Intraoperative Hemodynamic Instability Research Articles

Nulla Per Os (NPO) guidelines: time to revisit?

Preoperative fasting guidelines are generalized to elective procedures and usually do not distinguish between the ambulatory and inpatient setting. Prevalence of aspiration is low while prolonged preoperative fasting is common clinical reality. Recently, changes in preoperative fasting guidelines have been widely discussed. Rates of prolonged clear fluid fasting (>4 h) prior to surgery are reported in up to 80% of patients with mean fasting duration of up to 16 h and beyond. Prolonged fasting may result in adverse effects such as intraoperative hemodynamic instability, postoperative delirium, patient discomfort, and extended hospital length of stay. Liberal approaches allowing clear fluids up to 1 h prior to anesthesia or until premedication/call to the operating room have shown no increase in adverse events among children. Various anesthesia societies now encourage clear fluid intake up to 1 h prior to pediatric elective anesthesia. Similar reports in the adult cohort are scarce. Allowing sips of water until call to the operating room may help reducing prolonged preoperative fasting and improving patient comfort while keeping a flexibility in operating room schedule. The feasibility and safety of a liberal clear fluid fasting regimen among adults undergoing elective anesthesia needs to be evaluated in future studies.

S0935 Peroral Traction-Assisted Transanal NOTES Rectosigmoidectomy Followed by Intracorporeal Colorectal Anastomosis in a Live Porcine Model

INTRODUCTION: To introduce one novel technique of peroral external traction-assisted transanal NOTES sigmoidectomy followed by intracorporeal colorectal anastomosis by using only currently available and flexible endoscopic instrumentation in a live swine model. METHODS: Three female swine weighing 25–30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during operation. The procedure of trans-anal NOTES rectosigmoidectomy included 8 steps as follows: (1) rectosigmoid colon tattooed with India ink by submucosal injection; (2) creation of gastrostomy by directed submucosal tunneling; (3) peroral external traction using endoloop ligation; (4) creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) peroral external traction-assisted left side of the colon dissection; (6) trans-anal rectosigmoid specimen transection, an anvil was inserted into the proximal segment after a purse-string suture; (7) intracorporeal colorectal end-to-end anastomosis using a circular stapler with a single stapling technique; (8) closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed and the air-under-water leak test was done. RESULTS: The procedure was completed in all three animals, with the operation time ranging from 193 to 259 minutes. Neither intraoperative major complications nor hemodynamic instability occurred during operation. The length of the resected specimen ranged from 7cm to 13cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals. CONCLUSION: Peroral traction-assisted transanal NOTES sigmoidectomy followed by intracorporeal colorectal anastomosis is technically feasible and reproducible in an animal model, worthy of further improvement.Figure 1.: a The anterior wall of rectosigmoid colon tattooed with India ink by submucosal injection b An endoloop was placed over the anti-mesenteric side of one colonic segment for traction c Dissection of the inferior mesenteric vessels d The mobilized rectosigmoid colon was exteriorized and transected trans-anally.Figure 2.: a A purse-string suture was placed around the top of the open proximal colonic segment after an stapler anvil was inserted b An endoloop was used to ligate the lateral rectostomy by endoscopy c The anvil was approached to the stapler with the assistance of rigid grasper d Endoscopic observation of colorectal anastomotic tissue ring e. View via laparotomy of the lower abdomen and pelvis showing colorectal end-to-end anastomosis f The resected sigmoid colon specimen.

Modern possibilities of the urine steroid profile testing applying for the adrenocortical cancer diagnosis

BACKGROUND: X-ray diagnostics methods are important in detection of adrenal neoplasms malignant nature. The sensitivity and specificity of these methods are high enough. However the hormonal tests are also necessary to make an accurate clinical diagnosis with the high diagnostic efficiency of modern X-ray methods for adrenal tumors diagnosing. The urine steroid profile violations are detected with the adrenal glands various pathologies (primary hyperaldosteronism, hypercorticism, congenital hyperplasia of the adrenal cortex and adrenocortical cancer). Urine steroid profile tests in patients with diagnosed adrenal neoplasms are intended primarily to confirm or refute the adrenocortical cancer risk. At the same time in the medical community to date there are a number of disagreements accumulated regarding the accuracy and significance of the urine steroid profile tests.
 AIMS: The study aims to determine the urine steroid profile determination accuracy limits for the adrenocortical cancer diagnosis.
 MATERIALS AND METHODS: In total 62 samples were tested for urine steroid profile by gas chromatography-mass spectrometry. 58 patients had morphologically confirmed adrenal neoplasms. The study was blind prospective. To increase the study accuracy the 30 patients with adrenocortical adenomas (n = 17) and adrenocortical cancer (n = 13) were selected out of 58 tested persons. The sensitivity, specificity and accuracy of the urine steroid profile were determined in order to assess information content of such method for the adrenocortical carcinoma diagnosis.
 RESULTS: The possibilities of the urine steroid profile determining for the adrenocortical cancer diagnosis are estimated. The method sensitivity was 46.2%, specificity and accuracy were 70.6% and 60% respectively. The most reliable of adrenocortical cancer markers were tetrahydro-11-deoxycortisol and dehydroepiandrosterone (38.5% of cases) increasing concentrations.
 CONCLUSIONS: The present study demonstrates relatively low diagnostic efficacy of the urine steroid profile as a primary diagnostic method for adrenocortical cancer determining. This is especially evident in comparison with X-ray diagnostic methods. The technique interpretation is complex and accessible only to specialists with extremely high qualifications. Such fact complicates the distribution and widespread use in clinical practice of this testing method. At the same time the urine steroid profile determination in the future (after additional study) may be apply as an auxiliary diagnostic method which in some cases determines the treatment tactics for patients undergoing adrenocortical cancer adrenalectomy treatment.KEYWORDS: dPheochromocytoma; intraoperative hemodynamic instability; laparoscopic adrenalectomy; Endovascular embolization of preoperative; сase report.

The use of preoperative embolization as a method of preventing intraoperative hemodynamic disorders in a patient with pheochromocytoma

A clinical case of treating a patient with large pheochromocytoma complicated by acute cerebrovascular accident is presented. Its peculiarity is the implementation of preoperative embolization of the adrenal vessels in order to prevent intraoperative bleeding and intraoperative hemodynamic instability independent risk factors for perioperative complications and mortality. Such an approach allowed us to successfully perform laparoscopic adrenalectomy with minimal blood loss in conditions of stable hemodynamics.
 The treatment of patients with pheochromocytoma was discussed, special attention was paid to the category of patients with large tumors. The technical features of adrenalectomy in this group of patients, modern ideas about the safety of laparoscopic interventions are highlighted. The topics of the effectiveness of preoperative drug prevention of blood pressure fluctuations, as well as the use of endovascular methods in the treatment of patients with catecholamine-producing tumors are discussed.

Application of data mining for predicting hemodynamics instability during pheochromocytoma surgery

BackgroundSurgical resection of pheochromocytoma may lead to high risk factors for intraoperative hemodynamic instability (IHD), which can be life-threatening. This study aimed to investigate the risk factors that could predict IHD during pheochromocytoma surgery by data mining.MethodRelief-F was used to select the most important features. The accuracies of seven data mining models (CART, C4.5, C5.0, and C5.0 boosted), random forest algorithm, Naive Bayes and logistic regression were compared, the cross-validation, hold-out, and bootstrap methods were used in the validation phase. The accuracy of these models was calculated independently by dividing the training and the test sets. Receiver-Operating Characteristic curves were used to obtain the area under curve (AUC).ResultRandom forest had the highest AUC and accuracy values of 0.8636 and 0.8509, respectively. Then, we improved the random forest algorithm according to the classification of imbalanced data. Improved random forest model had the highest specificity and precision among all algorithms, including relatively higher sensitivity (recall) and the highest f1-score integrating recall and precision. The important attributes were body mass index, mean age, 24 h urine vanillylmandelic acid/upper normal limit value, tumor size and enhanced computed tomography difference.ConclusionsThe improved random forest algorithm may be useful in predicting IHD risk factors in pheochromocytoma surgery. Data mining technologies are being increasingly applied in clinical and medical decision-making, and provide continually expanding support for the diagnosis, treatment, and prevention of various diseases.

Predictors of hemodynamic instability in patients with pheochromocytoma and paraganglioma.

Background and ObjectivesIntraoperative hemodynamic instability is common in patients with pheochromocytoma and paraganglioma. The aim of this study was to identify the predictive risk factors of intraoperative hemodynamic instability.MethodsA total of 428 patients having elective resection of pheochromocytoma and/or paraganglioma at Peking Union Medical College Hospital between January 2014 and July 2019 were included. The association between preoperative parameters and the incidence of intraoperative hemodynamic instability were evaluated. Binary logistic regression was used to assess the predictive risk factors of hemodynamic instability.ResultsPatients with intraoperative hemodynamic instability were more prone to have elevated levels of norepinephrine and epinephrine. Binary Logistic regression showed the risk factors of hemodynamic instability were tumor size >5.0 cm (odds ratio [OR], 1.889; 95% confidence interval [CI], 1.243‐2.870; P = .003) and five‐fold increases of urine epinephrine (OR, 2.195; 95% CI, 1.242‐3.880; P = .007).ConclusionsIntraoperative hemodynamic instability is common despite adequate preoperative medical treatment. Tumor size and high level of urinary epinephrine are tumor‐related factors for intraoperative hemodynamic instability. Identifying these factors can help clinicians to manage patients more effectively and improve patients' outcomes.

Intraoperative hypotension is associated with increased postoperative complications in patients undergoing surgery for pheochromocytoma-paraganglioma: a retrospective cohort study

BackgroundDramatic hemodynamic fluctuation occurs frequently during surgery for pheochromocytoma or paraganglioma. However, the criteria of intraoperative hemodynamic instability vary widely, and most of them were defined arbitrarily but not according to patients’ prognosis. The objective was to analyze the relationship between different thresholds and durations of intraoperative hyper−/hypotension and the risk of postoperative complications in patients undergoing surgery for pheochromocytoma or paraganglioma.MethodsThis was a retrospective single-center cohort study performed in a tertiary care hospital from January 1, 2005 to December 31, 2017. Three hundred twenty-seven patients who underwent surgery for pheochromocytoma or paraganglioma, of which the diagnoses were confirmed by postoperative pathologic examination, were enrolled. Those who were less than 18 years, underwent surgery involving non-tumor organs, or had incomplete data were excluded. The primary endpoint was a composite of the occurrence of AKI or other complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between different thresholds and durations of intraoperative hyper−/hypotension and the development of postoperative complications.ResultsForty three (13.1%) patients developed complications during hospital stay after surgery. After adjusting for confounding factors, intraoperative hypotension, defined as systolic blood pressure (SBP) of ≤95 mmHg for ≥20 min (OR 3.211; 99% CI 1.081–9.536; P = 0.006), SBP of ≤90 mmHg for ≥20 min (OR 3.680; 98.8% CI 1.107–12.240; P = 0.006), SBP of ≤85 mmHg for ≥10 min (OR 3.975; 98.3% CI 1.321–11.961; P = 0.003), and SBP of ≤80 mmHg for ≥1 min (OR 3.465; 95% CI 1.484–8.093; P = 0.004), were associated with an increased risk of postoperative complications. On the other hand, intraoperative hypertension was not significantly associated with the development of postoperative complications.ConclusionsFor patients undergoing surgery for pheochromocytoma or paraganglioma, intraoperative hypotension is associated with increased postoperative complications; and the harmful effects are level- and duration-dependent. The effects of intraoperative hypertension need to be studied further.

MON-194 Phaeochromocytoma-Paraganglioma (PPGL): Post-Operative Hypotension Is a Vanishing Phenomenon

Background: Treatment of hemodynamic instability in patients with PPGL in the intra-and postoperative periods is challenging. Persistent postoperative hypotension is a common and serious complication, reportedly occurring in 30-60% of PPGL patients. This phenomenon reflects 1) high doses of pre-operative antihypertensive drugs; 2) low intravascular volume secondary to chronic catecholamine-induced vasoconstriction with pressure natriuresis; 3) the sudden drop in circulating catecholamines after surgery. It has been shown that tumor size and preoperative levels of catecholamines are directly related to the need for treatment with vasopressor agents in the early period after tumor removal. The aim of this study was to evaluate the efficacy and safety of the current perioperative treatment protocol for PPGL used in our Institute. Methods: We retrospectively reviewed the rate of hemodynamic instability and postoperative hypotension in relation to catecholamine levels, and the efficiency of preoperative pharmacological preparation in consecutive patients with PPGL treated between 2000-2019. Results: There were 39 patients (F/M 19/20; mean age 50.4 ±16.5 years) 33 of which had adrenal lesions and 6 had extra-adrenal tumors. Mean tumor size was 3.9 ±2.2 cm. Median metanephrine and normetanephrine levels were 5 and 10 fold the upper limit of the normal range respectively. All patients were treated with α-blockade (phenoxybenzamine-17, mean dose 60±38 mg/day; doxazosin-22; mean dose 9.6±6.1mg/day) along with β- blockade, and high sodium diet and IV saline 24 hours before the operation. The length of the preoperative preparation period was 3.4±2 weeks. Within the first 24-48 hours from surgery, no episodes of hypotension (<90 mmHg systolic pressure) were recorded. Mean systolic BP was 121 ±14 (range 95-150) with a mean diastolic BP of 70 ±11 (range 89-46). In contrast, intraoperative hypotension occurred in 22% of the patients; and BP surge occurred in 36% of patients, mostly during tumor manipulation. There were no differences between subjects with and without such BP rises/falls in terms of pre/post- surgical BP, catecholamine levels or type of medical treatment. Conclusion: In contrast with older literature and previous reports, the patients in our cohort did not experience postoperative hypotension. This is most likely due to tight BP control while avoiding pre-operative hypotension, and adequate volume control. We propose that proper preoperative management in the modern era can drastically minimize intraoperative hemodynamic instability and post-operative hypotension.

Perioperative management of paragangliomas and pheochromocytomas

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, characterized by a high morbidity rate due to catecholamine excess. These high levels are independent of physiologic stressors. For the diagnosis, a biochemical workup is paramount. The most widely used are plasma-free metanephrines and urinary fractionated metanephrines. Imaging studies should be initiated once the biochemical diagnosis is established. Evaluation of the patient with pheochromocytomas and paragangliomas must be done taking into account the leading causes of perioperative morbidity and mortality. The two primary interventions that have reduced perioperative mortality are alpha-adrenergic blockade and intravascular volume normalization. Another significant advance has been the establishment of laparoscopic surgery as the gold standard for the surgical approach. No anesthetic technique has been found to be superior to another. Intraoperative hemodynamic instability has been correlated with poorer outcomes; thus one of the main intraoperative goals is maintaining hemodynamic stability. Lower morbidity and almost zero mortality rates due to preoperative and intraoperative management improvements have led to a focus on the immediate and long-term postoperative care. Anual lifelong follow-up is recommended to detect recurrent disease.

Prevalence and risk factors of hemodynamic instability during endoscopic transsphenoidal pituitary surgery: a retrospective analysis

Objective: Intraoperative hemodynamic instability in patients undergoing endoscopic transsphenoidal pituitary surgery (ETSS) for pituitary adenoma may lead to significant complications. We aimed to investigate the prevalence of hemodynamic instability and its associated risk factors in these patients. Methods: This retrospective study included patients who underwent ETSS at Ankara Numune Training and Research Hospital between 14 January 2010 and 20 March 2014. Intraoperatively occurring episodes of bradycardia, hypotension, and hypertension were recorded. Distribution of hemodynamic instability was determined based on age groups, ASA class, tumor type, and anesthesia method. Results: A total of 323 patients met the study criteria. Mean age of the patients was 46.88 ± 13.91 years and 54.5% were female. Intraoperative bradycardia was detected in 137 patients (42.41%), hypotension in 57 patients (17.65%), and hypertension in five patients (1.55%). Hemodynamic instability occurred in all of the patients over the age of 51. Patients classified as ASA III were more likely to have hemodynamic instability than patients with ASA I and ASA II (p&amp;lt;0.05). All 18 patients who were transferred to intensive care unit were in the age group of 61 years and over. The rate of hemodynamic instability was higher in patients with non-functioning tumor compared to that in patients with functioning tumors. Conclusion: The rate of intraoperative hemodynamic instability in patients undergoing ETSS is higher in older patients than that in young patients. The elderly has multiple comorbidities and are more sensitive to anesthetic agents. This group needs a carefully planned anesthetic management during perioperative period.

Nomogram for predicting severe morbidity after pheochromocytoma surgery.

PurposeAlthough resection is the primary treatment strategy for pheochromocytoma, surgery is associated with a high risk of morbidity. At present, there is no nomogram for prediction of severe morbidity after pheochromocytoma surgery, thus the aim of the present study was to develop and validate a nomogram for prediction of severe morbidity after pheochromocytoma surgery.MethodsThe development cohort consisted of 262 patients who underwent unilateral laparoscopic or open pheochromocytoma surgery at our center between 1 January 2007 and 31 December 2016. The patients’ clinicopathological characters were recorded. The least absolute shrinkage and selection operator (LASSO) binary logistic regression model was used for data dimension reduction and feature selection, then multivariable logistic regression analysis was used to develop the predictive model. An independent validation cohort consisted of 128 consecutive patients from 1 January 2017 and 31 December 2018. The performance of the predictive model was assessed in regards to discrimination, calibration, and clinical usefulness.ResultsPredictors of this model included sex, BMI, coronary heart disease, arrhythmia, tumor size, intraoperative hemodynamic instability, and surgical duration. For the validation cohort, the model showed good discrimination with an AUROC of 0.818 (95% CI, 0.745, 0.891) and good calibration (Unreliability test, P = 0.440). Decision curve analysis demonstrated that the model was also clinically useful.ConclusionsA nomogram was developed to facilitate the individualized prediction of severe morbidity after pheochromocytoma surgery and may help to improve the perioperative strategy and treatment outcome.

COMBINED APPROACH TO SURGICAL TREATMENT OF ENDOMETRIAL CANCER IN PATIENTS WITH MORBID OBESITY

The purpose of the study was to evaluate a combined approach to surgical treatment of patients with morbid obesity. Material and methods . Between January 2017 and December 2018, 26 women with stage I endometrial cancer underwent laparoscopic gysterectomy in combination with panniculectomy. Results . No episodes of intraoperative hemodynamic instability, significant hypoxemia or hypercapnia were reported. The average blood loss was 236.4 ± 114.8 ml; surgery time: 264.2 ± 57.3 min; mass of the removed flap: 10.52 ± 6.5 kg; length of hospital stay: 11.2 ± 3.7 days. There was no delay in the start of adjuvant radiation therapy. Conclusion. Surgical treatment of endometrial cancer patients with morbid obesity presents significant technical challenges. The choice of surgical access in such cases may depend not on the stage and prevalence of the tumor, but on the constitutional characteristics of the patients. Sometimes surgeons can refuse to perform surgery for such patients and offer them an alternative treatment. Classical laparotomic access is associated with the maximum risk of perioperative complications. Laparoscopic techniques have technical limitations associated, for example, with the length of trocars and surgical instruments. Robotic surgery is considered generally safe, but due to its low availability, it is limited only to large clinical centers . The combined approach to surgical treatment of endometrial cancer patients with morbid obesity is the most effective surgical modality for these patients.

A rare case of pancreatitis following scoliosis correction

Acute pancreatitis following major spinal surgery is a rare potential complication. Several mechanisms such as positioning, intraoperative haemodynamic instability, mechanical compression and prolonged surgery can contribute to it. This should be suspected in a patient presenting with gastrointestinal symptoms, signs and raised serum amylase or lipase.Our case report is of a young patient with low BMI developing postoperative acute pancreatitis after single stage correction of right thoracic idiopathic scoliosis at National Hospital of Sri Lanka. Early identification of complications plays a key role in preventing severe morbidity after scoliosis surgery. When symptoms and signs are suggestive of abdominal complications, biochemical markers have to be analyzed for prompt diagnosis. Multidisciplinary approach and imaging are further steps in the differential diagnosis and management of this rare complication.

Intra-Operative Hypotension is a Risk Factor for Post-operative Silent Brain Ischaemia in Patients With Pre-operative Hypertension Undergoing Carotid Endarterectomy

Intra-operative haemodynamic instability during carotid endarterectomy (CEA) has been associated with an increased risk of procedural stroke. Diffusion weighted imaging (DWI) lesions have been proposed as a surrogate marker for peri-operative silent cerebral ischaemia. This study aimed to investigate the relationship between peri-operative blood pressure (BP) and presence of post-operative DWI lesions in patients undergoing CEA. A retrospective analysis was performed based on patients with symptomatic CEA included in the MRI substudy of the International Carotid Stenting Study. Relative intra-operative hypotension was defined as a decrease of intra-operative systolic BP≥20% compared with pre-operative ('baseline') BP, absolute hypotension was defined as a drop in systolic BP<80mmHg. The primary endpoint was the presence of any new DWI lesions on post-operative MRI (DWI positive). The occurrence and duration of intra-operative hypotension was compared between DWI positive and DWI negative patients as was the magnitude of the difference between pre- and intra-operative BP. Fifty-five patients with symptomatic CEA were included, of whom eight were DWI positive. DWI positive patients had a significantly higher baseline systolic (186±31 vs. 158±27mmHg, p=.011) and diastolic BP (95±15 vs. 84±13mmHg, p=.046) compared with DWI negative patients. Other pre-operative characteristics did not differ. Relative intra-operative hypotension compared with baseline occurred in 53/55 patients (median duration 34min; range 0-174). Duration of hypotension did not differ significantly between the groups (p=.088). Mean systolic intra-operative BP compared with baseline revealed a larger drop in BP (-37±29mmHg) in DWI positive compared with DWI negative patients (-14±26mmHg, p=.024). Absolute intra-operative systolic BP values did not differ between the groups. In this exploratory study, high pre-operative BP and a larger drop of intra-operative BP were associated with peri-procedural cerebral ischaemia as documented with DWI. These results call for confirmation in an adequately sized prospective study, as they suggest important consequences for peri-operative haemodynamic management in carotid revascularisation.

International multicentre review of perioperative management and outcome for catecholamine-producing tumours.

Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

Development and validation of a clinical model to predict intraoperative hemodynamic instability in patients with pheochromocytomas surgery.

Although currently the primary strategy for the treatment of pheochromocytomas is surgery, it is associated with a high risk of intraoperative hemodynamic instability (IHD), even with adequate preoperative medical preparation, which may result in life-threatening situations. The aim of this study was to develop and validate a nomogram for preoperative prediction of IHD related to pheochromocytoma surgery. The development cohort consisted of 283 patients with pheochromocytoma who underwent unilateral laparoscopic or open adrenaletomy at our center between January 1, 2007 and December 31, 2016. The clinicopathological characteristics of each patient were recorded. The least absolute shrinkage and selection operator binary logistic regression model was used for data dimension reduction and feature selection, while multivariable logistic regression analysis was used to develop the prediction model. An independent cohort consisting of 119 consecutive patients from January 1, 2017 to December 31, 2018 was used for validation. The performance of the prediction model was assessed in regards to discrimination, calibration, and clinical usefulness. The predictors of this model included body mass index, coronary heart disease, tumor size, and preoperative use of crystal/colloid fluid. For the validation cohort, the model showed good discrimination with an area under the receiver operating characteristic of 0.767 (95% CI, 0.667-0.857) and good calibration (unreliability test, p = 0.852; Hosmer-Lemeshow test, p = 0.9309). Decision curve analysis demonstrated that the model was clinically useful. This nomogram to facilitate preoperative individualized prediction of IHD in patients with pheochromocytoma may help to improve the perioperative strategy and treatment outcome.

The Duration of Preoperative Administration of Single α-Receptor Blocker Phenoxybenzamine before Adrenalectomy for Pheochromocytoma: 18 Years of Clinical Experience from Nationwide High-Volume Center.

Purpose There is no consensus for the optimum duration of preoperative administration of phenoxybenzamine (PXB) before adrenalectomy for pheochromocytoma. The aim of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of PXB administration. Methods In total, 102 patients managed preoperatively with single α-receptor blocker phenoxybenzamine were enrolled from 469 consecutive patients diagnosed histologically with pheochromocytoma. The patients received surgical treatment in the Department of Urology, Peking University First Hospital, between January 2001 and July 2018. All patients were divided into three groups: Group A (<14 d), Group B (14–30 d), and Group C (>30 d). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared among the three groups. Results These patients included 47 men and 55 women, with an average age of 43 years at the time of surgery. Clinical characteristics, except the status of preoperative biochemical tests (24 hr urine fractioned catecholamine or plasma-fractioned catecholamine) (p=0.020), preoperative hemodynamics, and medicine management and surgical approaches, in the three groups were comparable. Multivariate analyses demonstrated that the size of the tumor (p=0.034) was an independent risk factor for intraoperative hemodynamic instability. Among the three groups, we found no significant difference in intraoperative hemodynamics and postoperative outcomes. Conclusion The data from the current study indicated that the preoperative management of pheochromocytoma with single α-receptor blocker PXB for more than 2 weeks, after the final dose adjustment, could not further reduce the risk of intraoperative hemodynamic instability or postoperative complications. Thus, our study supports that 14 days would be enough for the duration of preoperative management of pheochromocytoma with single α-receptor blocker PXB in final dose.

Clinical characteristics during the perioperative period of pheochromocytomas in the elderly

Objective To investigate the clinical characteristics during the perioperative period of pheochromocytoma in patients aged 60 years and over. Methods Data of age, sex, tumor size, anesthesia time, intraoperative bleeding volume, intraoperative blood pressure, complications and hospitalization time from patients with pheochromocytoma in our hospital treated by the retroperitoneal laparoscopic adrenalectomy from January 2008 to October 2018 were retrospectively analyzed.The relationships of age with the intraoperative hemodynamic instability and postoperative complications were analyzed. Results A total of 203 patients with pheochromocytoma met the inclusion criteria were enrolled.Age over 60 years(OR1.771, 95%CI=1.015-3.089, P=0.044)was an independent risk factor for intraoperative hemodynamic instability. Conclusions Laparoscopic retroperitoneal adrenalectomy is a safe surgical method for pheochromocytoma patients aged 60 years and over.For elderly patients with pheochromocytoma, especially those with a tumor diameter of more than 5 cm, special attention should be paid to the prevention of intraoperative hypertension crisis. Key words: Pheochromocytoma; Perioperative period

Efficacy of α-Blockers on Hemodynamic Control during Pheochromocytoma Resection: A Randomized Controlled Trial.

ContextPretreatment with α-adrenergic receptor blockers is recommended to prevent hemodynamic instability during resection of a pheochromocytoma or sympathetic paraganglioma (PPGL).ObjectiveTo determine which type of α-adrenergic receptor blocker provides the best efficacy.DesignRandomized controlled open-label trial (PRESCRIPT; ClinicalTrials.gov NCT01379898)SettingMulticenter study including 9 centers in The Netherlands.Patients134 patients with nonmetastatic PPGL.InterventionPhenoxybenzamine or doxazosin starting 2 to 3 weeks before surgery using a blood pressure targeted titration schedule. Intraoperative hemodynamic management was standardized.Main Outcome MeasuresPrimary efficacy endpoint was the cumulative intraoperative time outside the blood pressure target range (ie, SBP >160 mmHg or MAP <60 mmHg) expressed as a percentage of total surgical procedure time. Secondary efficacy endpoint was the value on a hemodynamic instability score.ResultsMedian cumulative time outside blood pressure targets was 11.1% (interquartile range [IQR]: 4.3–20.6] in the phenoxybenzamine group compared to 12.2% (5.3–20.2)] in the doxazosin group (P = .75, r = 0.03). The hemodynamic instability score was 38.0 (28.8–58.0) and 50.0 (35.3–63.8) in the phenoxybenzamine and doxazosin group, respectively (P = .02, r = 0.20). The 30-day cardiovascular complication rate was 8.8% and 6.9% in the phenoxybenzamine and doxazosin group, respectively (P = .68). There was no mortality after 30 days.ConclusionsThe duration of blood pressure outside the target range during resection of a PPGL was not different after preoperative treatment with either phenoxybenzamine or doxazosin. Phenoxybenzamine was more effective in preventing intraoperative hemodynamic instability, but it could not be established whether this was associated with a better clinical outcome.

Intraoperative Hypertensive Urgency and Hemodynamic Instability during Microvascular Decompression for Trigeminal Neuralgia

Abstract Objective To evaluate the factors predisposing to rare events of intraoperative hypertensive urgency during microvascular decompression (MVD) for trigeminal neuralgia (TGN) and outcome of MVD on long-term blood pressure (BP) control. Patients and Methods Total 54 consecutive TGN patients who failed medical management in two institutions from January 2012 to January 2017 were included in the study. MVD of TGN was done through retromastoid suboccipital craniotomy. Intraoperative “hypertensive urgency” and hemodynamic instability were observed in two patients with BP shooting up to &gt; 180/120 mm Hg, which was controlled. Postoperative period was uneventful and patients were discharged. Patients were reviewed in the OPD clinic at 1 and 6 months after discharge and their clinical status was evaluated. The collected data were analyzed retrospectively. Results Of the 54 patients, 32 (59.26%) were male and 22 (40.74%) were female. Twenty-five (46.30%) patients were hypertensive, out of whom 19 (76%) were in Joint National Committee (JNC) 7 stage 1 and 6 (24%) were in stage 2. Two (3.70%) patients had an intraoperative hypertensive crisis, and in both the patients, the offending vessel was an atheromatous ectatic vertebrobasilar artery. Postoperative long-term BP control or normalization was observed in one of the two patients with a single antihypertensive drug who was on three antihypertensive drugs preoperatively. Conclusion Intraoperative hypertensive urgency is a medical emergency that can be encountered in MVD surgery for TGN, and an ectatic atheromatous vertebrobasilar arterial compression on the nerve is notorious for predisposing to hypertensive urgency. Postoperative long-term BP control in hypertensive patients is not feasible after MVD in this study, which needs further detailed analysis.