost exclusively to minimally invasive techniques, while improvements in the diagnostic techniques allow earlier and more precise detection of catecholamine-producing tumors.

METHODS

Conduction of a randomized, controlled study to investigate the effect of α‑receptor blockade on mortality is hampered by the rarity of the disease. With the currently low mortality rate, several thousands of patients would be needed to test such a hypothesis. Accordingly, intraoperative management is generally based on expert opinion. Hypertensive episodes are treated by intravenous administration of sodium nitroprusside, urapidil or nitroglycerine. Depending on the individual case a short-acting β‑blocker and magnesium might be added. Hypotension following tumor removal is treated with intravenous fluid infusion and continuous norepinephrine administration. Adrenal gland-sparing resection of pheochromocytoma does not seem to increase the risk of arterial hypertension.

CONCLUSION

Future research should focus on identification of risk factors for intraoperative hypertensive episodes and the question whether a time-consuming, unreliable α‑receptor blockade, burdened with significant side effects, is still needed.

Current perioperative management of pheochromocytomas

Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, ¹²³I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative "alpha-blockade." Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers.

Update in perioperative anesthetic management of pheochromocytoma

Pheochromocytoma is a tumor that originates from either chromaffincells in adrenal medulla or in other paraganglia tissues of the sympathetic nervous system. The perioperative management is quite challenging especially in view of hemodynamic fluctuations. Pheochromocytoma is challenging in view of the impact of excessive and depleted catecholamines in the perioperative period. It requires a through preoperative evaluation and optimization with meticulous intraoperative management. The postoperative period requires vigilance to prevent any untoward complication. In this review we review these concepts based on recent evidence for an optimal outcome.

MANAGEMENT OF CATECHOLAMINE-SECRETING TUMORS IN PREGNANCY: A REVIEW

OBJECTIVE

Catecholamine-secreting tumors (pheochromocytomas and paragangliomas) presenting during pregnancy are extremely rare, but they can be fatal to both mother and fetus. Recent discoveries in the genetic background of these tumors are expected to address an increasing number of at-risk women to prenatal diagnosis.

METHODS

The literature was reviewed in order to provide clinicians with a practical and updated guide on how to manage this life-threatening condition.

RESULTS

The clinical presentation of catecholamine-secreting tumors can be deceptive and mimic common disorders of pregnancy. Silent catecholamine-secreting tumors can become evident during pregnancy, and hypertension cannot be considered a hallmark for this condition: some women may be normotensive or develop orthostatic hypotension. Biochemical screening includes measurement of plasma free metanephrines or urinary fractioned metanephrines. Measurement of catecholamines, dopamine, and methoxytyramine can provide further information on tumor biology, location, and prognosis. Diagnostic imaging is limited, and medical treatment requires a cautious balance between hemodynamic control and effects on the fetoplacental unit. Several genes have been associated with syndromes including catecholamine-secreting tumors, and positive genetic testing can correlate with tumor behavior. Timing and modalities for tumor removal and delivery, including anesthetic management, depend on gestational age, maternal and fetal wellbeing, control of catecholamine excess, suspicion of multiple or malignant disease, and surgical accessibility to the tumor.

CONCLUSION

A timely diagnosis and a multidisciplinary approach are the keys to improve pregnancy outcomes in patients with a catecholamine-secreting tumor; each case should be managed in a tertiary referral center.

[High pressure trap]

Pheochromocytoma is a rare tumor potentially life-threatening and associated with non specific and diverse symptomatology. Cardiac symptoms may mislead diagnosis; they could manifest as myocardial sideration concomitant to a hypertensive peak or supraventricular arythmia. We report a case of pheochromocytoma associated with hypokaliemia revealed by a myocardial ischemia with acute cardiac failure and severe left ventricular depression and complete reversal after surgery.

Pheochromocytoma Presenting as Partial HELLP Syndrome

Diagnosis of pheochromocytoma in partial HELLP syndrome is extremely rare. We report a case of a 25-year-old multigravida woman at 30 weeks of gestation who presented with clinical features consistent with partial HELLP syndrome. Her symptoms were not controlled by pharmacologic therapy, and the patient underwent urgent cesarean section. The patient gave birth to a viable baby, but she sustained an episode of ventricular fibrillation intraoperatively that did not result in any long-term sequelae. The patient's symptoms persisted postoperatively and work-up for secondary etiologies of hypertension demonstrated a right adrenal pheochromocytoma. Following resection, the patient's signs and symptoms resolved, and her lab tests normalized.

Pheochromocytoma resection: Current concepts in anesthetic management

Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.

Anginalike pain and normal coronary arteries

Atherosclerotic CAD is the most common cause of cardiac chest pain in Western countries. Other cardiac syndromes may also cause anginalike pain and may be difficult to differentiate from atherosclerotic CAD. It is essential to make this distinction, because management and prognosis of these conditions are entirely different. A detailed history and, in some cases, special diagnostic methods can help make the diagnosis. When evaluating patients with anginalike chest pain and normal coronary arteries, physicians need to consider this group of diseases and tailor workup and diagnosis on an individual basis.

Perioperative management of catecholamine-secreting glomus jugulare tumors

To treat patients with a catecholamine-secreting glomus jugulare tumor, perioperative management is important. Perioperative catecholamine hypersecretion causes severe problems in the treatment of a catecholamine-secreting glomus tumor. Therefore, a precise therapeutic strategy and perioperative management are required through collaboration of the endocrinology, anesthesiology, and endocrine surgery departments . We describe our perioperative management for catecholamine-secreting glomus jugulare tumor. The patient was a 31-year-old woman with a 50-mm glomus jugulare tumor and a significantly elevated plasma noradrenaline level of 21,165 pg/ml. Before the surgery, oral α − blocker administration was initiated for ∼ 3 months, and her body weight increased from 52 kg at the time of examination to 54.2 kg. Coil embolization of the tumor vessel was performed 1 week before surgery, and the intense tumor stain was reduced by 90%. The patient underwent almost total removal of the tumor via mastoidectomy with high cervical exposure via the transsigmoid approach. Postoperatively, plasma noradrenaline decreased markedly. Preoperative pharmacologic stabilization and peri- and postoperative anesthetic management are essential for the treatment of a catecholamine-secreting glomus jugulare tumor.

Adrenergic crisis due to pheochromocytoma - practical aspects. A short review

Introduction

The definitive therapy in case of pheochromocytoma is complete surgical resection. Improper preoperative assessment and medical management generally places the patient at risk for complications, resulting from an adrenergic crisis. Therefore, it is crucial to adequately optimize these patients before surgery. Optimal preoperative medical management significantly decreases morbidity and mortality during the tumor resection.

Material and methods

This review addresses current knowledge in pre– and intraoperative assessment of a patient with pheochromocytoma.

Results

Before surgery the patient is conventionally prepared with α–adrenergic blockade (over 10–14 days) and subsequently, additional β–adrenergic blockade is required to treat any associated tachyarrhythmias. In preoperative assessment, it is obligatory to monitor arterial blood pressure, heart rate, and arrhythmias and to restore the blood volume to normal.

Conclusions

In conclusion, due to the pathophysiological complexity of a pheochromocytoma, the strict cooperation between the cardiologist, endocrinologist, surgeon and the anaesthesiologist for an uneventful outcome should be achieved in patients qualified for the surgical removal of such a tumor.

Successful Management of Phaeochromocytoma using Preoperative Oral Labetalol and Intraoperative Magnesium Sulphate: Report of four cases

Phaeochromocytoma is a rare neuroendocrine catecholamine-secreting tumour. This type of tumour poses multidimensional anaesthetic challenges as it has an unpredictable clinical course during surgical resection. The alpha-blocking agent phenoxybenzamine remained the mainstay in preoperative preparation before the introduction of beta-blocking agents. We report four cases operated between 2009-2012 at Sultan Qaboos University Hospital, Muscat, Oman. The cases were prepared with oral labetalol, as the alpha-blocking drug phenoxybenzamine was not immediately available. Responses to simulated stress were tested in the theatre before surgery. Anaesthesia was induced under invasive arterial pressure monitoring and magnesium sulphate infusion. Rare intraoperative surges in blood pressure during tumour manipulation were treated with sodium nitroprusside infusions and phentolamine boluses. All of the patients had an uneventful postoperative recovery. Preoperative treatment with labetalol has rarely been reported and can be considered as a potential therapeutic option with optimal patient monitoring if phenoxybenzamine is unavailable.

Laparoscopic cortical sparing adrenalectomy for pediatric bilateral pheochromocytoma: anesthetic management

INTRODUCTION

Pheochromocytoma is a catecholamine-secreting tumor, which is seen rarely in children. These tumors predominantly secrete norepinephrine and epinephrine. They might be familial and associated with hereditary tumors such as Von Hippel-Lindau syndrome and multiple endocrine neoplasia type II.

CASE PRESENTATION

The child might present with a spectrum of clinical manifestation including hypertension, headache, visual disturbances, and behavioral problems. A meticulous preoperative preparation is essential for a stable intraoperative and postoperative outcome.

CONCLUSIONS

We described successful perioperative management of a child who underwent bilateral laparoscopic cortical sparing adrenalectomy and a repeated surgery for the residual tumor removal.

Anesthetic management of laparoscopic pheochromocytoma excision in a patient with a Fontan circulation: a case report

An 18-year-old male with a Fontan circulation underwent excision of a pheochromocytoma after conversion from laparoscopic surgery. The pneumoperitoneum established for laparoscopic surgery may have adverse effects on the Fontan circulation, because it increases the intra-abdominal pressure (IAP), intra-thoracic pressure, pulmonary vascular resistance, and systemic vascular resistance (SVR), and decreases cardiac preload and cardiac output. Meticulous monitoring is also required during carbon dioxide exsufflation, because a rapid decrease in IAP can provoke hemodynamic deterioration by decreasing venous return and SVR. Furthermore, catecholamines released by the pheochromocytoma can worsen the hemodynamic status of Fontan circulation during surgery. Therefore, sophisticated intraoperative anesthetic care is required during laparoscopic pheochromocytoma excision in patients with a Fontan circulation.

Dexmedetomidine induced catecholamine suppression in pheochromocytoma

Pheochromocytoma is a neuroendocrine tumour of chromaffin cells, though rare but a known cause of paroxysmal hypertension with a triad of headache, diaphoresis and palpitation. The biochemical diagnosis of pheochromocytoma is based on estimation of plasma nor-adrenaline, adrenaline and their metabolites in plasma or urine. Clonidine suppression test is performed to differentiate the raised catecholamine level due to pheochromocytoma or other than heochromocytoma especially in cases where plasma nor-adrenaline levels are less than 2000 pg/ml. Clonidine is stated to be unable to suppress catecholamine level in cases of pheochromocytoma, therefore we tested the other α2-agonist Dexmedetomidine intravenous in a case of Pheochromocytoma with remarkably raised nor- adrenaline (25,183 pg/ml) and found 49.42% suppression.

Pheochromocytoma an adrenaline addict - a case report

Pheochromocytomas are rare catecholamine secreting neuroendocrine tumours arising from chromaffin cells of the sympathetic nervous system in the adrenal medulla or extra-adrenal paraganglia. A 20-years-old female presented with paroxysms of abdominal pain, palpitation, sweating and headache since last 2 years. Pheochromocytoma was confirmed by 24 hour urinary catecholamine level and CT of abdomen. After three weeks of preparation, tumour was excised. The following discussion outlines current approaches to preoperative, intraoperative and postoperative anaesthetic management of patients suffering from pheochromocytoma.

Concomitant elective resection of pheochromocytoma and repair of aortic abdominal aneurysm

Perioperative management of a patient with ischemic heart disease with coexisting abdominal aortic aneurysm and pheochromocytoma creates a difficult management dilemma, and surgical intervention in these patients carries a significant risk. The state of catecholamine excess and various other coexisting factors can lead to simultaneous occurrence of abdominal aortic aneurysm and pheocromocytoma. The purpose of this report is to present an integrated approach to the management of concomitant abdominal aortic aneurysm and pheochromocytoma, where a combined surgical approach in addressing these two lesions was preferable due to patient comorbidities and surgical implications without significant complication.