Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal?

Abstract

Adrenalectomy for pheochromocytoma is reported with a mortality close to zero in recent studies. The dogma of preoperative fluid and hypotensive drug administrations is widely applied in patients scheduled for pheochromocytoma removal and is assumed to have a beneficial effect on operative outcomes. This paradigm is only based on historical studies of non-standardized practices and criteria for efficacy, with no control group. Pre-and intraoperative hypovolemia have never been demonstrated in patients scheduled for pheochromocytoma removal. Recent improvements in outcome of patients undergoing adrenalectomy for pheochromocytoma could also be the result of improvement in surgical techniques and refinement in anesthetic practices. Whether better knowledge of the disease, efficiency of available intravenous short-acting vasoactive drugs, and careful intraoperative handling of the tumor make it possible to omit preoperative preparation in most patients scheduled for pheochromocytoma removal is presently questionable. We reviewed available literature in this respect.

Perioperative Management of Adrenalectomy and Inferior Vena Cava Reconstruction in a Patient With a Large, Malignant Pheochromocytoma With Vena Caval Extension

“…Vena cava cross-clamping was used intraoperatively and tolerated well, and VVB was not necessary. Preoperative care included, "as still recommended," 45 volume loading and administration of several hypotensive drugs together with an inhibitor of tyrosine hydroxylase enzyme. Intraoperatively, 4 hypotensive drugs were administered to control acute episodes of arterial hypertension resulting from tumor manipulation.…”

“…The author of this commentary believes that the time is ripe for a reappraisal of the available data regarding perioperative care of patients with pheochromocytoma. 45 Although a mortality rate of close to zero has been reported in all recent series of adrenalectomy for pheochromocytoma, irrespective of preoperative care, 45 this improved prognosis currently is attributed (1) to the widespread preoperative administration of vasodilating drugs, even to patients with normal arterial pressure in some series, and (2) to the administration of large fluid volumes, even to patients with normal or borderline elevation of catecholamine levels in other series. 1 None of these practices was evidence based.…”

“…48 Available published data clearly showed that regardless of whether patients have received fluid loading and/or regardless of the volume of fluid infused, intraoperative and postoperative courses did not differ in patients undergoing pheochromocytoma removal, as extensively reviewed. 45 Plouin et al 49 reported that high preoperative arterial pressure was correlated independently with intraoperative and postoperative complications in patients undergoing pheochromocytoma removal. However, the emphasis in that article was on non-hypertension-related complications such as allergy; pneumothorax; postoperative bleeding or pancreatitis; intraoperative surgically related liver, kidney, lung, or bladder wounds; or a pulmonary artery catheter-related complication, which would not have been associated with increased arterial pressure.…”

“…50 Irrespective of preoperative arterial pressure level or preoperative drug administration, the mortality rate was zero in these series, similar to the most recent series. 45,49,50 …”

“…45 Moreover, in general, it probably can be stated that the recommendation is for hypotensive drugs to be administered preoperatively, as is current medical practice, to patients with symptoms such as headache or tinnitus, and if systolic blood pressure is 4180 mmHg and diastolic blood pressure is4115 mmHg. 7 Indeed, these situations expose patients to an early risk in daily life.…”