Introduction: Pheochromocytomas and paragangliomas are rare neuroendocrine tumors arising from chromaffin cells. Surgical resection is the only curative therapy, though this procedure is associated with a significant risk of perioperative haemodynamic instability. Surgery-related morbidity and mortality have been largely reduced thanks to advances in radiological diagnostics, preoperative medical treatment, surgical technique and anaesthesia management. However, haemodynamic changes during and after surgery remain frequent complications that are not easily predictable. Aim of the study: the aims of the present retrospective study were i) to assess the predictive factors for intraoperative haemodynamic instability, then ii) to identify the predictive for postoperative hypotension, and finally iii) to assess the efficacy of the "PACS risk score" to predict the occurrence of postoperative hypotension in patients undergoing surgery for pheochromocytoma. Materials and Methods: The study included 79 adult patients (≥18 years old) undergoing surgery for pheochromocytoma and/or paraganglioma at Padova University Hospital between January 2012 and December 2022. Demographic, clinical, biochemical, radiological and histopathological data were collected from medical records. Data on preoperative, intraoperative and postoperative haemodynamic were also collected from medical reports. Parameters considered were age, comorbidity, clinical presentation, level and type of preoperative secretion, tumour size, preoperative medical treatment, preoperative, intraoperative and postoperative haemodynamic parameters, type of surgery and genetics. Intraoperative haemodynamic instability was assessed using the following definitions: 1) at least one episode of SBP≥160mmHG and/or one episode of MAP<60mmHg and/or a variation of intraoperative MAP ≥±30% of preoperative MAP; 2) at least one variation of intraoperative MAP ≥±30% of preoperative MAP. Postoperative hypotension was defined as SBP<90mmHg and/or the need for vasopressor therapy within 24h after surgery. Results: Intraoperative haemodynamic instability (HDI), defined as at least one episode of SBP≥160mmHG and/or one episode of MAP<60mmHg and/or a change in intraoperative MAP ≥±30% of preoperative MAP, occurred in 51 patients (68,9%). Tumour size, urinary adrenaline/24h, urinary metanephrine/24h and urinary normetanephrine/24h levels were identified as predictive factors for HDI (p<0,05). If HDI is defined as at least a change in MAP >±30%, tumour size, preoperative urinary normetanephrine/24h levels, age at surgery, presence of comorbidities and presence of acute cardiovascular events at diagnosis were identified as predictive factors for HDI (p<0,04). on multivariable analysis tumour size (p=0,009) and age at surgery (p=0,015) remained ad independent predictors for HDI. Postoperative hypotension (PH) occurred in 31 patients (40,26%). Tumour size, acute cardiovascular events at diagnosis and urinary noradrenaline/24h levels (p<0,05) were found as predictive factors for PH. Preoperative noradrenaline secretion (p=0,048) and the presence of acute cardiovascular events at diagnosis (p=0,029) remained independent predictive factors for PH. The PACS risk score was calculated in 72 patients with pheochromocytoma and it was significantly associated with the development of postoperative hypotension (p=0,022). Conclusion: Tumour size and age at surgery were independent predictors of intraoperative haemodynamic instability. The presence of acute cardiovascular events at diagnosis and increased preoperative urinary norepinephrine/24h levels were found to be independent predictors of postoperative hypotension. In addition, PACS risk score was found to be an effective predictor of postoperative hypotensive episodes and, in the future, this score could be clinically applied to identify patients for whom intensive postoperative monitoring is unnecessary.
Introduzione:Feocromocitomi e paragangliomi sono tumori rari che originano dalle cellule cromaffini. Il trattamento chirurgico è l’unico risolutivo della patologia; tale procedura è gravata da un significativo rischio di instabilità emodinamica peri-operatoria. Alterazioni emodinamiche durante e a seguito dell’intervento restano complicanze frequenti e difficilmente prevedibili. Scopo dello studio: valutare quali sono i fattori predittivi di instabilità emodinamica intraoperatoria, quindi di individuare i fattori predittivi di ipotensione postoperatoria, e infine valutare l’efficacia dell’indice di rischio di ipotensione postoperatoria “PACS risk score”. Materiali e Metodi: lo studio ha incluso 79 pazienti sottoposti ad intervento chirurgico per feocromocitoma e/o paraganglioma presso l’Unità Operativa di Endocrinochirugia di Padova nel periodo compreso tra 01/01/2012 e 31/12/2022. Dati demografici, clinici, biochimici, radiologici e istopatologici sono stati raccolti a partire dalle cartelle cliniche cartacee e informatizzate. I parametri considerati sono stati età, comorbidità, presentazione clinica, livello e tipo di secrezione preoperatoria, dimensioni della neoplasia, trattamento farmacologico preoperatorio, parametri emodinamici preoperatori, intraoperatori e postoperatori, tipo di intervento chirurgico e genetica. L’instabilità emodinamica intraoperatoria è stata valutata sulla base delle seguenti definizioni: 1) almeno un episodio di SBP≥160mmHG e/o un episodio di MAP<60mmHg e/o una variazione della MAP intraoperatoria ≥±30% della MAP preoperatoria; 2) almeno una variazione della MAP intraoperatoria ≥±30% della MAP preoperatoria. L’ipotensione postoperatoria è stata definita come la rilevazione di SBP<90mmHg e/o la necessità di terapia vasopressoria entro 24h dall’intervento. Risultati: L’instabilità emodinamica intraoperatoria, definita come almeno un episodio di SBP≥160mmHG e/o un episodio di MAP<60mmHg e/o una variazione della MAP intraoperatoria ≥±30% della MAP preoperatoria è stata osservata in 51 pazienti (68,9%). I fattori risultati predittivi di instabilità emodinamica intraoperatoria sono stati la dimensione del tumore, i livelli di Adrenalina urinaria/24h, Metanefrine urinarie/24h e Normetanefrine urinarie/24h (p<0,05). Se l’instabilità emodinamica è definita come almeno una variazione di MAP >±30% i fattori predittivi sono la dimensione del tumore, i livelli preoperatori di Normetanefrine urinarie/24h, l’età al momento dell’intervento, la presenza di comorbidità e la presenza di eventi cardiovascolari acuti nel preoperatorio (p<0,04). Sono fattori predittivi indipendenti dimensioni del tumore (p=0,009) e l’età al momento dell’intervento (p=0,015). L’ipotensione postoperatoria si è verificata in 31 pazienti (40,26%). Fattori predittivi sono stati le dimensioni del tumore, la presenza di eventi cardiovascolari acuti nel preoperatorio, i livelli di Noradrenalina urinaria/24h (p<0,05). La secrezione di Noradrenalina preoperatoria (p=0,048) e la presenza di acuzie cardiovascolari preoperatorie (p=0,029) sono rimasti fattori predittivi indipendenti. Il PACS risk score calcolato in 72 pazienti affetti da feocromocitoma è risultato significativamente associato allo sviluppo di ipotensione postoperatoria (p=0,022). Conclusioni: Le dimensioni e l’età al momento dell’intervento sono risultati fattori predittivi indipendenti di instabilità emodinamica intraoperatori. La presenza di acuzie cardiovascolari nel preoperatorio e il riscontro di livelli preoperatori elevati di noradrenalina urinaria delle 24h sono risultati fattori predittivi indipendenti di ipotensione postoperatoria. Inoltre, il PACS risk score è risultato un parametro efficace nel predire episodi ipotensivi postoperatori; tale score potrebbe essere applicato clinicamente per individuare i pazienti per i quali non è necessario il monitoraggio intensivo postoperatorio
GESTIONE PERIOPERATORIA DEL PAZIENTE SOTTOPOSTO A CHIRURGIA PER FEOCROMOCITOMA E PARAGANGLIOMA
GHIOZZI, FEDERICA
2022/2023
Abstract
Introduction: Pheochromocytomas and paragangliomas are rare neuroendocrine tumors arising from chromaffin cells. Surgical resection is the only curative therapy, though this procedure is associated with a significant risk of perioperative haemodynamic instability. Surgery-related morbidity and mortality have been largely reduced thanks to advances in radiological diagnostics, preoperative medical treatment, surgical technique and anaesthesia management. However, haemodynamic changes during and after surgery remain frequent complications that are not easily predictable. Aim of the study: the aims of the present retrospective study were i) to assess the predictive factors for intraoperative haemodynamic instability, then ii) to identify the predictive for postoperative hypotension, and finally iii) to assess the efficacy of the "PACS risk score" to predict the occurrence of postoperative hypotension in patients undergoing surgery for pheochromocytoma. Materials and Methods: The study included 79 adult patients (≥18 years old) undergoing surgery for pheochromocytoma and/or paraganglioma at Padova University Hospital between January 2012 and December 2022. Demographic, clinical, biochemical, radiological and histopathological data were collected from medical records. Data on preoperative, intraoperative and postoperative haemodynamic were also collected from medical reports. Parameters considered were age, comorbidity, clinical presentation, level and type of preoperative secretion, tumour size, preoperative medical treatment, preoperative, intraoperative and postoperative haemodynamic parameters, type of surgery and genetics. Intraoperative haemodynamic instability was assessed using the following definitions: 1) at least one episode of SBP≥160mmHG and/or one episode of MAP<60mmHg and/or a variation of intraoperative MAP ≥±30% of preoperative MAP; 2) at least one variation of intraoperative MAP ≥±30% of preoperative MAP. Postoperative hypotension was defined as SBP<90mmHg and/or the need for vasopressor therapy within 24h after surgery. Results: Intraoperative haemodynamic instability (HDI), defined as at least one episode of SBP≥160mmHG and/or one episode of MAP<60mmHg and/or a change in intraoperative MAP ≥±30% of preoperative MAP, occurred in 51 patients (68,9%). Tumour size, urinary adrenaline/24h, urinary metanephrine/24h and urinary normetanephrine/24h levels were identified as predictive factors for HDI (p<0,05). If HDI is defined as at least a change in MAP >±30%, tumour size, preoperative urinary normetanephrine/24h levels, age at surgery, presence of comorbidities and presence of acute cardiovascular events at diagnosis were identified as predictive factors for HDI (p<0,04). on multivariable analysis tumour size (p=0,009) and age at surgery (p=0,015) remained ad independent predictors for HDI. Postoperative hypotension (PH) occurred in 31 patients (40,26%). Tumour size, acute cardiovascular events at diagnosis and urinary noradrenaline/24h levels (p<0,05) were found as predictive factors for PH. Preoperative noradrenaline secretion (p=0,048) and the presence of acute cardiovascular events at diagnosis (p=0,029) remained independent predictive factors for PH. The PACS risk score was calculated in 72 patients with pheochromocytoma and it was significantly associated with the development of postoperative hypotension (p=0,022). Conclusion: Tumour size and age at surgery were independent predictors of intraoperative haemodynamic instability. The presence of acute cardiovascular events at diagnosis and increased preoperative urinary norepinephrine/24h levels were found to be independent predictors of postoperative hypotension. In addition, PACS risk score was found to be an effective predictor of postoperative hypotensive episodes and, in the future, this score could be clinically applied to identify patients for whom intensive postoperative monitoring is unnecessary.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/47823