Pheochromocytomas can be challenging tumors to treat because of the unique manifestations of chronic and acute catecholamine excess. In general, catecholamine excess results in hypertension, tachycardia, and a host of clinical manifestations. Laboratory diagnosis is made by elevated levels of catecholamines in the blood and urine. Radiographic diagnosis is achieved with either computed tomography scan or magnetic resonance imaging. Magnetic resonance imaging classically demonstrates a bright image on a T2-weighted study. Additionally, metaiodobenzylguanidine nuclear medicine scanning can help confirm and localize pheochromocytomas. The treatment of choice for most pheochromocytomas is surgical excision.

Successful surgical management of pheochromocytoma requires close collaboration among the surgeon, endocrinologist, and anesthesiologist.

It is essential to have an anesthesiologist familiar with pheochromocytoma, able to adequately manage blood pressure intra-operatively, and knowledgable about which anesthetic agents to avoid.

In the past, all pheochromocytomas were treated through an open approach, with early control of the adrenal vein. With increasing worldwide experience with laparo-scopic adrenalectomy, pheochromocytoma is no longer considered a contraindication to laparoscopic surgery. In fact, laparoscopic adrenalectomy for pheochromocytomas has now been performed successfully at many centers of laparoscopic excellence and reported in several series (14-16).

Regardless of the surgical approach chosen, preoperative medical preparation is essential, and includes optimal control of blood pressure with alpha blockade or calcium channel antagonists (2). Beta-blockers may be used to control reflex tachycardia after initiation of alpha blockade. In addition, aggressive fluid expansion is necessary to increase circulating plasma volume and prevent postoperative hypotension. Close intra-operative monitoring includes careful attention to blood pressure, central venous pressure, and urinary output. An arterial line and central venous line are routinely used, and occasionally a Swan-Ganz catheter is employed. Severe hypertension can be controlled with sodium nitropusside or phentolamine, and hypotension controlled with fluid resuscitation and norepinephrine.

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