Preoperative Risk Factors For Hemodynamic Instability During Unilateral Pheochromocytoma Resection And Optimization Of Perioperative Management

Background The most effective treatment for adrenal pheochromocytoma(PHEO)is surgery.Intraoperative hemodynamic instability(HDI)is a huge challenge for the removal of pheochromocytoma and anesthesia.The success rate of excision of PHEO has been significantly improved since the application of alpha receptor blockers to preoperative preparation of PHEO.However,HDI in the operation occurs sometimes,which can not be avoided completely,and it needs to be dealt with in a timely and effective manner.Severe intraoperative HDI will endanger the patient's life.The preoperative risk factors that cause the HDI in the operation are still inconclusive.Objective The purpose of this study is to identify preoperative risk factors associated with intraoperative HDI during PHEO resection.These risk factors should be used to optimize perioperative diagnosis and treatment,reduce the incidence of intraoperative HDI and improve the safety and efficacy of PHEO resection.Methods From January 2010 to February 2017,125 cases of adrenal PHEO resection were retrospectively analyzed.The clinical manifestations,preoperative use of alpha blockers,preoperative blood volume expansion,preoperative 24 h urinary catecholamine level,tumor characteristics,intraoperative hemodynamic changes,vasoactive drug usage and postoperative recovery were recorded.The HDI was defined as the occurrence of systolic pressure ? 160 mm Hg or mean arterial pressure < 60 mm Hg during the operation.It was divided into two groups according to the occurrence of HDI during the operation.Two groups were compared in age,sex,preoperative clinical manifestations,preoperative antihypertensive therapy,preoperative volume expansion,preoperative 24 h urinary catecholamine level,operative time,tumor size and postoperative recovery.First,the univariate analysis was carried out.Hemodynamic differences were analyzed in patients with hypertensive and non-hypertensive patients with PHEO.whether use of alpha blockers had different influence on intraoperative hemodynamics in PHEO patients with normal blood pressure,we would find out.The hemodynamic differences of patients with normal blood glucose and hyperglycemia were compared.The HDI in different surgical methods was analyzed.The high risk factors for intraoperative HDI were found by multivariable logistic regression analysis.Results Among the 125 patients,58(46.4%)were male and 67(53.6%)were female.22(17.6%)patients had typical triad syndrome with headache,palpitations,and sweating.48(38.4%)cases of adrenal PHEO were detected by ultrasonography during health examination.In 125 cases,there were 71(56.8%)patients with hypertension and54(43.2%)without significant hypertension.20(16%)patients had diabetes mellitus preoperatively.CT examination was performed before the operation.The maximum diameter of the tumor was 2 ~18cm,with an average of 6.1± 2.8cm.Prazosin was mainly used for preoperative antihypertensive treatment.There were 90(72.0%)cases who used of prazosin and 35(28.0%)of the non-users.Prazosin was used for an average of 8.1±6.2 days.10(8%)cases combined calcium antagonists to control blood pressure.5(4%)patients with tachycardia were treated with beta blocker.All 125 patients successfully completed the operation.Open adrenalectomy for PHEO was performed in54(43.2%)cases,retroperitoneal laparoscopic surgery was performed in 59(47.2%)cases,transperitoneal laparoscopic surgery was performed in 8(6.4%)cases,and Da Vinci robot laparoscopic surgery in 4(3.2%)cases.The operation time was 145±48min.Intraoperative HDI occurred in 92(73.6%)patients.56(44.8%)patients had hyperglycemia before operation.The HDI was more likely to occur in patients with preoperative hyperglycemia than normal(P=0.001).There was no statistically significant difference in HDI in different surgical methods(P=0.323).The operation time of retroperitoneal laparoscopic surgery was shorter than open surgery.Compared with open surgery,retroperitoneal laparoscopic surgery had faster recovery,less pain,and shorter hospital stay.54(43.2%)patients had not hypertension,preoperatie perazosin was treated in 29 cases,and 25 cases were not treated with it.Whether prazosin was used in patients with normal blood pressure or not,there was no statistically significant difference in hemodynamic instability(P=0.918).Multivariate logistic regression analysis revealed that the course of disease(P= 0.033),preoperative antihypertensive treatment days(P=0.048),preoperative 24 h urine catecholamine levels(P=0.042),preoperative volume expansion days(P=0.027),preoperative hyperglycemia(P=0.006)and tumor size(P=0.048)is statistically significant indicators,and is the risk factors of intraoperative HDI.Conclusions The number and proportion of adrenal PHEO were found to be increased by health examination.Preoperative application of antihypertensive therapy should be based on the patient's blood pressure.Patients with normal blood pressure can be treated by blood volume expansion alone and do not need antihypertensive drugs.The incidence of HDI in the operation did not increase significantly and the patient avoided the side effects caused by oral alpha receptor blockers.Patients with hypertension should be taken alpha receptor blocker preoperatively,controlling tachycardia and lowering the heart rate to normal.Preoperative capacity expansion was beneficial to stability of hemodynamics during the operation.Hypoglycemia may occur after resection of PHEO in patients with preoperative hyperglycemia.Blood glucose needed to be monitored after surgery to prevent hypoglycemia and timely treatment.The surgical approach of adrenal PHEO had evolved from open surgery to minimally invasive surgery.Robotic surgery has an advantage over traditional laparoscopic surgery in the treatment of larger pheochromocytoma.Minimally invasive surgery had less fluctuation in blood pressure than traditional open surgery.However,there was no significant difference in the incidence of HDI with different surgical approaches.Minimally invasive surgery had faster recovery,less pain and shorter hospitalization than the traditional open surgery.Multivariate logistic regression analysis revealed that the course of disease,preoperative antihypertensive treatment days,preoperative 24 h urine catecholamine levels,preoperative volume expansion days,preoperative hyperglycemia and tumor size is statistically significant risk factors of intraoperative HDI.Preoperative,intraoperative and postoperative preparations should be performed according to these risk factors to ensure the successful completion of the resection of pheochromocytoma.