Resection Of Pheochromocytoma Research Articles

Risk factors for prolonged hypotension in patients with pheochromocytoma undergoing laparoscopic adrenalectomy: a single-center retrospective study

Prolonged hypotension during pheochromocytoma resection is a significant complication. We sought to investigate the predictors of prolonged hypotension in patients with pheochromocytoma undergoing laparoscopic adrenalectomy (LA). Patients with pheochromocytoma who underwent LA between 2012 and 2015 were surveyed. Patients were considered to have prolonged hypotension if they had a mean arterial blood pressure <60 mmHg or required ≥30 consecutive minutes of catecholamine support intraoperatively. Among 123 patients, 54 (43.9%) developed prolonged hypotension requiring ≥30 consecutive minutes of catecholamine support. Compared with patients with nonprolonged hypotension, those with prolonged hypotension had higher levels of urinary norepinephrine (P = 0.011), epinephrine (P < 0.001), and dopamine (P = 0.019) preoperatively, and a higher incidence of vital organ injury postoperatively (P = 0.039). Multivariate logistic analysis showed that independent predictors for prolonged hypotension were multiples of the normal reference upper limit value of urinary epinephrine (odds ratio, 1.180; 95% confidence interval, 1.035–1.345) and dopamine (odds ratio, 4.375; 95% confidence interval, 1.207–15.855). The levels of preoperative urinary epinephrine and dopamine are clinical predictors for prolonged hypotension in patients with pheochromocytoma undergoing LA. Using these parameters, clinicians can assess and manage this patient population more effectively.

Risk factors of post-operative severe hyperlactatemia and lactic acidosis following laparoscopic resection for pheochromocytoma

Severe hyperlactatemia (SH)/lactic acidosis (LA) after laparoscopic resection of pheochromocytoma is an infrequently reported complication. The study aims to investigate the incidence of this complication and to determine the clinical risk factors. Patients who underwent laparoscopic resection for pheochromocytoma between 2011 and 2014 at Peking Union Medical College Hospital were enrolled. LA was defined as pH < 7.35, bicarbonate <20 mmol/L, and serum lactate ≥5 mmol/L; SH as lactate ≥5 mmol/L; and moderate hyperlactatemia (MH) as lactate 2.5–5.0 mmol/L without evidence of acidosis (pH > 7.35 and/or bicarbonate >20 mmol/L). Data concerning patient demographics, clinical history, and laboratory results were collected and statistical analyses were performed. Out of 145 patients, 59 (40.7%) developed post-operative hyperlactatemia. The incidences of MH and SH/LA were 25.5% and 15.2%, respectively. Multivariate analysis demonstrated that body mass index (BMI) (odds ratio [OR], 1.204; 95% confidence interval [CI], 1.016–1.426), 24-hour urine epinephrine concentration (OR, 1.012; 95% CI, 1.002–1.022), and tumor size (OR, 1.571; 95% CI, 1.102–2.240) were independent predictors of post-operative SH/LA. The data show that post-operative SH/LA is not a rare complication after pheochromocytoma resection and may be closely associated with higher BMI, larger tumor size, and higher levels of urine epinephrine.

Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review

ABSTRACTAimWe described the use of a hand-port assisted laparoscopic adrenalectomy for excising a large 10 cm vascular left adrenal pheochromocytoma. The useful technical tips and important pitfalls to avoid for a successful outcome are discussed in this article.IntroductionA 64-year-old man who was investigated for microalbuminuria was found to have a 10-cm left adrenal mass. Blood investigation and imaging confirmed it to be a pheochromocytoma.Case reportInitial mobilization of the adrenal mass was performed laparoscopically using two 5-mm ports in the epigastric. While dissecting the inferomedial pedicle, the aberrant adrenal vessel was injured and resulted in torrential bleeding. A gelport for hand assistance was inserted as a salvage approach for hemostasis.ConclusionHand-port assisted laparoscopic adrenalectomy is a very practical and easy-to-adopt technique that preserves the minimally invasive surgical advantages in patients with large adrenal masses.Clinical significance: We advocate the use of hand-assisted laparoscopic adrenalectomy technique for complex pheochromocytoma as an alternative for surgeons with vast experience in laparoscopic adrenalectomy.How to cite this articleLee DJK, Tan YP, Singaporewalla RM. Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review. World J Endoc Surg 2017;9(1):27-31.

Anesthesia for combined cesarean section and pheochromocytoma resection

Pheochromocytoma (PCC) is a rare cause of hypertension during pregnancy [1:54000 pregnancies]. Fetomaternal morbidity and mortality is about 58% if the diagnosis is missed. Administration of anesthesia to patients with PCC is challenging. Associated pregnancy adds to the problems. This is a case report of a patient having PCC diagnosed at 26 weeks of gestation. With medical management pregnancy was continued till 34 weeks. She was posted for cesarean section and resection of PCC. Patient underwent surgery lasting for 7 h due to inferior vena cava tear and had stormy intra as well as postoperative course. Mother and baby had uneventful recovery due to continuous invasive monitoring and a good teamwork, despite limited anesthetic resources.

Preoperative Levels of Catecholamines and Metanephrines and Intraoperative Hemodynamics of Patients Undergoing Pheochromocytoma and Paraganglioma Resection

To determine whether, despite pharmacologic adrenergic receptor blockade, higher preoperative levels of catecholamines and metanephrines (adrenergic activity) are associated with increased intraoperative complications. Records of patients undergoing paraganglioma and pheochromocytoma (PGL-PCC) resection from January 1, 2000, to June 30, 2015, were reviewed for preoperative levels of adrenergic activity, intraoperative variability in blood pressure and heart rate (range), and postoperative outcomes (hypotension requiring treatment). Patients were categorized by maximum preoperative adrenergic activity by greater degree of abnormality, categorized as normal (≤100%) or 101%-200%, 201%-500%, 501%-1000%, and ≥1001% of upper limit of normal. In total, 258 patients underwent intrathoracic or intra-abdominal PGL-PCC resection, of whom 240 received pretreatment with nonselective α1,2-blockers and 7 received pretreatment with selective α1-blockers. Intraoperative hemodynamic variability was greater with higher preoperative levels of adrenergic activity (P <.001). However, substantial variability was observed even with adrenergic activity levels within the normal range: systolic blood pressure (median [interquartile range], 75 [63-83] mm Hg) and heart rate (34 [26-43] beats per minute). Among patients with preoperative levels of adrenergic activity ≤500% vs ≥501% of the upper limit of normal, higher levels were associated with greater likelihood of postoperative diagnosis of volume overload (8% vs 2%, P = .04) and greater requirement for vasopressor infusions for hypotension (5% vs 1%, P = .01). Substantial intraoperative hemodynamic instability was encountered in patients with PGL-PCC resection, regardless of preoperative hormonal activity level; therefore, universal preoperative adrenergic receptor blockade should be recommended. Postoperative hypotension was rare and more prevalent in those with higher preoperative hormonal activity.

Laparoscopic Adrenalectomy for Removal of Unilateral Noninvasive Pheochromocytomas in 10 Dogs.

To report the surgical technique and outcome of dogs undergoing laparoscopic adrenalectomy for removal of unilateral noninvasive pheochromocytoma. Retrospective case series. Dogs with unilateral noninvasive adrenal tumors (n=10). Medical records of dogs that underwent laparoscopic adrenalectomy for histologically confirmed pheochromocytoma were reviewed. Dogs were positioned in lateral recumbency with the table tilted up to create a semi-sternal position. Three or 4 ports were used and dissection of the mass proceeded using a combination of laparoscopic instrumentation, bipolar vessel-sealing devices, and in some cases monopolar electrosurgical probes. Conversion rate, complications, surgical time, hospitalization time, and long-term follow-up were recorded. The procedure was completed without the need for conversion in 9 of 10 dogs. In 1 dog, hemorrhage obscured the visual field and conversion to an open approach was elected. In 5 cases, a 3-port approach was used, and in 5 cases, a 4th port was placed. Median surgical time was 105 minutes (range, 65-250). Intraoperative complications included 1 splenic laceration. Postoperatively, 1 dog developed gastric dilatation-volvulus. All dogs were discharged from the hospital. Median follow-up time was 16.0 months (range, 6.9-38.0). With careful case selection, laparoscopic adrenalectomy for resection of pheochromocytoma was feasible and could be performed efficiently by experienced laparoscopic surgeons.

Dexmedetomidine and magnesium sulphate as the anaesthetic adjuncts for intraoperative management for resection of pheochromocytoma - a case report

Pheochromocytoma, a tumour arising from adrenal medulla or other ganglia of sympathetic nervous system is notorious for secreting catecholamines. This form of the tumour is a major challenge to anaesthesia team as acute changes in blood pressure and heart rate usually occurs due to the release of catecholamines from the tumour site before tumour resection and cessation of the same after resection leading to hemodynamic instability intraoperatively. Better hemodynamic stability is desired during this form of tumour resection as acute fluctuations in blood pressure may lead to severe intracranial or cardiovascular events. Dexmedetomidine and magnesium sulphate were used as anaesthetic adjuncts to achieve good hemodynamic stability in a 35 years old female who presented with the history of headaches, palpitation and sweating on and off since last 2 years. The use of these agents allowed us to obtain an acceptable level of hemodynamic stability along with the help of other agents such as inotropes, vasopressors, vasodilators and antihypertensive agents. Dexmedetomidine and magnesium sulphate were used before resection of the tumour in our case and stopped thereafter. These agents may be an excellent option as anaesthetic adjuncts to obtain greater hemodynamic stability during resection of pheochromocytoma.

PP.25.14] RECURRENCE OR NEW TUMOURS AFTER COMPLETE RESECTION OF PHAEOCHROMOCYTOMAS AND PARAGANGLIOMAS

Objectives: To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco–abdomino–pelvic paraganglioma. Design: A systematic review and meta-analysis of published literature was performed. Methods: Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco–abdomino–pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis. Results: In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events. The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis. Conclusions: The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.

Cases of remission of psychosis following resection of pheochromocytoma or paraganglioma

The author previously proposed that schizophrenia has similar cytokine expression compared to melanoma, a neural crest cell tumor. One possible tumor model of schizophrenia includes anti-NMDA receptor encephalitis, a paraneoplastic syndrome. While examining the possible relationship of neural crest cell tumors to schizophrenia, the author found several case reports of psychosis resulting from pheochromocytomas and paragangliomas, types of neural crest cell tumors that secrete catecholamines. In most cases, surgical resection of the tumors resulted in remission of psychotic symptoms, and some remissions were associated with reduced levels of peripheral catecholamine levels. These reports suggest, first, that the differential diagnosis of psychosis with autonomic instability should include these tumors. Second, the cases raise a theoretical question as to how these tumors might cause psychosis. On one hand, the elevated peripheral catecholamines caused by these tumors generally agree with aspects of the dopamine hypothesis of schizophrenia although the mechanism of how peripheral dopamine would cause psychosis is unknown. On the other hand, these tumors could possibly secrete an unidentified antibody to a receptor similar to what is observed in anti-NMDA receptor encephalitis.

MANAGEMENT OF ENDOCRINE DISEASE: Recurrence or new tumors after complete resection of pheochromocytomas and paragangliomas: a systematic review and meta-analysis.

To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco-abdomino-pelvic paraganglioma. A systematic review and meta-analysis of published literature was performed. Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco-abdomino-pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis. In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events.The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis. The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.

496 Elevation of urinary metanephrine/normetanephrine and impairment of glucose tolerance predict the development of hypoglycemia after resection of pheochromocytoma

496 Elevation of urinary metanephrine/normetanephrine and impairment of glucose tolerance predict the development of hypoglycemia after resection of pheochromocytoma

Pheochromocytoma Resection: The Rule of Surgical Divergence

Pheochromocytoma Resection: The Rule of Surgical Divergence

Risk factors for hypertensive attack during pheochromocytoma resection.

PurposeWe aimed to retrospectively evaluate the risk factors for hypertensive attack during adrenalectomy in patients with pheochromocytoma. Despite the development of newer surgical and anesthetic techniques for the management of pheochromocytoma, intraoperative hypertensive attack continues to present a challenge.Materials and MethodsData from 53 patients diagnosed with pheochromocytoma at Kyungpook National Uriversity Medical Center between January 2000 and June 2012 were retrospectively analyzed. The subjects were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack. A univariate analysis was conducted, and a multivariate logistic regression analysis was also performed.ResultsIn the univariate analysis, systolic blood pressure at presentation, preoperative hormonal status (including epinephrine, norepinephrine, vanillylmandelic acid, and metanephrine levels in a 24-hour urine sample), tumor size, and postoperative systolic blood pressure were significantly associated with the development of hypertensive attack. In the multivariate analysis, preoperative epinephrine level and tumor size were independent factors that predicted hypertensive attack. The highest odds ratio for tumor size (2.169) was obtained at a cutoff value of 4.25 cm and the highest odds ratio for preoperative epinephrine (1.020) was obtained at a cutoff value of 166.3 µg/d.ConclusionsIn this study, a large tumor size and an elevated preoperative urinary epinephrine level were risk factors for intraoperative hypertensive attack in patients with pheochromocytoma.

Dexmedetomidine in anaesthesia for a high-risk case of pheochromocytoma with poor left ventricular function.

Sir, Anaesthesia for pheochromocytoma is challenging and stressful to the caregivers. Reports of a successful outcome in pheochromocytoma with limited cardiac reserve are few.[1] We present the management of one such case who underwent laparotomy and excision of pheochromocytoma. A 52-year-old male (weight = 53 kg) presented with paroxysmal headache, sweating, palpitation, chest pain, tremors and abdominal pain since 2 months. He was a smoker and was hypertensive for the past 3 years. He suffered anterior wall myocardial infarction 3 years back (thrombolysed) and coronary angiogram done revealed mild left anterior descending artery disease and with NYHA grade 3 then. His pulse rate (PR) was 120/min, regular, and blood pressure (BP) 214/140 mmHg. Haemoglobin was 11.8 g/dl, haematocrit 35.6, platelet count 471,000/mm3, urea 31 mg/dl, creatinine 1.7 mg/dl, blood sugar 86 mg/dl, blood group “O” negative and urinary vanillylmandelic acid 66 mg/24 h. Electrocardiogram showed left bundle branch block and left axis deviation [Figure 1a]. Echocardiography showed thin akinetic interventricular septum and anterior-wall, dilated left ventricle with apical aneurysm and left ventricular ejection fraction of 30%. Computed tomography revealed a 5.2 cm × 6.8 cm × 6.1 cm heterogeneously enhancing mass in the right suprarenal region with multiple non-enhancing necrotic areas and calcifications [Figure 1b]. Figure 1 (a) Electrocardiogram showing left bundle branch block and left axis deviation, (b) Computed tomography showing right suprarenal mass (5.2 cm × 6.8 cm × 6.1 cm) with multiple non-enhancing necrotic areas and small calcifications within ... He was started on oral prazosin 5 mg, clinidipine 10 mg and torsemide 10 mg twice daily, aspirin-atorvastatin 75/10 mg once daily and discharged after 1 week. On readmission 3 weeks later, his PR was 98/min, and BP 152/100 mmHg in sitting position and 142/100 mmHg on standing. Tablet atenolol 50 mg once daily was started and aspirin was stopped a week before surgery. He was fasted overnight and received oral diazepam 10 mg. A 14-gauge intravenous cannula was secured under local anaesthesia and intravenous fentanyl 50 µg was administered. A radial arterial cannula, epidural at T6-7 and central venous and pulmonary artery catheter, was secured via the right internal jugular vein. The mean pulmonary artery pressure (PAP) and wedge pressure were 29 mmHg and 24 mmHg, respectively. Initial cardiac output (CO) was 3.6 L/min. Bispectral index (BIS™) monitoring was commenced. Dexmedetomidine 50 µg was administered over 10 min followed by 0.5 µg/kg/h infusion which was stopped 30 min before extubation. Nitroglycerine infusion was started (5 µg/min) and continued until extubation. Epidural analgesia was initiated with 10 ml of bupivacaine 0.125% with fentanyl 50 μg and maintained with bupivacaine 0.125% and fentanyl 2 μg/ml infused at 4 ml/h intra- and post-operatively. Anaesthesia was induced with fentanyl 100 µg, propofol 40 mg and vecuronium 6 mg. Esmolol 20 mg was administered 90 s before endotracheal intubation. Anaesthesia was maintained (BIS = 35–50) with propofol, N2O, O2, vecuronium and dexmedetomidine infusion with controlled ventilation. Four boluses of phenylephrine 50 µg each of which three were administered 5–10 min post-intubation and one during tumour handling. Hypertension during tumour handling was managed with sodium nitroprusside, esmolol 100 mg and metoprolol 15 mg. Noradrenaline and dopamine infusions were started following ligation of the adrenal veins. The highest and lowest PRs were 130/min and 62/min and BPs were 219/94 mmHg and 75/40 mmHg respectively, during tumour handling. Mean PAP and CO showed fluctuations similar to the systemic BP and heart rate [Figure 2]. Arterial blood gas analysis performed intra-operatively showed no significant metabolic acidosis or electrolyte imbalance. Figure 2 Records of (a) intra-operative vital parameters showing fluctuations in haemodynamics and (b) cardiac output A total of 2.5 L crystalloid and 0.5 L starch was infused. Blood loss was 250 ml, urine output 750 ml and duration of anaesthesia was 4½ h. Trachea was extubated on the table. In the intensive-care-unit, invasive pressures and blood sugar were monitored, inotropes were tapered off, and he recovered well. Excessive catecholamine release, increased O2 demand, toxic effects and coronary spasm may be the cause of myocardial injury and infarction in pheochromocytoma. There is a correlation between intra-operative haemodynamic instability and plasma catecholamine levels.[2] There are a few reports of the use of dexmedetomidine as anaesthetic adjuvant for resection of pheochromocytoma.[3,4] Dexmedetomidine, a shorter-acting highly selective central α2-adrenoceptor agonist, attenuates the sympathetic response to intubation and emergence from anaesthesia,[5] reduces anaesthetic requirements and enhances post-operative analgesia. Considering the usual haemodynamic instability during pheochromocytoma resection, we think that dexmedetomidine contributed towards haemodynamic stability (systolic BP > 200 mmHg only once) in our patient by limiting the cardiac effects of catecholamines. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Oral Presentation I

ABSTRACT BACKGROUND AND AIMS Minimally invasive surgery of the adrenal gland is widespread. Although reports demonstrate the safety and feasibility of robot-assisted adrenalectomy, the objective benefits are still unclear, compared to those of conventional laparoscopy. Recently, robot-assisted approach has also become possible for pheochromocytoma resection. Since cardiopulmonary changes during robot-assisted dissection of the pheochromocytoma patient has not been studied in detail, we aimed to assess these concerns, compared to the routine laparoscopic technique. METHODS In this case-control study, 19 consecutive robot-assisted adrenal resections were compared with a control group consisting of 14 conventional laparoscopic adrenalectomy. Patient characteristics and intraoperative hemodynamic and respiratory parameters were assessed. Groups were compared using the χ2 test for categorical variables and Student's t-test for continuous variables. Significance was considered p &lt; 0.05. RESULTS The robot-assisted procedure was performed successfully in all patients, except one. The duration of the robot-assisted procedure, compared to the conventional laparoscopy group, was significantly longer (p &lt; 0.05). Intraoperative blood loss was significantly less in the robot-assisted group (p &lt; 0.05). Dissection of pheochromocytoma showed a significant difference between the groups, according to the incidence of intraoperative blood pressure fluctuations (p &lt; 0.05). The robot-assisted approach resulted in less incidents. Other hemodynamic and respiratory parameters did not differ between groups significantly. There were no perioperative deaths. Complication rates and postoperative hospital stays were not significantly different. CONCLUSION Robot-assisted adrenalectomy is a safe and technically feasible procedure for a pheochromocytoma patient. Robot-assisted resection of pheochromocytoma minimized the occurrence of intraoperative blood pressure fluctuations and blood loss.

Selective strategy for intensive monitoring after pheochromocytoma resection

Guidelines recommend 24-48 hours of intensive monitoring after resection of pheochromocytoma. However, many patients do not require it. The objective of this study is to identify preoperative risk factors associated with postoperative hemodynamic instability (HDI) so as to select patients who may not require intensive postoperative monitoring. Medical records of patients undergoing pheochromocytoma resection over a 12-year period were reviewed. Postoperative HDI was defined as systolic blood pressure of >200 or <90, heart rate >110 or <50 or needing active resuscitation. We included 41 patients; 49% had postoperative HDI but only 34% had HDI > 6 hours. Risk factors for HDI were preoperative mean arterial pressure (MAP) > 100 mm Hg (14% vs 45%), norepinephrine/normetanephrine levels >3x normal (44 vs 82%), and resection of another solid organ (0 vs 20%). Avoidance of planned postoperative monitoring for low-risk patients would have reduced estimated costs by 34%. Fewer than one-half of patients undergoing resection for pheochromocytoma benefit from intensive monitoring. High preoperative MAP, high norepinephrine/normetanephrine levels, and concomitant resection of another organ are risk factors for postoperative HDI. After a 6-hour interval of postoperative stability, selective rather than routine use of intensive monitoring may be an efficient strategy for monitoring lower risk patients.

Hemodynamic Stability During Pheochromocytoma Resection: Lessons Learned Over the Last Two Decades.

Ideal perioperative management of pheochromocytomas/paragangliomas (pheo) is a subject of debate and can be highly variable. The purpose of this study was to identify potential predictive factors of hemodynamic instability during pheo resection. A retrospective review of pheo resections from 1992 to 2013 was undertaken. Intraoperative hemodynamics, patient demographics, tumor characteristics, and perioperative management were examined. Postoperative intensive-care admission, myocardial infarction, stroke, and 30-day mortality were reviewed. Linear regression was used to analyze factors influencing intraoperative hemodynamics. During the 20-year study period, 100 patients underwent pheo resection. Postoperative morbidity and mortality was significantly reduced (p = 0.003) in the last 10 years of practice, and there was a trend towards greater morbidity and mortality with intraoperative hemodynamic instability (p = 0.06). The preoperative dose of phenoxybenzamine and the number of laparoscopic procedures has increased in the last decade [59 mg (95 % CI 32-108) to 106 mg (95 % CI 91-124), p = 0.008, and 27 vs. 54 %, p = 0.05, respectively]. Increased preoperative phenoxybenzamine dose was a significant predictor of improved intraoperative hemodynamic stability (p = 0.01). Lack of intraoperative magnesium use resulted in greater hemodynamic instability as preoperative systolic blood pressure increased (p = 0.002). Postoperative outcomes following pheo resection have improved over the last two decades. Preoperative α-blockade plays a significant role in improving intraoperative hemodynamics and post-op outcomes. Increased doses of phenoxybenzamine and utilization of laparoscopic approaches have likely contributed to improved outcomes in the last decade. Intraoperative magnesium use may provide protection against hemodynamic instability and warrants further study.

719 Can peri-operative parameters predict the need for post-operative inotropic support following surgical resection of pheochromocytomas?

719 Can peri-operative parameters predict the need for post-operative inotropic support following surgical resection of pheochromocytomas?

Pheochromocytoma resection: Current concepts in anesthetic management.

Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.

Hypoglycemia after resection of pheochromocytoma

Hypoglycemia after resection of pheochromocytoma is a rare and poorly understood complication thought to be secondary to rebound hyperinsulinemia and increased peripheral glucose uptake. We examined the incidence of this complication and aimed to identify predisposing risk factors. Patients who underwent pheochromocytoma resection between 1993 and 2013 at 2 large academic medical centers were identified retrospectively from a research patient data registry. The primary end point was postoperative hypoglycemia defined as blood glucose <55 mg/dL. A total of 213 patients underwent resection of pheochromocytoma for a total of 215 operations. Nine patients (4.2%) experienced postoperative hypoglycemia, with 8 of 9 episodes occurring in the first 24 hours. Patients who developed hypoglycemia were more likely to have greater preoperative 24-hour urinary metanephrine (4,726 vs 2,461 μg/24 h, P = .05) and experienced longer operative times (270 vs 142 minutes, P < .01) with larger neoplasms (7.6 vs 4.6 cm, P = .02). Postoperatively, patients with hypoglycemia required intensive care level monitoring more frequently (88.9% vs 34.5%, P < .01), but there was no difference in duration of hospital stay (5 vs 3 days, P = .10). Our data demonstrate that hypoglycemia is a rare complication after resection of pheochromocytoma and may be more common in patients with epinephrine-predominant neoplasms and longer operative times.