[Abstract] ①Objective To improve the diagnosis and treatment of pheochromocytoma (phe). ②Methods The clinical data and treatment experience of 51 phe patients were reviewed and summarized. ③Results 34 cases had typical hypertensive manifestations and 17 cases had atypical symptoms. Among them, 6 cases had family history, 3 cases combined with thyroid cancer. 49 cases were cured by surgery, 1 case was only surgically explored, 1 case remained small tumor after surgery, and there was no surgical death. The results showed that the patients should be examined for suspected phe cases and familial phe cases in order to prevent the missed diagnosis and misdiagnosis; adequate preoperative preparation and effective prevention of various risks of phe attacks are the primary aspects of successful surgery. [Keywords] Pheochromocytoma; diagnosis; treatment Pheochromocytoma (phe) has been an important topic of research for surgeons because of its special pathophysiology and high surgical risk. From 1987.8 to 2007.12, a total of 51 cases of phe were admitted to our hospital, and the results of surgical treatment were satisfactory, which are reported as follows. 1, data and methods 1.1 clinical data 51 cases, 23 men and 28 women, aged 24-70 years, with a medical history of 1 month to 9 years. There were 18 cases of left adrenal gland, 25 cases of right adrenal gland, 5 cases of bilateral adrenal gland and 3 cases of extra-adrenal gland. The tumor size ranged from 1.5 cm×1.8 cm to 13.5 cm×17.5 cm, including 3 cases of giant mass. Pathology confirmed benign in 48 cases and malignant in 3 cases. There were 22 cases of paroxysmal hypertension and 12 cases of paroxysmal exacerbation of persistent hypertension, among which 3 cases of bilateral adrenal phe were complicated by hypertensive crisis and heart failure when they were first admitted to the hospital; 9 cases of persistent hypertension and 8 cases without hypertensive symptoms in general, among which 2 cases were found in late pregnancy, 1 case during cesarean section, and 1 case of sudden blood pressure surge during postoperative peritoneal tumor exploration in oncology department; 6 cases had family history, among which 2 cases were The EKG showed various degrees of myocardial ischemic damage in 30 cases, left ventricular hypertrophy in 9 cases, and premature ventricular contractions in 5 cases. The rate of positive 24-hour urinary vanillo-mandelic acid (VMA) qualitative examination was 80.4% (37/46), the rate of positive ultrasound was 96.1% (49/51), CT 100% (49/49) and MRI 100% (18/18). 1.2 Treatment method Preoperative routine application of phenoxybenzamine or dextran and insulin were prepared for 2-3 weeks, 19 cases with unsatisfactory blood pressure control were added with cardioplegia and mercaptopropionic acid and other drugs, routine volume expansion for 3 days before surgery, 1500-2000 ml of fluid transfusion per day, 5 cases with bilateral adrenal phe (including 2 cases with giant mass type) were prepared for 4-6 weeks before surgery, 2 cases with 400 ml of blood transfusion again 1 day before surgery, another 1 All cases were prepared for 2 months, so that the blood pressure and heart rate were controlled close to the normal range before surgery and treated with epidural anesthesia or general anesthesia for surgical resection. 2, results 49 cases were cured by surgical resection, one case could not recover from postoperative hypertensive symptoms, and no residual tumor was found by whole body ultrasound and other examinations again, and 131I-MIBG whole body scan was done in a higher hospital, and the result was that there was small tumor residue in the contralateral retroperitoneum, and one case of giant mass type was closely related to the surrounding tissues, and the blood pressure was severely elevated and fluctuated during the operation, and only surgical exploration was performed, and hypertensive crisis and heart failure occurred on the second day after operation. It was successfully rescued in time. In this group, there were 3 cases of arrhythmia and early heart failure during the operation, which were corrected by timely treatment. 4 cases showed significantly elevated blood pressure fluctuations, and sodium nitroprusside was added to lower the blood pressure, and the rest of the cases did not have much fluctuation, and there were no intraoperative episodes of hypertensive crisis, hypotensive crisis and cardiovascular and cerebrovascular accidents and other complications. 3. Discussion 3.1 Diagnosis of phe can be made based on its clinical manifestations, qualitative and localization examinations. However, because of its variable clinical manifestations, people with a history of typical hypertensive episodes generally think of this disease easily, while it is difficult to identify and detect persistent hypertension or “resting phase” phe without hypertensive symptoms. Therefore, in order to raise the alarm and prevent missed diagnosis and misdiagnosis, those with atypical manifestations should be classified as suspected phe cases: ① those with alternating episodes of headache, sweating, chest and abdominal pain, hypotony, neuroticism and other suspicious signs; ② those with fluctuating hypertension in lean patients or those with a short course of malignant hypertension and diabetes mellitus or those with high basal metabolic rate but not hyperthyroidism; ③ those with good response to ganglion blockers (4) those with symptoms during surgery, anesthesia, trauma, or childbirth; (5) those with tumors of unknown nature in the adrenal region or in the renal hilum or para-abdominal aorta detected by imaging due to physical examination or other diseases; (6) those with hypertension in youth or a family history of phe. Whenever the above-mentioned suspected phe cases are encountered, they should be subjected to detailed screening examinations. The preferred qualitative test is the determination of 24-h urinary VMA, which is simple and has a high positive rate, with a positive rate of 80.4% in this paper and a positive rate of 93.4% (97/106) for three consecutive measurements of 24-h urinary VMA reported in the literature [1], but the sensitivity of 24 urinary VMA has been reported to be 63% and specificity 94%, while the determination of m-hydroxynephrine and norepinephrine The combination of the two is a more reliable qualitative screening test, which is important to help clarify the efficacy and early detection or anticipation of recurrence after surgery. If there is no condition for reliable qualitative examination, all suspected phe cases with positive localization examination at the site of phe predilection should be prepared according to phe before surgery to avoid intraoperative accidents. Ultrasound should be preferred for localization examination, and if there are positive or suspicious findings, CT or MRI examination should be performed to confirm the diagnosis, which is a recognized and reliable method for localization examination. If other parts of the adrenal glands or microscopic phe are suspected, whole-body scanning with 131I-MIBG should be used for both localization and characterization, which can make early diagnosis and is decisive for the diagnosis of resting or multiple phe [3] [4]. Also, for the diagnosis of familial phe, attention should be paid to the possibility of the combined presence of endocrine tumors, and long-term follow-up examination of their family members. For those who have adrenal tumors on only one side, regular postoperative review is needed to detect the possibility of recurrent tumors on the opposite side in a timely manner. 3.2 Treatment The majority of phe are pathologically benign tumors, but because they can secrete excessive CA, they are prone to cardiovascular and cerebrovascular complications or acute attacks of crisis and death. Therefore, it should be regarded as malignant tumor in terms of physiological function, and early surgery is recommended. However, the risk of surgery is high, and we believe that adequate preoperative preparation and effective prevention of various crises of phe attack are the first and foremost aspects of successful surgery. The central element of adequate preoperative preparation is the application of α-blockers to lower blood pressure and β-blockers to control heart rate. However, it is worth noting that α-blockers should be applied routinely for 2-3 days first, and if the heart rate is >100 beats/min then β-blockers should be applied in combination to avoid the stimulatory effect of α-blockers losing the antagonism of β-blockers, resulting in enhanced constrictive effect and further increase in blood pressure, which has been reported in the literature to avoid hypertensive crises [5]. Some patients also need a combination of angiotensin-converting enzyme inhibitors and calcium channel blockers to effectively lower blood pressure, for the following reasons: (i) there are other mechanisms of blood pressure elevation than CA, phe patients can produce hyperreninemia under the stimulation of high CA and hypovolemia, and some phe can also directly produce renin, angiotensin and other elevating substances when they are abnormally secreted; (ii) from the molecular biology point of view, calcium blockers can From the molecular biology point of view, calcium blockers can reduce the concentration of calcium ions in the cytoplasm of phe to inhibit CA release and inhibit the vasoconstrictive pressure-raising reaction produced by CA, renin and angiotensin. As for the preoperative preparation time, the patient’s blood pressure and heart rate should be stabilized in the normal range, emotional stability and good sleep, generally at least 2 weeks. The literature reports that the majority of patients with bilateral adrenal phe have significantly increased CA secretion, severe symptoms, and aggressive disease, requiring a long enough preparation to improve the safety of the procedure [6]. Among the 5 cases of bilateral adrenal phe in our group, 3 cases had severe and critical episodes, and after 4-6 weeks of preoperative preparation, 4 cases achieved successful surgery, while 1 case was only surgically explored, and its intraoperative blood pressure was severely elevated and fluctuated, and it had a critical episode the day after surgery, which was estimated to be related to insufficient preoperative preparation time. There was another case of left adrenal mass phe, which was not operated even after 1 month of out-of-hospital medication preparation and later continued to be prepared for 4 weeks. Because of the special pathophysiology of phe, preoperative preparation cannot completely avoid the sudden rise of blood pressure caused by intraoperative exploration and separation of tumor, especially for those with huge tumor or serious adhesions. safety. ②Before the start of anesthesia and surgery, we should routinely establish a good antihypertensive infusion channel, and use an intravenous microinfusion pump with phentolamine 0.5-1.0 mg/min rate as the initial antihypertensive, and adjust it at any time to control blood pressure in the normal range, which can achieve satisfactory results. Once BP>240/140mmHg is found, the precursor of hypertensive crisis should be considered, and rapid sedation of phentolamine 5-10mg should be preferred and can be repeated at intervals of 15-20 minutes, followed by intravenous microinfusion pump at 0.5-2.0mg/min and adjusted at any time to maintain hypotension, while rapidly expanding capacity and preventing heart failure. If the amount of phentolamine required in a short period of time is large or the hypotensive effect is poor, it should be changed to sodium nitroprusside, or alternating with sodium nitroprusside can be taken to be more effective. Phe releases a large amount of CA to make the microcirculation in the body in a contracted state, the patient has a relative lack of systemic blood volume before the operation, and after the tumor is removed, the CA decreases sharply, the microcirculation expands rapidly causing the rapid decrease of effective circulating blood volume and even shock, that is, hypotensive crisis, so the key to prevention and treatment is adequate expansion. Therefore, the key to prevention and treatment is adequate expansion. It is not enough to lower the pressure sufficiently before operation to make the ionic fluid inside and outside the blood vessel self-regulate expansion, but it is necessary to infuse fluids routinely before operation and transfuse blood to expand the volume if necessary, and it is also very necessary to infuse fluids and expand the volume under central venous pressure monitoring. At the same time, we should pay attention to accelerating the volume expansion before clamping the main vascular tissue of the tumor or completely removing the tumor, and discontinue the hypotension, establish a good norepinephrine infusion channel to prepare for boosting the blood pressure, and then continue to maintain normal blood pressure for 1 to 3 days after the operation according to the situation, so that serious hypotension or hypotensive crisis will not occur in general. Phe patients generally have varying degrees of CA cardiomyopathy and abnormal EKG performance preoperatively, but some patients may not always exhibit preoperative EKG and are prone to heart failure crisis, i.e., severe arrhythmia, heart failure or cardiac arrest, due to intraoperative blows from surgery and anesthesia or significant fluctuations in blood pressure. Therefore, for any phe patient, regardless of whether the EKG performance is abnormal or not, cardiac ultrasound should be routinely performed to understand the status of cardiac function. In addition to adequate preoperative hypotension that can open the vascular bed of the body, reduce cardiac load and improve myocardial nutrition, myocardial nutrient drugs must be routinely applied to promote myocardial function recovery. At the same time, pay close attention to intraoperative cardiac monitoring and control of blood pressure can not be too large fluctuations, if intraoperative tachycardia > 140 beats/min, with arrhythmia, should be promptly corrected with lidocaine, insulin, cetiran, etc., and in the 3-7 days after surgery still can not ignore monitoring, to achieve appropriate rehydration speed and rehydration amount, in order to prevent the occurrence of heart failure due to the poor compensatory capacity of the heart for excessive load and low blood volume. Heart failure. If there are episodes of hypertension or hypotensive crisis, blood pressure should be controlled in a timely manner while actively correcting and preventing heart failure.