RISK FACTORS FOR INTRAOPERATIVE AND POSTSURGICAL HYPERTENSIVE CRISIS IN PATIENTS WITH PHEOCHROMOCYTOMAS AND SYMPATHETIC PARAGANGLIOMAS: RESULTS FROM THE PHEO-RISK STUDY

Abstract

Objective: To identify presurgical and surgical risk factors for intraoperative and postoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas (PGLs) (PPGLs). Design and method: A retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals was performed. Results: A total of 296 surgeries performed in 289 patients with PPGLs (276 pheochromocytomas and 13 sympathetic PGL) were included. Laparoscopic PPGL resection was performed in 85.1% (n = 252) of the whole cohort. Alpha presurgical blockade was employed in 93.2% of the cases (n = 276) and beta-adrenergic in 53.4% (n = 158). Phenoxybenzamine was the treatment of choice in 126, doxazosin in 148 and the other 7 were treated with amlodipine and 4 with other antihypertensive drugs. Presurgical intravenous volume expansion was performed in 79% (n = 218) of the cases. In addition, 77.2% (n = 169/219) received oral sodium repletion. Hypertensive crisis occurred in 20.3% (n = 60) of the surgeries: intraoperative crisis in 56 and postoperative crisis in 6 cases. We identified as risk factors of hypertensive crisis (intraoperative and postoperative), a higher presurgical body mass index (BMI) (OR 1.16 per each kg/m2 increase CI 1.01-1.33) and HbA1c levels (OR 3.79 per each unit increase, CI 1.44-9.99), presurgical glucocorticoid therapy (OR 2.9, CI 1.08-7.59), higher presurgical SBP (OR 1.22 per each 10-mmHg increase, CI 1.03-1.45) and absence of oral sodium repletion (OR 2.3, CI 1.11-4.65). Patients with hypertensive crisis had a higher rate of intraoperative bleeding (18.3% vs. 3.4%, P<0.001), intraoperative hemodynamic instability (36.7% vs. 8.5%, P<0.001) and of intraoperative hypotensive episodes (41.7% vs. 11.4%, P<0.001) than those without hypertensive crisis. Hospital stay was longer in patients experienced hypertensive crisis (9.7 vs. 6.8 days, P = 0.007) than those without crisis Conclusions: Intraoperative and postoperative hypertensive crisis occurs in up to 20% of the PPGL resections. Patients with higher BMI, HbA1c levels, pretreated with glucocorticoid therapy before surgery, with higher presurgical SBP and who do not receive oral sodium repletion had a higher risk for developing hypertensive crisis during and after PPGL surgery.