Discussion
tumor, cardiac arrhythmias, pheochromocytomas, postoperative gastrointestinal complaints, gastrointestinal tract, hemorrhage, RA, tumors
TUMOR, CARDIAC ARRHYTHMIAS, PHEOCHROMOCYTOMAS, POSTOPERATIVE COMPLICATIONS, HEMORRHAGE, ADRENAL TUMOR, GIANT, TUMORS, COMPLICATIONS
Resection of giant pheochromocytomas has long been regarded a difficult challenge for surgeons. Surgical difficulties arise from not only the narrow operating space caused by the tumor occupation, but also the risks of hemorrhage and hazardous blood pressure elevation with fatal cardiac arrhythmias due to tumor overgrowth and exuberant synthesis of catecholamine. For these reasons, minimally invasive adrenalectomy surgeries in nowadays still have many intractable difficulties in handling giant pheochromocytomas [With the help of renal-rotation techniques, we have successfully increased the operating space by fully mobilizing and rotating the kidney downwards, making it feasible to extensively expose and safely resect GP. The key points of our methods lie in two steps, one is fully mobilizing the kidney, and the other is maintaining the suspended position of the adrenal tumor (the superior border of the tumor is dissected last). After thorough renal mobilization and rotation, the blocking effect from the kidney can be removed to the maximum extent. Besides, downward dragging and rotation of the kidney can provide excellent field exposure of the tumor bottom, which greatly facilitates dissection of the tumor inferior margin and sealing of nourishing vessels on the tumor surface (Figs. In clinical practice, many surgeons have alternatively chosen TA and OA for patients with GP to acquire adequate operative space and guarantee safety. Therefore, we also included these two surgical approaches in our comparative assessments. The results showed that our intervention group still had advantages in intraoperative measurements as well as postoperative complications and recovery. Among the reported complications, postoperative gastrointestinal complaints were the most common and were mostly contributed by the OA and TA groups. Based on our experience and relevant literature, this is because the gastrointestinal tract is inevitably disturbed when the transabdominal approach is adopted [Although our renal rotation techniques can effectively increase the operating space for GP resection, it must be noted that there is still upper limit for this method. In our experience, RA with renal rotation could barely handle large tumors with diameters > 12 cm, it is mainly recommended for GP with diameters ranging from 6 to 12 cm. However, considering the rarity of reported GP cases that were beyond the upper range limit, we believe that our method is suitable for most patients with GP. Also, it should be noted that this is a single-center study, and all the described improvements were summarized by comparing against our own previous surgical protocols. The efficiency and effects of our techniques may be inconsistent in other countries/hospitals, due to the regional differences of surgical standards. In addition, this study did not compare the effectiveness of our method with robot-assisted adrenalectomy, which has been gradually popularized for GP treatment owing to its excellent visualization and fine manipulation. We believe that our method is more economical and has edges in learning curve as well as accessibility. Nevertheless, a concrete comparative study is required in the future to fully clarify their advantages and disadvantages.