Doo et al.

BMC Surgery 2015, 15:11

http://www.biomedcentral.com/1471-2482/15/11

CASE REPORT Open Access

Hypertensive crisis caused by electrocauterization

of the adrenal gland during hepatectomy
A Ram Doo1†, Ji-Seon Son1†, Young-Jin Han1, Hee Chul Yu2 and Seonghoon Ko1*

Abstract
Background: Hypertensive crisis (i.e., systolic blood pressure over 300 mmHg) is very rare during operation except
pheochromocytoma, but it can be a fatal and embarrassing to surgeons and anesthesiologists. The right adrenal
gland can be electrocauterized during a right hemi-hepatectomy. We report a case of hypertensive crisis during
right hemi-hepatectomy in which the right adrenal gland was stimulated by monopolar electrocautery in a patient
with normal neuroendocrine function.
Case presentation: A 73-year-old man with hepatocellular carcinoma was scheduled to undergo right
hemi-hepatectomy. Three hours into the surgery, the patient’s blood pressure increased abruptly from 100/40 to
over 350/130 mmHg (the maximum measurement pressure of the monitor; 350 mmHg). The surgeon had cauterized
the right adrenal gland using monopolar electrocautery to separate the liver from the adrenal gland immediately prior
to the event. Approximately 3 minutes after suspending the operation, blood pressure returned to baseline levels. After
the event, the operation was successfully completed without any complication. Hormonal studies and iodine-123
meta-iodobenzylguanidine scintigraphy revealed no neuroendocrine tumor such as a pheochromocytoma.
Conclusion: Operations such as hepatectomy that stimulate the adrenal gland may lead to an unexpected
catecholamine surge and result in hypertensive crisis, even if neuroendocrine function of the adrenal gland is normal.
Keywords: Adrenal gland, Electrocautery, Hepatectomy, Hypertensive crisis

Background The adrenal gland stores and discharges catecholamines

Intraoperative hypertension is common during general into the blood stream by activation of the sympathetic
anesthesia, but it is usually well managed without serious nervous system. Surgical manipulation of the adrenal
complications. However, severe hypertension can cause gland, especially in the catecholamine producing tumors
cardio-cerebrovascular complications such as myocardial such as pheochromocytoma and paragangliomas, may
ischemia, arrhythmia, cerebral hemorrhage, or aortic dis- cause a catecholamine surge resulting in hypertensive
section during the perioperative period. Although control- crisis intraoperatively [3,6]. Furthermore, a case of severe
ling blood pressure has become easier to accomplish due hypertension caused by radiofrequency ablation of a meta-
to the development of anesthetic techniques and antihyper- static adrenal gland tumor with normal neuroendocrine
tensives, severe hypertension still remains a challenging function has been reported [7].
issue [1,2]. In particular, severe hypertension associated We report a case of abrupt and severe hypertension,
with secondary causes such as pheochromocytoma, car- with systolic blood pressures over 350 mmHg, during a
cinoid syndrome, or thyroid storm are even more difficult right hemi-hepatectomy in which the normal neuroen-
to manage during an operation [3-5]. docrine functioning adrenal gland was electrically stimu-
lated by monopolar electrocautery to separate the liver
from the adrenal gland.
* Correspondence: [email protected]
†
Equal contributors Case presentation
1
Department of Anesthesiology and Pain Medicine, Research Institute of A 73-year-old man with a 10-year history of hyperten-
Clinical Medicine, Chonbuk National University Medical School and Hospital,
Jeonju, Republic of Korea sion and diabetes mellitus presented with hepatocellular
Full list of author information is available at the end of the article carcinoma and complicated cyst in the liver. The patient
© 2015 Doo et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
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Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Doo et al. BMC Surgery 2015, 15:11 Page 2 of 3
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was scheduled to undergo right hemi-hepatectomy. homovanillic acid levels were 0.3 mg/day (normal refer-
Hypertension was controlled with an angiotensin II re- ence: 0–0.8 mg/day), 2.3 mg/day (0–8 mg/day) and
ceptor antagonist. Diabetic neuropathy was diagnosed 2.8 mg/day (1.4-8.8 mg/day), respectively. Iodine-123
in autonomic function test. Magnetic resonance im- meta-iodobenzylguanidine (123I-MIBG) scintigraphy re-
aging of the abdomen revealed a 2.6 × 2.6 sized hepato- vealed no neuroendocrine tumors such as pheochoro-
cellular carcinoma in segment VII and a 3.2 × 3.2 sized mocytoma. The postoperative course was uneventful,
atypical complicated cyst in segment VIII. The patient and the patient was discharged without any sequelae.
had no abnormal findings in the adrenal gland, spleen,
and pancreas, except for a simple renal cyst. Conclusion
Initial blood pressure was 150/80 mmHg and heart Severe hypertension is defined as an increase in systolic
rate was 65 beats per minute in the operating room. blood pressure ≥ 180 mmHg or diastolic blood pres-
Anesthesia was induced with thiopental 300 mg, rocur- sure ≥ 110 mmHg without end-organ damage. Hyperten-
onium 60 mg, and continuous infusion of remifentanil sive emergency is defined as rapidly evolving end-organ
(effect site concentration 3 ng/ml) using a target con- damage associated with hypertension of diastolic blood
trolled infusion system (Orchestra® Primea, Fresenius pressure > 120 mmHg [8]. Intraoperative hypertensive
vial, Brezins, France). After endotracheal intubation, emergency is rare, but it may cause critical complica-
anesthesia was maintained with 1-3% of sevoflurane and tions such as cerebral hemorrhage, acute congestive
remifentanil 2–4 ng/ml effect site concentration. The heart failure, myocardial infarction or aortic dissection.
left radial artery was cannulated for direct blood pressure Rapid reduction of blood pressure is required for better
monitoring using a pressure kit (Tru-Wave® Disposable patient outcomes during hypertensive emergency. In our
Pressure Transducer, Edwards Lifesciences, Irvine, USA). patient, systolic blood pressure was recorded over
The right subclavian vein was catheterized for fluid man- 350 mmHg. The arterial waveform was cut-off at
agement and central venous pressure monitoring. 350 mmHg, suggesting that the systolic blood pressure
From the start of the operation, blood pressures was more likely 380 mmHg according to arterial wave-
ranged from 100/40 to 150/70 mmHg with heart rates form. Although the systolic blood pressure of the pa-
55 to 70 beats per minute for three hours. Three hours tient abruptly peaked over 350 mmHg, this critical
into the surgery, systolic blood pressure abruptly in- moment lasted for only a very short period. The pa-
creased from 100 to over 350 mmHg, the maximum tient had no evidence of end organ damage and recov-
measurable pressure of the monitor incorporated with ered without complications.
anesthesia workstation (Zeus® anesthesia machine, Paix et al. [9] reported that factors causing intraopera-
Drager AG, Lübeck, Germany). Diastolic blood pressure tive hypertension include drug-related causes (59%), such
increased from 40 to 130 mmHg and heart rate increased as vasopressor administration by the anesthesiologist or
from 75 to 95 beats per minute. The anesthesiologist surgeon, excessive surgical stimulation or light anesthesia
checked the delivery system of the anesthetics, which (21%), equipment-related problems (13%), and miscellan-
was functioning normally. No drug was injected at that eous causes (7%). When considering the possible causes of
time. Anesthesia was deepened and labetalol 10 mg severe hypertension in the patient, no drug was adminis-
was administered. trated and anesthetic depth was sufficient for surgical
The operation was stopped immediately. Although a stimulation. The right adrenal gland was electrocauterized
vasopressor such as epinephrine was not injected in the just before the episode. Furthermore, this severe hyperten-
surgical field, the right adrenal gland had been cauter- sion quickly normalized within a few minutes once sur-
ized by monopolar electrocautery to separate the liver gical manipulation was suspended. In this setting, the
from the adrenal gland. Approximately 3 minutes after authors suspected a pheochromocytoma of the right ad-
suspending the operation, blood pressure and heart rate renal gland. Pheochromocytomas, neuroendocrine tu-
returned to baseline levels, which were maintained until mors that secrete catecholamines derived from adrenal
the end of the operation. After the event, the right liver chromaffin cells, causes secondary hypertension due to
was resected successfully without any complication. uncontrolled release of catecholamines including nor-
Postoperatively, the patient was transferred to the in- epinephrine and epinephrine [6,10]. Pheochromocyto-
tensive care unit for hemodynamic monitoring and mas usually manifest visible signs and symptoms such
neurologic examination. Neurologic examination per- as paroxysmal hypertension, headache, sweating, and
formed by a neurologist was within normal limits, and flushing, but some reports have suggested the possibility
the patient remained hemodynamically stable during re- of unexpectedly encountering a pheochromocytoma
covery. Hormonal studies were performed to investigate during general or spinal anesthesia for a surgery [11-13].
an undetected pheochromocytoma or paraganglioma. In this case, catecholamine metabolites including urine
However, urine metanephrine, vanillylmandelic acid, and metanephrine, vanillylmandelic acid, and homovanillic
Doo et al. BMC Surgery 2015, 15:11 Page 3 of 3
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acid, were within normal ranges and 123I-MIBG scintig- References

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Consent doi:10.1186/1471-2482-15-11
Cite this article as: Doo et al.: Hypertensive crisis caused by
Written informed consent was obtained from the patient electrocauterization of the adrenal gland during hepatectomy. BMC
for publication of this Case Report. A copy of the written Surgery 2015 15:11.
informed consent is available for review by the Editor of
this journal.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
ARD Performed anesthetic management and wrote the MS JSS Performed
anesthetic management and revised the MS YJH Performed anesthetic Submit your next manuscript to BioMed Central
management and collected the follow-up tests. HCY Performed the operation. and take full advantage of:
SK Performed anesthetic management and revised the MS critically. All authors
read and approved the final manuscript.
• Convenient online submission

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1
Department of Anesthesiology and Pain Medicine, Research Institute of • No space constraints or color figure charges
Clinical Medicine, Chonbuk National University Medical School and Hospital,
• Immediate publication on acceptance
Jeonju, Republic of Korea. 2Department of Surgery and Research Institute of
Clinical Medicine, Chonbuk National University Medical School and Hospital, • Inclusion in PubMed, CAS, Scopus and Google Scholar
Jeonju, Republic of Korea. • Research which is freely available for redistribution

Received: 16 August 2013 Accepted: 6 January 2015

Published: 14 February 2015 Submit your manuscript at
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