嗜铬细胞瘤围手术期全程管理：当前概念与临床管理

文献信息

中文摘要

嗜铬细胞瘤是一种不常见的神经内分泌肿瘤，具有多种非特异性临床表现。若未被识别和治疗，它与靶器官损害及并发症的发生相关，如心肌炎、心肌病、脑血管意外和糖尿病等众多并发症。嗜铬细胞瘤的诊断基于儿茶酚胺过量的生化证据，随后通过影像学定位肿瘤。新诊断的嗜铬细胞瘤患者应由多学科围手术期团队诊治，包括麻醉科医师、手术外科医师、内分泌科医师和心内科医师。应在肾上腺切除术前开始围手术期降压治疗，以允许心血管恢复，并有望减轻对喉镜检查和肿瘤操作的高血压反应。麻醉科医师必须准备好处理术中高血压、低血压和血糖紊乱等其他可能并发症。既往未诊断的嗜铬细胞瘤患者因无关手术就诊代表一个高风险群体。一旦术中怀疑，应优先立即稳定病情、在可行时停止手术，并与手术团队密切沟通，根据手术的紧急性和患者的临床状况决定是否中止、限制或继续该手术。在大多数情况下，应中止非必需手术。术后护理级别应基于术中患者过程和机构方案与指南，以监测和管理术后低血糖和血管麻痹（当发生时）。本叙述性综述旨在为执业麻醉科医师提供一个更新的、实用的框架，用于嗜铬细胞瘤的围手术期识别和管理。我们将当代证据与麻醉特异性决策相结合，包括儿茶酚胺诱导的心血管功能障碍的管理、围手术期液体和血管活性药物治疗、药物触发的危象，以及针对因无关手术就诊的既往未诊断嗜铬细胞瘤的专门处理方法。

英文摘要

Pheochromocytoma is an uncommon neuroendocrine tumor with myriad nonspecific clinical presentations. If not recognized and treated, it is associated with the development of target organ damage and complications such as myocarditis, cardiomyopathy, cerebrovascular accidents, and diabetes mellitus, among numerous others. The pheochromocytoma diagnosis is based on biochemical proof of catecholamine excess followed by imaging localization of the tumor. Patients with newly diagnosed pheochromocytoma should be seen by a multidisciplinary perioperative team, including the anesthesiologist, operating surgeon, endocrinologist, and cardiologist. Perioperative antihypertensive therapy should be instituted prior to adrenal resection to allow for cardiovascular recovery and to hopefully mitigate the hypertensive response to laryngoscopy and tumor manipulation. The anesthesiologist must be prepared to manage both intraoperative hypertension, hypotension, and glycemic disturbances, among other possible complications. Patients with previously undiagnosed pheochromocytoma who present for unrelated surgery represent a high-risk group. Once intraoperatively suspected, priority should be given to immediate stabilization, cessation of surgery when feasible, and close communication with the surgical team regarding whether the procedure should be aborted, limited, or continued based on the urgency of the operation and the patient's clinical status. In most cases, nonessential surgery should be aborted. The postoperative level of care should be based on intraoperative patient courses and institutional protocols and guidelines to monitor and manage postresection hypoglycemia and vasoplegia, when they occur. This narrative review aims to provide practicing anesthesiologists with an updated, practical framework for the perioperative recognition and management of pheochromocytoma. We integrate contemporary evidence with anesthesia-specific decision-making, including the management of catecholamine-induced cardiovascular dysfunction, perioperative fluid and vasoactive therapy, medication-triggered crises, and a dedicated approach to previously undiagnosed pheochromocytoma presenting during unrelated surgery.