Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma?

Abstract

Phaeochromocytomas and paragangliomas (PPGLs) are catecholamine secreting neuroendocrine tumours that predispose to haemodynamic instability. Currently, surgery is the only available curative treatment, but carries potential risks including hypertensive and hypotensive crises, cardiac arrhythmias, myocardial infarction and stroke, due to tumoral release of catecholamines during anaesthetic induction and tumour manipulation. The mortality associated with surgical resection of PPGL has significantly improved from 20-45% in the early 20th century (Apgar & Papper, AMA Archives of Surgery, 1951, 62, 634) to 0-2·9% in the early 21st century (Kinney et al. Journal of Cardiothoracic and Vascular Anesthesia, 2002, 16, 359), largely due to availability of effective pharmacological agents and advances in surgical and anaesthetic practice. However, surgical resection of PPGL still poses significant clinical management challenges. Preoperatively, alpha-adrenoceptor blockade is the mainstay of management, although various pharmacological strategies have been proposed, based largely on reports derived from retrospective data sets. To date, no consensus has been reached regarding the 'ideal' preoperative strategy due, in part, to a paucity of data from high-quality evidence-based studies comparing different treatment regimens. Here, based on the available literature, we address the Clinical Question: Is there an optimal preoperative management strategy for PPGL?

Effect of High or Low Dose Phenoxybenzamine on Per-Operative Hemodynamics in Pheochromocytoma

“…Furthermore, no major complications related to perioperative hypertensive episodes were reported. This is in agreement with the previous reports questioning the impact of alpha-receptor blockade prior to PPGL surgery for improving outcome and highlighting the anaesthesiological expertise for successful management [4,7,15]. Speculation on avoiding alpha-receptor pretreatment in certain groups of patients with PPGL has been raised [4,8,[16][17][18].…”

“…Previously the mortality related to surgical resection was high. However, with the improvement in pharmacological agents available and advances in surgical and anaesthetic practice, mortality has significantly reduced within the last decades [1,[3][4][5]. The mainstay in preoperative pharmacological therapy is alpha-adrenergic blockade to reduce effect of catecholamines released during anaesthesia and surgery and to optimize circumstances for hemodynamic stability [1].…”

“…Hence, guidelines regarding alpha-blockade dosage strategies are primarily based on retrospective studies and expert opinion, and clinical practice vary between centers. Furthermore, progress in surgical and anaesthetic practice within the last decades are speculated to have greater impact on per-operative outcome than pretreatment with alpha-receptor blockers [4,7]. As pretreatment is time consuming, related with significant side-effects and carries a risk of postoperative hypotension it has been speculated to be redundant and a preoperative risk stratification of patients may be usefull [8,9].…”

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

“…Our data suggest that there is no rationale for preoperative fluid therapy as recommended in guidelines or even excessive fluid administration (up to 6 l of saline 0.9% within 48 h preoperatively have been reported even recently [39]). Normalizing hypertension with antihypertensive drugs (in our trial, treatment was started at least 3 weeks before surgery) should help "normalize" fluid status, if at all altered.…”

Вплив Рентгенендоваскулярної Селективної Електрокоагуляційної Оклюзії Судин Надниркових Залоз На Періопераційні Зміни Гемодинаміки В Пацієнтів, Які Перенесли Лапароскопічну Адреналектомію З Приводу Феохромоцитом Та Інших Адренальних Пухлин

“…Низка авторів вважають доцільним подовжити цей термін до 2-6 тижнів [13]. Проте навіть проведення адекватної блокади не забезпечує відсутності ГН, яка залишається поширеним явищем під час адреналектомії з приводу феохромоцитоми [14][15][16]. Частота епізодів інтраопераційної ГН у ході ЛА з приводу феохромоцитоми варіює від 17% до 83% [13,14].…”