Pheochromocytoma: Management

by Kevin Pei, MD

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    00:01 Let’s move on to the management. Now that you’ve diagnosed a pheochromocytoma, what should we do? Vast majority of patients with pheochromocytomas require surgery. But the preparation is very, very important and extremely high-yield. Let’s say you’ve decided to go surgery, what’s the first step? We begin with alpha adrenergic blockade prior to the surgery for about two weeks.

    00:29 Then, we expand a contracted volume. With pure alpha adrenergic blockade, the vasculature particularly the peripheral vessels will be relaxed allowing a tolerance for more volume.

    00:44 The alpha adrenergic blockade of choice is a medication called phenoxybenzamine. Please familiarize yourself with this medication. And remember, some patients may need a beta blocker as an unopposed beta can drive tachycardia. Let’s move on to surgery. This is an image of a laparoscopic adrenalectomy. Remember, if you want to perform an open, there’s nothing wrong with that.

    01:12 These are some standard trocar placements with the patient placed on their side. I’ll describe to you what a right adrenalectomy looks like. In this image of a laparoscopic adrenalectomy on the right side, notice the clip applier on the right lower quadrant of that screen. The clip applier is about to ligate the right adrenal vein. Anatomically, remember, it’s very important.

    01:38 Drainage of the right adrenal vein goes directly into the inferior vena cava. Therefore, injury to the inferior cava is a potential catastrophic complication of this surgery. If you decide to perform this surgery, be careful on the side. The procedure for this surgery is usually involving the exposure of the Gerota’s fascia on the right side. In this schematic, note that the purple organ is a liver. It’s been retracted now using a fan retractor. As a reminder, the right renal vein directly drains into the inferior vena cava. The left renal vein however, drains to either variably to the left phrenic vein that supplies the diaphragm or the left renal vein.

    About the Lecture

    The lecture Pheochromocytoma: Management by Kevin Pei, MD is from the course General Surgery.

    Included Quiz Questions

    1. Perpare the patient for surgery with alpha-adrenergic blockade for 2 weeks prior to scheduled surgery and volume expansion.
    2. Schedule the patient for immediate emergency surgery to remove the right adrenal gland.
    3. Schedule the patient for immediate surgery to remove the right adrenal gland and prophylactic removal of the left adrenal gland.
    4. Prescribe beta-blockers for symptomatic management and repeat imaging in 3 months; only perform surgery if the tumor is greater than 5 cm.
    5. Schedule the patient for the next available outpatient surgical procedure appointment.
    1. Injury to the inferior vena cava.
    2. Injury to the right phrenic vein.
    3. Injury to the right renal vein.
    4. Injury to the adrenal cortex.
    5. Incomplete removal of the tumor.

    Author of lecture Pheochromocytoma: Management

     Kevin Pei, MD

    Kevin Pei, MD

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