Large adrenal incidentaloma in conjunction with perforated diverticulitis

Answer: C

Informed consent was obtained for a laparotomy, bowel resection, possible stoma, possible resection of the adrenal mass, and possible need for intensive care unit (ICU) management of hemodynamic instability. An arterial line was placed for invasive blood pressure monitoring and induction of general anesthesia was uneventful. Agents to rapidly control hypertensive crisis and arrhythmias were immediately available, with close attention to intraoperative fluid balance. Intraoperative findings included a large pelvic interloop abscess, 30 cm of sigmoid colon requiring resection, and two loops of small bowel densely adhered to the abscess cavity requiring resection due to transmural ischemia (remaining bowel shown in figure 2). The patient was hemodynamically stable throughout the initial bowel resections with minimal manipulation of the adrenal mass.

Request permission

The sigmoid and small bowel were initially left in discontinuity while the adrenal mass was assessed with HPB/endocrine surgery. As indicated by preoperative imaging, there was no invasion of other structures and the mass was not hypervascular except for a large draining vein (figure 3). A left adrenalectomy was completed in toto, and the patient remained hemodynamically stable. Two handsewn small bowel anastomoses were then created, and an end colostomy fashioned given the significant purulent contamination, the increased risk of postoperative hypotension, upstream anastomoses, and potential need for adjuvant therapy if the diagnosis was ACC. The anastomoses were performed at the end of the procedure in case the patient did develop hemodynamic instability, allowing for the bowel to be reassessed or anastomosed at a later operation if necessary. Drains were left in the pelvis and lesser sac.

Request permission

While waiting for diagnosis of the adrenal mass would be ideal, this patient required surgery for another urgent condition: complicated diverticulitis failing non-operative management.

Performing the adrenalectomy at this OR saved the patient another major surgery and allowed both procedures to be done using one incision. Definitively proceeding with the adrenalectomy was decided intraoperatively, as the patient tolerated manipulation of the mass without significant hemodynamic changes. If there were any complicating factors making it unsafe to proceed, the adrenalectomy could be abandoned and the patient reassessed for surgical management at a later time.

The patient recovered well postoperatively. His blood pressure fell to 110/70 several hours after surgery, however, increased back to a hypertensive range over the next few days. He had an ileus and a low volume pancreatic leak that resolved prior to discharge on postoperative day 9. The 24-hour urine metanephrines came back elevated at 2.5 (reference <1.3 µmol/day) and normetanephrines 44.3 (reference <4.3 µmol/day). Relevant final pathological findings revealed perforated diverticular disease (negative for malignancy) and a left pheochromocytoma.

Although perforated diverticulitis is a common presentation on acute care surgery services, pheochromocytomas are rare. They are even more rare to be found incidentally in the setting of another emergency general surgery presentation. Close multidisciplinary communication is recommended, as well as management in a tertiary center with ICU capability for aggressive hemodynamic intervention and management. Delaying surgery for definitive diagnosis of the adrenal mass would allow medical optimization; however, this is not always possible given the underlying emergency general surgery condition. We describe an approach to managing both conditions simultaneously, with alternatives described depending on the intraoperative findings and patient stability.