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A Journal on Surgery
Indexed/Abstracted in: EMBASE, Scopus, Emerging Sources Citation Index
Chirurgia 2005 April;18(2):69-72
Pheochromocytoma presenting as ischaemic toes: successful laparoscopic treatment of a symptomatic pheochromocytoma
Fiume I., Snook A., Bailey M. E.
Aim. We present a patient with an adrenal pheochromocytoma manifesting initially as right toes ischaemia. Hospital courses, treatments, pathogenic mechanism of distal ischaemia and advantages of laparoscopic approach are described.
Methods. A 50 year old man presented with cold, numb right toes and chest pain. No clots were found at peripheral MR angiography. A CT scan revealed a solid right adrenal mass. 131I-MIBG whole body scintiscan confirmed the presence of 131I-MIBG avid right suprarenal mass compatible with pheochromocytoma without other metastatic foci. His blood pressure was controlled with a combination of alfa and ß blockers, ACE inhibitors, Ca2+ cannel blockers. When he was stable, he underwent laparoscopic surgery to remove the mass.
Results. After excision, the size of the mass was of 6.5x5.5x4.5 cm with a necrotic center. The ischemia of his right foot led to a distal necrosis which was resolved with a partial auto-amputation of his 2nd and 3rd toe while a surgical removal was necessary for his 4th and 5th toe.
Conclusions. Signs of unilateral peripheral vascular disease are uncommon as initial manifestation of pheochromocytoma. The pathogenic mechanism of distal ischemia would be persistent arterial vasospasm due to excessive plasmatic catecholamine levels without thromboembolism. Several studies have compared laparoscopic adrenalectomy with open anterior or posterior approaches documenting the reduced pain, shorter hospital stay, improved cosmesis, and cost effectiveness of laparoscopy. Thanks to its numerous advantages as the magnification of images in a very difficult access place, the use of optimal instrumentation as Ultracision® that allows a precise dissection and accurate haemostasis, the transabdominal lateral approach that allows a gravity facilitated exposure of the gland, the laparoscopic adrenalectomy could be the procedure of choice not only for small and benign adrenal masses.