Removal Of Pheochromocytoma Research Articles

Long Term Follow-Up After Surgical Removal of Pheochromocytoma - Observations in 61 Patients

89 patients were operated on for pheochromocytoma. 61 patients (37 women and 24 men) were available for extended follow-up. The final survey, performed 79.1 +/- 66.9 months postoperatively, provided data on survival, blood pressure tumor recurrence, malignant metastatic lesions, cardiovascular complications and coexisting diseases. There were 4 deaths during the follow-up period, including 2 instances of malignant pheochromocytoma. Permanent normalization of blood pressure was achieved in 38 patients (62.3%). This hypotensive effect was noted in 79.2% of patients with preoperative paroxysmal hypertension and in 40.8% of those with sustained hypertension. Permanent or re-developing postoperative hypertension was noted in 23 (37.7%) patients. This includes 4 cases of malignant pheochromocytoma, 4 cases of recurrent benign pheochromocytoma and 15 cases of essential hypertension. Cardiovascular complications during follow-up were rare and concerned the patients with essential hypertension diagnosed postoperatively.

Hypoglycemia induced by excessive rebound secretion of insulin after removal of pheochromocytoma

During an 8-year-period from 1981, a total of 6 of 45 patients with pheochromocytoma developed severe hypoglycemia (plasma glucose, 12-50 mg/dl) 2-4 1/2 hours after removal of the tumor. In order to elucidate the pathogenesis of the hypoglycemic attack, the levels of plasma immunoreactive insulin (IRI) and glucose were sequentially measured at surgery in 10 patients with pheochromocytoma, from the beginning of the operation until usually 5 hours after tumor resection. The same examinations were carried out in 4 patients with primary aldosteronism and 1 patient with Cushing's syndrome as controls. The highest plasma IRI levels observed in the 2 patients with postexcisional hypoglycemia were 174 and 2,081 microU/ml and those in the 8 patients without hypoglycemia were 13-222 microU/ml (mean, 77), but they were only 14-33 microU/ml (mean, 22) in the 5 control patients. The mean of the highest plasma IRI/glucose ratios in the immediate postoperative phase was 1.37 +/- 0.87 in the 10 patients with pheochromocytoma but only 0.16 +/- 0.04 in the 5 control patients (p less than 0.01). Review of the clinical data in our series disclosed that patients with higher levels of preoperative urinary epinephrine excretion and those with either diabetes mellitus or impaired glucose tolerance tended to develop postoperative hypoglycemia. These observations suggest that endogenous insulin secretion is suppressed by increase plasma catecholamines, and that excessive rebound secretion of insulin after removal of a pheochromocytoma is a rather common phenomenon. Intravenous infusion of glucose is necessary and plasma glucose levels should be monitored after resection of a pheochromocytoma.

Caesarean Section at 27 Weeksʼ Gestation with Removal of Phaeochromocytoma

Caesarean Section at 27 Weeksʼ Gestation with Removal of Phaeochromocytoma

Adenosine

Severe hypertension and cardiac arrhythmias are well known problems during surgical removal of pheochromocytoma. This is due to extremely high circulating catecholamines during tumor manipulation. In this study, peroperative blood pressure control was obtained by the infusion of adenosine, which antagonized cardiovascular effects of catecholamines. During operation of 10 patients, none had systolic blood pressure exceeding 200 mm Hg or any cardiac arrhythmias despite extremely high plasma catecholamine levels. A mean blood pressure of 120–150 mm Hg was maintained in all patients. Peroperative use of adenosine seems to be a most effective compound for hemodynamic control during pheochromocytoma surgery.

Adenosine: a new antihypertensive agent during pheochromocytoma removal.

AbstractSevere hypertension and cardiac arrhythmias are well known problems during surgical removal of pheochromocytoma. This is due to extremely high circulating catecholamines during tumor manipulation. In this study, peroperative blood pressure control was obtained by the infusion of adenosine, which antagonized cardiovascular effects of catecholamines. During operation of 10 patients, none had systolic blood pressure exceeding 200 mm Hg or any cardiac arrhythmias despite extremely high plasma catecholamine levels. A mean blood pressure of 120–150 mm Hg was maintained in all patients. Peroperative use of adenosine seems to be a most effective compound for hemodynamic control during pheochromocytoma surgery.

A Case of Normalized Hypertrophic Cardiomyopathy after Removal of Pheochromocytoma

A Case of Normalized Hypertrophic Cardiomyopathy after Removal of Pheochromocytoma

Removal of pheochromocytoma by enucleation

In 6 cases pheochromocytomas were removed by enucleation. A typical case is reported in detail illustrating that it might be a procedure of choice in avoiding the risk of injuring the great vessels during operation.

Phaeochromocytoma removal and postoperative hypoglycaemia

A case of postoperative hypoglycaemia following removal of a phaeochromocytoma is presented. The hypoglycaemia is due to a reactive rise in insulin and is augmented by alpha adrenoceptor blocking agents. Beta adrenoceptor blockers impair recovery from this hypoglycaemia. Frequent monitoring of blood glucose and the administration of an appropriate solution of dextrose both during and after this operation is recommended.

Acute and chronic regulation of alpha 2-adrenoceptor number and function in man.

Agonist regulation of platelet alpha 2-adrenoceptors was examined in human volunteers after acute elevations of adrenoceptor agonist and during chronic elevation of plasma catecholamines in two patients with phaeochromocytoma. Platelet alpha 2-adrenoceptor number was measured by radioligand binding [( 3H]yohimbine) and alpha 2-adrenoceptor function measured by turbidimetric platelet aggregation. Short term infusion of adrenoceptor agonists with alpha 2 activity caused reductions in the platelet response to adrenaline in vitro; conversely an increase in activity was observed postoperatively in two patients after removal of phaeochromocytoma. The changes in platelet response were not accompanied by changes in alpha 2-adrenoceptor number. It is proposed that a process of receptor inactivation occurs during desensitization and this is responsible for the dynamic regulation of platelet responses.

Anesthetic management in patients with pheochromocytoma.

In expert hands, perioperative mortality of elective removal of pheochromocytoma can almost be completely eliminated. Isoflurane and enflurane plus nitrous oxide have proved to be suitable anesthetic agents and there are potent drugs for the treatment of intraoperative cardiovascular disturbances. The major factor responsible for mortality reduction is a well-balanced pre-, peri- and postoperative fluid replacement.

The renin-angiotensin-aldosterone system in Cushing's syndrome and pheochromocytoma.

We investigated the status of the renin-angiotensin-aldosterone axis in 5 patients with Cushing's syndrome and 7 patients with pheochromocytoma. In most of the patients with Cushing's syndrome no significant abnormalities of the renin-angiotensin-aldosterone system could be detected. In 4 out of 7 patients with pheochromocytoma, plasma renin activity remained high after saline suppression and decreased into the normal range in all 4 patients after removal of pheochromocytoma. These results imply that the postulated mineralocorticoid excess was not present in the patients with Cushing's syndrome studied. In pheochromocytoma, high levels of plasma catecholamines contribute to a high renin state which may have pathophysiologic implications.

Le remplissage vasculaire dans la chirurgie du phéochromocytome: Etude hémodynamique

Collapse following removal of pheochromocytoma can be usually prevented by fluid loading. Fluid infusion is administrated at the early begining of the surgical procedure and is accelerated just after removal. Some authors prefere to start the fluid infusion in the pre operative period. In every cases preload measurements are of primary importance for a safely fluid administration. Problems of fluid loading in course of pheochromocytoma surgery are studied in six patients. Hemodynamic data are collected during pre, per and post operative periods. Pre and post operative rapid fluid loading was performed in three patients in order to obtain a left ventricular function curve. Before any fluid treatment, two groups of patients are distinguished : 1) five hypovolemic patients who are about to receive 1 000 ± 300 ml to normalize pulmonary wedge pressure, 2) one patient with high pulmonary wedge pressure and with alterated myocardial performance observed during rapid fluid loading. Combined use of sodium nitroprusside and fluid loading allowed to control hypertensive accesses and preload elevations and to prevent collapse following tumor removal. Hypovolemia and myocardial lesions are not necessarily present in all cases of pheochromocytoma. The routine use of a pulmonary artery catheter is warranted to improve cardiac pump function by combined fluid and vasodilator management.

Effects of sodium nitroprusside during the excision of phaeochromocytoma.

A case report is presented which illustrates the use of sodium nitroprusside to control blood pressure levels during neurolept anaesthetic technique for removal of phaeochromocytoma. In this case the evanescent action of nitroprusside was advantageous since when the drug was discontinued elevation of blood pressure gave rise to suspicion that further catecholamine-secreting tumour was present. In all, four such tumours were removed from this patient.

Postoperative course and treatment in adrenal surgery. II. Cushing's syndrome and pheochromocytoma.

A simplified and standardized pre- and postoperative treatment technique for Cushing’s syndrome and pheochromocytoma was discussed from experiences on 21 and 18 cases, respectively, treated in our clinic since 1956. Results were summarized as follows: Cushing’s syndrome: A subtotal adrenalectomy with pre- and postoperative irradiation to the hypophysis by a large dosis of telecobalt was effective for the cases with bilateral adrenal hyperplasia. A standard program of postoperative substitution therapy, which was composed of minimized cortisol supplement without ACTH administration, was described. Pheochromocytoma: Three methods presented for blood pressure control after the removal of pheochromocytoma, i.e., noradrenaline drip method, blood overtransfusion method, and the treatment with receptor blocking drugs, were evaluated. Results of the hemodynamic determinations in the pre- and postoperative period were demonstrated. The most reliable management might be obtained from a combined technique with overtransfusion and receptor blockers.

A Case Report of Adrenal Pheochromocytoma

Pheochromocytoma is a rare catecholamine secreting tumour originating usually from adrenal medulla and produces signs and symptoms due excessive catecholamine secretion from tumour. A young female patient of 21 year age presented with paroxysmal attacks of hypertension causing palpitation, dizziness, blurring of vision and headache for last 06 months. Clinical suspicion of pheochromocytoma was confirmed by 24 hour urinary catecholamine level, transabdominal USG and CT scan of abdomen. After having two weeks of preoperative preparation with phenoxybenzamine and propanolol, open surgical removal of pheochromocytoma was done. Peroperative fluctuation of BP was well managed by IV fluid overload, intravenous phentolamine, intravenous esmolol and intravenous ephedrine. Postoperative recovery was uneventful and BP regains to normal range from 1st postoperative day. Pheochromocytoma is a rare cause of hypertension. If the diagnosis of pheochromocytoma is overlooked, the consequences could be disastrous, even fatal; however, if a pheochromocytoma is identified, it is potentially curable, as being one of the cause of surgically correctable hypertension. Key Words: Pheochromocytoma; catecholamine; hypertension; alpha blocker. DOI: 10.3329/fmcj.v6i1.7413 Faridpur Med. Coll. J. 2011;6(1): 55-58

Fluroxene Anesthesia for Pheochromocytoma Removal

In 1951 Apgar and Papper stated, There appears to be no agreement in the literature on the most desirable means of anesthetic management for pheochromocytoma excision. 1 This statement applies equally well today, even with better understanding of the autonomic nervous system 2 and the concept of alpha- and beta-adrenergic receptors and blockers. 3 Concomitant with development of adrenergic pharmacology has been the introduction of the halogenated anesthetic agents, halothane, methoxyflurane, and fluroxene. The literature is replete with reports of pheochromocytoma removal utilizing alpha- and beta-adrenergic blockade in conjunction with many general anesthetic agents. 4-6 Halothane is a popular general anesthetic agent and has both advocates 4 and opponents 7 concerning its use alone or with other drugs. Several reports have described the use of methoxyflurane for the removal of pheochromocytoma, 8,9 but, to our knowledge, there is only one published instance of fluroxene anesthesia for pheochromocytoma removal. 10 We have

Blood pressure control after the removal of pheochromocytoma.

Planning the schedule for the blood pressure control after the removal of pheochromocytoma with the NA drip method or with the blood overtransfusion method is described. Advantages and disadvantages of these methods are discussed. It is presumed that the following three points must be important on the postoperative treatment of pheochromocytoma; 1. A maintenance of the cardiac output. 2. A reasonable tension of the peripheral artery. 3. An improvement of the blood volume reduction. From the results presented in this paper, the conclusion could be made that the each method is not always complete when either one method is used alone. An assumption on the ‘NA-ineffective case’ was suggested.

Pheochromocytoma: Diagnosis and treatment

Pheochromocytoma is a rare disease, but since it is curable, every patient who has any of its characteristic signs and symptoms should be examined care-fully. The diagnosis is established in the majority of patients today by the demonstration of excessive amounts of catecholamines in the blood or urine, or of metabolites of catecholamines in the urine. The pharmacologic tests confirm the diagnosis. The tumors are usually benign, but some show microscopic evidence of malignancy and a few may show evidence of local extension to the regional lymph nodes or blood vessels. Some pheochromocytomas located in the adrenal gland are large enough to be visualized by ordinary radiographic procedures; others are small or in extra-adrenal locations and may be difficult to locate radiographically. Aortography may be used successfully to visualize the tumor provided the blood pressure is monitored. It is not necessary, however, to visualize the tumor once the diagnosis has been established chemically. Exploration of both adrenal glands and the entire retroperitoneal space down to the bladder is necessary in all cases because the tumors may be multiple. Surgical removal of pheochromocytoma should have no mortality when the internist, the anesthesiologist and the surgeon combine their skill and experience.

Techniques Involved in Surgical Removal of Pheochromocytoma

Techniques Involved in Surgical Removal of Pheochromocytoma

Refractory hypotension following removal of pheochromocytoma.

SINCE pheochromocytoma has been widely recognized clinically as a cause of hypertension, many unusual aspects of this tumor and the clinical syndrome it produces have been reported. These have included errors in diagnosis, false negative and false positive pharmacologic tests, and extra-adrenal location of the tumor.* The case to follow illustrates another unusual aspect of the clinical syndrome, the requirement of massive doses of arterenol ( Nor-epinephrine) following surgical removal of pheochromocytoma. The management of patients with pheochromocytoma before, during, and after surgery has recently been reviewed by Sprague and others,4and the usual methods of vasopressor maintenance will not be reviewed here. The following case illustrates the failure to maintain a normal postoperative blood pressure until massive doses of arterenol were used. The patient was an 11-year-old white boy first seen in September, 1954, because of weight loss, easy fatigability, lassitude, and night sweats of approximately three months' duration.