Resection of pheochromocytoma around the celiac trunk

In the celiac trunk and superior mesenteric artery, there are abundant accessory ganglia and pheochromic, which are the predilection sites of extra-adrenal pheochromocytoma. Among the 17 cases reported by Scott (1982), 7 cases occur here. Part. Of the 20 cases that have accumulated in the Cleveland Clinic over the past 30 years, 13 have tumors in this area. Tumors grow in the stomach and pancreas under the diaphragm, often between the aorta and its branches and the inferior vena cava, and extend to the upper and lower left and right renal veins, and some can invade the inferior vena cava. The technique of performing surgical resection is quite complicated in pheochromocytoma that grows in this danger zone. Treatment of diseases: pheochromocytoma Indication Due to the coverage of organs and large blood vessels, tumors <25g, imaging examination is difficult to make a localization diagnosis, often need to be diagnosed by catecholamine in the vena cava segmental blood test, or tumor imaging by abdominal aorta angiography. As long as it is detected, it should be surgically explored and strive to be removed. Inferior vena cava involvement is not a contraindication to surgery. Benign tumors can also spread diffusely. Even malignant tumors can be cured after eradication. Unless there are multiple metastatic cancers in the distal organs, surgery can be abandoned. Preoperative preparation Adequate preoperative preparation is the key to reducing the operative mortality. Preoperative mental stress, anesthesia, and surgical stimulation can lead to a sharp rise in blood pressure, acceleration of arrhythmia, etc.; or vasoconstriction due to pheochromocytoma The substance causes the systemic vascular bed to be in a contracted state for a long time, and the blood volume is reduced. When the tumor is removed, the vascular bed suddenly relaxes and expands, and the blood volume is seriously insufficient to shock, leading to death. Preoperative preparation is to be carried out around this pathological change. 1. Adrenal energy alpha blocker phenoxybenzamine should be routinely used for 1 to 2 weeks before surgery, dose 1mg / (kg · d) or 20 ~ 60mg divided into 3 times, or dissolved in 200ml of salt solution 2h drip is finished. Within 3 days, the blood pressure can be maintained normal, the symptoms disappear, and the blood volume is increased to meet the conditions suitable for surgery. The effective time of this drug is 8~12h. It is necessary to calculate the last administration time before surgery. It is expected that when the tumor is removed after the tumor is removed, the possibility of the second tumor being missed is considered according to the antihypertensive reaction. . 2. While applying the alpha blocker, a sufficient amount of colloidal fluid or crystalloid can be administered intravenously to supplement the insufficient blood volume. The inferior vena cava catheter was inserted 1 day before surgery, and the central venous pressure was measured periodically. Start to enter the liquid, after reaching the normal level, slow down the infusion rate, continue to maintain the venous channel until after surgery, the general infusion volume to the operation day should reach 2000 ~ 3000ml. 3. If the pulse is accelerated or the arrhythmia occurs after the application of the alpha blocker, the blocker can be added with 10 to 40 mg, 3 times a day, or 2 to 3 mg intravenously, which can lower the heart rate. Up to 120 to 80 times / min. 4. Preoperative indwelling catheter, routine application of antibiotics, supplement with multivitamins. 5. Prepare 8 to 64 g/ml of norepinephrine injection with different concentrations, in case of sudden drop in blood pressure after surgery. 6. Fully prepare the blood source and maintain a smooth upper extremity venous access. Surgical procedure A straight incision in the abdomen. If the tumor is huge, the anterior chest and abdomen combined incision path can be used, and the exposure must be sufficient. 1. If the tumor is biased to the right side, the peritoneum can be cut along the lateral edge of the descending part of the duodenum, the liver collateral ligament is broken, the antrum and duodenum are turned up, and the left anterior retraction is performed. The colonic hepatic flexure was removed and extended down to the aortic bifurcation plane, pulled to the medial side, and the right kidney was pushed to the lateral side. The tumor grown in the aortic celiac trunk and the vena cava was exposed and placed under direct vision. 2. If the tumor infiltrates to the upper or the right kidney, the upper right pole of the right kidney can be peeled off and the blood vessels of the renal hilum can be exposed. Try not to damage the renal vein, such as it is difficult to separate from the renal vein and inferior vena cava. At the time of controlling the blood vessels at both ends, the tumor is removed together with a part of the vein wall, and then anastomosis or repair is performed. The middle renal artery was resected with the tumor and the end of the anastomosis was performed. 3. More tumors grow to the left. Surgery can cut the small omentum and liver and stomach ligaments along the small curvature of the stomach, taking care not to injure the common bile duct. Free up the antrum of the stomach, pull it to the left, peel off the upper pole of the left kidney and pull it down to the outside, and pull the liver upward to reveal the front of the tumor. Sometimes the upper part of the left kidney should be turned up and pulled down to the outside to reveal the tumor that extends to the back of the kidney and the renal hilum. After the tumor is separated from the left renal blood vessel, it can be removed. 4. If the adhesion to the left renal vein is tight and cannot be separated, it can be cut and ligated into the inferior vena cava. As long as the adrenal vein and genital vein can be retained in the middle segment, the left kidney can be retained without causing renal function. influences. There are also cases where the left renal vein is severed, and the tumor is re-adjusted after removal of the tumor, which is generally determined by local specific conditions. 5. If the left renal artery is concurrent with stenosis, fibrosis, atresia, the left kidney has been extremely atrophied or has been invaded by the tumor, and can be removed with the left kidney. complication Gastrointestinal paralysis, bloating and infection. If the concurrent diabetes and hyperglycemia still do not disappear after surgery, postoperative diet control or medication should continue. All patients should be followed up for a long time after surgery. Observe blood pressure, catecholamines. If the symptoms recur, the diagnosis should be confirmed immediately. The case is multiple tumor suppression or cancer metastasis and recurrence, and corresponding treatment is taken.