Pheochromocytoma resection: Current concepts in anesthetic management

Cystic adrenal mass revealing a pheochromocytoma in the setting of multiple endocrine neoplasia: A case report

Pheochromocytoma, a neuroendocrine tumor, represents a rare medical condition characterized by the excessive secretion of catecholamines. These tumors often exhibit distinctive features on imaging studies, notably appearing hypervascular. Furthermore, they may present as cystic masses with thin walls, a characteristic that becomes more evident following the administration of contrast medium. The cystic form of adrenal pheochromocytoma, as exemplified in our case, is particularly uncommon, thus underscoring the importance of recognizing its atypical presentation. Accurate diagnosis hinges on a thorough understanding of both the clinical manifestations and radiological findings suggestive of pheochromocytoma. However, definitive confirmation typically necessitates histological examination of the surgical specimen post-adrenalectomy. By shedding light on this rare variant, our case emphasizes the critical role of comprehensive diagnostic approaches in managing such complex medical conditions. Additionally, it underscores the significance of multidisciplinary collaboration among clinicians, radiologists, and pathologists to ensure timely and accurate diagnosis, ultimately guiding appropriate treatment strategies and optimizing patient outcomes.

Perioperative management of phaeochromocytoma with stress cardiomyopathy and aberrant vascular drainage

The following case discusses the surgical considerations for a patient presenting with cardiogenic shock secondary to a phaeochromocytoma crisis with stress cardiomyopathy. The patient underwent an interval laparoscopic adrenalectomy. Pneumoperitoneum insufflation was performed at lower pressures; manipulation of the adrenal tumour was minimised, and the adrenal vein was ligated early. However, as intraoperative blood pressure (BP) remained elevated and rising, further gentle dissection revealed an aberrant inferior phrenic vein draining the adrenal nodule. BP was finally reduced following ligation of the inferior phrenic vein, demonstrating the clinical significance of an unusual dual venous drainage from the adrenal nodule in this patient.

Esmolol's Role in Hemodynamic Management During Pheochromocytoma Surgery: A Comprehensive Review

Pheochromocytoma (PCC) surgery presents significant challenges due to the hemodynamic instability induced by catecholamine release. Effective perioperative management is essential to minimize complications and ensure optimal outcomes. This comprehensive review examines the role of esmolol, a short-acting beta-blocker, in hemodynamic stabilization during PCC surgery. We provide an overview of the pathophysiology of PCC, highlighting the cardiovascular effects of excessive catecholamines. Challenges in perioperative management and the need for effective hemodynamic control are discussed. The pharmacology and mechanisms of action of esmolol are outlined, along with evidence from clinical studies supporting its use in PCC surgery. Comparative analyses with other hemodynamic agents are presented, along with recommendations for optimizing esmolol administration and monitoring. Key findings include the ability of esmolol to attenuate catecholamine-induced hypertension and tachycardia, thereby promoting hemodynamic stability and reducing the risk of intraoperative cardiovascular crises. Implications for clinical practice include the incorporation of esmolol into perioperative management protocols and the importance of multidisciplinary collaboration. Future research directions include further elucidating optimal dosing regimens, comparative effectiveness studies, and exploring novel therapeutic approaches. Collaboration among clinicians, researchers, and pharmaceutical companies is essential to advance the care of patients undergoing surgery for PCC.

Anesthetic management of a dog undergoing unilateral adrenalectomy for phaeochromocytoma excision using a partial intravenous anesthetic protocol

Background

The anesthetic management of adrenalectomies for phaeochromocytoma excision, a catecholamine-secreting tumor, is challenging due to the potential for fatal complications following severe hemodynamic variations, including hypertensive crisis following tumor manipulation or sympathetic stimulation, but also severe hypotension and volume depletion post resection.

Case Description

An 11 kg, 15-year-old male neutered Jack Russel Terrier, with mitral valve disease stage B2, was referred for adrenalectomy for phaeochromocytoma resection. The patient was administered per os prazosin 0.11 mg/kg twice a day and amlodipine 0.125 mg/kg once a day for preoperative stabilization. On the day of surgery, the dog received maropitant 1 mg/kg intravenously (IV) and was premedicated with 0.2 mg/kg methadone IV. Anesthesia was induced with alfaxalone 1 mg/kg IV and midazolam 0.2 mg/kg IV and maintained with partial intravenous anesthesia using sevoflurane in 70% oxygen and constant rate infusions of dexmedetomidine 0.5 μg/kg/hour and maropitant 100 μg/kg/hour. After induction of anesthesia, the dog was mechanically ventilated, and a transversus abdominal plane block was performed with ropivacaine 0.2%. The dog remained remarkably stable with a single, self-limiting, hypertension episode recorded intraoperatively. Postoperative rescue analgesia consisted of methadone and ketamine. The dog was discharged 48 hours after surgery, but persistent hypertension was reported at suture removal.

Conclusion

The use of a low-dose dexmedetomidine CRI, a maropitant CRI, and a transversus abdominal plane block provided stable perioperative hemodynamic conditions for phaeochromocytoma excision in a dog.

Individualized Anesthetic Management of a Patient With Pheochromocytoma and Concurrent Breast Cancer: A Case Report

Pheochromocytomas are rare tumors that present a challenge for surgical and anesthetic management due to their ability to produce significant amounts of catecholamines. This case report highlights the successful management of a 49-year-old woman simultaneously diagnosed with neurofibromatosis type 1, pheochromocytoma, and breast cancer. A key decision by the multidisciplinary team involving endocrinology, general surgery, senology, intensive care, and anesthesiology was to prioritize breast cancer surgery over pheochromocytoma resection. This decision considered the potential for improved prognosis and the need to minimize chemotherapy dosage. The case emphasizes the importance of thorough perioperative preparation, including assessing end-organ damage and optimizing medical therapy. Intraoperative management effectively navigated periods prone to catecholamine release, and postoperative care was closely monitored. This case demonstrates that with meticulous planning, a multidisciplinary approach, and a precise anesthetic strategy, safe anesthesia is achievable for patients with pheochromocytoma undergoing major elective surgeries other than pheochromocytoma resection, adding valuable knowledge to a scarcely documented clinical area.

Exploration of factors affecting hemodynamic stability following pheochromocytoma resection - cohort study

Purpose

Surgery is the only way to cure pheochromocytoma; however, postoperative hemodynamic instability is one of the main causes of serious complications and even death. This study's findings provide some guidance for improved clinical management.

Patients and methods

This study was to investigate the factors leading to postoperative hemodynamic instability in the postoperative pathology indicated pheochromocytoma from May 2016 to May 2022. They were divided into two groups according to whether vasoactive drugs were used for a median number of days or more postoperatively. The factors affecting the postoperative hemodynamics in the perioperative period (preoperative, intraoperative, and postoperative) were then evaluated.

Results

The median number of days requiring vasoactive drug support postoperatively was three in 234 patients, while 118 (50.4%) patients required vasoactive drug support for three days or more postoperatively. The results of the multivariate analysis indicated more preoperative colloid use (odds ratio [OR]=1.834, confidence interval [CI]:1.265-2.659, P=0.001), intraoperative use of vasoactive drug (OR=4.174, CI:1.882-9.258, P<0.001), and more postoperative crystalloid solution input per unit of body weight per day (ml/kg/d) (OR=1.087, CI:1.062-1.112, P<0.001) were risk factors for predicting postoperative hemodynamic instability. The optimal cutoff point of postoperative crystalloid use were 42.37 ml/kg/d.

Conclusion

Hemodynamic instability is a key issue for consideration in the perioperative period of pheochromocytoma. The amount of preoperative colloid use, the need for intraoperative vasoactive drugs, and postoperative crystalloid solution are risk factors for predicting postoperative hemodynamic instability (registration number: ChiCT2300071166).

Clinical Use of Adrenergic Receptor Ligands in Acute Care Settings

In this chapter, we review how ligands, both agonists and antagonists, for the major classes of adrenoreceptors, are utilized in acute care clinical settings. Adrenergic ligands exert their effects by interacting with the three major classes of adrenoceptors. Adrenoceptor agonists and antagonists have important applications, ranging from treatment of hypotension to asthma, and have proven to be extremely useful in a variety of clinical settings of acute care from the operating room to the critical care environment. Continued research interpreting the mechanisms of adrenoreceptors may help the discovery of new drugs with more desirable clinical profiles.

High rates of the SDHB p.Arg46Gln pathogenic variant predisposes New Zealand Māori to phaeochromocytoma/paraganglioma

BACKGROUND

Phaeochromocytomas (PCC) and paragangliomas (PGL; together PPGL) are rare tumours of the adrenal medulla or extra-adrenal paraganglia. They may secrete catecholamines with significant cardiovascular effects. Management of PPGL is predominantly surgical, despite the anaesthetic risks related to potential haemodynamic instability. Meticulous pre-treatment and intra-operative management are required to improve cardiovascular outcomes.

AIMS

There are limited local data regarding the incidence of PPGL and the clinical characteristics of individuals diagnosed with these tumours in New Zealand. We undertook a retrospective study investigating the local practice and patient characteristics with an additional focus on intra-operative haemodynamic stability and post-operative outcomes.

METHODS

Electronic patient records were searched for individuals with a diagnosis of PPGL. Clinical records and electronic databases were interrogated for pre-operative, intra-operative and post-operative data points. Particular attention was paid to rates and types of germline mutations, intra-operative haemodynamic stability and post-operative renal and cardiovascular outcomes.

RESULTS

We identified 49 individuals with PPGL, of whom 34 were from the local area. This gave a local incidence of PPGL of around five cases per million people per year. Māori were significantly over-represented in our cohort, with this being in part due to high rates of the SDHB R46Q mutation. Over 95% of our cohort met pre-specified pre-operative blood pressure parameters. Intra-operative monitoring revealed a tendency to hypotension, but this did not translate into adverse post-operative outcomes, which were infrequent.

CONCLUSIONS

Māori were over-represented due to high rates of germline SDHB R46Q mutations. There were few post-operative adverse outcomes in this contemporary cohort.

Surgical management of recurrent and extra-adrenal pheochromocytomas requiring vascular resection and reconstruction

This case series highlights that extra-adrenal and recurrent pheochromocytomas can require en bloc vascular resection to achieve negative margins. Through this series of cases performed in a multidisciplinary fashion, we aim to highlight the technical aspects of these cases that can add to their complexity. Vascular invasion alone should not preclude an otherwise feasible oncologic resection.

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. "

Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis

OBJECTIVE

Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries.

METHODS

This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay.

RESULTS

Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs.

CONCLUSIONS

Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.

Anaesthetic Management of a Labrador Retriever Undergoing Adrenalectomy for Phaeochromocytoma Excision, a Case Report

Perioperative management of cases undergoing phaeochromocytoma removal should aim at normalising blood pressure and heart rate, restoring volume depletion, and preventing catecholamine release induced by surgical manipulation. In this case report, a novel pharmacological approach in a dog undergoing surgical tumour excision is described. A 7-year-old 25-kg spayed female Labrador Retriever presented for repeated episodes of generalised weakness, pale mucous membranes, tachycardia, tremor, panting, vomiting, and hypertension over the last month was referred for surgical treatment of a left-sided adrenal tumour with invasion of the caudal vena cava. Severe hypertensive episodes occurred repeatedly, starting early during the anaesthetic period, while clipping and cleaning the abdominal area, and continued intraoperatively when the tumour was handled. Moderate hypotension occurred once the tumour was isolated and worsened during temporary caudal vena cava flow interruption and cavotomy. The patient was treated preoperatively with phenoxybenzamine to prevent hypertensive crises. Intraoperatively, magnesium sulphate and urapidil were used to control blood pressure. This treatment was effective in reducing the magnitude of blood pressure spikes but not sufficient to prevent hypertensive peaks, especially during tumour manipulation. Hypotension was treated with synthetic colloid and crystalloid boli, and noradrenaline continuous infusion. Blood transfusion was performed in response to acute bleeding during cavotomy. The dog recovered successfully from anaesthesia and its quality of life was deemed excellent by the owner at the last follow up, 22 months after surgery. The histopathology confirmed the diagnosis of phaeochromocytoma with an invasion of the phrenicoabdominal vein. In the present case, we obtained a successful outcome but failed to provide haemodynamic stability throughout the procedure.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study

BACKGROUND

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma.

MATERIALS AND METHODS

This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed.

RESULTS

In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy.

CONCLUSIONS

The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Predictors of prolonged hypotension requiring vasopressor support after resection of pheochromocytoma and paraganglioma

OBJECTIVE

Prolonged hypotension is a common complication after resection of pheochromocytoma (PCC) or paraganglioma (PGL). The objective of our study was to identify preoperative or intraoperative clinical factors that can predict prolonged hypotension after PCC/PGL resection.

PATIENTS AND METHODS

A total of 414 patients who underwent resection of PCC or PGL at our institution between January 2013 and January 2020 were included. Patients were divided into two groups according to whether or not vasopressor support was required postoperatively. Associations between preoperative and intraoperative variables and prolonged hypotension were evaluated.

RESULTS

Two hundred and one (48.6%) patients had postoperative hypotension that required vasopressor support with a median duration of 20 h. Multivariable analysis demonstrated that increased 24-h urinary norepinephrine (NE) levels (odds ratio [OR] = 1.091, 95% confidence interval [CI]: 1.052-1.132, p < .001), longer operative time (OR = 1.008, CI: 1.004-1.011, p < .001) and lower preoperative phenoxybenzamine dose (OR = 0.336, CI: 0.150-0.753, p = .008) were predictors of prolonged hypotension. Moreover, operative time, body mass index, 24-h urinary level of NE and preoperative phenoxybenzamine dose were significantly correlated with the duration of postoperative vasopressor support.

CONCLUSIONS

Increased urine NE level, longer operative time and lower preoperative phenoxybenzamine dose were predictors of prolonged hypotension requiring vasopressor support. Clinicians can identify these factors to manage their patients better and prevent severe complications.

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

OBJECTIVE

To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs).

METHODS

This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center.

RESULTS

Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications.

CONCLUSIONS

An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Intraoperative adenosine for pheochromocytoma with myocardial infarction and SARS-CoV-2. Case report

Introduction: Pheochromocytomas are neuroendocrine tumors capable of synthetizing, storing and releasing catecholaminergic hormones that may lead to life-threatening hemodynamic instability. The COVID-19 pandemic has increased the risks and perioperative complexity of the patients undergoing pheochromocytoma-associated adrenalectomy. This article discusses the use of adenosine for the management of hypertensive crisis during this intervention, as well as the need to individualize the suitable timing for surgery after recent COVID-19 infection. Case presentation: This article discusses the case of a patient with a finding of right adrenal incidentaloma; further studies determined a metanephrines secreting pheochromocytoma. Following hospital admission for preoperative optimization, the eve of the procedure the patient developed an acute myocardial infarction and subsequently SARS-CoV-2 symptomatic infection. Intraoperatively, hypertensive peaks were managed with continuous adenosine perfusion. The patient was discharged after 48 hours. Conclusions: Preoperative optimization positively influences the intraoperative management of patients with pheochromocytoma. The intraoperative use of adenosine allows for adequate and safe control of hypertensive crises. Each situation must be individualized in patients pending surgery, with a recent COVID-19 infection.

Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. The Perioperative Management of Adrenalectomy in a Jehovah’s Witness Patient: A Case Report

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Actualities in the anaesthetic management of pheochromocytoma/ paraganglioma

The anaesthetic management of pheochromocytoma is complicated and challenging. However, preoperative pharmacologic preparation, modern anaesthetic techniques and drugs associated with advanced monitoring in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic surgery and robotic approaches in the present day) improved significantly perioperative outcome, and intraoperative and postoperative hemodynamic stability. Although there are not randomised clinical trials to suggest one approach over another and there is a high international variability amongst intraoperative anaesthetic techniques, most management principles are still universal.

Anaesthetic challenges in perioperative management of thoracic paraganglioma in an 8-year-old child

Pheochromocytomas (PCC) are catecholamine-secreting tumours that arise from chromaffin cells of the sympathoadrenal system. These rare catecholamine-secreting tumours arising from adrenal glands are termed as PCC and those from extra--adrenal sites are termed paraganglioma (PGL). Thoracic PGL is very rarely found. we report the anaesthetic challenges and management of an 8-year-old child with functional thoracic PGL and its successful outcome.

Paraganglioma Presenting as Hypoxia and Syncope in Pregnancy: A Case Report

Paragangliomas (PGLs) are rare tumors with an incidence of 0.007% in pregnant women. Patients with PGLs commonly present with hypertension and tachycardia. This case report describes the evaluation and management of a multiparous woman at 32 weeks of gestation with syncope, hypoxia, and tachycardia as unusual presenting symptoms of PGL. Her symptoms were attributable to paradoxical effects of circulating catecholamines on downregulated alpha-adrenergic receptors resulting in decreased systemic vascular resistance.

Risk factors for hemodynamic instability during laparoscopic pheochromocytoma resection: a retrospective cohort study

Background

Adrenalectomy for pheochromocytoma, a rare catecholamine-secreting tumour, is a challenging procedure because of the high risk of intraoperative hemodynamic instability, which can cause life-threatening complications. Our study aimed to identify predictive factors for hemodynamic instability during pheochromocytoma resection as well as to assess the risk factors for postoperative morbidity.

Methods

Data of 96 patients, who underwent laparoscopic adrenalectomy were analysed retrospectively. Hemodynamic instability was defined as an occurrence of both intraoperative episodes of systolic blood pressure above 160 mmHg and vasoactive (vasodilators or vasoconstrictors) drug administration. Patients were divided into two groups: one which met both criteria, and another one without hemodynamic instability-42 (43.8%) and 54 (56.2%) respectively.

Results

The mean tumour size was 4.5±2.0 cm. 86 patients had a sporadic pheochromocytoma and 10 (10.4%) had a familial disease. Sixty-three patients were preoperatively treated with nonselective blockers and 33 patients with selective blockers. Mean operative time was 98.7±41.7 min. and mean intraoperative blood loss was 165.7±381.2 mL. In 26% of patients, postoperative complications occurred. The median length of hospital stay was 3 days. The multivariate logistic regression model showed that the size of adrenal tumour and diabetes were significant factors of hemodynamic instability. Intraoperative use of vasopressors was an independent risk factor for both all-cause and cardiovascular morbidity.

Conclusions

Adrenal tumour size and diabetes were associated with hemodynamic instability during pheochromocytoma resection. The only risk factor for complications in our group was intraoperative necessity to use vasopressors.

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.

Retrospective evaluation of labetalol as antihypertensive agent in dogs

Background

To evaluate the effect on arterial blood pressure (ABP) of labetalol infusion as treatment for perioperative non nociceptive acute hypertension in dogs. The clinical records of dogs receiving intra or postoperative labetalol infusion were retrospectively reviewed. Invasive systolic (SAP), mean (MAP) and diastolic (DAP) arterial pressure and heart rate (HR) before labetalol infusion (T0) and 15, 30, 45 and 60 min (T1, T2, T3 and T4 respectively) after infusion were retrieved. The dose rate of labetalol infusion and use of concurrently administered drugs that could have potentially affected ABP and/or HR were also recorded. ANOVA for repeated measures and Dunnett’s multiple comparison test were used to determine the effect of labetalol on ABP and HR. Differences were considered significant when p < 0.05.

Results

A total of 20 dogs met the inclusion criteria, and hypertension was documented after craniotomy (12/20), adrenalectomy (4/20) and other procedures (4/20). Five dogs received labetalol intraoperatively, 14 postoperatively, and 1 during the surgical procedure and recovery. Median infusion duration and rate were 463 (60-2120) minutes and 1.1 (0.2–3.4) mg/kg/h respectively. Median loading dose was 0.2 (0.2–0.4) mg/kg. Labetalol produced a significant decrease in SAP and DAP at all time points compared to T0 (p < 0.05), while the effect was not significant at T1 for MAP (p = 0.0519). Median maximum MAP decrease was 31 (20–90) mmHg. Heart rate did not increase significantly during treatment (p = 0.2454). Acepromazine given before or during labetalol treatment did not reduce significantly ABP (p = 0.735).

Conclusions

Labetalol produced a reliable and titratable decrease in ABP with non significant increase in HR.

Anesthesia for Endocrine Emergencies

Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.

The effect of combined Epidural-general Anesthesia on Hemodynamic Instability during Pheochromocytoma and Paraganglioma Surgery: A multicenter retrospective cohort study

Objectives: The purpose of this study was to compare the effects of combined epidural-general anesthesia with those of general anesthesia alone on hemodynamic instability (intraoperative hypotension and hypertensive crisis) during pheochromocytoma and sympathetic paraganglioma surgery. Methods: A total of 119 patients' medical records were reviewed who were diagnosed as having pheochromocytoma and sympathetic paraganglioma on the basis of histological findings. Intraoperative hypotension was defined as a mean blood pressure < 60 mmHg or a decrease > 30% in baseline systolic blood pressure after adrenal vein ligation. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The predictor variables for intraoperative hypotension and hypertensive crisis were analyzed with logistic regression models. Data were presented as adjusted odds ratio with 95% confidence interval. Results: The independent predictors of intraoperative hypotension were an increased attenuation number on unenhanced computed tomography (1.112 [1.009-1.226], p = 0.033), a high baseline mean blood pressure (1.063 [1.012-1.117], p = 0.015), and the combined epidural-general anesthesia (5.439 [1.410-20.977], p = 0.014). In contrast, an increased attenuation number on unenhanced computed tomography was the only independent predictor of hypertensive crisis (1.087 [1.021-1.158], p = 0.009). Conclusions: The combined epidural-general anesthesia was not effective in attenuating hypertensive responses, but could have exacerbated intraoperative hypotension. These findings should be taken into account before selecting the anesthetic technique in pheochromocytoma and sympathetic paraganglioma surgery.

The Duration of Preoperative Administration of Single α-Receptor Blocker Phenoxybenzamine before Adrenalectomy for Pheochromocytoma: 18 Years of Clinical Experience from Nationwide High-Volume Center

Purpose

There is no consensus for the optimum duration of preoperative administration of phenoxybenzamine (PXB) before adrenalectomy for pheochromocytoma. The aim of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of PXB administration.

Methods

In total, 102 patients managed preoperatively with single α-receptor blocker phenoxybenzamine were enrolled from 469 consecutive patients diagnosed histologically with pheochromocytoma. The patients received surgical treatment in the Department of Urology, Peking University First Hospital, between January 2001 and July 2018. All patients were divided into three groups: Group A (<14 d), Group B (14–30 d), and Group C (>30 d). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared among the three groups.

Results

These patients included 47 men and 55 women, with an average age of 43 years at the time of surgery. Clinical characteristics, except the status of preoperative biochemical tests (24 hr urine fractioned catecholamine or plasma-fractioned catecholamine) (p=0.020), preoperative hemodynamics, and medicine management and surgical approaches, in the three groups were comparable. Multivariate analyses demonstrated that the size of the tumor (p=0.034) was an independent risk factor for intraoperative hemodynamic instability. Among the three groups, we found no significant difference in intraoperative hemodynamics and postoperative outcomes.

Conclusion

The data from the current study indicated that the preoperative management of pheochromocytoma with single α-receptor blocker PXB for more than 2 weeks, after the final dose adjustment, could not further reduce the risk of intraoperative hemodynamic instability or postoperative complications. Thus, our study supports that 14 days would be enough for the duration of preoperative management of pheochromocytoma with single α-receptor blocker PXB in final dose.

Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.

Ectopic pheochromocytoma or paraganglioma of the ZUCKERKANDL organ: A case report and review of the literature

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EPIDEMIOLOGY: paraganglioma of the ZUCKERKANDL organ is a rare neuroendocrine tumour but must be known.

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DIAGNOSIS: The typical presentation which is the Menard Triad of symptoms, associating headaches, sweating and palpitation. Preoperative diagnosis can be difficult in pauci-symptomatic cases. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis.

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TREATMENT: Treatment is surgical. Preoperative medical preparation is aimed at reducing risks of peroperative hemodynamic instability. The anesthetist should therefore prepare himself to manage blood pressure peaks during the tumour’s dissection, but also the possible low blood pressure at the end of exeresis. Surgery remains the key element of treatment and consists in exeresis of the paragaglioma.

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PROGNOSIS: paraganglioma of the ZUCKERKANDL organ is often a benign tumor. The resuscitation determines the patient’s prognosis.

Introduction

Paraganglioma of the ZUCKERKANDL organ are rare. Diagnosis is based on clinical, radiological and biological arguments. We report a case to describe our surgical procedure and insist on the necessity of preoperative diagnosis.

Presentation of case

BA, 52-years-old male patient was seen in consultation for left hypochondrium pains. The clinical examination had revealed a painful tumefaction in the left flank and the left hypochondrium. A deep mass was observed, but was difficult to be assessed, due to pain. Abdominal-pelvic CT scan with contrast injection had revealed a tissue mass, suggesting a tumor of the tail of the pancreas. Laparotomy showed this mass was not attached to the tail of the pancreas, and was along the abdominal aorta up to the aortic bifurcation. Upon touching the mass, blood pressure raised up to 240 mmHg. A least mobilization of the mass and the use of nicardipine helped maintain blood pressure below 180mmhg. Dissection was carried out from the aortic bifurcation to the TREITZ’s angle and the mass was removed. The follow-ups were characterized by low blood pressure a few minutes following the resection of the mass.

Discussion

Pheochromocytoma is rare. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis. The surgery consists a lumpectomy. The resuscitation determines the patient’s prognosis.

Conclusion

Pheochromocytoma is an unusual mass. Preoperative diagnosis can be difficult in pauci-symptomatic cases. One should consider this in the face of any abdominal mass, so as to improve planning of resuscitation which determines the patient’s prognosis.

[Peculiarities of anesthesia for the surgical treatment of pheochromocytoma: about a case]

Nous rapportons la prise en charge d'une patiente de 37 ans, aux antécédents d'hypertension artérielle (HTA) mal suivie, adressée en consultation chirurgicale avec une symptomatologie faite de lombalgies droites, de vertiges, de céphalées, de sueurs et de palpitations. Durant l'hospitalisation, la tension artérielle (TA) oscillait entre 130/80 mm d'Hg et 190/120 mm d'Hg. Le reste de l'examen clinique ne retrouvait aucune autre anomalie. Le scanner thoraco-abdominal avait montré une masse surrénalienne de 55x45x65 mm comprimant la veine cave inférieure et la veine rénale droite. Le dosage de l'acide vanyl-mandélique urinaire (VMA) donnait un résultat de 11,8mg/24heures. Le dosage des catécholamines sanguin n'a pas été réalisé. Le diagnostic d'un phéochromocytome était retenu et l'indication opératoire était posée. En consultation d'anesthésie l'examen clinique retrouvait un bon état général, une tension artérielle (TA) à 190/120 mmHg, une auscultation cardiopulmonaire sans particularité et un critère prédictif d'intubation non difficile (Mallampati II). La patiente a bénéficiée d'une préparation préopératoire à base d'alpha-bloquants et bêta-bloquants, et d'un inhibiteur calcique. La surrénalectomie a été réalisée par laparotomie médiane. Il n'y avait pas eu d'instabilité hémodynamique lors de la mobilisation et de la résection de la tumeur. Les suites opératoires immédiates ont été simples. Elle a regagné son domicile à J7 postopératoire. Avec un recul de 3 mois, la patiente ne présentait plus de signes cliniques et ses chiffres tensionnels étaient normaux. L'anesthésie pour la chirurgie du phéochromocytome est faisable même en situation de ressources limitées. Une bonne préparation du patient permet d'éviter les complications périopératoires.

Echocardiographic Guidance for Surgical Excision of the Intracardiac Component of a Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors, with published incidence of 2 to 8 cases per million patients per year. The extension of these tumors into the vena cava and right atrium is rarely seen. Transesophageal echocardiography may be invaluable to delineate tumor extent and characteristics, which in turn may provide a useful tool to guide intraoperative surgical approach to these uncommon masses. In the case presented in this article, we describe the role of transesophageal echocardiography in guiding a safe and complete, excision of an invasive pheochromocytoma without embolization of tumor components.

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.

Perioperative management of a large, late presenting phaeochromocytoma

A 77-year-old man presenting to the emergency department with an acute coronary syndrome was later found to have a phaeochromocytoma. The lateness of this presentation was likely due to the protective α blocking effects of long-term terazosin therapy for his prostatism. α blockers such as terazosin are a well-recognised medical therapy in the perioperative optimisation of phaeochromocytoma because they treat the adrenergic effects of catecholamine release from the tumour such as hypertension. This patient was diagnosed with an ST elevation myocardial infarction (STEMI). A cardiac angiogram showed no evidence of vessel occlusion. A right adrenal mass of 9×8×9 cm was incidentally found and confirmed as a phaeochromocytoma with raised plasma metanephrines and normetanephrines. Following preoperative optimisation and multidisciplinary team involvement, an open right adrenalectomy was performed successfully some months later.

Perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma

Perioperative hemodynamic instability still remains the biggest surgical and anesthetic challenge in surgery for pheochromocytoma. The aim of this review was to discuss pre-, intra- and postoperative factors that may impact on hemodynamic condition of a patient. It describes patients' preparation with appropriate medication, principles of surgical technique as well as risk factors for development of hemodynamic instability in postoperative period. Currently the gold standard in the treatment of pheochromocytoma is preoperative use of alpha-blockers and laparoscopic surgery. This approach allowed improving outcomes by lowering both mortality and morbidity.

Anesthetic Management of Clinically Silent Familial Pheochromocytoma with MEN 2A: A Report of Four Cases

Familial pheochromocytomas are commonly associated with multiple endocrine neoplasia type 2 (MEN 2) syndrome. Majority of the patients present with normal clinical and biochemical parameters in the preoperative period, the incidence of hypertension being only 50 %. Even though patients may be clinically asymptomatic, surveillance and proper preoperative evaluation is important, as surgery for associated tumors may precipitate a hypertensive crisis and result in severe complications. A family of 19 members, of which 12 were positive for MEN 2A syndrome, presented to our hospital. Seven of the 12 patients had pheochromocytoma and medullary thyroid carcinoma (MTC), while the other 5 had only raised plasma calcitonin levels. Two of the 7 patients presented with bilateral pheochromocytoma and underwent an open adrenalectomy. The other 5 patients had a left-sided adrenal tumor and underwent left laparoscopic adrenalectomy under combined general and epidural anesthesia. We present our experience with four of these five cases. We here state that how paucity of literature on perioperative preparation of clinically and biochemically silent pheochromocytomas led to serious intraoperative complications in one of four cases.