Perioperative Management of Endocrine Active Adrenal Tumors

Abstract

Endocrine active adrenal tumors are associated with a relevant risk of complications during surgery, either due to direct hemodynamic effects of the hormone excess or due to hormone related comorbidities. Over the last decades, careful preoperative evaluation and improved peri-interventional medical management of affected patients has resulted in a significant reduction of perioperative complications. In addition, improvement in anesthesia and surgical techniques with the feasibility of laparoscopic adrenalectomy have contributed to reduce morbidity. Nevertheless, there are still several challenges to be considered in the perioperative care of these patients. Due to the rarity of functionally active adrenal tumors, there are no prospective data available to guide clinical management. Accordingly, most recommendations are based on retrospective data analysis, expert opinion or carry weak evidence based on small series or case reports. The aim of this review is to summarize the current knowledge and to suggest practical approaches to reduce perioperative complications in endocrine active adrenal tumors. This review exclusively deals with data from adult patients with functionally active adrenal tumors.

Perioperative management of pheocromocytoma/ paraganglioma: a comprehensive review

“…Half-life 2-3 hours ( 25) Initial dose 0.5 -1 mg every 4-6 hours titrated to a maximum dose of 20-24 mg/day (9,20) When the last dose is given the night before the surgery, blood concentration drops to ineffective levels (20).…”

“…However, current mortality appears to be lower due to preoperative management with α-blockers. The use of α-blockers is the suggested first choice for premedication (9,16,20) over a period of 10 to 14 días (19)(20)(21). In general, the use of β-blockers as adjunct therapy is required (19).…”

“…In general, the use of β-blockers as adjunct therapy is required (19). Regardless of the pharmacological regimen used, the sitting blood pressure goal is <130/80 mm Hg, and standing systolic blood pressure <90 mm Hg must be avoided (15,16,20). The recommended sitting and standing heart rate values are 60-70 bpm and 70-80 bpm, respectively (16,20).…”

“…Phenoxybenzamine is used to reduce vasoconstriction and intraoperative hypertensive crises, (18) and to achieve normal hemodynamic parameters (20). Its limitation is low availability in most countries.…”

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“…Erlic and Beuschlein [14] summarize the metabolic alterations found in PPGL, including impaired glucose homeostasis and lipolysis activation, changes in body weight, fat mass and distribution. Schreiner et al cover the highly relevant topic of perioperative management of adrenal tumors [15]. In clinical practice this area is associated with serious morbidity and mortality which can be avoided by appropriate management.…”