Pheochromocytoma treatment in Bangalore (Laparoscopic adrenal Surgery)


Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms  Is one of the leading surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous Laparoscopic Adrenal Gland Surgery  patients successfully in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

  Call Now ! –+91-9972446882 .

What is Pheochromocytoma ?

  • Catecholamine-producing tumor. In 90% of cases, the tumors are found in the adrenal medulla, but they may also be found in other tissues derived from the neural crest cells.
  • Systems affected: Endocrine/Metabolic; Cardiovascular (secondary effects from catecholamines)
Epidemiology
Incidence
<1% of people with severe hypertension (HTN)

Pheochromocytoma

Prevalence
  • 1–2 per 100,000 adults
  • No gender or race predilection
  • Can affect all ages
  • Sporadic tumors usually diagnosed in 3rd–5th decades, familial disease 1 decade earlier

Risk Factors of Pheochromocytoma

  • Familial pheochromocytoma
  • Multiple endocrine neoplasia types IIA and IIB
  • Neurofibromatosis type 1
  • Von Hippel-Lindau syndrome
  • Familial paraganglioma
Genetics Risk Factors of Pheochromocytoma
80–90% of cases are sporadic, 10% familial

pheochromocytomas produce what compounds?

  • Pheochromocytomas are tumors that release catecholamines (i.e., norepinephrine and epinephrine) into the bloodstream. These substances interact with the alpha and beta adrenergic receptors for pheochromocytoma treatment in Bangalore. Alpha-1 receptors cause arteriolar constriction, raising blood pressure. Alpha-2 receptors decrease insulin secretion, resulting in elevated glucose levels. Beta-1 receptors increase the cardiac rate (tachycardia). Beta-2 receptors cause arteriolar and venous dilation and relaxation of tracheobronchial smooth muscle.
  • Homovanillic acid (HVA) + vanillylmandelic acid (VMA) are catecholamine breakdown products, and the amount of these substances detected in the urine correlates with the size of the pheochromocytoma tumor.

Etiology of Pheochromocytoma

Catecholamine-producing tumor: Rule of 10:
  • 10% are extra-adrenal (organ of Zuckerkandl, neck, mediastinum, abdomen, pelvis).
  • 10% are multiple or bilateral.
  • 10% are malignant.
  • 10% recur after surgical removal.
  • 10% occur in children.
  • 10% or more are familial.
  • 10% present as adrenal incidentalomas.

Commonly Associated Conditions with Pheochromocytoma

  • Multiple endocrine neoplasia type IIA (medullary thyroid carcinoma and primary hyperparathyroidism)
  • Multiple endocrine neoplasia type IIB (medullary thyroid carcinoma and mucosal neuromas)
  • Von-Hippel-Lindau disease (retinal angiomas, cerebellar hemangioblastomas, renal cysts, carcinomas, pancreatic cysts, epididymal cystadenomas)
  • Neurofibromatosis type 1
  • Sturge-Weber syndrome for pheochromocytoma treatment in Bangalore
  • Tuberous sclerosis
  • Carney syndrome (gastric epithelioid leiomyosarcoma, pulmonary chondroma, extra-adrenal paraganglioma)
  • Familial paraganglioma
  • Ataxia-telangiectasia
  • Renal artery stenosis

Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms  Is one of the leading surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous Laparoscopic Adrenal Gland Surgery   patients successfully in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

  Call Now ! –+91-9972446882 .

Diagnostic Procedures/Surgery

Clonidine-suppression test distinguishes between pheochromocytoma and essential HTN when urine and plasma tests are equivocal.

Pathological Findings

A catecholamine-producing tumor in the adrenal medulla, para-aortic sympathetic chain, wall of the urinary bladder, or sympathetic chain in the neck or mediastinum

Differential Diagnosis

  • Labile essential hypertension
  • Anxiety and panic attacks
  • Paroxysmal cardiac arrhythmia
  • Thyrotoxicosis
    P.993
  • Menopausal syndrome
  • Hypoglycemia
  • Mastocytosis
  • Withdrawal of adrenergic-inhibiting medications for pheochromocytoma treatment in Bangalore
  • Angina
  • Hyperventilation
  • Migraine headache
  • Amphetamine or cocaine use
  • Sympathomimetic ingestion

Treatment

Pheochromocytoma medical treatmentMedication

First Line

  • α-adrenergic and possibly β-adrenergic blockade required preoperatively.
  • Initiate α-blockade first: Phenoxybenzamine (Dibenzyline) 10 mg p.o. b.i.d. and increased by 10–20 mg every 2 days as needed to control BP and paroxysmal spells (average dose is 0.5–1.0 mg/kg/d, max dose is 300–400 mg/d).
  • β-blockade can follow α-blockade: Propranolol (Inderal) 10 mg q6h initially and increase as necessary to control tachycardia
  • Treat acute hypertensive crisis with IV phentolamine (Regitine) or nitroprusside.
  • Contraindications:
    • β-adrenergic blockade in patients with asthma, sinus bradycardia, and > 1st degree block or congestive heart failure (CHF)
    • Avoid β-blockers with intrinsic sympathomimetic activity for pheochromocytoma treatment in Bangalore.
  • Precautions:
    • β-adrenergic blockade alone may result in more severe HTN owing to the unopposed α-adrenergic stimulation; patients should be cautioned about postural hypotension.
    • β-adrenergic blockade is initiated at low doses using a short-acting agent owing to the possible side effect of pulmonary edema in the patient with catecholamine myocardiopathy.
  • Significant possible interactions: For β-adrenergic blockade: Verapamil, phenytoin, phenobarbitone, rifampin, chlorpromazine, and cimetidine

Second Line

  • α-adrenergic blocking agents: Prazosin (Minipress) 1–2 mg t.i.d., terazosin (Hytrin), doxazosin (Cardura)
  • β-adrenergic blocking agents: Nadolol (Corgard), atenolol (Tenormin), metoprolol (Lopressor)
  • Combined β- and α-adrenergic blocker: Labetalol (Normodyne, Trandate)
  • Catecholamine synthesis inhibitor: Metyrosine (Demser) (2)[A]

Additional Treatment

  • General Measures
  • Control BP and volume repletion.
  • Issues for Referral
  • Endocrinology for definitive diagnosis and management recommendations for pheochromocytoma treatment in Bangalore
  • Additional Therapies
  • No generally effective systemic treatment with antineoplastic potential for malignant pheochromocytoma has been found. A proportion of patients do respond to MIBG radiotherapy or to cytotoxic chemotherapy with cyclophosphamide, vincristine, and dacarbazine (CVD) (3)[A].

Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms  Is one of the leading surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous Laparoscopic Adrenal Gland Surgery  patients successfully in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

  Call Now ! –+91-9972446882 .

What are the optins for pheochromocytoma surgery?

  •  Open pheochromocytoma surgery
  •  Laproscopic pheochromocytoma surgery

Open pheochromocytoma surgery OR Laproscopic surgery pheochromocytoma surgery

Laproscopic surgery pheochromocytoma surgery is sperior as avoids an cut, fast recovery.Howvever expensive and requires addtional surgical skilss.

 Pheochromocytoma surgery procedures

  • High-risk surgical procedure requires an experienced surgeon, anesthetist, and clinical team. It is often amenable to laparoscopic adrenalectomy:
    • The goal of surgery is to resect the tumor completely with minimal tumor manipulation or rupture of the tumor capsule.
  • Cortical-sparing subtotal adrenalectomy may preserve adrenocortical function in those with bilateral disease.

In-Patient Considerations for Pheochromocytoma surgery

Initial Stabilization

  • Control of HTN and replace volume is important before pheochromocytoma surgery for pheochromocytoma treatment in Bangalore.

Admission Criteria 

  • Severe or refractory HTN
  • IV Fluids
  • As needed to replace volume
  • Nursing
  • Monitor BP closely.

Discharge Criteria after pheochromocytoma surgery

  • When hemodynamically stable
 Ongoing Care for pheochromocytoma surgery

Follow-Up Recommendations .

  • Follow BP.
  • Post-op monitoring of catecholamines and metanephrines
Patient Monitoring .
  • Monitor BP daily before pheochromocytoma surgery .
  • Intraoperative hemodynamic monitoring
  • Test plasma-free metanephrines or urine catecholamine and metanephrines 2 weeks postoperatively. If normal, the resection is deemed complete. Recheck annually.
  • Assure resolution of HTN.
Diet in pheochromocytoma surgery.
  • Preoperatively, follow a high-salt diet to increase blood volume for pheochromocytoma treatment in Bangalore.
  • Patient Education.

Prognosis or success rate pheochromocytoma surgery.

  • The survival rate after removal of a benign pheochromocytoma is nearly that of controls when matched for age and gender.
  • For malignant pheochromocytoma, the 5-year survival rate is <50%.

Complications of  pheochromocytoma treatment in Bangalore.

  • When diagnosed at autopsy, 75% of patients died from myocardial infarction (MI) or cerebrovascular accident (CVA).
  • 1/3 of sudden deaths occurred after unrelated minor operative procedures for pheochromocytoma treatment in Bangalore.
  • Postural hypotension with α-adrenergic blockade
  • Pulmonary edema with β-adrenergic blockade
  • Intraoperative hypertensive crisis

Pregnancy Considerations for pheochromocytoma surgery.

  • Pheochromocytomas occurring during pregnancy carry a grave prognosis. The maternal and fetal mortality rates are 48% and 55%, respectively.
  • Spontaneous abortion is very likely  for pheochromocytoma treatment in Bangalore.

Clinical Pearls of Pheochromocytoma surgery.

  • Patients usually demonstrate severe and often episodic HTN as well as headache, palpitations, and diaphoresis.
  • Must give α-adrenergic agent to control BP, followed by a β-adrenergic agent to control tachycardia and prevent a hypertensive crisis
  • 10% rule: 10% are extra-adrenal, multiple or bilateral, malignant, recur after surgical removal, occur in children, are familial, present as adrenal incidentalomas
  • Consider as an etiology for severe, difficult-to-treat hypertensive patients (<1% incidence).
  • Profuse sweating common in children

Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms  Is one of the leading surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous Laparoscopic Adrenal Gland Surgery  patients successfully in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

  Call Now ! –+91-9972446882 .