Mas de feocromocitoma / More on pheochromocytoma

Julio 6, 2017. No. 2741

Alfa bloqueo selectivo versus no selectivo antes de adrenalectomía laparoscópica Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma. Randle RW1, Balentine CJ2, Pitt SC2, Schneider DF2, Sippel RS2. Ann Surg Oncol. 2017 Jan;24(1):244-250. doi: 10.1245/s10434-016-5514-7. Epub 2016 Aug 25. Abstract BACKGROUND: The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. METHODS: We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. RESULTS: We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar. CONCLUSION: Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications. PDF Manejo perioperatorio actual de los feocromocitomas Current perioperative management of pheochromocytomas. Ramachandran R1, Rewari V1. Indian J Urol. 2017 Jan-Mar;33(1):19-25. doi: 10.4103/0970-1591.194781. Abstract Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, 123I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative "alpha-blockade." Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers. HTLM XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Feocromocitoma / Pheochromocytoma

Julio 5, 2017. No. 2740

FEOCROMOCITOMA: MANEJO PERI-OPERATORIO Nidia Bustos Vásquez REVISTA MEDICA DE COSTA RICA Y CENTROAMERICA LXXI (609) 159 - 164, 2014 PDF Punto de controversia: el cuidado perioperatorio de los pacientes sometidos a la remoción de feocromocitoma. ¿Tiempo para una reevaluación? Point of controversy: perioperative care of patients undergoing pheochromocytoma removal-time for a reappraisal? Lentschener C1, Gaujoux S, Tesniere A, Dousset B. Eur J Endocrinol. 2011 Sep;165(3):365-73. doi: 10.1530/EJE-11-0162. Epub 2011 Jun 6. Abstract Adrenalectomy for pheochromocytoma is reported with a mortality close to zero in recent studies. The dogma of preoperative fluid and hypotensive drug administrations is widely applied in patients scheduled for pheochromocytoma removal and is assumed to have a beneficial effect on operative outcomes. This paradigm is only based on historical studies of non-standardized practices and criteria for efficacy, with no control group. Pre- and intraoperative hypovolemia have never been demonstrated in patients scheduled for pheochromocytoma removal. Recent improvements in outcome of patients undergoing adrenalectomy for pheochromocytoma could also be the result of improvement in surgical techniques and refinement in anesthetic practices. Whether better knowledge of the disease, efficiency of available intravenous short-acting vasoactive drugs, and careful intraoperative handling of the tumor make it possible to omit preoperative preparation in most patients scheduled for pheochromocytoma removal is presently questionable. We reviewed available literature in this respect. PDF Manejo del feocromocitoma: ideas Viejas y nuevas drogas Management of pheochromocytoma: old ideas and new drugs. Domi R1, Laho H. Niger J Clin Pract. 2012 Jul-Sep;15(3):253-7. doi: 10.4103/1119-3077.100616. Abstract Pheochromocytoma presents a challenge to the surgery team because of its clinical features and implications. The patient must be treated before the surgery until a stable hemodynamically state is achieved. The preoperative treatment includes α2-short acting adrenergic blocking and β-blocker agents. The most crucial intraoperative moments are induction of anesthesia and hemodynamic oscillations. An adequate preoperative preparation, modern anesthetic drugs, good collaboration between the surgeons and the anesthesiologists, and postoperative care decrease the rate of complications and improve the outcome. This review aims to discuss all the possible pharmacological strategies of perioperative management of phoechromocytoma, focusing on new drugs and treatments. PDF Guía norteamericana de consenso de la Sociedad Neuroendócrina de Tumores para el diagnóstico y manejo de tumores neuroendocrinos: feocromocitoma, paraganglioma y cáncer medular de tiroides. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Chen H1, Sippel RS, O'Dorisio MS, Vinik AI, Lloyd RV, Pacak K; North American Neuroendocrine Tumor Society (NANETS). Pancreas. 2010 Aug;39(6):775-83. doi: 10.1097/MPA.0b013e3181ebb4f0. Abstract Pheochromocytomas, intra-adrenal paraganglioma, and extra-adrenal sympathetic and parasympathetic paragangliomas are neuroendocrine tumors derived from adrenal chromaffin cells or similar cells in extra-adrenal sympathetic and parasympathetic paraganglia, respectively. Serious morbidity and mortality rates associated with these tumors are related to the potent effects of catecholamines on various organs, especially those of the cardiovascular system. Before any surgical procedure is done, preoperative blockade is necessary to protect the patient against significant release of catecholamines due to anesthesia and surgical manipulation of the tumor. Treatment options vary with the extent of the disease, with laparoscopic surgery being the preferred treatment for removal of primary tumors. Medullary thyroid cancer (MTC) is a malignancy of the thyroid C cells or parafollicular cells. Thyroid C cells elaborate a number of peptides and hormones, such as calcitonin, carcinoembryonic antigen, and chromogranin A. Some or all of these markers are elevated in patients with MTC and can be used to confirm the diagnosis as well as to follow patients longitudinally for recurrence. Medullary thyroid cancer consists of a spectrum of diseases that ranges from extremely indolent tumors that are stable for many years to aggressive types associated with a high mortality rate. Genetic testing for RET mutations has allowed identification of familial cases and prophylactic thyroidectomy for cure. The only curative treatment is complete surgical resection. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Encuentro Internacional de Manejo de la Vía Aérea Bariloche. Argentina. Nov 30-Dic 2, 20l7 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org