12/15/2009
Surgical treatment of
Hypertension
Update 11th Nov 2009
Dr Guy Adam
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Presentation
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JNL, Age 30
April 2008 Diabetes
Aug 2009 Amaurosis fugax, headaches, constipation, BP
240/120.
Treated by Asomex for HBP
Still headaches GP changed to Atacand
Seen by cardiologist added Lasix and suggested to see
nephrologist
Sep 2009 seen by nephrologist: anxiety, renal insufficiency,
BP 210/110, Urea:…, Creat: 572!
Ordered USS
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Urea
30
27
25
20
22
17
15
17
Urea
13
10
10
8
5
0
Urea
22- 26Sep Sep
22
27
27Oct
28Oct
29Oct
30Oct
3Nov
17
17
13
10
8
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Creatinine
450
400
350
300
250
200
150
100
50
0
399
259
Creatinine
210
156 149
125 115
22- 26- 27- 28- 29- 30- 3Sep Sep Oct Oct Oct Oct Nov
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USS
• Cannot include picture!
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CT Scans
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VMA Result
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Semi quantitative method: Positive
Mean Value for Ratio: 0.46
Reference range:
Normal subject: 1.58-2.26
Patient with Phaeo.: 0.41-1.16
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Pre-op and operative management
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a-blokade pre operatively normally.
Atacan stopped, started on Carvedilol & Loxen
Cathecholamines causes constriction of arterioles and great
veins.
As soon as the tumour is removed there is severe hypotension
due to (a) vasodilatation of the arterioles(low resistance) and
apparent reduction in circulatory volume due to (b)
venodilatation (low capacitance).
Infusion of noradrenaline to correct (a) and blood transfusion
for (b).
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Setting up
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Lateral incision. Supra 12th rib approach
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Phaeochromocytoma
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Histopathology
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Post-op
• Beta blockers have to wear off
• Negative feedback of excess catecholamines
of p
phaeo on left adrenal need to stabilize.
• Diabetes back to normal
• Blood pressure back to normal
• VMA level: Negative
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Presenting symptoms
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Incidence and Age distribution
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Pathology
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Arises from phaeocheomocytes in the adrenal
medulla (80%)
Elsewhere in the sympathetic nervous ganglia from
neck to pelvis
99% within the abdomen
Multiple in 20%
In the adrenal medulla secretes mostly adrenaline
Elsewhere mostly noradrenaline
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