S Jandali, A Mofti, S Al Muhaya, A Al-Zourkany, N Hussein, H Al-Gamal, M Takrouri
adrenalectomy [methods], anaesthesia, cholecystectomy, laparoscopy, pheochromcytoma
S Jandali, A Mofti, S Al Muhaya, A Al-Zourkany, N Hussein, H Al-Gamal, M Takrouri. Laparoscopic Adrenalectomy In A Patient With Nephrotic Syndrome. The Internet Journal of Nephrology. 2003 Volume 1 Number 2.
During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparoscopic adrenalectomy for adrenal tumor excision is one of these new applications, The Anaesthesia related implications are critical and note-worthy in the presence of long standing essential hypertension and nephrotic syndrome with poly-pharmacy.
The wealth of experience in laparoscopy from clinicians across the world has proved that this new technique is safe with reduced incidence of severe pain. The procedure is less expensive and the patient resumes his normal life within a short time thereafter. However it also presents special problems like complications of insufflation of carbon dioxide and its reabsorption to the blood, embolization, and the cardiovascular effects which occur due to the increased intra-abdominal pressure. To the best of our knowledge there is only one report in medical literature mentioning removal of pheochromocytoma in a patient on long term hemodialys. We describe the anaesthetic management in a case of nephrotic syndrome with diabetes and hypertension that warranted laparoscopic adrenalectomy, probably the first in the kingdom of Saudi Arabia.
A 58 year old Saudi obese woman was seen in the nephrology clinic at SFH, and diagnosed and on continuous treatment since 20 years for essential hypertension, non insulin dependent diabetes mellitus (NIDDM) since fourteen years, nephrotic syndrome since 4 years, and cholelithiasis. Investigations were directed towards secondary causes of hypertension like renal artery stenosis and adrenal tumors including pheochromocytoma. Clinically she had general oedema, ascites, anaemia, hypoalbuminemia, hyponatremia, uremia, high serum creatinine and proteinurea. Catecholamine blood level; measured on two occasions (Reference laboratory: JSPS London) indicated noradrenaline 6.4 nmol/l (normal range 2-6 nmol/l) and adrenaline 0.39 nmol/l ( normal range 0.1-5 nmol/l). Urinary catecholamines /24h, revealed Noreadrenaline 212 umol /24h, Adrenaline 18 umol/24h, and Dopamine 1335 Umol/24h. A kidney biopsy demonstrated immune complex mediated glomerulopathy complicating diabetic nephropathy. The ultrasound scan of the kidneys, adrenals, Magnetic Resonance Imaging (MRI) and Metaiodobenzylguinidine (MIBG) nuclear scanning demonstrated a solid mass lesion in the right suprarenal area probably tumor within the right adrenal which measured 38 mm. Otherwise the other organs of the abdomen looked normal [fig 1;a,b,c,&d]. EKG showed evidence of ST segment depression, with left ventricular hypertrophy. Echocardiogram was normal. Examining the back showed marked lordosis.
The preoperative preparation included Alpha-adrenergic blockers prazocin (15 mg), Beta-blockers atenolol 100mg, adalat 60 mg, Lasix 80 mg, clonidine 150 mg and predinsolone 30 mg daily. This regime had optimized the blood pressure which was at the morning of the operation 160/80 Torr. and no changes in these parameters were noted during the period 72 hours before the day of surgery. However, hyponatremia was present.
The anesthetic management included preoperative diazepam 10 mg orally 3 h before surgery, 5 mg iv midazolam in induction room. attaching the EKG leads, oximetry, insertion of radial artery catheter. Swan-Ganz catheter for CVP, PAP. and PAWP. A thoracic epidural catheter was inserted at T9-T10. Other monitored parameters included FiO2, capnography, and body temperature. The induction was gradual and fentanyl 100 ug, Thiopentone 210 mg, and intubation was facilitated by atracurium 40 mg. Xylocaine 1% intravenously was given to suppress the laryngoscopy and intubation response. Also, topical lignocaine 10% was administered over the larynx, vocal cords and in the trachea. Maintanence of the anaesthesia was achieved by adding isoflurane to 50:50 oxygen nitrous oxide mixture, 200 ug of fentanyl intravenously during the length of the surgery in intermittent doses and 100 ug of fentanyl epidurally. Muscle relaxation was maintained by infusion of atracurium 10 ug/kg/min. The course of the anaesthesia was uneventful. Fluctuation in blood pressure was minimal and adjusted by deepening of the anaesthesia, and guided by CVP, and PCWP reading a pressure of 10-12 mmHg and 15-20 mmHg respectively was maintained and infusion of plasma protein 5% 500 ml, albumin 20% 100 ml, and whole blood 300 ml were administered.
The patient was placed in the right nephrectomy position with table bridge at the level of the left flank. Then he was strapped to the table and placed in a 45° anti-Trendelenburg position with 30° tilt to the left. Pneumoperitonium was established through a Veress needle introduced at the mid-clavicular line below the costal margin. Then, a 10 mm port was introduced in the mid line above the umbilicus at a 30° angle. Subsequent 4 ports were introduced under direct vision. The liver and gall bladder were retracted cephalad while the other viscera retracted downward, medially exposing the retroperitoneal area at the superior pole of the right kidney. The right adrenal gland was exposed through the perinephric fat after dissecting the retroperitoneal covering. Dissection of the adrenal gland started laterally and proceeded toward the inferior vena cava in order to expose the central draining veins. Small vessel bleeding was controlled by diathermy while the medium size vessels were divided between metal clips. The whole gland was mobilized and dissected free and placed into an endo-bag. The gall bladder which contained several stones was also removed laparoscopically and placed in an endo-bag [fig. 2,3,&4]. Haemostasis was secured and the endo-bags were removed through one of the 10 mm ports opening and the port openings were closed with skin clips.
Intensive care management
At the end of the procedure, the patient was awake and extubated and transferred to the SICU for further management and monitoring. During the next five hours in the post operative period, the blood pressure tended to rise which necessitated the infusion of Na nitroprusside 4 ug/Kg/min. CVP and PCWP readings were reflecting good filling and at no time hypotension occurred. The urine output showed diuresis at rate of 200 ml/h and that continued for 18 hours post operatively. Hyponatremia improved, urea and creatinine decreased. Early mobilization, incentive spirometry and chest physiotherapy were repeated at 2-hour intervals. The patient needed minimal epidural narcotics consisting of 3 mg of morphine in 10 ml saline /12 h. On the morning of the second postoperative day the patient was mobile, pain free, and started a soft diet.
Discussion A case of long standing hypertension, with finding of a suprarenal mass should alert the clinician to the possibility of pheochromocytoma, which constitutes a serious risk for the patient posted for surgery (1) The control of the blood pressure peri-operatively was a major concern to the managing team. Two approaches are described in literature, the use of alpha (2,3) and beta sympathetic blockade(4,5), or Magnesium sulfate infusion.(6). If blood pressure is fluctuating Na nitroprusside is used for hypertension, and norepinephrine infusion if hypotension occurred after removal of the tumor. In this case blood pressure intra-operatively was controlled simply by the balanced anaesthesia technique adjusting isoflurane inhaled concentration and using thoracic epidural for pain relief. The manipulation of the mass by the surgeon did not affect the blood pressure, after recovery from anaesthesia the blood pressure raised to 190/110 Torr in the post operative period, which indicated the use of Na nitroprusside. Pheochromocytoma was a working diagnosis since all the clinical and scan information made it a distinct possibility and the anaesthesiologist was preparing himself for this possibility. Nephrotic syndrome added a new dimension with regard to the fluid therapy and the amount of the fluid in the body (ascites and edema fluid). The use of direct cardiovascular pressure measurements helped in controlling the fluid balance. Laparoscopy in this obese patient with ascites calls for more attention and steps to guard against the complications (7). It is known that pneumoperitonium affects the lung function tests and cardiac functions adversely, since it affects the diaphragmatic functions. The resorption of carbon dioxide from the peritoneum may demand greater rate of elimination, capnography alone does not reflect the extent of blood carbon dioxide level. Our technique involved close monitoring of the blood gases, saturation and capnography. The controlled ventilation was adjusted to prevent hypercarbia and acidosis, or hypoxemia. The choice of anesthetic agent was in accordance with the drugs suitable for quick recovery from anaesthesia e.g. isoflurane, and drugs non-dependent on urinary excretion such as atracurium which does not interact with the drugs used to control the blood pressure which helped in cardiovascular stability (8,9,10,11,12,13). In renal compromised patient the reduction of preload, Alph adrenergic blockade and adequate analgesia would assure the haemodynamic stability (14).
Laparoscopic adrenalectomy was well tolerated in this compromised patient although many co-existent diseases complicated the picture. The precautions taken against the effects of pneumoperitonium and careful monitoring of the cardiovascular and respiratory parameters as well as the use of post operative SICU admission helped to shorten the patient's post operative recovery and ultimately ensure a good outcome.
Safwan T Jandali,
Department of Anaesthesia, Security Forces Hospital,
P.O.box 3643, Riyadh 11481, Kingdom of Saudi Arabia.
Tel 009661 4774480
Fax 009661 4764747