Postoperative Management of Bilateral Adrenalectomy for Pheochromocytoma
After bilateral adrenalectomy for pheochromocytoma, immediate postoperative care must focus on aggressive management of hypotension, careful monitoring of glucose levels for hypoglycemia, and lifelong glucocorticoid and mineralocorticoid replacement therapy. 1, 2
Immediate Postoperative Management
Hemodynamic Management
- Aggressive treatment of postoperative hypotension is essential, as the sudden decrease in catecholamine levels following tumor removal can cause significant blood pressure drops 1
- Preoperative saline infusion (1-2 liters 24 hours before surgery) helps prevent postoperative hypotension, but additional fluid resuscitation may be required 2
- Vasopressors may be needed in cases of refractory hypotension, particularly in patients who received selective α-blockers preoperatively 3
Glucose Monitoring
- Close monitoring of blood glucose levels is crucial as hypoglycemia commonly occurs after the reduction of catecholamine levels 1
- More frequent glucose checks should be performed in the first 24-48 hours postoperatively 2
Pain Management
- Adequate pain control is important to prevent hemodynamic instability 2
- Epidural analgesia may be beneficial if placed preoperatively 4
Adrenal Insufficiency Management
Immediate Glucocorticoid Replacement
- High-dose hydrocortisone (150 mg/day) should be administered during the immediate postoperative period 1, 5
- Gradual tapering to maintenance doses should occur over several days 2
Long-term Hormone Replacement
- Standard maintenance therapy includes oral hydrocortisone 15-25 mg/day in divided doses (typically 2/3 in morning, 1/3 in afternoon) 5
- Fludrocortisone (0.05-0.2 mg daily) is required for mineralocorticoid replacement, with dosing based on blood pressure and serum potassium levels 5
- Monitoring should include serum electrolytes and plasma renin activity 5
Special Considerations
Stress Dosing Education
- Patients must be educated about stress dosing protocols for illness, surgery, or other stressors 5
- During periods of stress, glucocorticoid doses should be doubled or tripled 5
Medical Alert Identification
- All patients should wear medical alert identification indicating adrenal insufficiency 2
- Emergency injectable hydrocortisone kits should be prescribed and patients/family trained in their use 2
Follow-up Protocol
Early Follow-up
- First postoperative visit should occur within 2-4 weeks 2
- Biochemical testing should be performed 2-8 weeks after surgery to confirm complete tumor removal 2
- Imaging should be done at 3-6 months postoperatively to verify complete tumor resection 2, 6
Long-term Surveillance
- Regular monitoring of chromogranin A and metanephrines is recommended every 3-4 months for the first 2-3 years 6
- Imaging should be repeated periodically based on risk stratification 2
- Lifelong surveillance is recommended for patients with hereditary pheochromocytoma 2, 6
Potential Complications to Monitor
Adrenal Crisis
- Symptoms include severe hypotension, nausea, vomiting, abdominal pain, and altered mental status 5
- Requires immediate treatment with IV hydrocortisone 100 mg and fluid resuscitation 5
Recurrent Disease
- Even after bilateral adrenalectomy, recurrence can occur in adrenal remnants or at extra-adrenal sites 7, 8
- Long-term follow-up is necessary as recurrence may develop many years after operation 7
Quality of Life Considerations
- Patients should be monitored for symptoms of over- or under-replacement of steroids 5
- Psychological support may be beneficial for adjustment to lifelong medication dependence 2
Alternative Surgical Approaches (For Future Reference)
Cortical-Sparing Surgery
- In selected cases (particularly hereditary syndromes), cortical-sparing adrenalectomy may be considered to avoid lifelong steroid dependence 7, 8
- This approach carries approximately 7% risk of tumor recurrence in the adrenal remnant 8
- About 78% of patients with cortical-sparing procedures remain steroid-independent at 3-year follow-up 8