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Habeeb TAAM, Araujo-Castro M, Chiaretti M, Podda M, Aiolfi A, Kryvoruchko IA, Manangi MN, Shelat V, Kalmoush AE, Labib MF, Elshafey MH, Ibrahim SMM, Abo Alsaad MI, Elbelkasi H, Mansour MI, Elshahidy TM, Heggy IA, Elsayed RS, Fiad AA, Yehia AM, Yassin MA, Elballat MR, Hebeishy MH, AboZeid AK, Saleh MAA, Hamed AEM, Abdelghani AA, Mousa B. Side-specific factors for intraoperative hemodynamic instability in laparoscopic adrenalectomy for pheochromocytoma: a comparative study. Surg Endosc 2024; 38:4571-4582. [PMID: 38951238 PMCID: PMC11289338 DOI: 10.1007/s00464-024-10974-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/22/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA). METHODS We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included. RESULTS Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147-27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996-30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323-47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07-1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other. CONCLUSION LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.
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Affiliation(s)
- Tamer A A M Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Marta Araujo-Castro
- Neuroendocrinology & Adrenal Unit of the Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Ramón y Cajal Research Institute (IRYCIS), Madrid, Spain
| | - Massimo Chiaretti
- Department of General Surgery Specialties and Organ Transplant, Faculty of Pharmacy and Medicine, Sapienza Rome University, Rome, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Alberto Aiolfi
- Department of Biomedical Sciences for Health, Milan, Italy
| | - Igor A Kryvoruchko
- Surgery Department #2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Mallikarjuna N Manangi
- Department of General Surgery, Bangalore Medical College and Research Institute, Bengaluru, India
| | - Vishal Shelat
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Mohamed Fathy Labib
- General Surgery Department, Faculty of Medicine, Al-Azher University, Cairo, Egypt
| | | | | | | | | | | | | | - Ibrahim A Heggy
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rasha S Elsayed
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Alaa A Fiad
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed M Yehia
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud Abdou Yassin
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud R Elballat
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed H Hebeishy
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Khaled AboZeid
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Abd Elwahab M Hamed
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Amr A Abdelghani
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Bassam Mousa
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Huang H, Sun T, Liu Z. Robot-assisted versus laparoscopic pheochromocytoma resection and construction of a nomogram to predict perioperative hemodynamic instability. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107986. [PMID: 38325143 DOI: 10.1016/j.ejso.2024.107986] [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: 10/30/2023] [Revised: 12/25/2023] [Accepted: 01/25/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Despite recent improvements in perioperative outcomes after pheochromocytoma resection, hemodynamic instability (HI) remained of high concern. The emergence of robot-assisted surgery may bring different results to pheochromocytoma surgery. The purposes of this study were to investigate whether robot-assisted retroperitoneal pheochromocytoma resection promotes hemodynamic instability compared with laparoscopic retroperitoneal pheochromocytoma resection and construct a nomogram to predict perioperative hemodynamic instability. METHODS The clinical data of 221 patients who underwent pheochromocytoma resection were analyzed retrospectively. The patients were divided into two groups according to the mode of operation. Stepwise logistic regression was used to determine the independent risk factors of perioperative hemodynamic instability and to construct a visual prediction model. The final model was visualized via a nomogram. RESULTS 124 (56.1 %) out of 221 patients experienced HI. The variables that were eventually included in the model were tumor size (OR1.363(1.143-1.646), P < 0.001), abnormal blood glucose (OR3.381(1.534-7.903), P = 0.003), preoperative SBP(OR1.04(1.014-1.067),P = 0.002), robot-assisted surgery(OR0.241(0.108-0.513),P < 0.001), and catecholamines(OR4.567(2.424-8.834),P < 0.001). The receiver operating characteristic curve showed the area under curve was 0.816(95 %CI 0.761-0.871). CONCLUSION We developed a nomogram for successful prediction of perioperative hemodynamics based on five independent risk factors. Clinicians can leverage this easy-to-use nomogram to perform personalized risk predictions for HI and develop preventive interventions to improve patient safety and surgical outcomes.
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Affiliation(s)
- Hao Huang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China.
| | - Ting Sun
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China.
| | - Ziwen Liu
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China.
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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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Liu Y, Liu C, Wang Y, Li S, Li X, Liu X, Wang B, Pei Z, Li L, Lin L, Qu J, Chen K, Zang L, Gu W, Mu Y, Lyu Z, Dou J, Gao Z. Nomogram for Predicting Intraoperative Hemodynamic Instability in Patients With Normotensive Pheochromocytoma. J Clin Endocrinol Metab 2023; 108:1657-1665. [PMID: 36655387 DOI: 10.1210/clinem/dgad024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
CONTEXT Intraoperative hemodynamic instability (HI) deteriorates surgical outcomes of patients with normotensive pheochromocytoma (NP). OBJECTIVE To characterize the hemodynamics of NP and develop and externally validate a prediction model for intraoperative HI. METHODS Data on 117 patients with NP (derivation cohort) and 40 patients with normotensive adrenal myelolipoma (NAM) who underwent laparoscopic adrenalectomy from January 2011 to November 2021 were retrospectively collected. Data on 22 patients with NP (independent validation cohort) were collected from another hospital during the same period. The hemodynamic characteristics of patients with NP and NAM were compared. Machine learning models were used to identify risk factors associated with HI. The final model was visualized via a nomogram. RESULTS Forty-eight (41%) out of 117 patients experienced HI, which was significantly more than that for NAM. A multivariate logistic regression including age, tumor size, fasting plasma glucose, and preoperative systolic blood pressure showed good discrimination measured by area under curve (0.8286; 95% CI 0.6875-0.9696 and 0.7667; 95% CI 0.5386-0.9947) for predicting HI in internal and independent validation cohorts, respectively. The sensitivities and positive predictive values were 0.6667 and 0.7692 for the internal and 0.9167 and 0.6111 for the independent validations, respectively. The final model was visualized via a nomogram and yielded net benefits across a wide range of risk thresholds in decision curve analysis. CONCLUSION Patients with NP experienced HI during laparoscopic adrenalectomy. The nomogram can be used for individualized prediction of intraoperative HI in patients with NP.
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Affiliation(s)
- Yingshu Liu
- Dalian Medical University, Dalian, Liaoning 116044, China
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Chao Liu
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Yao Wang
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Shen Li
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Xinyu Li
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Xuhan Liu
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Bing Wang
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Zuowei Pei
- Department of Cardiology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Linfeng Li
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Lu Lin
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jianchang Qu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Kang Chen
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Li Zang
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhaohui Lyu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhengnan Gao
- Dalian Medical University, Dalian, Liaoning 116044, China
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
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Ma L, Yu X, Huang Y. Risk factors for postoperative complications after pheochromocytoma and/or paraganglioma: a single-center retrospective study. Front Oncol 2023; 13:1174836. [PMID: 37213287 PMCID: PMC10198611 DOI: 10.3389/fonc.2023.1174836] [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: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Background Perioperative complications are higher in patients with pheochromocytoma and/or paraganglioma. The aim of this study was to identify the risk factors of postoperative complications after pheochromocytoma and/or paraganglioma resection surgery. Method We retrospectively reviewed 438 patients who underwent laparoscopic or open surgery for pheochromocytoma and/or paraganglioma at our center between January 2014 and December 2019. Demographic characteristics and intraoperative and postoperative data were recorded. Complications were defined as deviations from the normal postoperative course and Clavien-Dindo classification was used to grade the severity of postoperative complication. Patients with complications of grade II or above were included for analysis. Binary logistic regression was used to determine the risk factors for postoperative complications. Results The median age of the patients was 47 years old. There were 295 cases (67.4%) of phepchromocytoma and 143 cases (32.6%) of paraganglioma. Three hundred sixty-seven (87.8%) patients had laparoscopic approach, and 55 (12.6%) patients had laparotomy; the conversion rate from laparoscopy to laparotomy was 3.7%. Eighty-seven complications occurred in 65 patients (14.8%). No death occurred in our study and transfusion (36, 8.2%) was the most common complication. The mean follow-up length was 14 months. Independent risk factors for postoperative complications included a tumor size larger than 5.6 cm (OR = 2.427, 95% CI 1.284-4.587, P = 0.006), laparotomy (OR 2.590, 95% CI 1.230-5.453, P = 0.012), conversion to laparotomy (OR = 8.384, 95% CI 2.247-31.285, P = 0.002), and the operation time longer than 188 min (OR = 3.709, 95% CI 1.847-7.450, P < 0.001). Conclusion Complications were not uncommon after pheochromocytoma and/or paraganglioma surgery. Tumor size, surgical type, and operation time were determined as the risk factors for postoperative complications. These factors should be considered to improve perioperative management.
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Yao Y, Guo Y, Fan J, Lin T, Wang L, Zhang S. Influence of duration of preoperative treatment with phenoxybenzamine and secretory phenotypes on perioperative hemodynamics and postoperative outcomes in pheochromocytoma and paraganglioma. Front Endocrinol (Lausanne) 2023; 14:1139015. [PMID: 37152936 PMCID: PMC10154584 DOI: 10.3389/fendo.2023.1139015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
Objectives Resection of pheochromocytoma and paraganglioma (PPGL) carries risks with perioperative hemodynamic instability. Phenoxybenzamine (PXB) is a commonly used α-blockade to prevent it. It is unclear whether lengthening the preoperative duration of PXB is better for hemodynamic stability and postoperative outcomes. Furthermore, different types of catecholamines have varying effects on perioperative hemodynamics. Thus, our study aimed to investigate the impact of the duration of preoperative preparation with PXB and secretory phenotypes of the patients on intraoperative hemodynamic stability and postoperative complications in PPGL. Methods Between Dec 2014 and Jan 2022, 166 patients with PPGL were operated on by the same team at Sun Yat-sen Memorial Hospital. They were divided into group A(1-14d), Group B(15-21d), and Group C(>21d) based on the duration of management with PXB and into the adrenergic and the noradrenergic phenotype group based on secretory profiles. Data on intraoperative hemodynamics and postoperative outcomes were collected and compared among groups. Results A total of 96 patients occurred intraoperative hemodynamic instability, and 24 patients had 29 postoperative complications related to the surgery. Among the 145 patients treated with PXB, no significant differences were found in the cumulative time outside the target blood pressure(6.67%[0-17.16%] vs. 5.97%[0-23.08%] vs. 1.22%[0-17.27%], p=0.736) or in the median total HI-score(42.00[30.00-91.00] vs. 89.00[30.00-113.00] vs. 49.00[30.00-93.00], p=0.150) among group A(n=45), B(n=51) and C(n=49). Multivariate analysis demonstrated that the level of plasma-free metanephrine(MN) was an independent risk factor for intraoperative hemodynamic instability. And the median cumulative time outside of the target blood pressure in the adrenergic phenotype group was significantly greater than that in the noradrenergic phenotype group(8.17%[0-26.22%] vs. 1.86%[0-11.74%], p=0.029). However, the median total HI-score(99.50[85.00-113.25] vs. 90.00[78.00-105.00], p=0.570) and postoperative outcomes showed no differences between the two groups. Conclusions A preoperative duration of nearly 14 days with PXB is sufficient for ensuring intraoperative hemodynamic stability in PPGL. And lengthening the preparation duration may not provide additional benefits in the era of widespread application and advanced techniques of laparoscopic surgery. Additionally, patients with the adrenergic phenotype are more prone to intraoperative hemodynamic instability than the noradrenergic phenotype. Thus, more attention should be given to the adrenergic phenotype during surgery.
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Affiliation(s)
- Yao Yao
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Guo
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Fan
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lin Wang
- Department of Pathology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Shaoling Zhang, ; Lin Wang,
| | - Shaoling Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Shaoling Zhang, ; Lin Wang,
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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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Pang Y, Li M, Jiang J, Chen X, Fu Y, Wang C, He Y, Zhao Y, Wang Y, Guan X, Zhang L, Xu X, Gan Y, Liu Y, Xie Y, Tang T, Wang J, Xie B, Liang Z, Chen D, Liu H, Chen C, Eisenhofer G, Liu L, Yi X, Chen BT. Impact of body composition and genotype on haemodynamics during surgery for pheochromocytoma and paraganglioma. J Cachexia Sarcopenia Muscle 2022; 13:2843-2853. [PMID: 36068986 PMCID: PMC9745493 DOI: 10.1002/jcsm.13071] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Maintaining intraoperative haemodynamic stability can reduce cardiovascular complications during surgery for pheochromocytoma and paraganglioma (PPGL). Risk factors such as tumour size and catecholamine levels are reported to predict haemodynamic responses during surgery for PPGL. We hypothesized that additional factors including body composition and genetic information could further improve prediction. METHODS Consecutive patients with PPGL confirmed by surgical pathology between June 2010 and June 2019 were retrospectively included. Cross-sectional computed tomography images at the L3 level were used to assess body composition parameters including skeletal muscle area and visceral fat area. Next-generation sequencing was performed using a panel containing susceptibility genes of PPGL. Differences in clinical-genetic characteristics and body composition parameters were analysed and compared in patients with and without intraoperative haemodynamic instability (HDI). RESULTS We included 221 patients with PPGL (median age 47 [38-56] years, and 52% male). Among them, 49.8% had Cluster 2 mutations (related to kinase signalling pathways), 44.8% had sarcopenia, and 52.9% experienced intraoperative HDI. Compared with patients without HDI, more patients with HDI had Cluster 2 mutations (59.8% vs. 38.5%, P = 0.002) and less had sarcopenia (35.9% vs. 54.8%, P = 0.005). Multivariate analysis showed that urine vanillylmandelic acid ≥ 58 μmol/day (adjusted odds ratio [OR] = 1.840, 95% confidence interval [CI] = 1.012-3.347, P = 0.046), tumour size ≥ 4 cm (adjusted OR = 2.278, 95% CI = 1.242-4.180, P = 0.008), and Cluster 2 mutations (adjusted OR = 2.199, 95% CI = 1.128-4.285, P = 0.021) were independent risk factors for intraoperative HDI, while sarcopenia (adjusted OR = 0.475, 95% CI = 0.266-0.846, P = 0.012) decreased the risk. CONCLUSIONS Body composition and genotype were associated with intraoperative haemodynamics in patients with PPGL. Our results indicated that inclusion of body composition and genotype in the overall assessment of patients with PPGL helped to predict HDI during surgery, which could assist in implementing preoperative and intraoperative measures to reduce perioperative complications.
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Affiliation(s)
- Yingxian Pang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Minghao Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jingjing Jiang
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xiang Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yan Fu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Cikui Wang
- Department of Urology, Hubei Armed Police Corps Hospital, Wuchang, P. R. China
| | - Yao He
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yuanzhe Zhao
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yong Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiao Guan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Liang Zhang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaowen Xu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yu Gan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yalin Liu
- Xiangya School of Medicine, Central South University, Changsha, Hunan, P. R. China
| | - Yaoling Xie
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Tingyuan Tang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Jing Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Bin Xie
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Zhihao Liang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Danlei Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Haipeng Liu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Changyong Chen
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany
| | - Longfei Liu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaoping Yi
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Hunan Key Laboratory of Skin Cancer and Psoriasis, Changsha, Hunan, P. R. China.,Hunan Engineering Research Center of Skin Health and Disease, Changsha, Hunan, P. R. China.,National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Central South University, Changsha, Hunan, P. R. China
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA
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9
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Yang M, Kang C, Zhu S. Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31768. [PMID: 36451496 PMCID: PMC9704962 DOI: 10.1097/md.0000000000031768] [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] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries. METHODS This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay. RESULTS Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs. CONCLUSIONS Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.
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Affiliation(s)
- Min Yang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Chao Kang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Shuai Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- * Correspondence: Shuai Zhu, Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, China (e-mail: )
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10
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Huang YS, Yan L, Li ZY, Fang ZQ, Liu Z, Xu ZH, Gu GL. Risk factors for hemodynamic instability during laparoscopic resection of pheochromocytoma. BMC Urol 2022; 22:158. [PMID: 36180851 PMCID: PMC9526242 DOI: 10.1186/s12894-022-01109-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Laparoscopic adrenalectomy for pheochromocytoma is associated with high risk of intraoperative hemodynamic instability. Our study aimed to identify predictive factors for hemodynamic instability during laparoscopic resection of pheochromocytoma. Methods Between January 2011 and December 2021, 136 patients underwent unilateral laparoscopic adrenalectomy for pheochromocytoma. The patients were divided into 2 groups depending on the presence or absence of hemodynamic instability during surgery. Intraoperative hemodynamic parameters were compared between the 2 groups. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to intraoperative hemodynamic instability via both univariate analysis and multivariate logistic regression analysis. Results There was greater blood pressure fluctuations and higher maximum blood pressure and heart rate in the hemodynamic instability group. More patients need intraoperative administration of vasoactive drugs in the hemodynamic instability group. In the univariate analysis, presence of coronary artery disease, tumour size, and previous hypertension history were significantly associated with intraoperative hemodynamic instability. The multivariate logistic regression analysis showed that tumour size and previous hypertension history were independent risk factors for intraoperative hemodynamic instability. Conclusion Tumour size and previous hypertension history were associated with hemodynamic instability during laparoscopic resection of pheochromocytoma.
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Affiliation(s)
- Yong-Sheng Huang
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Lei Yan
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Ze-Yan Li
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Zhi-Qing Fang
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Zhao Liu
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Zhong-Hua Xu
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China
| | - Gang-Li Gu
- Department of Urology, Qilu Hospital, Shandong University, No 107, Wenhuaxi Road, 250012, Jinan, PR China.
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11
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Fagundes GFC, Almeida MQ. Perioperative Management of Pheochromocytomas and Sympathetic Paragangliomas. J Endocr Soc 2022; 6:bvac004. [PMID: 35128297 PMCID: PMC8807163 DOI: 10.1210/jendso/bvac004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors arising from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia, respectively. PPGLs have the highest degree of heritability among endocrine tumors. Currently, ~40% of individuals with PPGLs have a genetic germline and there are at least 12 different genetic syndromes related to these tumors. Metastatic PPGLs are defined by the presence of distant metastases at sites where chromaffin cells are physiologically absent. Approximately 10% of pheochromocytomas and ~40% of sympathetic paragangliomas are linked to metastases, explaining why complete surgical resection is the first-choice treatment for all PPGL patients. The surgical approach is a high-risk procedure requiring perioperative management by a specialized multidisciplinary team in centers with broad expertise. In this review, we summarize and discuss the most relevant aspects of perioperative management in patients with pheochromocytomas and sympathetic paragangliomas.
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Affiliation(s)
- Gustavo F C Fagundes
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 05403-000 São Paulo, Brasil
| | - Madson Q Almeida
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 05403-000 São Paulo, Brasil
- Unidade de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, 01246-000 São Paulo, Brasil
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12
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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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