Perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma

Pheochromocytomas are tumors arising from catecholamine producing chromaffin cells in the adrenal medulla (1). They almost always produce, store, metabolize and secrete catecholamines. Currently the only way to cure pheochromocytoma is its surgical removal. Roux and Mayo were the first to remove pheochromocytoma in 1926 and 1927, respectively (2). Unfortunately, due to the lack of understanding of pathophysiology of catecholamine secreting tumors and no antihypertensive medication adrenalectomy for pheochromocytoma was associated with extremely high mortality exceeding 50% (2). Only in 1956 priestly used alpha-blockers perioperatively which resulted in dramatic reduction in postoperative mortality (3). In 1996 Gagner et al. published a series of laparoscopic cases showing that minimally invasive access is safe and feasible (4). Over the last two decades adrenal gland surgery has transformed, so that laparoscopic access has become the gold standard in the surgical treatment of adrenal tumors, including pheochromocytomas (5,6). The advances in operative technique and perioperative management have lowered mortality rates to 0–3% with complications occurring in 5% to 22% of patients (4,7-9). Although these numbers are now relatively low, perioperative hemodynamic instability still remains the biggest surgical and anesthetic challenge which apart from intraoperative bleeding is responsible for serious adverse events. The aim of this review was to discuss pre-, intra- and postoperative factors that may impact on hemodynamic condition of a patient