To block, or not to block … is it still the question? Effectiveness of alpha- and beta-blockade in phaeochromocytoma surgery: an institutional analysis

• Published in: Annals of the Royal College of Surgeons of England Vol. 104; no. 2; pp. 138 - 143
• Main Authors: Van Den Heede, K, Paspala, A, Chander, N, Chidambaram, S, Wernig, F, Todd, JF, DiMarco, AN, Palazzo, FF
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01.02.2022; Royal College of Surgeons
• Subjects: Adrenal Gland Neoplasms - surgery; Adrenalectomy - adverse effects; Adrenergic alpha-Antagonists - therapeutic use; Beta blockers; Blood pressure; Body mass index; Cardiac arrhythmia; Catecholamines; Drug dosages; Hemodynamics; Hemoglobin; Humans; Hypertension; Laparoscopy; Morbidity; Mortality; Neuroendocrine tumors; Oncology; Paraganglioma - surgery; Patients; Pheochromocytoma - surgery; Postoperative period; Retrospective Studies; Surgery; Adrenalectomy; Phenoxybenzamine; Haemodynamic instability; Phaeochromocytoma; Alpha-blockers
• ISSN: 0035-8843; 1478-7083; 1478-7083
• DOI: 10.1308/rcsann.2021.0133

Phaeochromocytomas/paraganglioma (PPGL) surgery was historically associated with significant risks of perioperative complications. The decreased mortality (<3.0%) had been attributed in part to optimal preoperative alpha-blockade. The value of alpha-blockade in decreasing morbidity is being challenged. The aim of our study is to present an institutional experience of preoperative alpha-blocking of PPGL and its effect on cardiovascular stability and postoperative morbidity. A retrospective study using data from our institutional database was conducted. All patients undergoing adrenalectomy for PPGL from October 2011 to September 2020 were included. All patients were routinely alpha-blocked. Intraoperative cardiovascular instability (ICI) was assessed through number of systolic blood pressure (SBP) episodes >160mmHg, SBP <90mmHg, the need for vasoactive drugs and volume of intraoperative crystalloids administered. Morbidity was also evaluated. A total of 100 consecutive patients undergoing surgery were identified of whom 53 patients had complete anaesthetic records available for analysis. Thirty-two patients (60%) had at least one episode with an SBP >160mmHg. Nine (17%) cases had no intraoperative hypotensive episodes, while 3 (6%) patients had >10 intraoperative episodes of an SBP <90mmHg. Twenty-one (40%) patients received vasoactive drugs during surgery. The median volume of intraoperative crystalloids was 2 litres (1-4). Postoperatively, no patient experienced cardiovascular complications, including arrhythmia or myocardial ischaemia. Only two were admitted to an intensive care unit (ICU) and one 30-day readmission occurred. Cardiac instability remained significant in PPGL surgery despite optimal alpha- and beta-blockade. While omitting blockade would appear empirically questionable, a randomised controlled trial (RCT) of surgery with and without alpha-blockade will provide an answer.