Perioperative hemodynamic management in surgery for phaeochromocytoma: A narrative review

Pheochromocytomas are rare adrenal tumors that produce excessive catecholamines and their surgical removal poses significant risks of intraoperative hemodynamic instability (HI) due to catecholamine release. This review article discusses the perioperative factors that impact hemodynamic lability and its management in patients undergoing surgical removal. A literature review was conducted by searching the electronic databases - Ovid MEDLINE, Embase, and Cochrane Library using appropriate Medical Subject Heading terms and keywords such as phaeochromocytoma, HI, and perioperative hemodynamic monitoring. The advancements in surgical and anesthetic techniques and appropriate preoperative medical optimization have contributed to a significant decrease in mortality rates. However, perioperative HI remains the biggest surgical and anesthetic challenge in treating pheochromocytomas. Patients with larger and more hormonally active tumors are at higher risk for extreme hypertensive episodes during surgery. Preoperative α-blockade, higher phenoxybenzamine doses, and laparoscopic approach improve the outcomes in phaeochromocytoma removal. Anesthetic techniques and drugs used during surgery may help prevent HI, but careful intraoperative management is essential. Perioperative HI can lead to increased surgical blood loss, patient morbidity, and prolonged intensive care unit (ICU) and hospital stay. Therefore, a multidisciplinary approach involving the surgeon, anesthesiologist, and ICU team is essential to ensure optimal perioperative management of patients with pheochromocytoma. Intensive hemodynamic monitoring may be required in the postoperative period to manage hypotension seen after tumor removal. In conclusion, perioperative HI is a significant risk during the surgical removal of pheochromocytomas, even with preoperative pharmacological treatment. Therefore, the use of appropriate preoperative medical optimization, surgical and anesthetic techniques, and careful intraoperative management can significantly improve the outcomes.