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Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas

Fluctuations hémodynamiques variables pendant la résection de phéochromocytomes extrasurrénaliens multicentriques

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Abstract

Purpose

To report the perioperative management and the serious hemodynamic fluctuations during manipulation of an organ of Zuckerkandl tumour in a patient undergoing resection of multicentric extraadrenal pheochromocytomas.

Clinical findings

A 28-yr-old man who had undergone at age 12 a laparotomy for excision of an extraadrenal pheochromocytoma complained of paroxysmal headache, occasional sweating and palpitations. The arterial blood pressure (BP) was 200/100 mmHg. A 24-hr-urine collection showed catecholamines 5076 μg·24 hr−1 (normal < 25 μg·24 hr−1). Computed tomography of the abdomen revealed two retroperitoneal masses, one adjacent to the lower pole of the right kidney and a second larger mass located at the aortic bifurcation in the region of the organ of Zuckerkandl. The patient was scheduled for excision of multiple extraadrenal pheochromocytomas. He was prepared preoperatively for two weeks with prazosin 1 mgpo q six hours and propranolol 10 mgtid. Manipulation of the infrarenal tumour was uneventful but manipulation of the Zuckerkandl tumour resulted in severe hypertensive episodes with BP ranging from 200/100 to 320/120 mmHg. Surgery was interrupted temporarily; the hypertensive crisis was controlled by the infusion of sodium nitroprusside and byiv phentolamine and esmolol.

Conclusion

In a patient undergoing resection of recurrent multicentric extraadrenal pheochromoctyomas, severe hypertensive episodes occurred during manipulation of one tumour but not during manipulation of the other. This may be attributed to inadequate preparation of the patient, difficult surgical dissection of the large Zuckerkandl pheochromocytoma, and/or secondary to an excessive and different pattern of release of catecholamines during manipulation of the Zuckerkandl tumour.

Résumé

Objectif

Présenter le traitement périopératoire et les fluctuations hémodynamiques inquiétantes survenues pendant la manipulation d’une tumeur de l’organe de Zuckerkandl chez un patient qui devait subir la résection de phéochromocytomes extrasurrénaliens multicentriques.

Constatations cliniques

Un homme de 28 ans qui, à 12 ans, avait subi l’excision laparoscopique d’un phéochromocytome extrasurrénalien, se plaignait de céphalées paroxystiques, de sueurs et de palpitations occasionnelles. La tension artérielle (TA) était de 200/100 mmHg. Un prélèvement d’urine sur 24 h a montré une concentration de catécholamines de 5076 μg·24 h−1 (la normale étant < 25 μg·24 h−1). La tomodensitométrie de l’abdomen a montré deux masses rétropéritonéales, l’une adjacente au pôle inférieur du rein droit et une seconde, plus grosse, localisée à la bifurcation aortique dans la région de l’organe de Zuckerkandl. L’excision des multiples phéochromocytomes extrasurrénaliens a été planifiée. Le patient a été préparé en recevant, deux semaines avant l’opération 1 mg de prazosin po q à prendre aux six heures et 10 mg de propranolol tid. La manipulation de la tumeur infrarénale s’est faite sans incident, mais celle de la tumeur de Zuckerkandl a entraîné des épisodes d’hypertension sévère, la TA allant de 200/100 à 320/120 mmHg. L’intervention chirurgicale a été interrompue temporairement pour permettre de traiter la crise d’hypertension par une perfusion de nitroprussiate de sodium et par de la phentolamine et de l’esmolol iv.

Conclusion

Des épisodes d’hypertension sévères sont survenus chez un patient subissant la résection de phéochromocytomes multicentriques récurrents pendant la manipulation d’une des deux tumeurs. Cette situation peut relever d’une préparation inadéquate du patient, de la difficulté de la dissection chirurgicale du plus gros phéochromocytome de Zuckerkandl et/ou elle peut être secondaire à une sécrétion excessive et différente de catécholamines pendant la manipulation de la tumeur de Zuckerkandl.

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Correspondence to Anis Baraka.

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Baraka, A., Siddik-Sayyid, S., Jalbout, M. et al. Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas. Can J Anesth 49, 682–686 (2002). https://doi.org/10.1007/BF03017445

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Keywords

  • Sevoflurane
  • Prazosin
  • Sodium Nitroprusside
  • Esmolol
  • Phentolamine