Pheochromocytoma surgery: Difference between revisions
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*It may also be nescessary to perform a complete surgical [[resection]] of the affected adrenal gland(s). | *It may also be nescessary to perform a complete surgical [[resection]] of the affected adrenal gland(s). | ||
'''Adrenalictomy:''' | '''Adrenalictomy:''' | ||
*Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for non-metastatic abdominal pheochromocytmas. | *Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for non-metastatic abdominal pheochromocytmas.<ref name="pmid21494137">{{cite journal| author=Nehs MA, Ruan DT| title=Minimally invasive adrenal surgery: an update. | journal=Curr Opin Endocrinol Diabetes Obes | year= 2011 | volume= 18 | issue= 3 | pages= 193-7 | pmid=21494137 | doi=10.1097/MED.0b013e32834693bf | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21494137 }}</ref> | ||
*Complicationa are less in laparoscopic than open surgery. Catecholamine secretion falls to normal level within a week. Major intraoperative complications include: intraoperative tumor capsule rupture, hypertensive crisis, myocardial infarctions, or cerebrovascular haemorrhages. Hyperdynamic instability after tumor resection is poosible. Hypoglycemia can occur after tumour resection due to unopposed insulin effect after decline of catecholamines levels. | *Complicationa are less in laparoscopic than open surgery. Catecholamine secretion falls to normal level within a week. Major intraoperative complications include: intraoperative tumor capsule rupture, hypertensive crisis, myocardial infarctions, or cerebrovascular haemorrhages. Hyperdynamic instability after tumor resection is poosible. Hypoglycemia can occur after tumour resection due to unopposed insulin effect after decline of catecholamines levels.<ref name="pmid25188716">{{cite journal| author=Rafat C, Zinzindohoue F, Hernigou A, Hignette C, Favier J, Tenenbaum F et al.| title=Peritoneal implantation of pheochromocytoma following tumor capsule rupture during surgery. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 12 | pages= E2681-5 | pmid=25188716 | doi=10.1210/jc.2014-1975 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25188716 }}</ref> | ||
*Severe | *Severe hypotension can occur after removal of the gland due to decreased catecholamines level in blood and downregulation of adrenergic receptors. It can be controlled by vasopressors induction.<ref name="pmid14734011">{{cite journal| author=Flávio Rocha M, Faramarzi-Roques R, Tauzin-Fin P, Vallee V, Leitao de Vasconcelos PR, Ballanger P| title=Laparoscopic surgery for pheochromocytoma. | journal=Eur Urol | year= 2004 | volume= 45 | issue= 2 | pages= 226-32 | pmid=14734011 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14734011 }}</ref> | ||
* | * | ||
'''''Prognosis''''' | '''''Prognosis''''' | ||
* Good prognosis pateints include: small tumor size, short duration of surgery, systolic blood pressure less than 160 mmhg, and low levels of urinary catecholamines. | * Good prognosis pateints include: small tumor size, short duration of surgery, systolic blood pressure less than 160 mmhg, and low levels of urinary catecholamines.<ref name="pmid20336320">{{cite journal| author=Murphy MM, Witkowski ER, Ng SC, McDade TP, Hill JS, Larkin AC et al.| title=Trends in adrenalectomy: a recent national review. | journal=Surg Endosc | year= 2010 | volume= 24 | issue= 10 | pages= 2518-26 | pmid=20336320 | doi=10.1007/s00464-010-0996-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20336320 }}</ref> | ||
* Postoperative hypotension can be avoided by adequate fluid replacement. | * Postoperative hypotension can be avoided by adequate fluid replacement. | ||
* Recurrence is more in patients with familial pheochromocytoma and extraadrenal tumors. | * Recurrence is more in patients with familial pheochromocytoma and extraadrenal tumors.<ref name="pmid11297571">{{cite journal| author=Plouin PF, Duclos JM, Soppelsa F, Boublil G, Chatellier G| title=Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single center. | journal=J Clin Endocrinol Metab | year= 2001 | volume= 86 | issue= 4 | pages= 1480-6 | pmid=11297571 | doi=10.1210/jcem.86.4.7392 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11297571 }}</ref> | ||
* Familial pheochromocytoma have a high incidence of bilateral disease. | * Familial pheochromocytoma have a high incidence of bilateral disease. | ||
* Partial adrenalectomy is recommended for these patients with bilateral pheochromocytomas to prevent permanent glucocorticoid deficiency. | * Partial adrenalectomy is recommended for these patients with bilateral pheochromocytomas to prevent permanent glucocorticoid deficiency. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2]
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Overview
Surgery is the mainstay of treatment for pheochromocytoma.
Surgery
- Surgical resection is the treatment of choice for benign localized tumor.
- Given the complexity of perioperative management, and the potential for catastrophic intra and postoperative complications, such surgery should be performed only at centers experienced in the area.
- It may also be nescessary to perform a complete surgical resection of the affected adrenal gland(s).
Adrenalictomy:
- Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for non-metastatic abdominal pheochromocytmas.[1]
- Complicationa are less in laparoscopic than open surgery. Catecholamine secretion falls to normal level within a week. Major intraoperative complications include: intraoperative tumor capsule rupture, hypertensive crisis, myocardial infarctions, or cerebrovascular haemorrhages. Hyperdynamic instability after tumor resection is poosible. Hypoglycemia can occur after tumour resection due to unopposed insulin effect after decline of catecholamines levels.[2]
- Severe hypotension can occur after removal of the gland due to decreased catecholamines level in blood and downregulation of adrenergic receptors. It can be controlled by vasopressors induction.[3]
Prognosis
- Good prognosis pateints include: small tumor size, short duration of surgery, systolic blood pressure less than 160 mmhg, and low levels of urinary catecholamines.[4]
- Postoperative hypotension can be avoided by adequate fluid replacement.
- Recurrence is more in patients with familial pheochromocytoma and extraadrenal tumors.[5]
- Familial pheochromocytoma have a high incidence of bilateral disease.
- Partial adrenalectomy is recommended for these patients with bilateral pheochromocytomas to prevent permanent glucocorticoid deficiency.
- Complete bilateral adrenalectomy is recommended for MEN2 patients. There is highrt rate of reccurence than in sporadic cases. Follow up for long duration after surgery is needed. Most patients should have annual biochemical screening.
References
- ↑ Nehs MA, Ruan DT (2011). "Minimally invasive adrenal surgery: an update". Curr Opin Endocrinol Diabetes Obes. 18 (3): 193–7. doi:10.1097/MED.0b013e32834693bf. PMID 21494137.
- ↑ Rafat C, Zinzindohoue F, Hernigou A, Hignette C, Favier J, Tenenbaum F; et al. (2014). "Peritoneal implantation of pheochromocytoma following tumor capsule rupture during surgery". J Clin Endocrinol Metab. 99 (12): E2681–5. doi:10.1210/jc.2014-1975. PMID 25188716.
- ↑ Flávio Rocha M, Faramarzi-Roques R, Tauzin-Fin P, Vallee V, Leitao de Vasconcelos PR, Ballanger P (2004). "Laparoscopic surgery for pheochromocytoma". Eur Urol. 45 (2): 226–32. PMID 14734011.
- ↑ Murphy MM, Witkowski ER, Ng SC, McDade TP, Hill JS, Larkin AC; et al. (2010). "Trends in adrenalectomy: a recent national review". Surg Endosc. 24 (10): 2518–26. doi:10.1007/s00464-010-0996-z. PMID 20336320.
- ↑ Plouin PF, Duclos JM, Soppelsa F, Boublil G, Chatellier G (2001). "Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single center". J Clin Endocrinol Metab. 86 (4): 1480–6. doi:10.1210/jcem.86.4.7392. PMID 11297571.