Case Report
Intraoperative use of Indocyanine Green to Confirm Perfusion of Remnant Tissue in Cortical-Sparing Retroperitoneoscopic Adrenalectomy
Long KL*, Graham PH, Grubbs EG, Lee JE and Perrier ND
Department of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, USA
*Corresponding author: Kristin L. Long, Department of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Unit 1484 PO Box 301402, Houston TX 77230, USA
Published: 14 Sep, 2016
Cite this article as: Long KL, Graham PH, Grubbs EG,
Lee JE, Perrier ND. Intraoperative
use of Indocyanine Green to Confirm
Perfusion of Remnant Tissue in
Cortical-Sparing Retroperitoneoscopic
Adrenalectomy. Clin Surg. 2016; 1:
1111.
Abstract
A 53-year old male was diagnosed with bilateral pheochromocytomas after abdominal imaging
revealed bilateral adrenal masses. Elevated serum catecholamines confirmed a pheochromocytoma,
MIBG scan identified bilateral isotope uptake and genetic testing revealed a TMEM 127 mutation.
Antihypertensive catecholamine-blocking medication was initiated. Given the desire to retain
adequate cortical function, selective resection with a left total adrenalectomy and a cortical-sparing
right sided adrenalectomy was planned via a retroperitoneoscopic approach. Intraoperatively,
fluorescent indocyanine green was utilized to confirm perfusion to the right-sided adrenal remnant
prior to proceeding with a left-sided total resection. This case exemplifies a method of intraoperative
confirmation of cortex perfusion that enhances laparoscopic cortical-sparing adrenalectomy.
Keywords: Adrenal; Retroperitoneoscopic; Indocyanine green; Cortical-Sparing
Introduction
Posterior retroperitoneoscopic adrenalectomy (PRA) has emerged as a safe and effective
treatment modality for surgical resection of adrenal tumors, and in many scenarios, may represent
the preferred approach. In cases where bilateral adrenal masses require intervention, PRA offers the
ability to access both adrenal glands without a cumbersome and time-consuming change in position
while retaining the patient-derived benefits of minimally invasive surgery [1]. Certain genetic
syndromes predispose patients to the development of bilateral tumors. In TMEM 127 mutations,
patients frequently present with multifocal, bilateral tumors necessitating surgical resection [2].
In these cases, a cortical-sparing approach is of utmost value to prevent post-operative adrenal
insufficiency.
Indocyanine green (ICG), a water-soluble dye initially used in near-infrared photography,
has been utilized in multiple surgical procedures to facilitate tissue identification and subsequent
dissection. ICG has been employed to localize the adrenal gland, a highly vascular organ, and to
aid in tumor removal for attempted cortical-sparing procedures [3-6]. While it has been useful
in delineating the tumor boundaries for resection, reserving the administration of ICG until after
tumor removal to examine perfusion to the cortical remnant has not been described. We describe
a novel technique to assess perfusion of adrenal cortical remnant tissue using indocyanine green
infusion after removal of bilateral pheochromocytomas.
Case Presentation
A 53-year old previously healthy avid marathon runner was evaluated in the emergency
department of a regional hospital with abdominal pain, syncope, irritability and severe
hypertension. Abdominal computed tomography revealed bilateral adrenal nodularity, including
a large left-sided mass measuring approximately 5 centimeters as well as 2 distinct subcentimeter
right-sided nodules (Figure 1). Elevated serum catecholamines confirmed apheochromocytoma.
Metaiodobenzylguanidine (MIBG) scan identified bilateral isotope uptake and genetic testing
revealed a TMEM 127 mutation. Antihypertensive catecholamine-blocking medication with both
alpha- and beta-blockers was initiated in preparation for surgical resection and continued until the
patient demonstrated mild orthostatic hypotension.
Given the desire to retain adequate cortical function, selective resection with a left
total adrenalectomy and a cortical-sparing right-sided adrenalectomy was planned via a
retroperitoneoscopic approach. The right-sided adrenal gland was
approached first, and after enucleation of the two small tumors, 5
milliliters of indocyanine green was injected intravenously. After
approximately 1 minute, a laparoscopic infrared camera (Novadaq
Pinpoint™, Bonita Springs, Florida) was placed into a trocar and a
bright green hue was identified in the remaining adrenal tissue (Figure
2). Once perfusion to the right-sided adrenal remnant was confirmed,
a left-sided total resection was performed via retroperitoneoscopic
approach.
The patient tolerated the procedure well and was discharged
home on postoperative day 1 with no steroid supplementation. A
cosyntropin stimulation test was performed with resulting cortisol
levels in the normal range. Post-operatively, he developed intermittent
symptoms of nausea, cramping, numbness and profound malaise.
These symptoms were ultimately felt to be linked to cigar smoking,
which appeared to produce an acute mineralocorticoid insufficiency
not identified by standard post-operative cortisol stimulation testing
[7]. A short course of fludrocortisone dosing resolved his symptoms.
He has since returned to normal activity, including distance running
and defensive trial work with no further side effects or medication
requirements.
Figure 1
Figure 1
Computed Tomography demonstrating 2 distinct sub-centimeter
nodules in the right adrenal gland.
Figure 2
Figure 2
Intraoperative imaging demonstrating bright green perfusion of
remnant adrenal tissue after resection of small pheochromocytoma.
Discussion
Use of ICG to effectively assess perfusion has been validated in
several surgical procedures, including gastrointestinal anastomoses
[8]. Likewise, ICG-confirmed perfusion has been demonstrated to
predict post-operative function in parathyroid glands after thyroid
surgery [9]. To our knowledge, this is the first report of using ICG in
such a manner for adrenal surgery.
This case exemplifies a method of intraoperative confirmation of
cortex perfusion that enhances minimally invasive cortical-sparing
adrenalectomy. The bright green hue of cortical remnant minimized
concern for adrenal insufficiency. This, in turn, may help guide
surgeons in proceeding with total adrenalectomy on the contralateral
side if necessary. Increased confidence in the viability of the adrenal
remnant may also facilitate withholding routine steroid hormone
supplementation post-operatively. Although the green hue confirmed
cortex preservation, perfusion itself does not directly ensure adequate
post-operative adrenal function. We feel this novel technique will be
particularly valuable for patients with bilateral adrenal nodules, as
well as those with genetic predispositions to developing multifocal
tumors, as is seen in the TMEM127 mutation. Working towards
the ultimate goal of minimizing post-surgical adrenal insufficiency,
further studies are needed to delineate the relationship between
intraoperative tissue perfusion and post-operative adrenal function.
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