Routine Glucose Monitoring in Postoperative Pheochromocytoma Patients: Yes or No?

  • Neha Goel
  • James A. Lee
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Pheochromocytomas are rare neuroendocrine tumors characterized by the release of catecholamines. In the preoperative setting, the release of these catecholamines can lead to hyperglycemia by promoting liver glycogenolysis and gluconeogenesis, inhibiting pancreatic insulin secretion, and enhancing peripheral insulin resistance. Postoperatively, there is often a period of rebound hypoglycemia that can be dangerously prolonged given the preoperative depletion of glycogen stores secondary to high catecholamine levels. This complication of postoperative hypoglycemia can be extremely detrimental given that it often goes unrecognized secondary to the masking effects of anesthesia. The change in mental status associated with hypoglycemia may be incorrectly attributed to residual anesthesia. Alpha and beta-blockade further blunt the body’s natural response to hypoglycemia which is usually tachycardia, palpitations, and sweating. Prolonged, unrecognized hypoglycemia can lead to severe neurologic consequences such as seizures, unconsciousness, or even irreversible brain damage. This complication must therefore be preemptively anticipated and acutely managed. A thorough literature search over the years provides data in favor of routine postoperative glucose monitoring after pheochromocytoma resection. Given the high stakes involved with missing this relatively common diagnosis seen in 4–15% of pheochromocytoma patients undergoing resection, a GRADE 1C recommendation for routine monitoring in all postoperative pheochromocytoma patients for the first 5 h has been deemed appropriate.


Pheochromocytoma resection Postoperative hypoglycemia Unrecognized hypoglycemia Routine postoperative glucose monitoring in all patients Elevated preoperative urine metanephrine levels Alpha and beta blockade Neurologic complications 


  1. 1.
    Manger WM, Gifford RW. Clinical and experimental pheochromocytoma. Hoboken: Blackwell Science; 1996.Google Scholar
  2. 2.
    Därr R, Lenders JW, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma - update on disease management. Ther Adv Endocrinol Metab. 2012;3(1):11–26.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Prejbisz A, Lenders JW, Eisenhofer G, Januszewicz A. Cardiovascular manifestations of phaeochromocytoma. J Hypertens. 2011;29:2049–60.CrossRefPubMedGoogle Scholar
  4. 4.
    La Batide-Alanore A, Chatellier G, Plouin PF. Diabetes as a marker of pheochromocytoma in hypertensive patients. J Hypertens. 2003;21:1703–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Witteles RM, Kaplan EL, Roizen MF. Safe and cost-effective preoperative preparation of patients with pheochromocytoma. Anesth Analg. 2000;91:302–4.PubMedGoogle Scholar
  6. 6.
    Bravo EL, Tagle R. Pheochromocytoma: state-of-the-art and future prospects. Endocr Rev. 2003;24:539–53.CrossRefPubMedGoogle Scholar
  7. 7.
    Kinney MA, Narr BJ, Warner MA. Perioperative management of pheochromocytoma. J Cardiothorac Vasc Anesth. 2002;16:359–69.CrossRefPubMedGoogle Scholar
  8. 8.
    Kocak S, Aydintug S, Canakci N. Alpha blockade in preoperative preparation of patients with pheochromocytomas. Int Surg. 2002;87:191–4.PubMedGoogle Scholar
  9. 9.
    Prys-Roberts C, Farndon JR. Efficacy and safety of doxazosin for perioperative management of patients with pheochromocytoma. World J Surg. 2002;26:1037–42.CrossRefPubMedGoogle Scholar
  10. 10.
    Tokioka H, Takahashi T, Kosogabe Y, Ohta Y, Kosaka F. Use of diltiazem to control circulatory fluctuations during resection of a phaeochromocytoma. Br J Anaesth. 1988;60:582–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Gray RJ. Managing critically ill patients with esmolol. An ultra short-acting Beta-adrenergic blocker. Chest. 1988;93:398–403.CrossRefPubMedGoogle Scholar
  12. 12.
    Reach G, Thibonnier M, Chevillard C, Corvol P, Milliez P. Effect of labetalol on blood pressure and plasma catecholamine concentrations in patients with phaeochromocytoma. Br Med J. 1980;280:1300–1.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Van Stratum M, Levarlet M, Lambilliotte JP, Lignian H, De Rood M. Use of labetalol during anesthesia for pheochromocytoma removal. Acta Anaesthesiol Belg. 1983;34:233–40.PubMedGoogle Scholar
  14. 14.
    Yabe R, Suenaga K, Niimura S, Itoh N, Tani M, Kunii N, et al. Treatment of pheochromocytoma with dilevalol. J Med. 1987;18:147–52.PubMedGoogle Scholar
  15. 15.
    Briggs RS, Birtwell AJ, Pohl JE. Hypertensive response to labetalol in phaeochromocytoma. Lancet. 1978;1:1045–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Akiba M, Kodama T, Ito Y, Obara T, Fujimoto Y. Hypoglycemia induced by excessive rebound secretion of insulin after removal of pheochromocytoma. World J Surg. 1990;14:317–24.CrossRefPubMedGoogle Scholar
  17. 17.
    Yamaguchi N. Sympathoadrenal system in neuroendocrine control of glucose: mechanisms involved in the liver, pancreas, and adrenal gland under hemorrhagic and hypoglycemic stress. Can J Physiol Pharmacol. 1992;70:167–206.CrossRefPubMedGoogle Scholar
  18. 18.
    Steiner KE, Stevenson RW, Green DR, Cherrington AD. Mechanism of epinephrine’s glycogenolytic effect in isolated canine hepatocytes. Metab Clin Exp. 1985;34:1020–3.CrossRefPubMedGoogle Scholar
  19. 19.
    Ahrén B, Veith RC, Taborsky GJ. Sympathetic nerve stimulation versus pancreatic norepinephrine infusion in the dog: 1. Effects on basal release of insulin and glucagon. Endocrinology. 1987;21:323–31.CrossRefGoogle Scholar
  20. 20.
    Porte D, Williams RH. Inhibition of insulin release by norepinephrine in man. Science. 1966;152:1248–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Ostenson CG, Cattaneo AG, Doxey JC, Efendic S. Alpha-adrenoceptors and insulin release from pancreatic islets of normal and diabetic rats. Am J Phys. 1989;257:439–43.Google Scholar
  22. 22.
    Ahrén B. Autonomic regulation of islet hormone secretion—implications for health and disease. Diabetologia. 2000;43:393–410.CrossRefPubMedGoogle Scholar
  23. 23.
    Deibert DC, DeFronzo RA. Epinephrine-induced insulin resistance in man. J Clin Investig. 1980;65:717–21.CrossRefPubMedGoogle Scholar
  24. 24.
    Wiesner TD, Blüher M, Windgassen M, Paschke R. Improvement of insulin sensitivity after adrenalectomy in patients with pheochromocytoma. J Clin Endocrinol Metab. 2003;88:3632–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Martin R, St. Pierre B, Moliner OR. Phaeochromocytoma and postoperative hypoglycaemia. Can Anaesth Soc J. 1979;26(4):260–2.CrossRefPubMedGoogle Scholar
  26. 26.
    Meeke RI, O’Keefe JD, Gaffney JD. Phaeochromocytoma removal and postoperative hypoglycaemia. Anaesthesia. 1985;40(11):1093–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Kato Y, Saga Y, Hou K, Yamaguchi S, Hashimoto H, Kaneko S, Yachiku S. Postoperative hypoglycemia after resection of pheochromocytoma: a case report. Hinyokika Kiyo. 2004;50(7):479–83.PubMedGoogle Scholar
  28. 28.
    Plouin PF, Duclos JM, Soppelsa F, Boublil G, Chatellier G. Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single center. J Clin Endocrinol Metab. 2001;86:1480–6.PubMedGoogle Scholar
  29. 29.
    Chen Y, Hodin RA, Pandolfi C, Ruan DT, McKenzie TJ. Hypoglycemia after resection of pheochromocytoma. Surgery. 2014;156(6):1404–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med. 1987;147:1273–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Tsujimoto G, Honda K, Hoffman BB, Hashimoto K. Desensitization of postjunctional alpha 1- and alpha 2-adrenergic receptor-mediated vasopressor responses in rat harboring pheochromocytoma. Circ Res. 1987;61:86–98.CrossRefPubMedGoogle Scholar
  32. 32.
    Tsujimoto G, Manger WM, Hoffman BB. Desensitization of beta-adrenergic receptors by pheochromocytoma. Endocrinology. 1984;114:1272–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Cremer GM, Molnar GD, Taylor WF, et al. Studies of diabetic instability. II. Tests of insulinogenic reserve with infusions of arginine, glucagon, epinephrine, and saline. Metab Clin Exp. 1971;20:1083–98.CrossRefPubMedGoogle Scholar
  34. 34.
    Costello GT, Moorthy SS, Vane DW, Dierdorf SF. Hypoglycemia following bilateral adrenalectomy for pheochromocytoma. Crit Care Med. 1988;16:562–3.CrossRefPubMedGoogle Scholar
  35. 35.
    Pacak K, Eisenhofer G, Lenders JWM. Pheochromocytoma: diagnosis, localization, and treatment. Birmingham: Blackwell Pub; 2007.CrossRefGoogle Scholar
  36. 36.
    Mannelli M. Management and treatment of pheochromocytomas and paragangliomas. Ann N Y Acad Sci. 2006;1073:405–16.CrossRefPubMedGoogle Scholar
  37. 37.
    Yanaru T, Sugi Y, Higa K, Katori K, Shono S, Nitahara K. Postoperative profound hypoglycemia after resection of adrenaline-predominant pheochromocytoma. Masui. 2007;56(12):1419–21.PubMedGoogle Scholar
  38. 38.
    Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ, GRADE Working Group. Going from evidence to recommendations. BMJ. 2008;336(7652):1049–51.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, Norris SL, Williams JW Jr, Atkins D, Meerpohl J, Schünemann HJ. GRADE guidelines: 4. Rating the quality of evidence-study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryNew York Presbyterian-Columbia University Medical CenterNew YorkUSA
  2. 2.Department of SurgeryColumbia University Medical CenterNew YorkUSA

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