Haemodynamic changes during retroperitoneoscopic adrenalectomy for phaeochromocytoma

F. Atallah1, T. Bastide-Heulin1, M. Soulié2, F. Crouzil1, A. Galiana1, K. Samii1 and C. Virenque1

1Department of Anaesthesiology and 2Department of Urology, Rangueil Hospital, Toulouse University Hospitals, F-31403 Toulouse Cedex 4, France*Corresponding author

Accepted for publication January 4, 2001


    Abstract
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 Abstract
 Introduction
 Case reports
 Discussion
 References
 
Surgical removal of phaeochromocytoma may be accompanied by acute cardiovascular changes. We report the haemodynamic changes in seven patients with retroperitoneal laparoscopic adrenalectomy for phaeochromocytoma. Transient hypertension (systolic pressure (SBP) >160 mm Hg) was observed in all patients during manipulation of the tumour, in two patients during pneumoretroperitoneum insufflation, and in one patient during intubation. Small doses of nicardipine were sufficient to control these episodes of hypertension. Transient hypotension (SBP <100 mm Hg) was observed in two patients during exsufflation and in one patient during repositioning to the lateral position. Our observations suggest that this approach provides relative haemodynamic stability, especially during pneumoretroperitoneum insufflation.

Br J Anaesth 2001; 86: 731–3

Keywords: phaeochromocytoma; cardiovascular system, responses; measurement techniques, retroperitoneoscopy


    Introduction
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 Abstract
 Introduction
 Case reports
 Discussion
 References
 
Surgical removal of adrenal phaeochromocytoma may be accompanied by severe and acute haemodynamic changes.1 The laparoscopic approach allows more gentle manipulation of the tumour and direct access to the adrenal vein, resulting in less catecholamine release. Production of a pneumoperitoneum is, however, known to induce haemodynamic changes and catecholamine release.2

Retroperitoneal laparoscopy has some advantages compared with transperitoneal laparoscopy. It causes only a small increase in intra-abdominal pressure and fewer haemodynamic changes.3 It facilitates early clipping of the adrenal vein by direct retroperitoneal access to the vessels.

No previous study has reported the haemodynamic changes during retroperitoneal laparoscopy for phaeochromocytoma. We report them in seven such patients.


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 Case reports
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Seven consecutive patients with a clinical and laboratory diagnosis of phaeochromocytoma were studied retrospectively. The diagnosis of phaeochromocytoma was confirmed histologically in all patients post-operatively. Retroperitoneoscopic adrenalectomy was done through a lateral approach, by the same surgeon. Patient characteristics and anaesthetic management are shown in Table 1.


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Table 1 Patient characteristics, anaesthetic management, arterial pressure changes and doses of hypertensive and hypotensive drugs used. Ep, epinephrine; Norep, norepinephrine; F, female; M, male; {uparrow}=systolic hypertension; {downarrow}=systolic hypotension. *Patient 7 developed palpable subcutaneous emphysema resulting in a moderate refractory hypercapnia
 
All patients were treated for 7–10 days pre-operatively with labetalol 150–400 mg orally, to stabilize the arterial pressure (<150/90 mm Hg) and the heart rate (<100 beats min–1 and regular). Labetalol was given on the morning of surgery and patients were pre-medicated with oral flunitrazepam 2 mg. Radial artery cannulation was performed under local anaesthesia. General anaesthesia was induced by i.v. midazolam 5 mg, sufentanil 0.5 µg kg–1 and either propofol 2 mg kg–1 or etomidate 0.25 mg kg–1. Tracheal intubation was facilitated with a non-depolarizing neuromuscular blocking drug. Anaesthesia was maintained with isoflurane or desflurane (MAC 0.6–0.8), sufentanil 0.2–0.5 µg kg–1 h–1 and a continuous infusion of a non-depolarizing neuromuscular blocking drug (Table 1). Patients were mechanically ventilated with nitrous oxide 50% in oxygen, at a tidal volume of 10 ml kg–1. Ventilatory rate was adjusted to keep PE'CO2 between 4.0 and 4.8 kPa. If needed, either nicardipine (starting with 2 mg h–1) or norepinephrine (starting with 1 mg h–1) was administered by continuous infusion to maintain a systolic pressure (SBP) between 120 and 160 mm Hg. Esmolol 0.5 mg kg–1 was used if heart rate exceeded 100 beats min–1.

After induction, a central vein was cannulated. Patients were then placed in the lateral position. Retroperitoneal insufflation with carbon dioxide was maintained with a pressure between 12–14 mm Hg. The duration of surgery varied between 100 and 255 min (mean 171 (SD 60) min) and that of anaesthesia varied between 195 and 360 min (269 (70) min). This difference is explained by the time needed to cannulate a central vein and the position changes of the patient. Patients received 2600 (450) ml of lactated Ringer’s solution and 710 (270) ml of hydroxyethyl starch solution (colloid); no blood transfusion was needed.

Transient hypertension (SBP >160 mm Hg) was observed in all patients during manipulation of the tumour, in two patients during pneumoretroperitoneal insufflation and in one patient during intubation. Small doses of nicardipine (bolus of 1–2 mg, followed by infusion of 2–6 mg h–1) were sufficient to control these episodes of hypertension. Transient hypotension (SBP <100 mm Hg) was observed in two patients during exsufflation and in one patient during repositioning to the lateral position. No arrhythmia or tachycardia (>100 beats min–1) was observed in any patient (Fig. 1A and B).




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Fig 1 (A) Pre-operative systolic pressure changes (mm Hg). (B) Pre-operative heart rate changes (beats min–1).

 

    Discussion
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 Abstract
 Introduction
 Case reports
 Discussion
 References
 
When we were first undertaking adrenalectomy for phaeochromocytoma using the retroperitoneal laparoscopic approach, we expected more haemodynamic disturbances than that reported with the transperitoneal approach; we predicted greater carbon dioxide absorption. But we rapidly noticed haemodynamic stability with this technique.

In this case-series, manipulation of the tumour was the only event consistently associated with hypertension (Fig. 1). In a report of eight patients undergoing laparoscopic transperitoneal adrenalectomy for phaeochromocytoma, Joris and colleagues observed two causes of significant hypertension: creation of the pneumoperitoneum and adrenal gland manipulation.2

Retroperitoneal laparoscopy produces only a small increase in intra-abdominal pressure; Chiu and colleagues3 reported an increase of 3 mm Hg. This difference may explain the relative haemodynamic stability we observed during insufflation. With retroperitoneoscopy, there is little stimulation of the peritoneum and, hence, less sympathetic response and less catecholamine release.

There is still some controversy concerning whether retroperitoneoscopy produces more4 5 or less6 7 carbon dioxide absorption than i.p. laparoscopy. Ng and colleagues recently demonstrated that the retroperitoneal approach produces the same or even less hypercapnia, provided that insufflation is limited to the retroperitoneal space.8 This can be explained by the larger absorptive area available in the peritoneal cavity and the greater absorptive capacity of the peritoneal membrane.9 Furthermore, operating on a retroperitoneal viscera by transperitoneal laparoscopy allows systemic carbon dioxide absorption from both the peritoneal cavity and the retroperitoneal areas.

Subcutaneous emphysema remains a common complication of retroperitoneal laparoscopy with a reported incidence of 45%.8 In our report, palpable surgical emphysema developed in patient 7 causing a refractory hypercapnia (PaCO2=6.0–6.4 kPa), despite doubling of the minute ventilation. This was not accompanied by any haemodynamic changes.

Operative time is decreasing with this teams’ experience. We recently reported a mean time of 135 min in 52 retroperitoneal laparoscopic adrenalectomies.10

Phaeochromocytoma is rare and although this report concerns a small number of patients, we reviewed the effect of the following possible predictive factors on haemodynamic instability: pre-operative degree and type of catecholamine excretion; size and side of the adrenal tumour; presence and severity of pre-operative symptoms; and choice of the halogenated anaesthetic. None of these factors seems to predict the incidence or the importance of the haemodynamic changes.

Our observations in seven patients suggest that retroperitoneal laparoscopy is a valuable technique for adrenalectomy, resulting in relatively good haemodynamic stability in patients with phaeochromocytoma.

A prospective, randomized comparative study between the two approaches, transperitoneal and retroperitoneal, is needed to confirm these findings. This may, however, be difficult because of the rarity of these cases and the satisfaction of our surgical and anaesthetic team with this new approach.


    References
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 Abstract
 Introduction
 Case reports
 Discussion
 References
 
1 Prys-Roberts C. Phaeochromocytoma—recent progress in its management. Br J Anaesth 2000; 85: 44–57[Free Full Text]

2 Joris JL, Hamoir EE, Hartstein GM, et al. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Anesth Analg 1999; 88: 16–21[Abstract/Free Full Text]

3 Chiu AW, Chang LS, Birkett DH, Babayan RK. The impact of pneumoperitoneum, pneumoretroperitoneum, and gasless laparoscopy on the systemic and renal hemodynamics. J Am Coll Surg 1995; 181: 397–406[ISI][Medline]

4 Wolf JS, Monk TG, McDougall EM, McClennan BL, Clayman RV. The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery. J Urol 1995; 154: 959–63[ISI][Medline]

5 Mullet CE, Viale JP, Sagnard PE, et al. Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg 1993; 76: 622–6[Abstract]

6 Bannenberg JJ, Rademaker BM, Froeling FM, Meijer DW. Hemodynamics during laparoscopic extra- and intraperitoneal insufflation. An experimental study. Surg Endo 1997; 11: 911–5[ISI]

7 Wolf JS, Carrier S, Stoller ML. Intraperitoneal versus extraperitoneal insufflation of carbon dioxide gas for laparoscopy. J Endourol 1995; 9: 63–6[ISI][Medline]

8 Ng CS, Gill IS, Sung G, Whalley DG, Graham R, Schweizer D. Retroperitoneoscopic surgery is not associated with increased carbon doxide absorption. J Urol 1999; 162: 1268–72[ISI][Medline]

9 Collins J. Inert gas exchange of subcutaneous and intraperitoneal gas pockets in piglets. Respir Physiol 1981; 46: 391[ISI][Medline]

10 Soulie M, Mouly P, Caron P, et al. Retroperitoneal laparoscopic adrenalectomy: Clinical experience in 52 procedures. Urology 2000; 56: 921–5[ISI][Medline]