Laparoscopic adrenalectomy for pheochromocytoma: evaluation of experience and strategy at a single institute

[Surgical treatment of pheochromocytoma]

This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.

Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk score

BACKGROUND

Due to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring.

METHODS

Data for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score.

RESULTS

PH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI95%, 1.09-3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI95%, 1.74-5.55, p < 0.001), open surgery (OR: 3.31, CI95%, 1.57-6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI95%, 0.48-1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively.

CONCLUSION

The derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.

Management of Patients with Treatment of Pheochromocytoma: A Critical Appraisal

Simple Summary

Preoperative medical preparation with an alpha blockade has been implemented early 1960s to prevent intraoperative hemodynamic instability and consequently decrease morbi-mortality in patients at a high risk of complications. Indeed, surgery at that time consisted of open adrenalectomies with a high morbidity and mortality rate. Current clinical guidelines are based on these early experiences. However, emerging technologies have permitted a drastic reduction of the morbi-mortality rate in patients treated for pheochromocytoma. However, the clinical guidelines have not evolved at the same rate. The aim of this systematic review is to assess the evolution of the management of pheochromocytomas and to appraise the current clinical guidelines to the current clinical practices.

Abstract

The management of pheochromocytomas has significantly evolved these last 50 years, especially with the emergence of new technologies such as laparoscopic procedures in the 1990s. A preoperative blockade using antihypertensive medications to prevent intraoperative hemodynamic instability and cardiocirculatory events is recommended by current clinical guidelines. However, these guidelines are still based on former experiences and are subject to discussion in the scientific community. The aim of this systematic review was to assess the evolution of the management of pheochromocytomas. Laparoscopic procedure is established as the standard of care in current practices. Preoperative medical preparation should be questioned because it does not significantly improve intraoperative events or the risk of postoperative complications in current clinical practice. Current clinical recommendations should be revised and upgraded to current clinical practices.

When a Multidisciplinary Approach Is Life-Saving: A Case Report of Cardiogenic Shock Induced by a Large Pheochromocytoma

BACKGROUND

Pheochromocytoma is known for its instantaneous presentation, especially in the younger population. Hemodynamic instability may be the cause of severe complications and impede patients' ability to undergo surgical treatment. These tumours are surgically difficult to treat due to the risk of catecholamine release during their manipulations, and when they are large, the tumour size represents an additional challenge. In our report, cardiogenic shock developed due to increases in systemic vascular resistance, and the lesion's size induced surgeons to perform open surgery.

CASE PRESENTATION

A 46-year-old female patient was admitted to our intensive care unit with hypertension and later cardiogenic shock. Systolic dysfunction was noted, along with severely increased systemic vascular resistance. A CT scan showed a left-sided 8.5 cm adrenal mass, which was confirmed as pheochromocytoma using meta-iodobenzylguanidine scintigraphy. Anaesthesiologists and the surgical team planned an effective strategy of treatment. Given the lesion's size and its apparent invasion of the neighbouring organs, open adrenalectomy (after prolonged hemodynamic stabilisation) was considered safer. The surgery was successful, and the patient remains free from disease two years after the initial event.

CONCLUSIONS

Large pheochromocytoma can be safely and effectively treated with open surgery by experienced hands but only by seeking to reach hemodynamic stabilisation and minimising the release of catecholamine before and during surgery.

Predictors of prolonged hypotension requiring vasopressor support after resection of pheochromocytoma and paraganglioma

OBJECTIVE

Prolonged hypotension is a common complication after resection of pheochromocytoma (PCC) or paraganglioma (PGL). The objective of our study was to identify preoperative or intraoperative clinical factors that can predict prolonged hypotension after PCC/PGL resection.

PATIENTS AND METHODS

A total of 414 patients who underwent resection of PCC or PGL at our institution between January 2013 and January 2020 were included. Patients were divided into two groups according to whether or not vasopressor support was required postoperatively. Associations between preoperative and intraoperative variables and prolonged hypotension were evaluated.

RESULTS

Two hundred and one (48.6%) patients had postoperative hypotension that required vasopressor support with a median duration of 20 h. Multivariable analysis demonstrated that increased 24-h urinary norepinephrine (NE) levels (odds ratio [OR] = 1.091, 95% confidence interval [CI]: 1.052-1.132, p < .001), longer operative time (OR = 1.008, CI: 1.004-1.011, p < .001) and lower preoperative phenoxybenzamine dose (OR = 0.336, CI: 0.150-0.753, p = .008) were predictors of prolonged hypotension. Moreover, operative time, body mass index, 24-h urinary level of NE and preoperative phenoxybenzamine dose were significantly correlated with the duration of postoperative vasopressor support.

CONCLUSIONS

Increased urine NE level, longer operative time and lower preoperative phenoxybenzamine dose were predictors of prolonged hypotension requiring vasopressor support. Clinicians can identify these factors to manage their patients better and prevent severe complications.

Risk factors for hemodynamic instability during laparoscopic pheochromocytoma resection: a retrospective cohort study

Background

Adrenalectomy for pheochromocytoma, a rare catecholamine-secreting tumour, is a challenging procedure because of the high risk of intraoperative hemodynamic instability, which can cause life-threatening complications. Our study aimed to identify predictive factors for hemodynamic instability during pheochromocytoma resection as well as to assess the risk factors for postoperative morbidity.

Methods

Data of 96 patients, who underwent laparoscopic adrenalectomy were analysed retrospectively. Hemodynamic instability was defined as an occurrence of both intraoperative episodes of systolic blood pressure above 160 mmHg and vasoactive (vasodilators or vasoconstrictors) drug administration. Patients were divided into two groups: one which met both criteria, and another one without hemodynamic instability-42 (43.8%) and 54 (56.2%) respectively.

Results

The mean tumour size was 4.5±2.0 cm. 86 patients had a sporadic pheochromocytoma and 10 (10.4%) had a familial disease. Sixty-three patients were preoperatively treated with nonselective blockers and 33 patients with selective blockers. Mean operative time was 98.7±41.7 min. and mean intraoperative blood loss was 165.7±381.2 mL. In 26% of patients, postoperative complications occurred. The median length of hospital stay was 3 days. The multivariate logistic regression model showed that the size of adrenal tumour and diabetes were significant factors of hemodynamic instability. Intraoperative use of vasopressors was an independent risk factor for both all-cause and cardiovascular morbidity.

Conclusions

Adrenal tumour size and diabetes were associated with hemodynamic instability during pheochromocytoma resection. The only risk factor for complications in our group was intraoperative necessity to use vasopressors.

Incidence, risk factors and clinical significance of postoperative haemodynamic instability after adrenalectomy for phaeochromocytoma

Background

Due to risk of haemodynamic instability (HDI), it has been recommended that patients undergoing adrenalectomy for phaeochromocytoma should be monitored in an intensive care facility. The aim of this study was to evaluate the incidence, risk factors and outcomes of postoperative HDI in these patients. Retrospective cohort study of 46 consecutive patients who underwent open (OA, N=26) or laparoscopic (LA, N=20) adrenalectomy for phaeochromocytoma at a single centre [2007-2017].

Methods

HDI was defined as systolic BP >200 or <90 mmHg, heart rate >120 or <50 bpm or vasopressor therapy within 24 hours. Risk factors for intraoperative and postoperative HDI were evaluated by univariable and multivariable analyses.

Results

Intraoperative hypertension occurred in 25/42 patients (60%). Preoperative plasma normetanephrine levels ≥3,500 pmol/L were significantly associated with intraoperative hypertension on multivariable analysis [odds ratio (OR) 42; 95% CI: 4-429; P=0.002). Postoperative hypotension occurred in 21/45 patients (47%), and 13 (29%) required vasopressor therapy. Preoperative beta-blockade therapy was the only independent risk factor for postoperative hypotension on multivariable analysis (OR 4.0; 95% CI: 1.2-13.9, P=0.029). No patients (0/9) with tumours <5 cm treated by LA needed postoperative vasopressor therapy, compared to 39% (7/18) treated by OA (P=0.059). Complications developed in 9 patients (20%), and were less likely in those with intraoperative hypertension (8% vs. 41%; P=0.019). There was one postoperative death.

Conclusions

Preoperative beta-blockade therapy is an independent risk factor for postoperative HDI after adrenalectomy for phaeochromocytoma. Patients who undergo laparoscopic adrenalectomy (LA) for phaeochromocytomas <5 cm are unlikely to need postoperative vasopressor therapy, and may not require intensive care monitoring.

Multidisciplinary management of a large pheochromocytoma presenting with cardiogenic shock: a case report

BACKGROUND

Pheochromocytoma is well-known for sudden initial presentations, particularly in younger patients. Hemodynamic instability may cause serious complications and delay a patient's ability to undergo surgical resection. Larger tumors present a further challenge because of the risk of catecholamine release during manipulations. In the case we present, increases in systemic vascular resistance caused cardiogenic shock, and the size of the lesion prompted surgeons to veer off from their usual approach.

CASE PRESENTATION

A 38-year-old female patient was admitted to our intensive care unit with hypertension and later cardiogenic shock. Profound systolic dysfunction (left ventricular ejection fraction of 0.12) was noted together with severely increased systemic vascular resistance, and gradually responded to vasodilator infusion. A left-sided 11-cm adrenal mass was found with computed tomography and confirmed a pheochromocytoma with a meta-iodo-benzyl-guanidine scintigraphy. Surgical treatment was carefully planned by the endocrinologist, anesthesiologist and surgeon, and was ultimately successful. After prolonged hemodynamic stabilization, open adrenalectomy and nephrectomy were deemed safer because of lesion size and the apparent invasion of the kidney. Surgery was successful and the patient was discharged home 5 days after surgery. She is free from disease at almost 2 years from the initial event.

CONCLUSIONS

Large, invasive pheochromocytoma can be safely and effectively managed with open resection in experienced hands, provided all efforts are made to achieve hemodynamic stabilization and to minimize. Catecholamine release before and during surgery.

Risk factors for postoperative cardiovascular morbidity after pheochromocytoma surgery: a large single center retrospective analysis

Surgical resection is the primary treatment strategy for pheochromocytoma; however, it carries a high risk of morbidity and mortality, especially with respect to cardiovascular complications, which is the most common kinds of morbidity. The risk factors for morbidity remain unclear and require further exploration, moreover no studies focus on risk factors for cardiovascular morbidity. Herein we identified the risk factors for cardiovascular morbidity after pheochromocytoma surgery in Chinese patients. We retrospectively reviewed 262 patients who underwent unilateral surgical resection of pheochromocytoma at our center between 1 January 2007 and 31 December 2016. Patient demographics and extensive perioperative data were recorded and evaluated. Adjusted odds ratios and 95% confidence intervals were determined by multivariate logistic regression. Cut-off values and the area under the curve for continuous risk factors were calculated based on receiver operating characteristic curve analysis. A p-value <0.05 was considered statistically significant. Of the 262 patients, 63 (24.0%) had cardiovascular morbidity. The independent risk factors for cardiovascular morbidity were low body mass index, large radiographic tumor size, coronary heart disease, no preoperative crystal/colloid administration, and intraoperative hemodynamic instability; the corresponding odds ratio were 0.762 (p < 0.001), 1.208 (p = 0.010), 2.378 (p = 0.012), 2.720 (p = 0.011), and 4.764 (p = 0.001), respectively. The optimal cut-off values for body mass index and radiographic tumor size were 24.59 kg/m² and 6.05 cm. We found that cardiovascular morbidity is common in patients after pheochromocytoma surgery. We identified five independent risk factors for cardiovascular morbidity. Identification of these risk factors may help to improve treatment strategies.

Comparison of transperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: A retrospective propensity score-matched cohort study

BACKGROUND

Surgical resection is the main treatment strategy for pheochromocytoma. Whether laparoscopic techniques are feasible for large pheochromocytoma treatments is controversial. The aim of this study was to evaluate the feasibility and safety of transperitoneal laparoscopic adrenalectomy (LA) compared with open adrenalectomy (OA).

METHODS

We retrospectively studied 182 patients with radiographic tumor sizes ≥ 6 cm who underwent adrenalectomy at our center between 1 January 2007 and 31 December 2017. After propensity score-matching to balance baseline variables, 82 patients treated with LA and 100 patients treated with OA were grouped into 64 pairs. Patient demographics, and extensive peri-operative and oncologic data were recorded and compared.

RESULTS

In the matched group, the incidence of intra-operative hemodynamic instability, transfusion rate, prolonged hypotension, and cardiovascular morbidity in the LA group were lower than the OA group (25.0% vs. 48.4%, 29.7% vs. 46.9%, 4.7% vs. 23.4%, and 14.1% vs. 37.5%, respectively). The estimated blood loss was less (100 ml vs. 300 ml) and bowel recovery was quicker (1.9 d vs. 2.3 d) in the LA group. The proportion of patients in whom blood pressure returned to normal (P = 0.184), had recurrences (P = 0.197), and survived (P = 0.763) were equivalent. The surgical approach (OA vs. LA) was an independent risk factor for IHD, prolonged hypotension, cardiovascular morbidity, and longer bowel recovery.

CONCLUSIONS

This propensity score-matched cohort study showed that LA was feasible, safe, and superior to OA for patients with large pheochromocytoma, meanwhile LA had comparable oncological outcomes compared with OA after a lengthy follow-up.

Risk factors for prolonged hypotension in patients with pheochromocytoma undergoing laparoscopic adrenalectomy: a single-center retrospective study

Prolonged hypotension during pheochromocytoma resection is a significant complication. We sought to investigate the predictors of prolonged hypotension in patients with pheochromocytoma undergoing laparoscopic adrenalectomy (LA). Patients with pheochromocytoma who underwent LA between 2012 and 2015 were surveyed. Patients were considered to have prolonged hypotension if they had a mean arterial blood pressure <60 mmHg or required ≥30 consecutive minutes of catecholamine support intraoperatively. Among 123 patients, 54 (43.9%) developed prolonged hypotension requiring ≥30 consecutive minutes of catecholamine support. Compared with patients with nonprolonged hypotension, those with prolonged hypotension had higher levels of urinary norepinephrine (P = 0.011), epinephrine (P < 0.001), and dopamine (P = 0.019) preoperatively, and a higher incidence of vital organ injury postoperatively (P = 0.039). Multivariate logistic analysis showed that independent predictors for prolonged hypotension were multiples of the normal reference upper limit value of urinary epinephrine (odds ratio, 1.180; 95% confidence interval, 1.035–1.345) and dopamine (odds ratio, 4.375; 95% confidence interval, 1.207–15.855). The levels of preoperative urinary epinephrine and dopamine are clinical predictors for prolonged hypotension in patients with pheochromocytoma undergoing LA. Using these parameters, clinicians can assess and manage this patient population more effectively.

Perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma

Perioperative hemodynamic instability still remains the biggest surgical and anesthetic challenge in surgery for pheochromocytoma. The aim of this review was to discuss pre-, intra- and postoperative factors that may impact on hemodynamic condition of a patient. It describes patients' preparation with appropriate medication, principles of surgical technique as well as risk factors for development of hemodynamic instability in postoperative period. Currently the gold standard in the treatment of pheochromocytoma is preoperative use of alpha-blockers and laparoscopic surgery. This approach allowed improving outcomes by lowering both mortality and morbidity.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

OBJECTIVE

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series.

MATERIAL AND METHODS

322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications.

RESULTS

Twenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V).

CONCLUSIONS

Standardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Laparoscopic adrenal surgery in children: Lessons from a single centre experience

PURPOSE:

Although commonly performed in adults, laparoscopic adrenalectomy in children is performed only in centres with advanced laparoscopic expertise.

MATERIALS AND METHODS:

This is a retrospective analysis of laparoscopic adrenalectomies performed at a single centre between January 2003 and May 2010. After preoperative evaluation with biochemical assays and radiologic imaging, surgery was performed by using the lateral transabdominal approach in all patients.

RESULTS:

Ten laparoscopic adrenalectomies (including three bilateral) were performed in seven children, with a mean age of 9.6 years. The tumours ranged from 2 – 7 cms in size. The operative durations were 75 – 130 minutes (unilateral) and 250 – 270 minutes (bilateral). Operative blood loss was minimal. There were no open conversions, but terminal hand assistance was required in one large right pheochromocytoma. The postoperative hospital stay ranged from 3 – 10 days. The final pathological diagnoses included pheochromocytoma, hyperplasia and neuroblastoma. Follow-up at 24 – 87 months was uneventful.

CONCLUSION:

With adequate experience in laparoscopy, it is possible to perform adrenalectomy in selected children.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group

OBJECTIVE

To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain.

PATIENTS AND METHODS

The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed.

RESULTS

The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively.

CONCLUSION

LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.