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Lachmann B, Schweigert M, Almeida AB, Spieth S, Rössel T, Richter T. Case of functional paraganglioma with intraoperative hypertensive crisis during robot-assisted thoracoscopic resection. Surg Case Rep 2024; 10:127. [PMID: 38772971 PMCID: PMC11109067 DOI: 10.1186/s40792-024-01930-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Mediastinal paragangliomas are rare. Their dangerousness may unfold during surgery, especially if hormonal activity was previously unknown. We report our experience with this case in context to the incidence and localization of atypically located mediastinal paragangliomas in the literature. CASE PRESENTATION A 69-year-old female patient who was scheduled for thoracoscopic resection due to a posterior mediastinal tumor that had been progressing in size for several years and increasing symptoms. The induction of anesthesia, the ventilation of the lungs and the gas exchange after lung separation was uneventful. After initially stable circulatory conditions, there was a sudden increase in blood pressure up to 300/130 mmHg and tachycardia up to 130/min. This hypertensive phase was difficult to influence and required a rapid and consistent use of antihypertensive medication to bring down the blood pressure to reasonable values. The patient stabilized after tumor resection. The postoperative course was unremarkable. During the intraoperative blood pressure crisis, blood was drawn for analysis. These samples showed elevated concentrations of normetanephrine and metanephrine. The tumor subsequently presented as a catecholamine-secreting paraganglioma. CONCLUSION In order to avoid life-threatening blood pressure crises, hormone activity should be ruled out preoperatively in the case of mediastinal tumor, in which a paraganglioma could be considered in the differential diagnosis, especially if there are indications of hypertension in the medical history. Robotic-assisted thoracoscopic resection of the posterior mediastinal tumor was a feasible surgical method, even in the case of unexpected functional paraganglioma.
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Affiliation(s)
- Björn Lachmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Michael Schweigert
- Department of Thoracic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Ana Beatriz Almeida
- Department of Thoracic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Stephanie Spieth
- Department of Radiology, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Thomas Rössel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Torsten Richter
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Liu L, Shang L, Zhuang Y, Su X, Li X, Sun Y, Long B. Exploration of factors affecting hemodynamic stability following pheochromocytoma resection - cohort study. Front Endocrinol (Lausanne) 2024; 15:1336128. [PMID: 38650714 PMCID: PMC11033385 DOI: 10.3389/fendo.2024.1336128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Purpose Surgery is the only way to cure pheochromocytoma; however, postoperative hemodynamic instability is one of the main causes of serious complications and even death. This study's findings provide some guidance for improved clinical management. Patients and methods This study was to investigate the factors leading to postoperative hemodynamic instability in the postoperative pathology indicated pheochromocytoma from May 2016 to May 2022. They were divided into two groups according to whether vasoactive drugs were used for a median number of days or more postoperatively. The factors affecting the postoperative hemodynamics in the perioperative period (preoperative, intraoperative, and postoperative) were then evaluated. Results The median number of days requiring vasoactive drug support postoperatively was three in 234 patients, while 118 (50.4%) patients required vasoactive drug support for three days or more postoperatively. The results of the multivariate analysis indicated more preoperative colloid use (odds ratio [OR]=1.834, confidence interval [CI]:1.265-2.659, P=0.001), intraoperative use of vasoactive drug (OR=4.174, CI:1.882-9.258, P<0.001), and more postoperative crystalloid solution input per unit of body weight per day (ml/kg/d) (OR=1.087, CI:1.062-1.112, P<0.001) were risk factors for predicting postoperative hemodynamic instability. The optimal cutoff point of postoperative crystalloid use were 42.37 ml/kg/d. Conclusion Hemodynamic instability is a key issue for consideration in the perioperative period of pheochromocytoma. The amount of preoperative colloid use, the need for intraoperative vasoactive drugs, and postoperative crystalloid solution are risk factors for predicting postoperative hemodynamic instability (registration number: ChiCT2300071166).
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Affiliation(s)
| | | | | | | | | | | | - Bo Long
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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3
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Araujo-Castro M, García Sanz I, Mínguez Ojeda C, Hanzu F, Mora M, Vicente A, Blanco Carrera C, Miguel Novoa PD, López García MDC, Lamas C, Manjón-Miguélez L, Del Castillo Tous M, Rodríguez de Vera P, Barahona San Millán R, Recasens M, Fernández-Ladreda MT, Valdés N, Gracia Gimeno P, Robles Lazaro C, Michalopoulou T, Álvarez Escolá C, García Centeno R, Calatayud M. Risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas. J Hypertens 2024; 42:252-259. [PMID: 37851004 DOI: 10.1097/hjh.0000000000003596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
PURPOSE To identify presurgical and surgical risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas (PGLs) (PPGLs). METHODS Retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. Intraoperative hypertensive crisis was defined as systolic blood pressure (SBP) greater than 200 mmHg lasting more than 1 min and postoperative hypertensive crisis as SBP greater than 180 mmHg or diastolic blood pressure (DBP) greater than 110 mmHg. RESULTS A total of 296 surgeries were included. Alpha presurgical blockade was employed in 93.2% of the cases and beta-adrenergic in 53.4%. Hypertensive crisis occurred in 20.3% ( n = 60) of the surgeries: intraoperative crisis in 56 and postoperative crisis in 6 cases (2 cases had both types of crises). We identified as risk factors of intraoperative hypertensive crisis, absence of presurgical glucocorticoid therapy (odds ratio [OR] 3.48; 95% confidence interval [CI] 1.19-10.12) higher presurgical SBP (OR 1.22 per each 10 mmHg, 95% CI 1.03-1.45), a larger tumor size (OR 1.09 per each 10 mm, 95% CI 1.00-1.19) and absence of oral sodium repletion (OR 2.59, 95% CI 1.25-5.35). Patients with hypertensive crisis had a higher rate of intraoperative bleeding ( P < 0.001), of intraoperative hemodynamic instability ( P < 0.001) and of intraoperative hypotensive episodes ( P < 0.001) than those without hypertensive crisis. CONCLUSION Intraoperative hypertensive crisis occurs in up to 20% of the PPGL resections. Patients not pretreated with glucocorticoid therapy before surgery, with larger tumors and higher presurgical SBP and who do not receive oral sodium repletion have a higher risk for developing hypertensive crisis during and after PPGL surgery.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid
- University of Alcalá
| | - Iñigo García Sanz
- General & Digestive Surgery Department, Hospital Universitario de La Princesa
| | | | - Felicia Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic, Barcelona
| | - Mireia Mora
- Endocrinology & Nutrition Department, Hospital Clinic, Barcelona
| | - Almudena Vicente
- Endocrinology & Nutrition Department, Hospital Universitario de Toledo, Toledo
| | | | | | | | - Cristina Lamas
- Endocrinology & Nutrition Department, Hospital Universitario de Albacete, Albacete
| | - Laura Manjón-Miguélez
- Endocrinology & Nutrition Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias. Oviedo
| | | | | | | | - Mónica Recasens
- Endocrinology & Nutrition Department, Institut Català de la Salut Girona, Girona
| | | | - Nuria Valdés
- Endocrinology & Nutrition Department, Hospital Universitario de Cabueñes, Asturias
| | | | | | | | | | | | - María Calatayud
- Endocrinology & Nutrition Department, Hospital Universitario Doce de Octubre, Madrid, Spain
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Yan KW, Tian XF, Wu YN, Cai M, Guo MT. Abandonment of intravenous volume expansion after preoperative receipt of α-blockers in patients with adrenal pheochromocytoma was not an independent risk factor for intraoperative hemodynamic instability. Front Endocrinol (Lausanne) 2023; 14:1131564. [PMID: 37152944 PMCID: PMC10160639 DOI: 10.3389/fendo.2023.1131564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 04/11/2023] [Indexed: 05/09/2023] Open
Abstract
Background There is no consensus on whether intravenous rehydration must be added after preoperative phenoxybenzamine (PXB) administration for pheochromocytoma. The aim of this study is to investigate whether abandonment of intravenous volume expansion after PXB administration is associated with intraoperative hemodynamic instability. Methods 83 Patients with pheochromocytoma received surgical treatment in the Department of Urology, Handan First Hospital, between October 2014 and July 2022. All patients were subclassified into either the hemodynamic stability group (HS group) or the hemodynamic instability group (HU group) according to whether intraoperative hemodynamic instability occurred, with 51 cases in HS group and 32 cases in HU group. Differences in data between the two groups were examined, and the risk factors for intraoperative hemodynamic instability were analyzed using logistic regression. Results The results of the analysis showed no statistically significant differences in age, sex, location of the tumor, surgical method, body mass index (BMI) ≥ 24 kg/m2, blood and urine catecholamine test results, preoperative oral PXB followed by combined intravenous volume expansion, proportion of patients with hypertension or diabetes mellitus or coronary heart disease between the two groups (P>0.05). The size of the tumor in the HS group was smaller than that in the HU group (5.3 ± 1.9 cm vs 6.2 ± 2.4 cm P=0.010). Multivariate analyses demonstrated that abandonment of intravenous volume expansion after preoperative receipt of α-blockers in patients with adrenal pheochromocytoma was not an independent risk factor for intraoperative hemodynamic instability. Only the tumor size (P=0.025) was an independent risk factor for intraoperative hemodynamic instability. Conclusion The purpose of general preoperative intravenous fluid expansion is to prevent hypotension after the tumor has been resected. In the current study, we indicated that preoperative management of pheochromocytomas using the α-blocker PXB in combination with intravenous volume expansion does not further reduce the risk of intraoperative hemodynamic instability or postoperative complications compared with oral PXB alone. Therefore, our study supports preoperative management of pheochromocytoma with a single α-blocker, PXB, as sufficient.
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Affiliation(s)
- Kun-wu Yan
- Department of Urology, Handan First Hospital, Handan, China
- *Correspondence: Kun-wu Yan,
| | - Xiao-fei Tian
- Department of General Surgery, Handan First Hospital, Handan, China
| | - Yan-ni Wu
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Heze Domestic Professional College, Heze, China
| | - Meng Cai
- Department of Oncology, Handan First Hospital, Handan, China
| | - Ming-tao Guo
- Department of Urology, Handan First Hospital, Handan, China
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5
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Bladder paraganglioma: basic characteristics and new perspectives on perioperative management. World J Urol 2022; 40:2807-2816. [PMID: 36205740 DOI: 10.1007/s00345-022-04166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/24/2022] [Indexed: 10/10/2022] Open
Abstract
PURPOSE Paraganglioma and pheochromocytoma are rare neuroendocrine tumors with severe metabolic and cardiovascular complications. Bladder PGLs are rare, and their clinical management is not precise. Here, we discuss the basic characteristics and perioperative management of bladder PGLs. METHODS We retrospectively reviewed 20 bladder PGL cases diagnosed at Sun Yat-sen University Cancer Center. Case notes were reviewed, clinical presentations, therapies, and outcomes were collected, and data analysis was performed. RESULTS Ten male and ten female patients with a median age of 47.5 years (range 14-69 years) were included. Most patients (65%) had no symptoms, and PGL was detected incidentally during medical checkups. All patients were treated surgically; 4 (20%) underwent transurethral resection of bladder tumor (TURBT), and 16 (80%) underwent partial cystectomy. Strong intraoperative blood pressure fluctuations were observed in 13 patients (65%). Two patients who were treated preoperatively with α-receptor blockers also experienced severe intraoperative blood pressure fluctuations. Postoperative measurements of troponin I were available for 3 patients, and all were significantly elevated. All patients were diagnosed with bladder PGL on postoperative pathological examination. The median follow-up time was 51 months (range 2-147 months), and 2 patients were lost to follow-up at 1 and 3 months; 16 (88.9%) survived without recurrence, 2 patients (11.1%) experienced recurrence, and 1 patient died. CONCLUSION Most bladder paragangliomas are easily mistaken for bladder urothelial carcinoma, and robust hemodynamic instability during surgery might be a challenge for urologists. Postoperative monitoring of troponin I, regardless of the presence of clinical symptoms, is recommended for patients with bladder PGL.
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Kim WW, Kim DH, Cho JW, Rah CS, Lee YM, Chung KW, Koh JM, Lee SH, Hong SJ, Kim YJ, Sung TY. The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study. Surg Endosc 2022; 36:5491-5500. [PMID: 35001223 DOI: 10.1007/s00464-021-08910-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. MATERIALS AND METHODS This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed. RESULTS In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy. CONCLUSIONS The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.
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Affiliation(s)
- Won Woong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jae Won Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Cheong-Sil Rah
- Department of Surgery, UiJeongbu Eulji Medical Center, Eulji University, 712, Dongil-ro, Uijeongbu-si, 11759, Gyeonggi-do, Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ki-Wook Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Suck Joon Hong
- Department of Surgery, UiJeongbu Eulji Medical Center, Eulji University, 712, Dongil-ro, Uijeongbu-si, 11759, Gyeonggi-do, Korea
| | - Yeon Ju Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Kim JH, Lee HC, Kim SJ, Lee KE, Jung KC. Characteristics of Intraoperative Hemodynamic Instability in Postoperatively Diagnosed Pheochromocytoma and Sympathetic Paraganglioma Patients. Front Endocrinol (Lausanne) 2022; 13:816833. [PMID: 35282440 PMCID: PMC8907447 DOI: 10.3389/fendo.2022.816833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/27/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite an improved understanding of pheochromocytoma and extra-adrenal sympathetic parganglioma (PPGL), including diagnosis and management, some PPGLs are postoperatively diagnosed. Clinical characteristics and intraoperative haemodynamic instability (HI) in postoperatively diagnosed PPGL patients have been poorly defined. Thus, we investigated the clinical characteristics and HI in patients with postoperatively diagnosed PPGLs compared to patients with preoperatively diagnosed PPGLs. METHODS We obtained clinical and haemodynamic data from the electronic medical records of 256 patients with pathologically confirmed PPGLs at our institution from January 2005 to December 2019. We assessed the intraoperative HI (systolic blood pressure [SBP]>160 mmHg (min) or mean blood pressure [MBP]<60 mmHg (min)) over time. RESULTS Twenty-nine patients (11.3%) were diagnosed with PPGLs postoperatively. Hypertension (34.5% vs. 63.0%, P=0.006) and pheochromocytoma (17.2% vs. 81.1%, P<0.001) case rates were lower in postoperatively diagnosed patients than in preoperatively diagnosed patients. Preoperative SBP in the ward was similar between groups, but the use of α-blockers and β-blockers was more frequent in preoperatively diagnosed patients (89.0% vs. 3.4%, P<0.001; 36.3% vs. 6.9%, P=0.003). Considering intraoperative HI, postoperatively diagnosed patients demonstrated a similar percentage of time with SBP>160 mmHg (median [IQR]; 7.9% [2.5; 11.9] % vs. 4.6% [0.0; 11.9], P=0.088) but a significantly lower percentage of time with MBP<60 mmHg (0.0% [0.0; 3.0] vs. 5.6% [0.0, 12.6], P=0.002) compared with preoperatively diagnosed patients. CONCLUSIONS Patients diagnosed with PPGLs postoperatively may have no further higher risk of intraoperative hypertension than those diagnosed preoperatively despite insufficient preoperative management for PPGLs. Further study will be needed to ascertain intrinsic tumour characteristics, and need for universal preoperative use of α- and β-blockers in PPGL patients postoperatively diagnosed or without typical symptoms related PPGLs.
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Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Su-jin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul, South Korea
- Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul, South Korea
- *Correspondence: Su-jin Kim, ;
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul, South Korea
- Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul, South Korea
| | - Kyeong Cheon Jung
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
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Araujo-Castro M, García Centero R, López-García MC, Álvarez Escolá C, Calatayud Gutiérrez M, Blanco Carrera C, De Miguel Novoa P, Valdés Gallego N, Hanzu FA, Gracia Gimeno P, Fernández-Ladreda MT, Percovich Hualpa JC, Mora Porta M, Lorca Álvaro J, Pian H, Caracuel IR, Sanjuanbenito Dehesa A, Gómez Dos Santos V, Serrano Romero A, Oliveira CL. Surgical outcomes in the pheochromocytoma surgery. Results from the PHEO-RISK STUDY. Endocrine 2021; 74:676-684. [PMID: 34373995 DOI: 10.1007/s12020-021-02843-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/27/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify presurgical and surgical risk factors for postsurgical complications in the pheochromocytoma surgery. METHODS A retrospective study of pheochromocytomas submitted to surgery in ten Spanish hospitals between 2011 and 2021. Postoperative complications were classified according to Clavien-Dindo scale. RESULTS One hundred and sixty-two surgeries (159 patients) were included. Preoperative antihypertensive blockade was performed in 95.1% of the patients, being doxazosin in monotherapy (43.8%) the most frequent regimen. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more frequently (49.4% vs 25.0%, P = 0.003) than patients treated with phenoxybenzamine, but no differences in the rate of intraoperative and postsurgical complications were observed. However, patients treated with phenoxybenzamine had a longer hospital stay (12.2 ± 11.16 vs 6.2 ± 6.82, P < 0.001) than those treated with doxazosin. Hypertension resolution was observed in 78.7% and biochemical cure in 96.6% of the patients. Thirty-one patients (19.1%) had postsurgical complications. Prolonged hypotension was the most common, in 9.9% (n = 16), followed by hypoglycaemia in six patients and acute renal failure in four patients. 13.0% of complications had a score ≥3 in the Clavien-Dindo scale. Postsurgical complications were more common in patients with diabetes, cerebrovascular disease, higher plasma glucose levels, higher urinary free metanephrine and norepinephrine, and with pheochromocytomas larger than 5 cm. CONCLUSION Preoperative medical treatment and postsurgical monitoring of pheochromocytoma should be especially careful in patients with diabetes, cerebrovascular disease, higher levels of plasma glucose and urine free metanephrine and norepinephrine, and with pheochromocytomas >5 cm, due to the higher risk of postsurgical complications.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit. Department of Endocrinology & Nutrition. Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Department of Health Science, Universidad de Alcalá, Madrid, Spain.
| | | | | | | | | | | | - Paz De Miguel Novoa
- Department of Endocrinology & Nutrition, Hospital Clínico San Carlos, Madrid, Spain
| | - Nuria Valdés Gallego
- Department of Endocrinology & Nutrition, Hospital de Universitario de Cabueñes, Asturias, Spain
| | - Felicia A Hanzu
- Department of Endocrinology & Nutrition & Group of Endocrine Disorders. Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Paola Gracia Gimeno
- Department of Endocrinology & Nutrition, Hospital Royo Villanova, Zaragoza, Spain
| | | | | | - Mireia Mora Porta
- Department of Endocrinology & Nutrition & Group of Endocrine Disorders. Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Javier Lorca Álvaro
- Department of Urology, IRYCIS. Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor Pian
- Department of Pathology, IRYCIS. Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Ruz Caracuel
- Department of Pathology, IRYCIS. Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | | | - Ana Serrano Romero
- Department of Anesthesia, IRYCIS. Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Cristina Lamas Oliveira
- Department of Endocrinology & Nutrition, Hospital Universitario de Albacete, Albacete, Spain
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9
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Kim JH, Lee HC, Kim SJ, Yoon SB, Kong SH, Yu HW, Chai YJ, Choi JY, Lee KE, Lee KW, Min SK, Shin CS, Park KJ. Perioperative hemodynamic instability in pheochromocytoma and sympathetic paraganglioma patients. Sci Rep 2021; 11:18574. [PMID: 34535733 PMCID: PMC8448751 DOI: 10.1038/s41598-021-97964-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 09/02/2021] [Indexed: 02/04/2023] Open
Abstract
For pheochromocytoma and sympathetic paraganglioma (PPGL), surgery can be used as a curative treatment; however, the life-threatening risk of perioperative hemodynamic instability (HI) presents challenges. This study aimed to analyze the incidence and predictive factors of perioperative HI. The electronic medical records of 114 consecutive patients who underwent surgery for PPGLs at our institution were retrospectively reviewed. HI was defined as one or more episodes of systolic blood pressure > 200 mmHg or mean blood pressure < 60 mmHg during surgery. The factors predictive of perioperative HI were determined using both univariate and multivariate analyses. Intraoperative HI occurred in 79 (69.3%) patients. In multivariate analysis, α-adrenergic receptor blocker duration (days) (odds ratio, 1.015; 95% confidence interval, 1.001–1.029) was a predictor for intraoperative HI. Postoperative hypotension occurred in 36 (31.6%) patients. Higher urine epinephrine levels, and greater preoperative highest heart rate (HR) were predictive factors for postoperative hypotension in PPGL patients. Caution should be taken in perioperative management for PPGL, especially with long duration of α-adrenergic receptor blocker use, higher urine epinephrine levels, and greater preoperative highest HR.
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Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Su-Jin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea. .,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea. .,Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul, Republic of Korea.
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.,Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea.,Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul, Republic of Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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10
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Guo Y, You L, Hu H, Tong A, Zhang X, Yan L, Zhang S. A Predictive Nomogram for Red Blood Cell Transfusion in Pheochromocytoma Surgery: A Study on Improving the Preoperative Management of Pheochromocytoma. Front Endocrinol (Lausanne) 2021; 12:647610. [PMID: 33790869 PMCID: PMC8006300 DOI: 10.3389/fendo.2021.647610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/15/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose Surgery is the major treatment option for pheochromocytoma but carries potential risks, including hemorrhage and hemodynamic instability. Even with laparoscopic adrenalectomy, intraoperative blood transfusion happens from time to time, but few studies have investigated risk factors. For the first time we develop and validate a nomogram for prediction of red blood cell transfusion in pheochromocytoma surgery. Methods There were 246 patients in our center and 56 patients in Peking Union Medical College Hospital, who underwent pheochromocytoma surgery, enrolled in the study. We incorporated clinical and radiological risk factors, and presented this with a nomogram. Lasso regression model was used for feature selection. Logistic regression analysis was performed to identify the odd ratios. The performance of the nomogram was assessed with respect to its discrimination, calibration and clinical usefulness. Results Thirty-two features were reduced to five, which were phenoxybenzamine use, phenoxybenzamine treatment duration, preinduction heart rate, tumor diameter and surgical procedure. The model showed good discrimination (C-index, 0.857; 95% CI, 0.781-0.836) and application in the validation sets also gave good discrimination (internal validation: C-index, 0.831; 95% CI, 0.750-0.822; external validation: C-index, 0.924; 95% CI, 0.766-1.000). Calibration tested with the Hosmer-Lemeshow test yielded a good agreement between prediction and observation (training P=0.358; internal validation P=0.205; external validation P=0.395). Odd ratios of phenoxybenzamine use, phenoxybenzamine treatment duration, preinduction HR, tumor diameter and open surgery were 13.32 (95% CI, 1.48-197.38; P = 0.034), 1.04 (95% CI, 0.99-1.08; P = 0.092), 1.04 (95% CI, 1.01-1.08; P=0.006), 1.03 (95% CI, 1.02-1.06; P<0.001), 17.13 (95% CI, 5.18-78.79; P<0.001), respectively. Decision curve analysis demonstrated the clinical usefulness of the nomogram. Conclusions This study presents a nomogram that may be used to facilitate the prediction of red blood cell transfusion in pheochromocytoma surgery and help to do the preoperative management more efficiently.
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Affiliation(s)
- Ying Guo
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lili You
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huijun Hu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Anli Tong
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoyun Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Yan
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoling Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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