Skip to main content

Advertisement

SpringerLink
Log in

Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Adrenalectomy for pheochromocytoma is considered to be a challenging procedure because of the risk of hemodynamic instability (HI), which is poorly defined and unpredictable. The objective of this retrospective study from a prospectively maintained database was to determine the predictive factors for perioperative HI, which is defined as a morbidity-related variable, in patients undergoing unilateral laparoscopic adrenalectomy (LA) for pheochromocytoma.

Methods

A total of 149 patients with unilateral pheochromocytoma undergoing LA were included. First, HI was defined using independent hemodynamic variables associated with perioperative morbidity. Next, a multivariable logistic regression analysis was performed to determine the independent preoperative risk factors for HI.

Results

There was no postoperative mortality, and the overall morbidity rate was 10.7 %. The use of a cumulative dose of norepinephrine >5 mg was the only independent hemodynamic predictive factor for postoperative complications; thus, this variable was used to define HI. A multivariate analysis revealed that a symptomatic high preoperative blood pressure (p = 0.003) and a ten-fold increase in urinary metanephrine and/or normetanephrine levels (p < 0.0001) were significant predictors of HI. When no predictive factors were present, the risk of HI and the postoperative morbidity were 1.5 and 4.3 %, respectively. However, when two predictive factors were present, the HI risk and the postoperative morbidity were 53.8 and 30.8 %, respectively.

Conclusion

Perioperative HI, defined as the need for a cumulative dose of norepinephrine >5 mg, is significantly associated with postoperative morbidity and can be predicted by symptomatic preoperative high blood pressure and above a ten-fold increase in urinary metanephrine and/or normetanephrine levels.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Gagner M, Lacroix A, Bolte E (1992) Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 327(14):1033

    Article  CAS  PubMed  Google Scholar 

  2. Assalia A, Gagner M (2004) Laparoscopic adrenalectomy. Br J Surg 91(10):1259–1274

    Article  CAS  PubMed  Google Scholar 

  3. Gaujoux S et al (2011) Risk factors for conversion and complications after unilateral laparoscopic adrenalectomy. Br J Surg 98(10):1392–1399

    Article  CAS  PubMed  Google Scholar 

  4. Gagner M et al (1996) Is laparoscopic adrenalectomy indicated for pheochromocytomas? Surgery 120(6):1076–1079 (discussion 1079-80)

    Article  CAS  PubMed  Google Scholar 

  5. Kim AW et al (2004) Outcome of laparoscopic adrenalectomy for pheochromocytomas vs aldosteronomas. Arch Surg 139(5):526–529 (discussion 529-31)

    Article  PubMed  Google Scholar 

  6. Fernandez-Cruz L et al (1996) Laparoscopic approach to pheochromocytoma: hemodynamic changes and catecholamine secretion. World J Surg 20(7):762–768 (discussion 768)

    Article  CAS  PubMed  Google Scholar 

  7. Inabnet WB et al (2000) Comparison of the hemodynamic parameters of open and laparoscopic adrenalectomy for pheochromocytoma. World J Surg 24(5):574–578

    Article  CAS  PubMed  Google Scholar 

  8. Shen WT et al (2010) One hundred two patients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy. Arch Surg 145(9):893–897

    Article  PubMed  Google Scholar 

  9. Gumbs AA, Gagner M (2006) Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab 20(3):483–499

    Article  PubMed  Google Scholar 

  10. Shen WT, Sturgeon C, Duh QY (2005) From incidentaloma to adrenocortical carcinoma: the surgical management of adrenal tumors. J Surg Oncol 89(3):186–192

    Article  PubMed  Google Scholar 

  11. Walz MK et al (2006) Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas: results of 161 tumors in 126 patients. World J Surg 30(5):899–908

    Article  PubMed  Google Scholar 

  12. Nau P et al (2010) Pheochromocytoma does not increase risk in laparoscopic adrenalectomy. Surg Endosc 24(11):2760–2764

    Article  PubMed  Google Scholar 

  13. Paganini AM et al (2014) Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients. Surg Endosc 28(9):2683–2689

    Article  PubMed  Google Scholar 

  14. Cheah WK et al (2002) Laparoscopic adrenalectomy for pheochromocytoma. World J Surg 26(8):1048–1051

    Article  PubMed  Google Scholar 

  15. Jaroszewski DE et al (2003) Laparoscopic adrenalectomy for pheochromocytoma. Mayo Clin Proc 78(12):1501–1504

    Article  PubMed  Google Scholar 

  16. Solorzano CC et al (2007) Outcomes of pheochromocytoma management in the laparoscopic era. Ann Surg Oncol 14(10):3004–3010

    Article  PubMed  Google Scholar 

  17. Berber E et al (2009) Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy. Surgery 146(4):621–625 (discussion 625-6)

    Article  PubMed  Google Scholar 

  18. Perry KA et al (2010) Laparoscopic adrenalectomy for large unilateral pheochromocytoma: experience in a large academic medical center. Surg Endosc 24(6):1462–1467

    Article  PubMed  Google Scholar 

  19. Lentschener C et al (2009) Increased arterial pressure is not predictive of hemodynamic instability in patients undergoing adrenalectomy for phaeochromocytoma. Acta Anaesthesiol Scand 53(4):522–527

    Article  CAS  PubMed  Google Scholar 

  20. Plouin PF et al (2001) Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single center. J Clin Endocrinol Metab 86(4):1480–1486

    CAS  PubMed  Google Scholar 

  21. Bruynzeel H et al (2010) Risk factors for hemodynamic instability during surgery for pheochromocytoma. J Clin Endocrinol Metab 95(2):678–685

    Article  CAS  PubMed  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lee TH et al (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100(10):1043–1049

    Article  CAS  PubMed  Google Scholar 

  24. Behnia R, Molteni A, Igic R (2003) Angiotensin-converting enzyme inhibitors: mechanisms of action and implications in anesthesia practice. Curr Pharm Des 9(9):763–776

    Article  CAS  PubMed  Google Scholar 

  25. Gilman A, Limbird L, Hardman J (2001) Goodman & Gilman‘s: the pharmacological basis of therapeutics. McGraw-Hill Professional, New York

    Google Scholar 

  26. Gagner M et al (1994) Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position. Surg Endosc 8(2):135–138

    Article  CAS  PubMed  Google Scholar 

  27. Desmonts JM et al (1977) Anaesthetic management of patients with phaeochromocytoma. A review of 102 cases. Br J Anaesth 49(10):991–998

    Article  CAS  PubMed  Google Scholar 

  28. Galetta F et al (2010) Cardiovascular complications in patients with pheochromocytoma: a mini-review. Biomed Pharmacother 64(7):505–509

    Article  CAS  PubMed  Google Scholar 

  29. Tauzin-Fin P et al (2004) Effects of perioperative alpha1 block on hemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 92(4):512–517

    Article  CAS  PubMed  Google Scholar 

  30. Flavio Rocha M et al (2004) Laparoscopic surgery for pheochromocytoma. Eur Urol 45(2):226–232

    Article  PubMed  Google Scholar 

  31. Hull CJ (1986) Phaeochromocytoma. Diagnosis, preoperative preparation and anaesthetic management. Br J Anaesth 58(12):1453–1468

    Article  CAS  PubMed  Google Scholar 

  32. Prys-Roberts C (2000) Phaeochromocytoma—recent progress in its management. Br J Anaesth 85(1):44–57

    Article  CAS  PubMed  Google Scholar 

  33. Aliyev S et al (2013) Robotic versus laparoscopic adrenalectomy for pheochromocytoma. Ann Surg Oncol 20(13):4190–4194

    Article  PubMed  Google Scholar 

  34. Conzo G et al (2013) Laparoscopic adrenalectomy, a safe procedure for pheochromocytoma. A retrospective review of clinical series. Int J Surg 11(2):152–156

    Article  PubMed  Google Scholar 

  35. Toniato A et al (2007) Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment? Surgery 141(6):723–727

    Article  PubMed  Google Scholar 

  36. Toniato A et al (2007) Laparoscopic adrenalectomy for pheochromocytoma: is it really more difficult? Surg Endosc 21(8):1323–1326

    Article  PubMed  Google Scholar 

  37. Chang RY et al (2014) High pre-operative urinary norepinephrine is an independent determinant of peri-operative hemodynamic instability in unilateral pheochromocytoma/paraganglioma removal. World J Surg 38(9):2317–2323

    Article  PubMed  Google Scholar 

  38. Lenders JW et al (2005) Phaeochromocytoma. Lancet 366(9486):665–675

    Article  PubMed  Google Scholar 

  39. Kinney MA et al (2000) Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection. Anesth Analg 91(5):1118–1123

    CAS  PubMed  Google Scholar 

  40. Weingarten TN et al (2010) Comparison of two preoperative medical management strategies for laparoscopic resection of pheochromocytoma. Urology 76(2):508.e6–508.e11

    Article  Google Scholar 

  41. Brunaud, L et al (2015) Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: a multicenter retrospective analysis in 225 patients. Surg Endosc. doi:10.1007/s00464-015-4294-7

    PubMed  Google Scholar 

  42. Rady MY, Ryan T, Starr NJ (1998) Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery. Crit Care Med 26(2):225–235

    Article  CAS  PubMed  Google Scholar 

  43. Gomes RV et al (2007) A first postoperative day predictive score of mortality for cardiac surgery. Ann Thorac Cardiovasc Surg 13(3):159–164

    PubMed  Google Scholar 

  44. Gaies MG et al (2010) Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 11(2):234–238

    Article  PubMed  Google Scholar 

  45. Davidson J et al (2012) Prospective validation of the vasoactive-inotropic score and correlation to short-term outcomes in neonates and infants after cardiothoracic surgery. Intensive Care Med 38(7):1184–1190

    Article  PubMed  Google Scholar 

  46. Wilkman E et al (2013) Association between inotrope treatment and 90-day mortality in patients with septic shock. Acta Anaesthesiol Scand 57(4):431–442

    Article  CAS  PubMed  Google Scholar 

  47. Inoue T et al (2013) Medical and surgical management after spinal cord injury: vasopressor usage, early surgery and complications. J Neurotrauma 31(3):248–291

    Google Scholar 

  48. Pacak K et al (2007) Pheochromocytoma: recommendations for clinical practice from the first international symposium. October 2005. Nat Clin Pract Endocrinol Metab 3(2):92–102

    Article  PubMed  Google Scholar 

  49. Pacak K (2007) Preoperative management of the pheochromocytoma patient. J Clin Endocrinol Metab 92(11):4069–4079

    Article  CAS  PubMed  Google Scholar 

  50. Prys-Roberts C, Farndon JR (2002) Efficacy and safety of doxazosin for perioperative management of patients with pheochromocytoma. World J Surg 26(8):1037–1042

    Article  PubMed  Google Scholar 

  51. Lentschener C et al (2011) Point of controversy: perioperative care of patients undergoing pheochromocytoma removal-time for a reappraisal? Eur J Endocrinol 165(3):365–373

    Article  CAS  PubMed  Google Scholar 

  52. Gaujoux S, Lentschener C (2010) Re: Weingarten et al.: comparison of two preoperative medical management strategies for laparoscopic resection of pheochromocytoma (Urology 2010;76:508). Urology 76(6):1526 (author reply 1526-7)

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Digestive and Endocrine Surgery, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75014, Paris, France

    Sébastien Gaujoux, Stéphane Bonnet, Jean-Marc Thillois & Bertrand Dousset

  2. Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France

    Sébastien Gaujoux, Denis Duboc, Jérôme Bertherat, Charles Marc Samama & Bertrand Dousset

  3. INSERM Unité1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France

    Sébastien Gaujoux, Jérôme Bertherat & Bertrand Dousset

  4. Department of Anesthesiology and Critical Care, Cochin Hospital, APHP, Paris, France

    Claude Lentschener & Charles Marc Samama

  5. Department of Cardiology, Cochin Hospital, APHP, Paris, France

    Denis Duboc

  6. Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Cochin Hospital, APHP, 75014, Paris, France

    Jérôme Bertherat

Authors
  1. Sébastien Gaujoux
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stéphane Bonnet
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Claude Lentschener
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jean-Marc Thillois
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Denis Duboc
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jérôme Bertherat
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Charles Marc Samama
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Bertrand Dousset
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bertrand Dousset.

Ethics declarations

Disclosures

Sébastien Gaujoux, Stéphane Bonnet, Claude Lentschener, Jean-Marc Thillois, Denis Duboc, Jérôme Bertherat, Charles Marc Samama, and Bertrand Dousset have no conflicts of interest or financial ties to disclose.

Additional information

Sébastien Gaujoux and Stéphane Bonnet should be considered as first co-authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gaujoux, S., Bonnet, S., Lentschener, C. et al. Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma. Surg Endosc 30, 2984–2993 (2016). https://doi.org/10.1007/s00464-015-4587-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-015-4587-x

Keywords

Search

Navigation