Change in Perioperative Management of 14 Consecutive Patients with Pheochromocytoma – Is Alpha Blockade Still Necessary?

Abstract

Abstract Background Pretreatment with alpha-blockers before surgery for pheochromocytoma or paraganglioma is considered the gold standard and is recommended in the 2014 Endocrine Consensus Guidelines. Meanwhile, there is evidence at specialized clinics that alpha blockade does not provide any benefit preoperatively. Due to an index case with severe side effects from alpha blockade and the recent evidence, we have refrained from preoperative alpha blockade before planned surgery for a catecholamine-secreting tumor in our hospital since 2018. Aims The aim of the study is to evaluate the outcome after change of perioperative management. Methods A retrospective analysis of patients was performed using data prospectively collected in the Eurocrine quality registry of all patients with pheochromocytomas and paragangliomas operated on at our hospital from 2018 to 2022. Results During this period, 14 patients with pheochromocytomas (n=10) and paragangliomas (n=4) underwent surgery. 21% (3 of 14) patients were pretreated by alpha blockers for 7-14 days, 79% (11/14) patients did not receive preoperative alpha blockade after interdisciplinary discussion. All patients with alpha blockade had significant orthostasis symptoms, and 2 patients experienced syncope despite adequate volume delivery. One of these patients suffered a traumatic brain injury after a fall. Intraoperatively, 50% (7 of 14) of the patients experienced a hypertensive crisis >200 mmHg, which was resolved with rapid anesthetic intervention. The 3 patients with alpha blockade had prolonged hypotension postoperatively, so catecholamines had to be administered after extubation in 2 patients. No relevant complications occurred. Conclusions In our hospital, no relevant complications occurred despite omission of alpha blockade for pretreatment in pheochromocytomas and paragangliomas. However, the number of cases in these rare tumors is low, nevertheless this seems to be feasible in a good interdisciplinary setting.