Editing Surgery of the Adrenals (section)

== Pre-operative Management ==

* '''All patients undergoing surgery for large adrenal masses must be counseled about the possibility of concurrent en bloc nephrectomy'''
*'''Consider peri-operative steroids in patients undergoing adrenalectomy'''

=== Pheochromocytoma ===

*'''See [[Adrenal: Pheochromocytoma|Pheochromocytoma]] Chapter Notes'''
* '''Excessive secretion of catecholamines from chromaffin tissue may result in tachycardia, diaphoresis, headache, hypertension, cardiac arrhythmias, left ventricular dysfunction, and impaired glucose tolerance.'''
* '''Preoperative cardiac workup, including electrocardiography and echocardiography, and assessment of hypertension-induced end-organ dysfunction are indicated.'''
* '''Preoperative sympatholytic therapy with α-adrenergic blockers for at least 2 weeks before surgery helps in both hemodynamic and glucose control and should be continued until the day of surgery'''
** '''Phenoxybenzamine is time proven to be safe and effective but has its associated problems. Its nonselective nature may lead to tachycardia and β-adrenergic blockade may be necessary. Being an irreversible noncompetitive α-adrenergic blocker, prolonged hypotension in the immediate postoperative period and central nervous system effects such as somnolence may be expected.'''
** '''Newer selective and competitive α1-adrenergic blockers such as doxazosin, prazosin, and terazosin obviate the drug-induced need for β-blockade.'''
* '''β-Adrenergic blockade, if needed, must be given with caution in patients with myocardial depression and started only after phenoxybenzamine therapy.'''
* '''Intraoperatively, hypertensive episodes should be anticipated and can be controlled with intravenous drugs with rapid onset and short half-life such as nitroprusside, phentolamine, nitroglycerin, and nicardipine. Temporary cessation of surgical manipulation of the pheochromocytoma may be necessary. Short-acting β-blockers such as labetalol and esmolol are also good choices.'''

=== Hyperaldosteronism ===
* '''An aldosterone antagonist (spironolactone) should be started at least 1-2 weeks before surgery, especially in patients on long-term angiotensin-converting enzyme inhibitors'''