Surgery For Pheochromocytoma Research Articles

Changes in blood pressure, blood sugar, and quality of life in patients undergoing pheochromocytoma surgery: a prospective cohort study.

Introduction:Pheochromocytoma surgery is associated with significant hemodynamic and metabolic changes that require post-operative monitoring. We prospectively evaluated the trends of blood pressure, blood sugar, body mass index (BMI), and quality of life (QoL) changes in a cohort of patients undergoing pheochromocytoma surgery to determine the minimum duration of monitoring and assess factors that could predict these changes.Materials and Methods:Consecutive patients undergoing surgery for pheochromocytoma over a 20-month period were included in this ethics review board-approved, prospective cohort study. Blood pressure and sugar levels were serially monitored using a fixed protocol in the perioperative period and subsequently at 3 months after surgery. BMI and QoL (using World Health Organization Quality of Life [WHOQOL-BREF] questionnaire) were recorded at baseline and 3 months. Changes were compared and assessed for the predictive factors.Results:Twenty-six patients undergoing 31 procedures were included in the study of whom 8 (30%) developed hypotension and 4 (15%) developed hypoglycemia after surgery. All hypotension episodes occurred within 6 hours of surgery. However, while 3 of the 4 patients who developed hypoglycemia manifest in the first 4 h after surgery, one occurred after 12 h. Occurrence of hypotension correlated with preoperative 24-h urinary vanillylmandelic acid (VMA) levels (P = 0.02) and the total daily dose of prazosin (P = 0.04). Out of 21 hypertensive patients, 7 (33%) had persistent hypertension (HTN) at 3 months and this was associated with age (P = 0.04) and diabetes mellitus (DM) at presentation (P = 0.04). Among six diabetic patients, 1 (16%) had persistent DM. There was significant increase in the BMI (P < 0.0001) and in WHOQOL-BREF scores postoperatively.Conclusions:Hypotension occurs in 30% patients and hypoglycemia in 15% after pheochromocytoma surgery. Hypotension occurs immediately but hypoglycemia may manifest upto 12h after surgery. Older, diabetic patients are more likely to have persistent HTN. Surgery results in increase in BMI and improvement in QoL.

Risk factors for postoperative cardiovascular morbidity after pheochromocytoma surgery: a large single center retrospective analysis.

Surgical resection is the primary treatment strategy for pheochromocytoma; however, it carries a high risk of morbidity and mortality, especially with respect to cardiovascular complications, which is the most common kinds of morbidity. The risk factors for morbidity remain unclear and require further exploration, moreover no studies focus on risk factors for cardiovascular morbidity. Herein we identified the risk factors for cardiovascular morbidity after pheochromocytoma surgery in Chinese patients. We retrospectively reviewed 262 patients who underwent unilateral surgical resection of pheochromocytoma at our center between 1 January 2007 and 31 December 2016. Patient demographics and extensive perioperative data were recorded and evaluated. Adjusted odds ratios and 95% confidence intervals were determined by multivariate logistic regression. Cut-off values and the area under the curve for continuous risk factors were calculated based on receiver operating characteristic curve analysis. A p-value <0.05 was considered statistically significant. Of the 262 patients, 63 (24.0%) had cardiovascular morbidity. The independent risk factors for cardiovascular morbidity were low body mass index, large radiographic tumor size, coronary heart disease, no preoperative crystal/colloid administration, and intraoperative hemodynamic instability; the corresponding odds ratio were 0.762 (p < 0.001), 1.208 (p = 0.010), 2.378 (p = 0.012), 2.720 (p = 0.011), and 4.764 (p = 0.001), respectively. The optimal cut-off values for body mass index and radiographic tumor size were 24.59 kg/m2 and 6.05 cm. We found that cardiovascular morbidity is common in patients after pheochromocytoma surgery. We identified five independent risk factors for cardiovascular morbidity. Identification of these risk factors may help to improve treatment strategies.

Risk factors for postoperative severe morbidity after pheochromocytoma surgery: A single center retrospective analysis of 262 patients

PurposeSurgical resection is the primary treatment strategy for pheochromocytoma; however, it carries a high risk of morbidity and mortality. The risk factors for severe morbidity remain unclear and require further exploration. We aimed to identify the risk factors for severe morbidity after pheochromocytoma surgery in Chinese patients. MethodsWe retrospectively reviewed 262 patients who underwent unilateral laparoscopic or open pheochromocytoma surgery at our center between January 1, 2007 and December 31, 2016. Patient demographics, as well as extensive perioperative data were recorded. Adjusted odds ratios and 95% confidence intervals were determined by multivariate binary logistic regression. Cutoff values and the area under the curve for continuous risk factors were calculated through receiver operating characteristic curve analysis. A P < 0.05 was considered statistically significant. ResultsOf the 262 patients, 78 (29.8%) had severe morbidity. The independent risk factors for severe morbidity were female sex, lower body mass index, coronary heart disease, longer duration of surgery, and intraoperative hemodynamic instability, with odds ratios of 2.624 (P = 0.003), 0.780 (P < 0.001), 2.098, (P = 0.024), 1.005 (P = 0.031), and 2.920 (P = 0.005). The optimal cut off values for body mass index and duration of surgery were 24.25 kg/m2 and 203 min. ConclusionsSevere morbidity is common in patients after pheochromocytoma surgery. We identified five independent risk factors for severe morbidity: female sex, lower body mass index, coronary heart disease, longer duration of surgery, and intraoperative hemodynamic instability. Identification of these risk factors may help to improve perioperative strategy.

Risk factors of postoperative complications after laparoscopic surgery for pheochromocytoma

Objective: To investigate the effects of intraoperative hemodynamic instability on postoperative complications of laparoscopic surgery for pheochromocytoma. Methods: It was a retrospective cohort study. According to inclusion/exclusion criteria, adult patients underwent laparoscopic surgery for pheochromocytoma from January 2005 to December 2017 in Peking University First Hospital were enrolled in this study. Eligible patients were divided into two groups by evidence of postoperative complications to find out the effects of intraoperative hemodynamic instability and its' effects on other prognostic indices. The normally distributed continuous variables were compared between two groups by Student's t test, Mann-Whitney U test were used for the comparison for non-normally distributed continuous variables and χ(2) test for categorical variables. Results: A total of 198 patients were finally enrolled in this study, including 87 males and 111 females with an average age of (47±15) years. Postoperative complications occurred in 17 patients with an incidence of 8.6%, and intraoperative hemodynamic instability occurred in 45 patients (22.7%). It was found that history of stroke[odds ratio (OR)=13.387, 95% confidence interval (CI): 2.284-78.460, P=0.004], intraoperative hemodynamic instability (OR=3.351, 95%CI: 1.119-10.039, P=0.031) and intraoperative positive fluid balance (for each additional 100 ml) (OR=1.087, 95%CI: 1.031-1.146, P=0.002)were the independent risk factors of postoperative complications of laparoscopic surgery for pheochromocytoma. Furthermore, more postoperative complications, higher rate of admitting to ICU and longer hospital stay was found in patients with hemodynamic instability. Conclusion: Intraoperative hemodynamic instability is an independent risk factor for postoperative complications of laparoscopic surgery in patients with pheochromocytoma, and it associates with more postoperative complications and higher rate of admitting to ICU.

VE42 - Robot-assisted surgery for huge adrenal pheochromocytoma

VE42 - Robot-assisted surgery for huge adrenal pheochromocytoma

Clevidipine for hypertension treatment in pheochromocytoma surgery

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery.

MP03-19 BLOOD PRESSURE AND SUGAR TRENDS AND QUALITY OF LIFE IN PATIENTS UNDERGOING PHEOCHROMOCYTOMA SURGERY

You have accessJournal of UrologyAdrenal1 Apr 2018MP03-19 BLOOD PRESSURE AND SUGAR TRENDS AND QUALITY OF LIFE IN PATIENTS UNDERGOING PHEOCHROMOCYTOMA SURGERY Pradeep Prakash, Rashmi Ramachandran, Nikhil Tandon, and Rajeev Kumar Pradeep PrakashPradeep Prakash More articles by this author , Rashmi RamachandranRashmi Ramachandran More articles by this author , Nikhil TandonNikhil Tandon More articles by this author , and Rajeev KumarRajeev Kumar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.3062AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hemodynamic, sugar and metabolic fluctuations occur after surgery for pheochromocytoma and some patients may have complete resolution of hypertension (HTN) and diabetes (DM) with changes in body-mass index (BMI), all of which could impact their quality of life (QoL). We evaluated the trends of such changes in a cohort of patients and assessed factor that could predict them. METHODS Consecutive patients undergoing surgery for pheochromocytoma over a 20 months period were included in this ethics review board approved, prospective cohort study. Blood pressure and sugar levels were serially monitored using a fixed protocol in the perioperative period and at 3 months after surgery. BMI and QoL (using WHOQOL-BREF questionnaire) were recorded at baseline and 3 months. Changes were compared and assessed for predictive factors. RESULTS Out of 26 patients, 8 (30%) developed hypotension and 4 (15%) developed hypoglycemia after surgery. Occurrence of hypotension correlated with 24 hour urinary VMA levels (p = 0.02) and total daily dose of prazosin (p = 0.04; table 1). Out of 21 hypertensive patients, 7 (33%) had persistent HTN at 3 months. Persistence was associated with age (p = 0.04) and DM at presentation (p = 0.04; table 2). Among 6 diabetic patients, 1 (16%) had persistent DM. There was significant increase in the BMI (p < 0.0001) and in WHOQOL-BREF scores postoperatively (table 3). CONCLUSIONS Hypotension occurs in 30% patients after pheochromocytoma surgery and is associated with urinary VMA levels and dose of alpha blockers. Older, diabetic patients are more likely to have persistent hypertension. Surgery causes increase in BMI and improvement in QOL. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e30-e31 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Pradeep Prakash More articles by this author Rashmi Ramachandran More articles by this author Nikhil Tandon More articles by this author Rajeev Kumar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery: An observational study.

Perioperative acute kidney injury (AKI) is common and increases the risk of morbidity and mortality. To determine the association between intraoperative hypotension, defined as an individual decrease from baseline and the risk of perioperative AKI. Observational cohort study. Karolinska University Hospital, Stockholm, Sweden, from October 2012 to May 2013 and October 2015 and April 2016. All adult patients undergoing major elective noncardiac surgery who were scheduled for an overnight admission in the postoperative unit were included. Patients undergoing phaeochromocytoma surgery were excluded. Preoperative risk factors (comorbidities), intraoperative events (hypotension defined as a more than 40 or 50% decrease in SBP relative to each patient's baseline and lasting more than 5 min) and postoperative data were collected from medical records. AKI within the first two postoperative days. Of the final cohort of 470 patients, 127 (27%) developed AKI in the perioperative period. AKI was associated with male sex [(66 vs. 48%) P < 0.001], a higher preoperative creatinine (81 vs. 73 μmol l, P = 0.003), American Society of Anaesthesiologists class more than two (54 vs. 42%, P = 0.014) and preoperative hypertension (54 vs. 40%, P = 0.005). During surgery, the AKI subgroup had more hypotensive events (>40%, 70 vs. 57%, P = 0.013; >50%, 20 vs. 12%, P = 0.024) and greater blood loss (800 vs. 400 ml, P < 0.001). Postoperatively, in AKI patients a positive fluid balance was more common (3123 vs. 2700 ml, P < 0.001), as was 30-day mortality (4 vs. 1%, P < 0.005). Multivariate analyses demonstrated that an intraoperative reduction of SBP more than 50% was associated with a more than doubled risk of AKI, adjusted odds ratio 2.27; 95% CI, 1.20 to 4.30, P = 0.013. In patients undergoing noncardiac surgery, there was a high incidence of perioperative AKI. Intraoperative avoidance of hypotension may decrease the risk of AKI.

Combined epidural-general anesthesia was associated with lower risk of postoperative complications in patients undergoing open abdominal surgery for pheochromocytoma: A retrospective cohort study

BackgroundCurrent evidences show that regional anesthesia is associated with decreased risk of complications after major surgery. However, the effects of combined regional-general anesthesia remain controversial. The purpose of our study was to analyze the impact of anesthesia (combined epidural-general anesthesia vs. general anesthesia) on the risk of postoperative complications in patients undergoing open surgery for pheochromocytoma.MethodsThis was a retrospective cohort study. 146 patients who underwent open surgery for pheochromocytoma (100 received combined epidural-general anesthesia and 46 received general anesthesia) in Peking University First Hospital from January 1, 2002 to December 31, 2015 were enrolled. The primary outcome was the occurrence of postoperative complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between the choice of anesthetic method and the risk of postoperative complications.Results17 (11.6%) patients developed complications during postoperative hospital stay. The incidence of postoperative complications was lower in patients with combined epidural-general anesthesia than in those with general anesthesia (6% [6/100] vs. 23.9% [11/46], P = 0.006). Multivariate Logistic regression analysis showed that use of combined epidural-general anesthesia (OR 0.219, 95% CI 0.065–0.741; P = 0.015) was associated with lower risk, whereas male gender (OR 5.213, 95% CI 1.283–21.177; P = 0.021) and perioperative blood transfusion (OR 25.879; 95% CI 3.130–213.961; P = 0.003) were associated with higher risk of postoperative complications.ConclusionsFor patients undergoing open surgery for pheochromocytoma, use of combined epidural-general anesthesia may decrease the occurrence of postoperative complications.

Application of Three-Dimensional Visualization Technology in Laparoscopic Surgery for Pheochromocytoma/Paraganglioma: A Single-Center Experience.

To compare the feasibility of three-dimensional visualization technology (3DVT) with that of routine computed tomography (CT) examination during planning of laparoscopic surgery for pheochromocytoma (PHEO) and paraganglioma (PGL) and the effects on operative and postoperative outcomes. The clinical data for 36 patients who underwent laparoscopic surgery for PHEO/PGL in our department from January 2016 to April 2017 were analyzed retrospectively. Fourteen patients underwent laparoscopic surgery for PHEO/PGL after preoperative 3DVT-based assessment and 22 after conventional CT examination. The demographic parameters, surgical procedures used, and perioperative outcomes were compared between the two groups. Data were entered into a Microsoft Excel worksheet and analyzed using SPSS version 24.0. No significant differences were found between the groups with regard to age, gender, body mass index, tumor size, surgical approach, estimated blood loss, mean length of hospital stay, number of hypertensive and hypotensive episodes during surgery, peak blood pressure (BP) values during tumor handling, and minimum values after tumor excision. However, the operating time was significantly shorter and the fluctuations in BP were significantly lower in the 3DVT group. 3DVT is a feasible and useful preoperative assessment method in patients undergoing laparoscopic surgery for PHEO/PGL. This imaging technique accurately shows the relationship between the tumor and peripheral structures and aids the surgeon's understanding of the anatomic structure in the operative area and in surgical planning.

Preoperative risk factors for haemodynamic instability during pheochromocytoma surgery in Chinese patients.

Pheochromocytoma surgery carries a high risk of haemodynamic instability (HI). However, there are few studies investigating the risk factors for HI for pheochromocytoma surgery in a Chinese population. Therefore, our objective was to identify preoperative risk factors for HI during surgery in a Chinese population with pheochromocytoma. In this retrospective study, 134 patients undergoing surgery for pheochromocytoma at a single university-affiliated hospital between November 2002 and July 2017 were enrolled. Demographics, comorbidities, preoperative medical preparation, operation details and perioperative haemodynamics of these patients were retrospectively collected and analysed. Multivariable logistic regression analysis was performed to identify the preoperative risk factors for intraoperative HI. 32.8% (44/134) patients suffered from intraoperative HI. According to the result of multivariate analysis, tumour diameter >50mm (odds ratio [OR] 2.526; 95% confidence interval [CI] 1.163-5.485; P=.019), diabetes/prediabetes (OR 2.251; 95% CI 1.039-4.876; P=.040) and preoperative systolic blood pressure fluctuation >50mm Hg (OR 3.163; 95% CI 1.051-9.522, P=.041) were independent predictors for intraoperative HI. The observed incidence of HI was 8.9%, 42.6%, 47.8% and 60% when zero, one, two or three risk factors were present, respectively. HI is common among Chinese patients undergoing surgery for pheochromocytoma. Our study identified three predictive factors for intraoperative HI: a large tumour diameter, diabetes/prediabetes and a great preoperative systolic blood pressure fluctuation. Furthermore, patients are more likely to suffer from HI when they have more predictive risk factors. Identification of these risk factors can help to improve perioperative management.

Prikaz slučaja prve laparoskopske adrenalektomije kod feohromocitoma u Kliničkom centru Srbije

Introduction Endoscopic surgery progressed and developed significantly during the last two decades and laparoscopic adrenalectomy is now considered as the treatment of choice for pheochromocytoma. Still, this procedure can be associated with high incidence of intraoperative hypertension. We present a case of the first laparoscopic adrenalectomy for pheochromocytoma in Serbia. Case Outline A 55-year-old female was admitted to Center for surgery for pheochromocytoma of the left adrenal gland. Clinically patient acquires classical manifestation of pheochromocytoma (hypertension, palpitations, tachycardia and pain below the left rib cage). CT and MR revealed necrotic-cystic oval formation of the left adrenal gland, 50x48x48mm in diameter. The pre-operative preparation was with phenoxybenzamine, ACE inhibitors and rehydratation prior the surgery. Left laparoscopic adrenalectomy was performed with 3 ports (two 10-mm and one 5-mm ports). The anesthesia lasted 155 minutes and the operation 125 minutes. Regarding the blood pressure there were no hypertension crises during the surgery. The patient was discharged on the 3rd postoperative day to our endocrinology department, and during stay in our institution the patient was normotensive. Conclusion Laparoscopic adrenalectomy is the safe and effective surgical method for pheochromocytoma surgery.

Surgery for pheochromocytoma: A 20-year experience of a single institution.

Resection of pheochromocytomas is a challenging procedure due to hemodynamic lability. Our aim was to evaluate surgical outcomes in 67 patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. This study is a retrospective review. A total of 68 procedures for pheochromocytoma were performed between June 1997 and February 2017. All patients were investigated and operated on using an established departmental protocol. Relevant data were retrieved from the hospital records of 533 patients who underwent 541 adrenalectomies for benign and malignant adrenal tumors in the same period. Sixty-nine tumors were removed from 67 patients. One patient with/MEN2A underwent bilateral resection of pheochromocytomas in two stages. Tumor size in laparoscopic procedures ranged from 1.2 cm to 11.0 cm (mean 5.87 cm). Thirty-seven patients had benign disease, 31 potentially malignant (based on PASS) and 1 malignant with metastasis. Eight were in the context of a familial syndrome. Forty-nine patients underwent laparoscopic adrenalectomy, 8 patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, 1 patient had open approach due to inoperable malignant pheochromocytoma and 10 patients had conversions from laparoscopic to open procedure. Nine patients received sodium nitroprusside intraoperatively to treat hypertension. One patient developed pulmonary embolism and succumbed 1 month later. There were no recurrences of the benign or potentially malignant tumors during the follow-up period. Laparoscopic resection of pheochromocytomas, despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure.

Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients

Intraoperative hemodynamic instability is a major challenge during adrenalectomy for pheochromocytoma. Typically, pheochromocytoma is performed laparoscopically either through the retroperitoneal or transperitoneal approach. We aimed to determine if the operative approach affects intraoperative hemodynamic instability during surgery for pheochromocytoma in a large multicenter multicenter cohort. Retrospective, multicenter analysis of consecutive patients with pheochromocytoma who underwent total unilateral laparoscopic adrenalectomy without conversion were included. Statistical analysis was performed using established intraoperative criteria for intraoperative hemodynamic instability: 1) systolic blood pressure >160 mm Hg; 2) systolic blood pressure > 200 mm Hg; 3) mean arterial pressure <60 mm Hg; 4) systolic blood pressure >160 mm Hg + mean arterial pressure <60 mm Hg; and 5) systolic blood pressure >200 mm Hg + mean arterial pressure <60 mm Hg; and 6) intravenous vasopressor + vasodilator. In total, 341 patients met the inclusion criteria, 101 (29.6%) underwent retroperitoneal adrenalectomy and 240 (70.4%) transperitoneal adrenalectomy. Multivariate analysis showed that retroperitoneal adrenalectomy carries greater risk for mean arterial pressure <60 mm Hg (odds ratio 6.255, confidence interval 1.134-34.235, P = .035) compared with transperitoneal adrenalectomy. Overall and cardiovascular morbidity rates were comparable between the 2 approaches. The medical center was a significant independent influencing factor for all 6 intraoperative hemodynamic instability definitions. Variability in institutional management of pheochromocytoma intraoperatively has significant impact on all 6 intraoperative hemodynamic instability definitions. Standardization of anesthesia should be considered to reduce this variability.

Preoperative risk factors for massive blood loss in adrenalectomy for pheochromocytoma.

BackgroundThis retrospective analysis of patients who underwent adrenalectomy for pheochromocytoma aimed to determine preoperative risk factors for intraoperative massive blood loss. Preoperative identification of patients at high-risk of massive blood loss may be helpful in anesthesia management and preoperative preparation.Materials and MethodsThe study involved data of 268 patients who had undergone pheochromocytoma surgery at the Peking Union Medical College Hospital between January 1, 2013 and October 31, 2016. For analysis, the patients were grouped according to intraoperative blood loss: ≥ 20% of estimated blood volume (group A, n = 38) and < 20% of estimated blood volume (group B, n = 230). Perioperative characteristics were compared between the two groups. Significant variables were selected for a forward stepwise binary logistic regression analysis to determine the independent risk factors for massive blood loss.ResultsThe two groups showed significant differences in tumor location, tumor size, operative approach, preoperative 24-hour urine level of total noradrenaline, preoperative hemoglobin concentration, phenoxybenzamine maximum daily dose, preoperative preparation time, intraoperative urine volume, crystalloid and colloidal fluid volumes, allogeneic red blood cell transfusion, plasma and autologous blood transfusion volumes, incidence of prolonged hypotension, postoperative drainage volume, lowest and discharge hemoglobin concentrations, length of stay in intensive care unit and length of postoperative hospitalization. Binary logistic regression analysis indicated increased risk of intraoperative massive blood loss in subjects with tumors proximal to vessels or other organs (odds ratio (OR): 4.227), with tumors ≥ 5 cm (OR: 7.321), or with preoperative preparation time of ≤ 14 days (OR: 17.747).ConclusionsTumors proximal to vessels and other organs or with maximum diameter of ≥ 5 cm (as shown by preoperative radiographic evidence), and preoperative preparation time of ≤ 14 days were independent risk factors of intraoperative massive blood loss in patients treated with adrenalectomy for pheochromocytoma.

Significant decreases in blood propofol concentrations during adrenalectomy for phaeochromocytoma.

The kinetics of propofol are influenced by cardiac output. The aim of this study was to examine changes in blood propofol concentrations during phaeochromocytoma surgery using target-controlled infusion (TCI) anaesthesia with propofol. This is a prospective observational study. Ten patients with phaeochromocytoma who underwent unilateral adrenalectomy were included. Cardiac output was measured using an arterial pressure-based cardiac output analysis method. The target blood propofol concentrations were adjusted to maintain an approximate bispectral index (BIS) value of 40 before initiating surgery. The settings remained constant during surgery. Blood samples for propofol concentrations were collected from the radial artery at seven time points: two before tumour manipulation (T1, 2), two during tumour manipulation (T3, 4), and three after tumour vein ligation (T4-7). BIS values, the arterial pressure cardiac index (APCI) and haemodynamic parameters were measured at the same time points as the blood samples. The prop-ratio was calculated by dividing blood propofol concentrations by target concentrations of TCI. APCI increased during tumour manipulation and after tumour vein ligation. The prop-ratio was reduced significantly by approximately 40% and showed a significant negative correlation with APCI. BIS values increased significantly and showed a significant negative correlation with the prop-ratio. The increased APCI during tumour manipulation and after tumour vein ligation was associated with markedly reduced blood propofol concentrations. These results reveal that significant decreases in the anaesthetic effect may be observed in patients undergoing phaeochromocytoma surgery even if TCI anaesthesia is used with propofol.

Perioperative α-receptor blockade in phaeochromocytoma surgery: an observational case series

BackgroundMortality associated with surgery for phaeochromocytoma has dramatically decreased over the last decades. Many factors contributed to the dramatic decline of the mortality rate, and the influence of an α-receptor blockade is unclear and has never been tested in a randomized trial. We evaluated intraoperative haemodynamic conditions and the incidence of complications in patients with and without α-receptor blockade undergoing surgery for catecholamine producing tumours. MethodsHaemodynamic conditions and perioperative complications were assessed in 110 patients with (B) and 166 without (N) α-receptor blockade. Data were analysed as a consecutive case series of 303 cases and subsequently via propensity score matching, and presented as mean and confidence interval (CI). ResultsNo difference in maximal intraoperative systolic arterial pressures (B = 178 mm Hg (CI 169-187) vs N = 185 mm Hg (CI 177-193; P = 0.2542) and hypertensive episodes above 250 mm Hg were found (P = 0.7474) for the closed case series. No major complications occurred. Propensity score matching (75 pairs) revealed a significant difference of 17 mm Hg in maximal intraoperative systolic bp for these selected pairs (P = 0.024). ConclusionsOnly a slight difference in mean maximal systolic arterial pressure was detected between patients with or without an α-receptor blockade. There was no difference in the incidence of excessive hypertensive episodes between groups and no major complications occurred. The basis for the general recommendation of perioperative α- receptor blockade for phaeochromocytoma surgery demands further study.

Laparoscopic Surgery for Pheochromocytoma and Paraganglioma Removal: A Retrospective Analysis of Anaesthetic Management.

Minimal invasive approaches to pheochromocytoma (PCC) and paraganglioma (PGL) removal may be complicated by the hemodynamic disturbances that are associated with the catecholamine secretion from the tumour. The anaesthetic and perioperative monitoring techniques need to be customized to handle these complications effectively. This retrospective analysis was undertaken to review the perioperative management of these patients handled by the same anaesthetic and surgical team. Case details were collected and data analysed for the perioperative management of 29 patients who underwent laparoscopic removal of PCC and PGL. Parameters collected included details of preoperative alpha-and beta blockade, tumour size, number of hypertensive surges, dose of sodium nitroprusside (SNP) and other vasodilators used and incidence of postoperative hypotension and other complications. All patients received prazosin for pre-operative optimization. Hypertensive emergencies were seen in 4 patients during induction and endotracheal intubation and in 1 patient during pneumoperitoneum insufflation. Overall mean number of hypertensive emergencies was 3.41 (SD-2.45). The patients undergoing PGL removal had significantly more crisis compared to those undergoing unilateral PCC removal. The dose of SNP used correlated significantly with tumour size. Laparoscopic surgery for PCC and PGL removal is associated with hypertensive emergencies which are amenable to usual doses of antihypertensives used intraoperatively. Surgical factors like tumour size and location affect the number of crisis and the dose of anti-hypertensives used more than the anaesthetic drugs and procedures.

Resection of Pheochromocytoma Improves Diabetes Mellitus in the Majority of Patients.

Catecholamine excess in patients with pheochromocytoma often results in impaired glucose tolerance, leading to diabetes mellitus. Little data are available on the long-term effect of surgery on diabetes. The primary aim of this study was to determine the likelihood of diabetes cure after surgery, while secondary objectives were to determine risk factors for development of diabetes preoperatively and persistence of diabetes postoperatively. All patients undergoing surgery for pheochromocytoma from 1996 to 2015 were retrospectively reviewed to identify those with a preoperative diagnosis of diabetes. Demographic and diabetes-specific data were collected. Median follow-up was 52.1months. Overall, 153 patients underwent surgery. Diabetes was seen in 36 (23.4%) patients. Eight patients met the exclusion criteria and were removed from the final analysis, while 22 (78.6%) patients had complete resolution of diabetes. Four patients remained on medication with improved control. Overall, 93.0% of patients had improvement of their diabetes; two patients did not improve. Patients with large, symptomatic tumors were more likely to develop preoperative diabetes, and diabetes was more likely to persist in patients who had an elevated body mass index (BMI). Diabetes was found concurrently with pheochromocytoma in 23% of patients, more often in those with large, symptomatic tumors. The majority of patients had long-term resolution of diabetes after successful resection; however, some patients may continue to require treatment of diabetes after operation, especially those with a higher BMI.

Surgical and Hemodynamic Outcomes in Pheochromocytoma Surgery: A Prospective Cohort Study

To prospectively evaluate the surgical complications of pheochromocytoma and paraganglioma surgery and assess perioperative hemodynamic outcomes in terms of risk for intraoperative vasodilator use and risk for postoperative vasopressor requirements in these patients. This was an institutional review board-approved prospective observational study of patients undergoing pheochromocytoma or paraganglioma surgery. Operative and recovery data for all patients undergoing open, laparoscopic, and robotic surgery were analyzed for surgical complications on the modified Clavien-Dindo classification. The need for intraoperative vasodilators for pressure spikes of greater than 180 mmHg and vasopressor support after surgery was recorded. Factors predictive of these parameters were assessed. Forty patients underwent 45 procedures including five bilateral adrenalectomies over the 2-year study period. This included 40 adrenalectomies and 5 paraganglioma excisions. Twenty-nine patients had minimally invasive surgery (25 laparoscopic, 4 robot-assisted) and 11 had open surgery. Sixty percent of patients required intraoperative vasodilators for hypertensive crisis, and this was significantly related to the size of the tumor (P = .02). The need for postoperative vasopressors was related to the number of intraoperative pressure spikes (P = .007). Five percent of the patients suffered a complication greater than grade 2 on the Clavien-Dindo classification. Pheochromocytoma and paraganglioma surgeries are associated with minimal postoperative morbidity. Larger tumors may be associated with greater intraoperative pressure surges, but this does not impact patient outcomes.