Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Berends, Annika M A; Kerstens, Michiel N.; Lenders, Jacques W.M.; Timmers, Henri J L M

doi:10.1210/clinem/dgaa441

Cited by 42 publications

(48 citation statements)

References 138 publications

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“…Current guidelines suggest that in order to normalize BP of PCC patients, the preoperative medication should be initiated 7 to 14 days before surgery, and adrenergic blockade is recommended as the first choice mostly ( 1 , 8 ). Liu et al ( 13 ) reported that preoperative adrenergic blockade treatment duration ≤ 14 days was a risk factor of massive hemorrhage in PCC surgery and increased RBC transfusion rate.…”

Section: Discussionmentioning

confidence: 99%

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A Predictive Nomogram for Red Blood Cell Transfusion in Pheochromocytoma Surgery: A Study on Improving the Preoperative Management of Pheochromocytoma

Guo

You

et al. 2021

Front. Endocrinol.

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PurposeSurgery 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.MethodsThere 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.ResultsThirty-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.ConclusionsThis 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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Section: Discussionmentioning

confidence: 99%

“…Pheochromocytoma (PCC) is a catecholamine secreting tumor arising from chromaffin cells of the adrenal medulla. Circulating catecholamines cause a series of clinical symptoms such as elevated blood pressure, palpitation, headache, as well as heart, brain, kidney and other organ complications ( 1 ).…”

Section: Introductionmentioning

confidence: 99%

A Predictive Nomogram for Red Blood Cell Transfusion in Pheochromocytoma Surgery: A Study on Improving the Preoperative Management of Pheochromocytoma

Guo

You

et al. 2021

Front. Endocrinol.

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“…The primary goals of the preoperative treatment of pheochromocytomas and sympathetic PGLs are to normalize BP and HR, restore cardiac volume depletion, and avoid the risk of a catecholaminergic storm and its negative consequences on the cardiovascular system induced by surgery. The objectives of the preoperative treatment are [1,43]:…”

Section: Presurgical Treatmentmentioning

confidence: 99%

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

Araujo‐Castro

Pascual‐Corrales

Nattero‐Chávez

et al. 2021

J Endocrinol Invest

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Objective To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). Methods This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. Results Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. Conclusions An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction. Keywords Pheochromocytoma • Paragangliomas • Presurgical management • Anesthetic treatment • α-blockadeThis article was elaborated by the multidisciplinary adrenal/ paraganglioma team of the Hospital Ramón y Cajal. Madrid (Spain).

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“…Before surgery, current recommendations include management with alpha-blockers and volume expansion using saline, aiming to prevent hemodynamic intraoperative complications during surgery derived from a massive catecholamine release while the tumor is in situ and a marked blood pressure fall that starts when large veins are sectioned. In 2014, our center started a preoperative protocol similar to one recently published [ 20 ] that also involves monitoring patient blood pressure/electrocardiogram/glucose during and after surgery via arterial catheters. We found fewer hypertensive crises over the past decade, compared with similar cohorts that did not apply such preparation protocols [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A 4-Decade Experience

Uslar¹,

Francisco

Olmos³

et al. 2021

Journal of the Endocrine Society

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Purpose Latin American reports on pheochromocytomas and paragangliomas (PPGL) are scarce. Recent studies demonstrate changes in clinical presentation and management of these patients. Herein, we assessed the main characteristics of PPGL patients in our academic center over the last four decades. Methods Demographic, clinical, biochemical and perioperative data from 105 PPGL patients were retrospectively and prospectively collected over the 1980-2019 period. Data were organized into four time periods by decades. Results Age at diagnosis, gender, tumor size and percentage of bilaterality, percentage of paragangliomas and metastases remained stable across the four decades. The proportion of genetic testing and incidentalomas increased in recent decades (all p<0.001). Therefore, we compared PPGLs diagnosed as incidentalomas (36%) to those clinically suspected (64%). Incidentalomas had fewer adrenergic symptoms (38 vs. 62%; p<0.001), lower rates of hypertension (64 vs. 80%; p=0.01) and hypertensive crisis (28 vs. 44%; p=0.02); also they had lower functionality (79 vs. 100%; p=0.01) and lower catecholamines levels (8.4 vs. 12.5-fold above upper cut-offs; p=0.04). Regarding management of all PPGLs over the decades, we observed significant increases in both perioperative doxazosin dose (p=0.003) and laparoscopic approach rates (p<0.001), along with a decrease in the length of hospital stays (p=0.007). Conclusions We observed a change in the clinical presentation of PPGL in recent decades, with a marked increase in incidental cases and milder symptoms. The implementation of a multidisciplinary program for adrenal disorders in our institution has translated into more timely diagnoses, more genetic testing, and improvements in perioperative management.

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Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Cited by 42 publications

References 138 publications

A Predictive Nomogram for Red Blood Cell Transfusion in Pheochromocytoma Surgery: A Study on Improving the Preoperative Management of Pheochromocytoma

A Predictive Nomogram for Red Blood Cell Transfusion in Pheochromocytoma Surgery: A Study on Improving the Preoperative Management of Pheochromocytoma

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A 4-Decade Experience

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