Adrenalectomy for “non-active” adrenal mass

Gabrielle Morris

46-year-old man for Adrenalectomy.

Background

  • Incidental finding of a non-active adrenal tumour in 2019 while being investigated for a testicular mass
  • Normal urinary catecholamines at time of diagnosis
  • Uncertainty as to cause of testicular mass
  • Surgery being performed after a delay due to the coronavirus pandemic

Issues

Pathway to OT

  • Distance patient. No fixed abode.
  • Phone consult – reported some asthma and recreational cannabis use.
  • DOS – presented with cough and sputum.
  • Cancelled in anaesthetic bay, admitted to hospital under medical team and treated for LRTI/exacerbation of asthma
  • Improved with treatment of infection and asthma therapy
  • Decision made to rebook after one week. Surgeon unaware that patient listed

Intraoperative Events

  • Profound hypertension and tachycardia after induction; SBP 250mmHg, HR 120bpm
  • Resistant to propofol and increased depth of anaesthesia
  • Entropy placed, values consistently below 10.
  • Surgery not commenced
  • Hypertension persisted despite GTN and phentolamine
  • Given Hydralazine, labetalol, and morphine with some effect
  • Surgery performed, no change in haemodynamic status with removal of adrenal mass

Postoperatively

  • Ongoing hypertension, SBP 170-180mmHg. HR 80bpm
  • Excessive pain despite 20mg morphine
  • History revealed extensive cannabis use – 7g/week. Continued use throughout admission.
  • Alcohol abuse – had been inpatient for a week and should be on AWS

Discussion

Differentials:

  1. Phaeochromocytoma – undiagnosed at time of tumour discovery. No recent surgical or endocrine review. Literature states that during unplanned phaeochromocytoma surgery it is not uncommon to have catecholamine surges post tumour devascularisation due to lack of preoperative alpha and beta-blockade. (See attached BJA article)
  2. Carcinoid syndrome – previous testicular mass of uncertain aetiology. May have Multiple Endocrine Neoplasia
  3. Withdrawal from cannabis, alcohol, and possible other illicit drug use – hypertension and tachycardia are common in cannabis withdrawal, but this would be very unlikely given that patient was deeply anaesthetised

Patients presenting for surgery after a delay

  • Common scenario that patient may see a surgeon and wait for a length of time before surgery. Magnified significantly by COVID.
  • Should patients be reassessed by proceduralist before being booked?
  • This is tricky, time-consuming and may cause more delays than benefits
  • Possible that surgeons themselves may be keen to resolve, worth a discussion between specialties