adrenal pheochromocytoma removal

In the past, a simple summary of adrenal pheochromocytoma was called 90:10 tumors, that is, 90% of those growing in the adrenal gland, 10% of those outside the adrenal gland, 90% of unilateral tumors, 10% of bilateral tumors, and single tumors. 90%, multiple tumors accounted for 10%; benign tumors accounted for 90%, malignant tumors accounted for 10%. However, in the past 20 years, the above-mentioned proportional relationship has undergone significant changes. Due to the use of advanced diagnostic techniques, early detection of some extra-adrenal tumors and bilateral multiple tumors that were not easily detected and diagnosed, early diagnosis of asymptomatic tumors, familial pheochromocytoma and multiple endocrine organs The rate has also increased significantly, and this trend in morbidity should be given special attention in surgical treatment. Using modern diagnostic techniques, there is no difficulty in locating the diagnosis of adrenal tumors, and the surgical site can be clearly defined before surgery. In the case of only showing catecholamine augmentation, but no tumor was found in the adrenal gland, the pathology was confirmed as adrenal medullary hyperplasia. In 1976, after a long-term follow-up and pathological study of 19 patients with medullary proliferative disorder in Mayo Clinic, Garney believed that diffuse proliferation of unilateral or bilateral can gradually develop into nodular proliferation, followed by a diameter of 1 cm or more. The microadenomas, which are the precursors of medullary proliferative pheochromocytoma, are unclear. Therefore, medullary proliferation should be treated as pheochromocytoma in the adrenal gland and should be treated surgically. Adrenal medullary pheochromocytoma is caused by the abnormal development of neural crest cells in the embryonic stage, so pheochromocytoma can occur in the adrenal gland or in other parts of the body rich in ganglion cells. Most common around the kidneys and adrenal glands, on both sides of the abdominal aorta and branches of the internal organs of the viscera, such as the vicinity of the celiac trunk, the gland of the Zuckerhandle at the bifurcation of the abdominal aorta, and the end of the ureter entering the bladder wall. Such as the chest, mediastinum, intracranial and other parts can also be occasionally seen. Due to the abnormal development of neural crest cells in the embryonic stage, while the pheochromocytoma is formed, the development of other endocrine gland cells may be affected and may be complicated by tumors. The thyroid gland, parathyroid gland, pancreas, and pituitary gland are the most susceptible endocrine glands. According to the different organs of the disease, Sipple is divided into I, II, and III types. Such a complicated onset phenomenon is obviously related to familial inheritance and is a result of the disorder of embryonic neural crest cell differentiation and development. Treatment of diseases: adrenal tumors Indication Adrenal pheochromocytoma removal is suitable for: After the diagnosis is confirmed, regardless of the size of the tumor, the pathological nature is benign or malignant, and any of the following various conditions will be the indication for surgery. 1. Symptoms are typical. Biochemical tests, drug test results are in line with the diagnosis, and there is a space-occupying lesion in the adrenal gland. 2. There were no symptoms in the past, but under the strong stimulation of childbirth, anesthesia, surgery, trauma, etc., severe hypertension, arrhythmia, and even unexplained shock syndrome occurred. Re-examination revealed that the adrenal gland had Space-occupying lesions. 3. Where there are thyroid tumors, complicated by hyperparathyroidism, islet cell tumor, pituitary tumor, multiple mucosal fibroma and other multiple endocrine adenomas with typical pheochromocytoma symptoms, vena cava segmental blood collection test The catecholamine level in the renal vein plane is increased, and the drug test is in accordance with the diagnosis. Although no adrenal tumor is seen, it can be surgically explored. 4. One side of pheochromocytoma, after the surgical removal, there are typical symptoms, such as tumors found in other parts of the body, may consider the presence of the second or third tumor in the contralateral adrenal gland or ipsilateral adrenal gland, especially Family history should be operated again. 5. The pathological tissue of the removed pheochromocytoma showed malignant changes, and the symptoms recurred after surgery. Other distant organs had no metastatic carcinoma, and local recurrence was considered. Contraindications Surgery may be suspended or unsuitable for surgery in the following situations. 1. Malignant pheochromocytoma has multiple cancers of liver, lung, and distant brain metastases. The primary cancer is extensively infiltrated and fixed, and it cannot be surgically removed. 2. The course of disease is longer and more serious. Myocardial damage, arrhythmia or cerebrovascular disease caused by catecholamines. Drug therapy can be suspended in the short term without any improvement. The drug can be treated with a blocker or (and) inhibitor for a long time. 3. Although treated with alpha blockers or (and) beta blockers, blood pressure, pulse, central venous pressure, etc. still failed to reach the desired level. There is an attack on the symptoms and it is necessary to continue the treatment. 4. During other operations or laparotomy, the symptoms of pheochromocytoma are suddenly unprepared before surgery. Although intravenously infused with alpha blocker, blood pressure can be temporarily controlled, but it cannot be sustained, and the pulse rate is fast. 160/min, adults above 120/min, those with arrhythmia should stop the operation, to be clearly positioned, and then perform surgery before surgery. 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. Surgical procedure The abdominal incision or the transverse incision of the upper abdomen is most suitable for the transabdominal approach. It can perform bilateral adrenal adenoma removal, and can detect other parts of the pelvic ganglionoma from the diaphragmatic muscle to the pelvic cavity, especially on both sides of the abdominal aorta. And the beginning of each visceral blood vessel. Large tumors can also be combined with chest and abdomen incision. If it is an isolated adenoma and has a complete capsule, it is judged to be a benign tumor, and tumor excavation can be performed. The normal part of the adrenal gland can be retained. If the tumor is too large, multiple or adenomas, the adrenal gland still has suspicious microadenomas or nodular proliferation, then one side of the adrenal gland is removed. For a large tumor with local infiltration involving the ipsilateral kidney, it can be determined as a cancer, and the lymphatic radical resection can be performed together with the kidney and surrounding affected tissue, but the chest and abdomen combined incision path is often needed. After the tumor is removed, if the blood pressure is lowered once, and then the blood pressure is increased again, or the blood pressure is not obvious, it is determined that there is still a tumor in the contralateral adrenal gland or other parts, and the removal should be continued. In the surgical exploration or exfoliation of the adrenal gland, if the blood pressure exceeds 24.0/18.7 kPa (180/140 mmHg), a small dose of phenoxybenzamine or a short-acting alpha blocker may be administered intravenously, or sodium nitroprusside (nitroprusside) may be added. In case of arrhythmia or tachycardia, the beta blocker propranolol or lidocaine may be used together. When a tumor is found, it is best to clamp the adrenal vein first to prevent a large amount of vasoconstrictor from flowing into the blood circulation. When the tumor or adrenal gland is removed, although the blood pressure is still fully prepared before surgery, the blood pressure will be greatly reduced immediately. At this time, the infusion or blood transfusion speed can be accelerated. According to the central venous pressure, an appropriate amount of adrenaline and armor can be instilled. Adrenalin mixture. If there is no tumor in the adrenal gland, there is no extra-adrenal tumor in the abdominal cavity, which is confirmed by pathology as medullary proliferation. One side is treated with one side adrenalectomy, and both sides undergo bilateral subtotal resection or total resection. Surgical procedure and adrenal cortex Proliferative adrenalectomy is the same. Anesthesia and intraoperative treatment are the same as tumor removal. 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.