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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 ?-adrenergic blockade (over 10-14 days) and subsequently, additional ß-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.
Key Words: adrenergic crisis <> pheochromocytoma <> surgery
Adrenergic crisis is not a rare phenomenon associated with pheochromocytoma. The factors triggering an adrenergic storm are attributed to excessive release of catecholamines from the pheochromocytoma tumor secondary to anxiety of the patient, or secondary to the induction of anesthesia and intubation. Moreover, these hormones released may be induced by drugs due to dopamine receptor blockade (e.g. droperidol), histamine release (e.g. morphine, atracurium), sympathetic stimulation (e.g. pancuronium), anticholinergic drugs (e.g. atropine), or catecholamine-sensitizing anesthetics (e.g. halothane, desflurane). Additionally, squeezing of the tumor during straining, positioning of the patient, by scrubbing, by intraperitoneal carbon dioxide insufflations during laparoscopy, or by direct manipulation of the tumor may induce adrenergic storm. Previously, the pheochromocytoma crisis was also associated with contrast media. In pregnancy excessive uterine contractions, fetal movements, normal vaginal delivery or Cesarean section may precipitate the adrenergic crisis [1]. The perioperative pheochromocytoma crisis may mimic other conditions such as a thyroid storm [2] or a malignant hyperthermia [3].
Pheochromocytomas are rare, catecholamine-secreting (predominantly norepinephrine) tumors arising from chromaffin cells of the adrenal medulla. Additionally, other substances are released by such a tumor, such as: dopamine, VIP, adrenocorticotropic hormones, and ß-endorphins. Once the pheochromocytoma has been diagnosed, the mainstay of definitive therapy is complete surgical resection....