[Surgical treatment of pheochromocytoma--personal experience]

The first description of the adrenal gland dates since 1563 by Eustachius in a study "Opscula anatomica". Despite earlier recognition of the presence of adrenals and division into cortex and medulla, the precise observations of Addison appeared in 1855 that the essential role of these glands was recognized in patients who died with adrenal destruction secondary to tuberculosis. Frankel first described a medulary adrenal tumour in 1886. In 1912 the pathologist Pick formulated the descriptive term pheochromocytoma. The first surgical removal of pheochromocytoma in Europe was performed by Rouks in 1926 and by Mayo in USA in 1927. The work of the later had greater impact. For a long period of time the Military Medical Academy is involved in clinical diagnosis and management of adrenal tumours. The first description of diagnosed pheochromocytoma was by Professor Ratibor Mitshitsh. The first surgical removal of pheochromocytoma in the Military Medical academy and in Yugoslavia was performed by Professor Isidor Papo. Over the period January 1974-December 2001, 268 patients with tumours of adrenal origin(93 patients/34.7%/had pheochromocytoma) underwent surgical treatment in the Military Medical Academy. Of our particular interest was the relation between the surgical approach to pheochromocytoma and the incidence and severe intraoperative and immediate postoperative complications. Although numerous studies favorise transabdominal and thoracic approach, our experience in flank approach is very favorable. By the lateral high intercostal approach above the eleventh costae we operated on 67 (72%) patients with only one (1.5%) major complication--cardiac arrest. With successful reanimation the patient survived. The transperitoneal approach was performed in 21 (22%) cases and we had 7 (33.1%) severe complications: one lethal outcome, cardiac arrest, injury of the aorta, injury of the VCI, postoperative bleeding that required relaparatomy and two splenectomies. The lethal outcome was the result of nonidentified ectopic retropancreatic pheochromocytoma that was not identified preoperatively and intraoperatively. At that time ultrasound, CT and MRI were not available. By transthoracic and posterior approach we operated on a small number of pheochromocytomas. DISSCUSSION: We analysed the advantages and disadvantages of some surgical approaches and our experience in these methods of management of pheochromocytoma and other adrenal tumours; we confirmed multiple advantages of flank intercostal approach above the eleventh costae compared to other approaches. This approach is simple, extrapleural and extraperitoneal. It offers a broad surgical field with the adrenal in its centre which permits an atraumatic operation with little risk of complications.

The flank intercostal approach above the eleventh costae is indicated(option of choice) in unilateral pheochromocytoma and other unilateral adrenal tumours. The transabdominal approach is indicated in cases of bilateral pheochromocytomas, in cases of abdominal localization of ectopic pheochromocytomas, in tumours which involve the VCl and most of the left renal vein, and in patients with extremely large adrenal tumours. The thoracic approach is indicated in intrathoracic ectopic pheochromocytomas.