Perianesthetic Risks and Outcomes of Pheochromocytoma and Paraganglioma Resection

Kinney, Michelle A.O.; Warner, Mary E.; vanHeerden, Jon A.; Horlocker, Terese T.; Young, William F.; Schroeder, Darrell R.; Maxson, Pamela M.; Warner, Mark A.

doi:10.1097/00000539-200011000-00013

Cited by 118 publications

(114 citation statements)

References 17 publications

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“…Larger tumors have been shown to result in a significant increase in the number and duration of intraoperative hypertensive episodes as a consequence of increased catecholamine release. 3, 11, 18, 19 However, in the current study, when controlling for other factors catecholamine levels alone were not associated with HDI. This suggests that the intraoperative manipulation of larger tumors may lead to the release of larger amounts of catecholamines than are recorded at baseline.…”

Section: Discussioncontrasting

confidence: 74%

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Predictors of Hemodynamic Instability During Surgery for Pheochromocytoma

et al. 2014

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Background Resection of pheochromocytoma is often associated with hemodynamic instability (HDI). We examined patient and tumor factors that may influence HDI. The effect of pre-treatment with non-selective alpha-blockade phenoxybenzamine (PXB) vs. selective alpha-blockade on HDI and outcomes was also evaluated. Methods The records of 91 patients who underwent adrenalectomy between 2002 and 2013 were retrospectively reviewed. HDI was determined by: number of intraoperative episodes of systolic blood pressure (SBP) >200mmHg, those greater than or less than 30% of baseline, heart rate >110 and the need for postoperative vasopressors. Fishers exact, t-test and regressions were performed. Results Among the 91 patients, 78% received PXB, 18% selective alpha-blockade and 4% no adrenergic blockade. Patient demographics, tumor factors and surgical approach were similar among the blockade groups. On multivariate analysis increasing tumor size was associated with a significant rise in the number of episodes of SBP >30% (RR 1.40) and an increased postoperative vasopressor requirement (OR 1.23). Open adrenalectomy and use of selective blockade were associated with an increased number of episodes of SBP >200mmHg (RR 27.8 and RR 20.9, respectively). Open adrenalectomy was also associated with increased readmissions (OR 12.3), complications (OR 5.6), use of postoperative vasopressors (OR 4.4) and hospital stay (4.6 days longer). There were no differences in other HDI measurements or postoperative outcomes among the blockade groups. Conclusions Tumor size, open adrenalectomy and type of alpha-blockade were associated with intraoperative HDI during pheochromocytoma resection. Selective blockade was associated with significantly more episodes of intraoperative hypertension but no perioperative adverse outcomes.

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Section: Discussioncontrasting

confidence: 74%

“…The current low mortality of pheochromocytoma resection is thought to be a result of adequate preoperative blockade, volume repletion and anesthetic and pharmacologic advances yet prospective randomized data are lacking. 11 …”

Section: Introductionmentioning

confidence: 99%

Predictors of Hemodynamic Instability During Surgery for Pheochromocytoma

et al. 2014

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“…The aim of meticulous preoperative planning is not only to plan the surgical approach, but also to prevent potentially life-threatening catecholamine-induced complications that can be caused by tumour manipulation during surgery. These include hypertensive crisis, cardiac arrhythmias, pulmonary oedema and cardiac ischaemia 11. A thorough anaesthetic assessment with optimisation of blood pressure, heart rate, antihypertensive medication and increasing salt and fluid intake in the preoperative period can reduce perioperative mortality to less than 3% 12…”

Section: Discussionmentioning

confidence: 99%

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat

et al. 2015

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SUMMARYA 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas.Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation. BACKGROUND

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“…This preoperative preparation lessens the risk of intraoperative hypertension and helps to avoid postoperative hypotension after tumor resection. 10 Once α-adrenergic blockade is achieved, β-adrenergic as well as calcium-channel blockers may also be employed for heart rate and further blood pressure control. The tyrosine hydroxylase inhibitor, alpha-methylparatyrosine (metyrosine), can be used in selected cases when blood pressure cannot be controlled with traditional agents or if a complicated resection is anticipated.…”

Section: Discussionmentioning

confidence: 99%

Paravesicular Paraganglioma manifesting as Chronic Hypertension and Hypertensive Crisis

Cai¹,

Kundel²,

Young³

et al. 2014

World Journal of Endocrine Surgery

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We describe a woman with a rare extra-adrenal pheochromocytoma who presented with a chronic hypertension and a hypertensive crisis initiated by an invasive cardiac catheterization procedure. We present a case report, review the relevant literature, and discuss management strategies. A 49-year-old woman with a 4-year history of hypertension experienced a hypertensive crisis following a catheterization procedure. Evaluation of the episode led to identification of a catecholaminesecreting pelvic paraganglioma as confirmed by 24-hour urine fractioned metanephrines and catecholamines as well as magnetic resonance imaging. The patient was carefully pharmacologically prepared for surgical resection. Paragangliomas may exhibit 30% inheritability, and the patient was counseled on genetic testing for early diagnosis of tumor in family members. Catecholamine-secreting paragangliomas are rare tumors that may present as hypertensive emergencies. Diagnosis relies on biochemical testing followed by imaging to avoid crisis induced by invasive procedures. Surgical excision is the treatment of choice, and pharmacological preparation for surgery begins at least 1 week prior to the procedure to ensure adequate adrenergic blockade. Following treatment for a paraganglioma, genetic testing should be recommended for early identification of affected family members.

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Perianesthetic Risks and Outcomes of Pheochromocytoma and Paraganglioma Resection

Cited by 118 publications

References 17 publications

Predictors of Hemodynamic Instability During Surgery for Pheochromocytoma

Predictors of Hemodynamic Instability During Surgery for Pheochromocytoma

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat

Paravesicular Paraganglioma manifesting as Chronic Hypertension and Hypertensive Crisis

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