[Anesthetic management during pheochromocytoma surgery : Current strategies]

Abstract

Background: Surgery-related mortality in patients with pheochromocytoma or paraganglioma has dramatically decreased over the last few decades. This effect has often been attributed to perioperative α‑receptor blockade. However, this has never been tested in a randomized trial and many other changes have contributed to this improvement. At the same time α‑receptor blockade was introduced, short-acting and well controllable agents became available for intraoperative arterial blood pressure management. Subsequently, surgical techniques improved and led almost exclusively to minimally invasive techniques, while improvements in the diagnostic techniques allow earlier and more precise detection of catecholamine-producing tumors.

Methods: Conduction of a randomized, controlled study to investigate the effect of α‑receptor blockade on mortality is hampered by the rarity of the disease. With the currently low mortality rate, several thousands of patients would be needed to test such a hypothesis. Accordingly, intraoperative management is generally based on expert opinion. Hypertensive episodes are treated by intravenous administration of sodium nitroprusside, urapidil or nitroglycerine. Depending on the individual case a short-acting β‑blocker and magnesium might be added. Hypotension following tumor removal is treated with intravenous fluid infusion and continuous norepinephrine administration. Adrenal gland-sparing resection of pheochromocytoma does not seem to increase the risk of arterial hypertension.

Conclusion: Future research should focus on identification of risk factors for intraoperative hypertensive episodes and the question whether a time-consuming, unreliable α‑receptor blockade, burdened with significant side effects, is still needed.

Keywords: Alpha-receptor blockade; Blood pressure control; Hypotension; Paraganglioma; Sodium nitroprusside.