Neuroblastoma Resection

Catecholamines without a phaeochromocytoma - most of these tumors secrete catecholamines and urinary VMA and HVA are usually raised, but hemodynamic consequences are rare and preoperative alpha blockade is not routinely required. Do not run this as a phaeochromocytoma.

Pressure surges on handling - resting hypertension is uncommon, but squeezing the tumor can release catecholamines and spike the pressure mid-dissection. Have a short-acting agent drawn up and treat the surge, rather than deepening the anesthetic in a child who is bleeding.

Hypotension after tumor removal - circulating catecholamine levels fall the moment the tumor is out, and the pressure drops on top of whatever blood has been lost. Anticipate it at that step, keep volume ahead of the surgeon, and have a vasopressor ready rather than chasing it late.

VIP-secreting tumors - a minority secrete vasoactive intestinal peptide and cause persistent watery diarrhea, so the child arrives hypovolemic and hypokalemic. Send electrolytes and correct potassium and volume before induction, not after the first gas comes back.

Encasement of great vessels - this tumor invades and wraps the aorta, celiac axis and renal vessels instead of displacing them. Dissection is slow and picking tumor off a vessel is where sudden bleeding comes from, so stay ahead of losses through the quiet hours.

A small circulating volume - expect 20 to 50 mL/kg of loss, a quarter to two thirds of this child's blood volume, and it arrives in seconds. Have crossmatched blood in the room before incision and site two upper limb cannulae and an arterial line before the abdomen is opened.

Prior chemotherapy - most come to resection after chemotherapy, and anthracyclines carry dose-related cardiac toxicity. Read the cumulative dose off the oncology record and look at the echocardiogram before committing to a cardiac-depressant technique.

Marrow suppression - chemotherapy leaves many of these children anemic and thrombocytopenic on the day. Get a full blood count and clotting, and settle the neuraxial question against those numbers rather than assuming a catheter is available.

Modified rapid sequence induction - a bulky abdominal mass compresses the stomach and raises aspiration risk whatever the fasting time. Use a modified rapid sequence when the mass is large and palpable, then decompress the stomach once the airway is secure.

Thoracic extension of the incision - a high tumor needs the chest opened to reach above the diaphragm. That adds lung retraction, a chest drain and a bigger respiratory hit, so ask the surgeon before induction whether the chest is in the plan.

Epidural analgesia - a long transverse laparotomy in a small child is what a catheter is for, and it is the analgesic technique of choice here. Check the imaging for tumor tracking through the intervertebral foramina, and check the counts, before siting it.

Heat loss - hours of open abdomen in a 10 to 16 kg child cools fast, and hypothermia costs coagulation exactly when bleeding matters. Warm the room before the child arrives, warm every fluid, and run forced air wherever the drapes allow.

Emergence and handover - most are extubated in the operating room, but suction the gastric tube and confirm a leak around the tube first, because a long case with this much fluid buys airway edema. These children go to intensive care, where atelectasis is the early problem.

Neuroblastoma is an embryonal tumor of neural crest origin arising anywhere along the sympathetic chain, most often in the adrenal gland or the paraspinal retroperitoneum. It is a disease of the very young, from a few months old to school age and most commonly one to four years, and it is usually large by the time an abdominal mass is felt. Two features separate it from the other pediatric abdominal tumors. First, it invades and encases adjacent structures rather than pushing them aside, so it wraps the aorta, the celiac axis and the renal vessels and comes off them slowly. Second, it is often hormonally active: most produce catecholamines, reflected in raised urinary VMA and HVA, and a minority secrete vasoactive intestinal peptide and cause a secretory diarrhea.

Staging and planning - imaging defines tumor extent, vessel encasement and any extension through the intervertebral foramina. Very large tumors are usually biopsied first, with definitive resection following chemotherapy.

Incision - a generous transverse incision, extended into the chest when a high tumor needs control above the diaphragm.

Exposure - the bowel is mobilized and packed away to expose the retroperitoneum and the great vessels along the length of the tumor.

Dissection off the vessels - encased aorta, celiac axis and renal vessels are cleared piece by piece, and encasing tumor may be divided to preserve end-organ blood supply.

Resection - the tumor is taken with its adrenal gland where relevant, and regional nodes are sampled for staging.

Closure - the tumor bed is checked for bleeding and lymphatic leak, and the abdomen closed.

Ask what stage of the treatment you are anesthetizing for. A first operation is often a line and a biopsy in a child who has not been optimized, while the definitive resection comes months later after chemotherapy has changed the heart, the marrow and the size of the tumor. The two are not the same anesthetic and the preoperative work differs. For the resection, plan analgesia around a neuraxial catheter and keep patient-controlled or nurse-controlled opioid with regular acetaminophen as the fallback when counts or clotting rule it out.