Does α and β blockade in patients undergoing adrenalectomy for phaeochromocytoma increase postoperative morbidity? – An Institutional analysis
A Paspala, C Camenzuli, A Sam, R Almazrouei, N Chander, A DiMarco, F Palazzo,
Hammersmith Hospital, Imperial College NHS Trust
Introduction: Adrenalectomy for phaeochromocytoma (PCC) is associated with a higher rate of perioperative complications and even mortality. Historically the decreased mortality to under 3.0% has been attributed to the preoperative of α-blockade however this practice is now being challenged. The aim of our study is to present our institutional experience in preoperative alpha-blocking of PCC and its effect on postoperative morbidity.
Methods: This is a retrospective study from our institutional database. All patients undergoing adrenalectomy for PCC from September 2017 to October 2019 were included. All patients are routinely α and β blocked. Intraoperative hemodynamic instability (IHI) was assessed through number of Systolic blood pressure (SBP) episodes >160mmHg, episodes of SBP<80mmHg, use of vasoactive drugs and volume of intraoperative crystalloids. Postoperative morbidity and characteristics, such as hospital stay, complications BP and hemoglobin, were also evaluated.
Results: A total of 36 patients were included (19 male, 17 female) with mean age 55(±16) years underwent adrenalectomy for PCC. Bodyweight ranged from 46 to 110kg (mean 77.5±15 kg). The mean maximum diameter of tumors was 44.5±27.8mm.
Pre-operatively the mean SBP was 147.11±29.9mmHg. Eighteen patients (50%) had no hypertensive episodes, 13 (36%) patients had 1-5 episodes of SBP>160mmHg, 4(11%) patients 6-10 episodes and 1(2%) patient a single hypertensive episode during the surgical procedure. Eight (22%) cases had no intraoperative hypotensive episodes, 21(58%) had 1-5 hypotensive (SBP<80mmHg) episodes, 6 (16%) showed 6-10 episodes, while only 1(2%) patient presented intraoperatively 15 episodes of SBP<80mmHg. Fourteen patients received vasoactive drugs during the operation. The mean volume of intraoperative crystalloids was 2.24±0.84l. The mean operative time was 114.2±59min.
Postoperatively, the mean SBP was 115.8±16.9mmHg. The mean hemoglobin on postoperative day 1 was 113.9±24.9g/l. No patient presented with arrhythmia during adrenalectomy, and none needed blood transfusion or ICU admission. Three cases presented complication regarding to their respiratory system, but no intervention was needed. No reoperation or readmission was required.
Conclusions: IHI remains numerically significant in PCC surgery even with α and β blockade. Omitting blockade would appear empirically questionable but only a randomised controlled trial of surgery with and without blockade will provide an answer to this new question.