The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

Martin B Niederle, Edith Fleischmann, Barbara Kabon, Bruno Niederle, Martin B Niederle, Edith Fleischmann, Barbara Kabon, Bruno Niederle

Abstract

Background: Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications.

Methods: Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters.

Results: Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg-1 h-1, p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min-1 m-2, p = 0.005; HIAT: 2.08 vs. 2.56 l min-1 m-2, p = 0.225).

Conclusions: As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course.

Trial registration: ClinicalTrials.gov, Identifier: NCT01425710.

Keywords: Adrenalectomy; Advanced intra-operative monitoring; Fluid management; Hemodynamics; Pheochromocytoma; Preoperative preparation.

Conflict of interest statement

Drs. Martin B. Niederle, Edith Fleischmann, Barbara Kabon and Bruno Niederle have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Type and maximum level of intraoperative catecholamine release [ng/l] and maximum intraoperative rate of vasoactive medication [µg kg−1 min−1] for each pheochromocytoma (PCC) patient. White bar: norepinephrine, black bar: epinephrine, gray bar: dopamine. Reference values: norepinephrine: < 420 ng/l, epinephrine: < 84 ng/l, dopamine: < 85 ng/l
Fig. 2
Fig. 2
Intraoperative hemodynamic parameters. Solid red lines: patients with pheochromocytoma; broken blue lines: patients with hormonally inactive adrenal tumors. 1: Period 1—intubation until incision. 2: Period 2—incision until creation of pneumoperitoneum. 3: Period 3—creation of pneumoperitoneum until ligature of suprarenal vein. 4: Period 4—ligature of suprarenal vein until tumor extirpation. 5: Period 5—first 10 min after tumor extirpation. 6: Period 6—tumor extirpation until end of operation. ABP arterial blood pressure, CI Cardiac Index, FTc aortic corrected flow time, HR heart rate, PV peak velocity, SVI Stroke Volume Index, SVRI Systemic Vascular Resistance Index (Color figure online)

References

    1. Berends AMA, Buitenwerf E, de Krijger RR, Veeger N, van der Horst-Schrivers ANA, Links TP, Kerstens MN. Incidence of pheochromocytoma and sympathetic paraganglioma in the Netherlands: a nationwide study and systematic review. Eur J Intern Med. 2018;51:68–73. doi: 10.1016/j.ejim.2018.01.015.
    1. Ebbehoj A, Sondergaard E, Trolle C, Stochholm K, Poulsen P (2017) The epidemiology of pheochromocytoma: increasing incidence and changing clinical presentation. A population-based retrospective study 1977–2015. Endocrine Abstracts 49. 10.1530/endoabs.49.OC1.4
    1. Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, Naruse M, Pacak K, Young WF, Jr, Endocrine S. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99:1915–1942. doi: 10.1210/jc.2014-1498.
    1. Beninato T, Kluijfhout WP, Drake FT, Lim J, Kwon JS, Xiong M, Shen WT, Gosnell JE, Liu C, Suh I, Duh QY. Resection of pheochromocytoma improves diabetes mellitus in the majority of patients. Ann Surg Oncol. 2017;24:1208–1213. doi: 10.1245/s10434-016-5701-6.
    1. Gaujoux S, Bonnet S, Lentschener C, Thillois JM, Duboc D, Bertherat J, Samama CM, Dousset B. Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma. Surg Endosc. 2016;30:2984–2993. doi: 10.1007/s00464-015-4587-x.
    1. Livingstone M, Duttchen K, Thompson J, Sunderani Z, Hawboldt G, Sarah Rose M, Pasieka J. Hemodynamic stability during pheochromocytoma resection: lessons learned over the last two decades. Ann Surg Oncol. 2015;22:4175–4180. doi: 10.1245/s10434-015-4519-y.
    1. Weingarten TN, Welch TL, Moore TL, Walters GF, Whipple JL, Cavalcante A, Bancos I, Young WF, Jr, Gruber LM, Shah MZ, McKenzie TJ, Schroeder DR, Sprung J. Preoperative levels of catecholamines and metanephrines and intraoperative hemodynamics of patients undergoing pheochromocytoma and paraganglioma resection. Urology. 2017;100:131–138. doi: 10.1016/j.urology.2016.10.012.
    1. Joris JL, Hamoir EE, Hartstein GM, Meurisse MR, Hubert BM, Charlier CJ, Lamy ML. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Anesth Analg. 1999;88:16–21.
    1. Wu G, Zhang B, Yu C, Gao L, Gao Y, Huang Y, Yu L, Zhang G, Yang L, Yuan J. Effect of early adrenal vein ligation on blood pressure and catecholeamine fluctuation during laparoscopic adrenalectomy for pheochromocytoma. Urology. 2013;82:606–611. doi: 10.1016/j.urology.2013.05.011.
    1. Namekawa T, Utsumi T, Kawamura K, Kamiya N, Imamoto T, Takiguchi T, Hashimoto N, Tanaka T, Naya Y, Suzuki H, Ichikawa T. Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2016;159:763–770. doi: 10.1016/j.surg.2015.09.016.
    1. Bruynzeel H, Feelders RA, Groenland TH, van den Meiracker AH, van Eijck CH, Lange JF, de Herder WW, Kazemier G. Risk factors for hemodynamic instability during surgery for pheochromocytoma. J Clin Endocrinol Metab. 2010;95:678–685. doi: 10.1210/jc.2009-1051.
    1. Kiernan CM, Du L, Chen X, Broome JT, Shi C, Peters MF, Solorzano CC. Predictors of hemodynamic instability during surgery for pheochromocytoma. Ann Surg Oncol. 2014;21:3865–3871. doi: 10.1245/s10434-014-3847-7.
    1. Chen H, Sippel RS, O’Dorisio MS, Vinik AI, Lloyd RV, Pacak K, North American Neuroendocrine Tumor S The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Pancreas. 2010;39:775–783. doi: 10.1097/MPA.0b013e3181ebb4f0.
    1. Stefanidis D, Goldfarb M, Kercher KW, Hope WW, Richardson W, Fanelli RD, Society of G, Endoscopic S SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc. 2013;27:3960–3980. doi: 10.1007/s00464-013-3169-z.
    1. Mallat J, Pironkov A, Destandau MS, Tavernier B. Systolic pressure variation (Deltadown) can guide fluid therapy during pheochromocytoma surgery. Can J Anaesth. 2003;50:998–1003. doi: 10.1007/BF03018362.
    1. Iijima T, Takagi T, Iwao Y. An increased circulating blood volume does not prevent hypotension after pheochromocytoma resection. Can J Anaesth. 2004;51:212–215. doi: 10.1007/BF03019097.
    1. Lentschener C, Gaujoux S, Baillard C, Dousset B. Inappropriate adrenoreceptor blockade prior to phaeochromocytoma removal is perhaps a ‘timely reappraisal’? Clin Endocrinol. 2016;85:989–990. doi: 10.1111/cen.13142.
    1. Lentschener C, Gaujoux S, Tesniere A, Dousset B. Point of controversy: perioperative care of patients undergoing pheochromocytoma removal-time for a reappraisal? Eur J Endocrinol. 2011;165:365–373. doi: 10.1530/EJE-11-0162.
    1. Groeben H, Nottebaum BJ, Alesina PF, Traut A, Neumann HP, Walz MK. Perioperative alpha-receptor blockade in phaeochromocytoma surgery: an observational case series. Br J Anaesth. 2017;118:182–189. doi: 10.1093/bja/aew392.
    1. Kinney MA, Narr BJ, Warner MA. Perioperative management of pheochromocytoma. J Cardiothorac Vasc Anesth. 2002;16:359–369. doi: 10.1053/jcan.2002.124150.
    1. Randle RW, Balentine CJ, Pitt SC, Schneider DF, Sippel RS. Selective versus non-selective alpha-blockade prior to laparoscopic adrenalectomy for pheochromocytoma. Ann Surg Oncol. 2017;24:244–250. doi: 10.1245/s10434-016-5514-7.
    1. Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia. 2016;71:40–45. doi: 10.1111/anae.13309.
    1. Kinney MA, Warner ME, vanHeerden JA, Horlocker TT, Young WF, Jr, Schroeder DR, Maxson PM, Warner MA. Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection. Anesth Analg. 2000;91:1118–1123.
    1. Mihm FG. Pulmonary artery pressure monitoring in patients with pheochromocytoma. Anesth Analg. 1983;62:1129–1133. doi: 10.1213/00000539-198312000-00016.
    1. Colson P, Ryckwaert F, Ribstein J, Mann C, Dareau S. Haemodynamic heterogeneity and treatment with the calcium channel blocker nicardipine during phaeochromocytoma surgery. Acta Anaesthesiol Scand. 1998;42:1114–1119. doi: 10.1111/j.1399-6576.1998.tb05387.x.
    1. Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826. doi: 10.1097/00000542-200210000-00012.
    1. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71. doi: 10.1093/bja/88.1.65.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642. doi: 10.1093/bja/aei223.
    1. Okrainec A, Bergman S, Demyttenaere S, Feldman LS, Nutting A, Carli F, Fried GM. Validation of esophageal Doppler for noninvasive hemodynamic monitoring under pneumoperitoneum. Surg Endosc. 2007;21:1349–1353. doi: 10.1007/s00464-006-9106-7.
    1. Matsuda Y, Kawate H, Shimada S, Matsuzaki C, Nagata H, Adachi M, Ohnaka K, Nomura M, Takayanagi R. Perioperative sequential monitoring of hemodynamic parameters in patients with pheochromocytoma using the non-invasive cardiac system (NICaS) Endocr J. 2014;61:571–575. doi: 10.1507/endocrj.EJ13-0471.
    1. Roizen MF, Hunt TK, Beaupre PN, Kremer P, Firmin R, Chang CN, Alpert RA, Thomas CJ, Tyrrell JB, Cahalan MK. The effect of alpha-adrenergic blockade on cardiac performance and tissue oxygen delivery during excision of pheochromocytoma. Surgery. 1983;94:941–945.
    1. Brunaud L, Nguyen-Thi PL, Mirallie E, Raffaelli M, Vriens M, Theveniaud PE, Boutami M, Finnerty BM, Vorselaars WM, Rinkes IB, Bellantone R, Lombardi C, Fahey T, 3rd, Zarnegar R, Bresler L. Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: a multicenter retrospective analysis in 225 patients. Surg Endosc. 2016;30:1051–1059. doi: 10.1007/s00464-015-4294-7.
    1. Connor D, Boumphrey S. Perioperative care of phaeochromocytoma. BJA Educ. 2016;16:153–158. doi: 10.1093/bjaed/mkv033.
    1. James MFM (2010) Anaesthesia for patients with endocrine disease. Oxford University Press, Oxford
    1. Dyer RA, Reed AR, van Dyk D, Arcache MJ, Hodges O, Lombard CJ, Greenwood J, James MF. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery. Anesthesiology. 2009;111:753–765. doi: 10.1097/ALN.0b013e3181b437e0.
    1. Langesaeter E, Rosseland LA, Stubhaug A. Continuous invasive blood pressure and cardiac output monitoring during cesarean delivery: a randomized, double-blind comparison of low-dose versus high-dose spinal anesthesia with intravenous phenylephrine or placebo infusion. Anesthesiology. 2008;109:856–863. doi: 10.1097/ALN.0b013e31818a401f.
    1. Peck T. Pharmacology for anaesthesia and intensive care. 3. New York: Cambridge University Press; 2008.
    1. Lentschener C, Gaujoux S, Mion G, Dousset B, Baillard C. Most patients undergoing phaeochromocytoma removal could be safely discharged from the post-anaesthesia care unit to the ward after three hours monitoring. Br J Anaesth. 2018;120:879–880. doi: 10.1016/j.bja.2017.12.030.
    1. Challis BG, Casey RT, Simpson HL, Gurnell M. Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma? Clin Endocrinol. 2017;86:163–167. doi: 10.1111/cen.13252.
    1. Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97:755–757. doi: 10.1093/bja/ael290.
    1. Wilson RTJ, Minto G. The great fluid debate: time for Flexit? Br J Anaesth. 2017;118:819–822. doi: 10.1093/bja/aex076.
    1. Vorselaars W, Postma EL, Mirallie E, Thiery J, Lustgarten M, Pasternak JD, Bellantone R, Raffaelli M, Fahey T, 3rd, Vriens MR, Bresler L, Brunaud L, Zarnegar R. Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients. Surgery. 2018;163:176–182. doi: 10.1016/j.surg.2017.05.029.

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