Selective vs non-selective alpha-blockade prior to adrenalectomy for pheochromocytoma: systematic review and meta-analysis

Zawadzka, Karolina; Więckowski, Krzysztof; Małczak, Piotr; Wysocki, Michał; Major, Piotr; Pędziwiatr, Michał; Pisarska-Adamczyk, Magdalena

doi:10.1530/eje-20-1301

Cited by 21 publications

(16 citation statements)

References 36 publications

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“…We also observed that patients receiving selective alpha-blockade required intraoperative vasodilators more frequently than those treated with non-selective alpha-blockade. Similar results were reported in a recent systematic review and meta-analysis of 1344 patients [29], describing that intraoperative vasodilators were used more frequently in the group of selective alpha-blockade (OR: 2.46, 95% CI 1.44-4.20, P = 0.001). They also found a shorter length of hospital stay (WMD: -0.58 days, 95% CI: -1.12 to -0.04, P = 0.04) in patients treated with selective-alpha blockers, maybe the shorter stay could be related to the tendency to use phenoxybenzamine in hospitalized patients and use doxazosin on an outpatient basis.…”

Section: Surgical Outcomessupporting

confidence: 88%

Surgical outcomes in the pheochromocytoma surgery. Results from the PHEO-RISK STUDY

et al. 2021

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Purpose: To identify presurgical and surgical risk factors for postsurgical complications in the pheochromocytoma surgery.Methods: A retrospective study of pheochromocytomas submitted to surgery in ten Spanish hospitals between 2011 and 2021. Postoperative complications were classi ed according to Clavien-Dindo scale.Results: One hundred and sixty-two surgeries (159 patients) were included. Preoperative antihypertensive blockade was performed in 95.1% of the patients, being doxazosin in monotherapy (43.8%) the most frequent regimen. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more frequently (49.4% vs 25.0%, P=0.003) than patients treated with phenoxybenzamine, but no differences in the rate of intraoperative and postsurgical complications were observed. However, patients treated with phenoxybenzamine had a longer hospital stay (12.2±11.16 vs 6.2±6.82, P<0.001) than those treated with doxazosin. Hypertension resolution was observed in 78.7% and biochemical cure in 96.6% of the patients. Thirty-one patients (19.1%) had postsurgical complications. Prolonged hypotension was the most common, in 9.9% (n=16), followed by hypoglycaemia in 6 patients and acute renal failure in 4 patients. 13.0% of complications had a score ≥3 in the Clavien-Dindo scale. Postsurgical complications were more common in in patients with diabetes, cerebrovascular disease, higher plasma glucose levels, higher urinary free metanephrine and norepinephrine, and with pheochromocytomas larger than 5 cm. Conclusion:Preoperative medical treatment and postsurgical monitoring of pheochromocytoma should be especially careful in patients with diabetes, cerebrovascular disease, higher levels of plasma glucose and urine free metanephrine and norepinephrine, and with pheochromocytomas >5 cm, due to the higher risk of postsurgical complications. Introduction:Pheochromocytomas are rare neuroendocrine tumours that produce catecholamines [1]. They are a lifethreatening condition because catecholamine secretion is unpredictable, resulting in hypertension, arrhythmia, and/or other cardiovascular complications [2]. Surgery represents the primary treatment for pheochromocytomas [1]. Due to improvements in perioperative treatment, anaesthesia and surgical techniques, the mortality has dropped markedly in the last thirty years, but the risk of cardiovascular complications remains still high [3]. Intraoperative complications, including hypertensive crisis, hemodynamic instability and tachyarrhythmias, among others, have been reported in 30-50% of the pheochromocytoma surgeries [4][5][6]. The main postoperative major complications are prolonged hypotension and rebound hypoglycaemia [1]. However, postsurgical complications are usually less reported in pheochromocytoma studies, and are usually described in around 20-30% of the patients in recent series [4][7][8][9].Few studies have evaluated the grade of these complications using validate scales as the Clavien-Dindo score [4][10][9][8]. Moreover, studies evaluating risk factors for p...

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Section: Surgical Outcomessupporting

confidence: 88%

Surgical outcomes in the pheochromocytoma surgery. Results from the PHEO-RISK STUDY

et al. 2021

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“…Our findings are different from Zawadzka et al . [ 25 ] where authors reported that NSAB was superior to SAB in preventing intra-operative BP fluctuations. The only similar finding is a requirement of intra-operative vasodilator drug, which was more in the SAB group.…”

Section: Discussionmentioning

confidence: 99%

Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma–Paraganglioma Patients Undergoing Surgery: A Meta-Analysis

Yadav

Johri

Jha

et al. 2022

Indian Journal of Endocrinology and Metabolism

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The main objective of this systematic review and meta-analysis was to review, assess and report on the studies that have evaluated selective alpha blockade (SAB) vs. non-selective alpha blockade (NSAB) therapy in patients undergoing surgery for pheochromocytomas and paragangliomas (PPGL). We performed a systematic search of electronic databases. A meta-analysis was conducted to examine the effectiveness of the two blockades. RevMan 5.3 was used for the meta-analysis. Of the eight articles that met the inclusion criteria, there was only one randomized control trial. Meta-analysis showed that there was no significant difference between the groups SAB and NSAB with regard to intra-operative systolic blood pressure (SBP) >160 mm Hg (relative risk (RR) 0.95 [95% CI 0.57, 1.56] P = 0·83) and intra-operative vasopressor requirement (RR 1.10 [95% CI 0.96, 1.26] P = 0·16). Meta-analysis revealed that there was a significant difference between the groups (SAB vs NSAB) with respect to post-operative vasopressor requirement (RR 1.66 [95% CI 1.0, 2.74] P = 0·05). There was no significant difference between the groups with respect to post-operative complications (RR 0.84 [95% CI 0.58, 1.22] P = 0·36). In conclusion, as patients blocked selectively may have a higher incidence of vasodilator requirement intra-operatively, NSAB offers some haemodynamic advantage over SAB. However, NSAB’s real clinical benefit cannot be ascertained with the current studies as this difference did not result in any significant advantage over SAB with regard to morbidity or mortality.

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“…Compared to phenoxybenzamine, doxazosin is most prescribed due to its lower cost and worldwide availability. Nonselective α-blocker are associated with less intraoperative hypertension rates than selective agents with similar hypotension and vasopressor needs [ 47 ]. Morbimortality is similar in these 2 types of α-blockers [ 10 , 47 ].…”

Section: Preoperative Carementioning

confidence: 99%

“…Nonselective α-blocker are associated with less intraoperative hypertension rates than selective agents with similar hypotension and vasopressor needs [ 47 ]. Morbimortality is similar in these 2 types of α-blockers [ 10 , 47 ]. The α-adrenergic blocker treatment is associated with orthostatic hypotension, reflex tachycardia, dizziness, and syncope particularly when using phenoxybenzamine [ 48 , 49 ].…”

Section: Preoperative Carementioning

confidence: 99%

Perioperative Management of Pheochromocytomas and Sympathetic Paragangliomas

Fagundes

Almeida

2022

Journal of the Endocrine Society

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Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors arising from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia, respectively. PPGLs have the highest degree of heritability among endocrine tumors. Currently, ~40% of PPGL individuals have a genetic germline and there exist at least 12 different genetic syndromes related to these tumors. Metastatic PPGLs are defined by the presence of distant metastases at sites where chromaffin cells are physiologically absent. Approximately 10% of pheochromocytomas and ~40% of sympathetic paragangliomas are linked to metastases explaining why complete surgical resection is the first-choice treatment for all PPGL patients. The surgical approach is a high-risk procedure requiring perioperative management by a specialized multidisciplinary team in centers with broad expertise. In this review, we summarize and discuss the most relevant aspects of perioperative management in patients with pheochromocytomas and sympathetic paragangliomas.

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Selective vs non-selective alpha-blockade prior to adrenalectomy for pheochromocytoma: systematic review and meta-analysis

Cited by 21 publications

References 36 publications

Surgical outcomes in the pheochromocytoma surgery. Results from the PHEO-RISK STUDY

Surgical outcomes in the pheochromocytoma surgery. Results from the PHEO-RISK STUDY

Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma–Paraganglioma Patients Undergoing Surgery: A Meta-Analysis

Perioperative Management of Pheochromocytomas and Sympathetic Paragangliomas

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