PGL is originated from pheochromaffin cells in the adrenal paravertebral ganglion. It was more common near the abdominal aorta that is accounting for about 10%-15%, and followed by the hilum of the kidney and the inferior vena cava[3]. It’s incidence is between 0.01% and 0.03%[4]. The PGL that have function can secrete large amounts of catecholamines which leading to persistent or paroxysmal hypertension and related signs in more than 95% of patients[5]. Headache, sweating, and palpitations are the typical triad of PGL. Some patients also experience orthostatic hypotension, pallor, tremor and even psychological symptoms including acute anxiety and panic attacks. In addition, large amounts of catecholamines can lead to constipation, intestinal dilatation, cholestasis, or gallstones and so on.
PGL is often presented as a slow-growing, painless mass in the clinical, so many PGL are detected by imaging during physical examination. CT and MRI are common imaging methods. On CT, benign PGL usually presents as round or quasi-round soft tissue masses with well-defined boundaries and uneven density[6]. In MRI, PGL usually presents hypointensity on T1WI, while T2WI and DWI show hyperintensity [7]. In addition, the content of catecholamines, normetanephrine, metaneph-rine in plasma in blood, and 131I-MIBG, PET-CT and genetic tests can be used as auxiliary examination methods.
At present, surgery is still the primary treatment for radical treatment of PGL, but sudden increase in intraoperative blood pressure and sharp drop in postoperative blood pressure may increase the risk of death. In order to reduce the incidence of surgical complications and mortality, preoperative medication should be adequately prepared to control blood pressure. At the same time, restoring blood volume is indispensable. Adrenergic block is usually administered at least 7 days before surgery with nonselective or selective alpha-receptor antagonists, along with a high-sodium diet and high fluid intake[6, 8]. Sudden reduction of catecholamines after surgery can lead to sudden drop in blood pressure, decreased circulation resistance and relatively insufficient circulating blood volume which can lead to severe hypotension. At this point, α-receptor agonists and fluid supplementation should be given to perform the symptomatic treatment.
In this case, the possibility of PGL was not considered duo to the patient's good blood pressure control with previous antihypertensive drugs. So preoperative preparation for the treatment of α-receptor antagonist was not performed on the patient during the perioperative period. The rapid release of catecholamines during the separation mass during surgery causes a sudden increase in blood pressure, which increases the risk of adverse outcomes such as a hypertensive crisis, acute left heart failure, pulmonary edema, cerebrovascular accident, or severe arrhythmias. After considering the possibility that the tumor was PGL, the surgeon suspended the operation. And the tumor was carefully and slowly removed after the anesthesiologist gave phentolamine to reduce and stabilize the blood pressure. The patient showed hypotension after tumor resection, and the anesthesiologist and the ICU physician gave norepinephrine dopamine, fluid rehydration and volume dilation symptomatic treatment. On the second day after the operation, the patient's blood pressure returned to the normal range. After the condition was stable, the patient was transferred to the general ward for observation and treatment. After the condition was stable, the patient was transferred to the general ward for observation and treatment.
Early detection, complete tumor resection and appropriate clinical follow-up are key management strategies for patients with PGL. The case report of the sigmoid mesangial PGL is helpful to improve the preoperative understanding, diagnosis and treatment of parageneuroma by clinicians. For patients diagnosed as space-occupying lesions accompanied by long-term persistent or intermittent hypertension, careful differentiation and diagnosis should be made in combination with the history and relevant examinations to reduce the misdiagnosis rate of the disease. The adequate preoperative preparation, intraoperative anesthesia monitoring and postoperative symptomatic supportive treatment should be done to reduce the risk of surgical treatment of this disease in the perioperative period.