Haemodynamic instability of the phaeochromocytoma

Intraoperative hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma without preoperative medical preparation compared with nonsecreting tumor

BACKGROUND

Control of hemodynamic features during adrenalectomy for pheochromocytoma is recommended to minimize perioperative cardiovascular complications. However, episodes of intraoperative hemodynamic instability have been observed during adrenalectomies with other indications than pheochromocytoma. The objective of this study was to compare the hemodynamic instability score assessed during unilateral adrenalectomy for pheochromocytoma without preoperative medical preparation to hemodynamic instability score in nonsecreting tumor.

METHODS

This was an observational study with prospective intraoperative hemodynamic data collection (every 20 seconds) and retrospective analysis.

RESULTS

During the study period, 60 consecutive patients (30 pheochromocytomas vs 30 nonsecreting tumors) were included with a median number of data collections during total procedure time of 318 (interquartile range, 257-388). Mean cumulative intraoperative time outside the target blood pressure range expressed as a percentage of total procedure time was 13.3% vs 6.8% for systolic blood pressure >160 mm Hg (P = .01) and 2.4% vs 2.8% for mean arterial pressure <60 mm Hg (P = ns), respectively. The median hemodynamic instability score during total procedure time was 33 (interquartile range, 27-43) and 20 (interquartile range, 11-26) in the pheochromocytoma and nonsecreting tumor group, respectively (P < .01). Hemodynamic instability score were similar in patients with compared with without long-term antihypertensive treatment in each patient group (P = ns). The mean length of hospital stay was 2.0 ± 1.5 days, and 30-day morbidity rate was 6.6% (4/60) with no significant difference observed between both groups.

CONCLUSION

Although intraoperative hemodynamic instability remains greater in the pheochromocytoma group without preoperative medical preparation, both groups have similar hypotensive episodes. These data highlight the need to better understand the role of preoperative medical preparation in pheochromocytoma patients.

Hemorrhage in pheochromocytoma surgery: evaluation of preoperative risk factors

OBJECTIVE

Pheochromocytoma surgery carries a higher risk of hemorrhage. Our objective was to identify preoperative risk factors for hemorrhage during pheochromocytoma surgery.

METHODS

Patients who underwent surgery and with postoperative pathological confirmation were enrolled. A total of 251 patients from our center were included in the investigation, and 120 patients from the First Affiliated Hospital, Sun Yat-sen University were included as an external validation dataset. Family and medical history, demographics, hemodynamics, biochemical parameters, image data, anesthesia and operation records, postoperative outcomes were collected. Postoperative complications were graded by the Clavien-Dindo classification. Correlation between intraoperative hemorrhage volume and postoperative outcomes was assessed. The features associated with intraoperative hemorrhage were identified by linear regression. All features that were statistically significant in the multiple linear regression were then used to construct models and nomograms for predicting intraoperative hemorrhage. The constructed models were evaluated by Akaike Information Criterion. Finally, internal and external validations were carried out by tenfold cross-validation.

RESULTS

Intraoperative hemorrhage volume was positively correlated with the postoperative hospitalization time (R = 0.454, P < 0.001) and the Clavien-Dindo grades (R = 0.664, P < 0.001). Features associated with intraoperative hemorrhage were male gender (β = 0.533, OR = 1.722, P = 0.002), tumor diameter (β = 0.027, OR = 1.027, P < 0.001), preoperative CCB use (β = 0.318, OR = 1.308, P = 0.123) and open surgery (β = 1.175, OR = 3.234, P < 0.001). Validations showed reliable results (internal (R = 0.612, RMSE = 1.355, MAE = 1.111); external (R = 0.585, RMSE = 1.398, MAE = 0.964)).

CONCLUSION

More intraoperative hemorrhage is correlated with longer postoperative hospitalization time and more severe postoperative complications. Male gender, larger tumor, preoperative CCB use and open surgery are preoperative risk factors for hemorrhage in PCC surgery.

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

Purpose

Surgery 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.

Methods

There 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.

Results

Thirty-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.

Conclusions

This 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.

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.