Control of the phaeochromocytoma patient revisited

Editor—We read with interest the article by Tauzin-Fin and colleagues.1 The authors report on 18 patients, over a period of 6.5 yr, being operated upon for removal of a phaeochromocytoma using the laparoscopic surgical technique. This technique is growing in popularity both in Europe and the USA. The authors point out that insufflation of carbon dioxide into the peritoneal cavity can cause a hypertensive episode because of the pressure increase within the cavity. This increase in pressure can cause an efflux of catecholamines from the tumour at any time during the procedure. Once the pressure is maintained at 15 cm H2O, the intra-abdominal pressure should stabilize. Intraperitoneal insufflation of carbon dioxide can also lead to release of vasopressin, with an increase in systemic vascular resistance and gradual decrease in cardiac output.2 Carbon dioxide pneumoperitoneum can produce significant hypercapnia and respiratory acidosis.3 These complications are rarely a problem in younger patients, but older patients with pre-existing pulmonary disease and those with increased respiratory dead space may have difficulty eliminating the carbon dioxide burden despite mechanically increased minute ventilation.4 Helium has been investigated as an alternative insufflating gas in a porcine model.3 Further investigation on the use of helium for pneumoperitoneum is warranted. We believe that it may be an excellent alternative to carbon dioxide, especially in those patients with pre-existing cardiopulmonary disease or with decreased respiratory reserve.

Tauzin-Fin and colleagues1 used urapidil, an {alpha}1 adrenergic blocker, intermittently, to control the intraoperative surges in blood pressure attributable to either tumour manipulation or the pneumoperitonium. In the USA, urapidil is an investigational drug and can not be used in clinical practice.

The authors' paper reminds us of the one we had published in the British Journal of Anaesthesia in 1994.5 This paper recommends the use of metyrosine, an agent that reduces biosynthesis of catecholamines (often to normal levels) and also phenoxybenzamine, a non-competitive long-acting mixed {alpha}-antagonist. Both are continued to the morning of surgery. In the Lippmann paper,5 desflurane was used, then a new inhalational agent released by the Federal Drug Administration for general use. This inhalational agent has a powerful and fast vasodilating effect and can be easily titrated to control hypertensive surges. Tauzin-Fin and colleagues,1 used isoflurane or sevoflurane, which also have a vasodilating effect, although slower in onset.

Lippmann's5 paper stresses that whatever inhalational agent or other drugs are used, the main aspect that the anesthetist should be concerned with is that the patient should be well prepared before surgery by either the surgeon or endocrinologist. It is the unprepared (lack of adequate {alpha}-blockade) patient who is most at risk. Volume expansion, {alpha}-blockade and the use of metyrosine are, we think, the keys to success in the phaeochromocytoma patient going for surgery.

M. Lippmann and C. Kakazu

Los Angeles, CA, USA


 
Editor—We appreciate the interest of Drs Lippmann and Kakazu in our study.1 Indeed, laparoscopic surgery for phaeochromocytoma is now widely considered to be the gold standard, and the anaesthetist should be aware of the pathophysiological repercussions from both the phaeochromocytoma and pneumoperitoneum. In an animal study, vasopressin release has been shown to be involved in haemodynamic instability.2 This situation has not been reported in humans undergoing normovolaemic anaesthesia with adequate monitoring of the depth of anaesthesia.6 Hypercapnia in relation to the carbon dioxide pneumoperitoneum induces small changes in plasma catecholamine levels.7 Hypercapnia can be of importance in patients with pre-existent cardiorespiratory disease. Close monitoring of and more precisely of avoids the consequences of hypercapnia in such patients. Helium can be used as an insufflating gas in laparoscopic surgery for phaeochromocytoma.8 However, because of its low water solubility, helium is more prone to induce gas embolism than carbon dioxode.9 10 Creation of the pneumoperitoneum is the main triggering factor for catecholamine release, even when close monitoring of intra-abdominal pressure during insufflation is performed.

We agree with Dr Lippmann's view that the key to success is pre- and intra-operative {alpha}-blockade, probably using short-acting agents. Unfortunately, the ideal short-acting {alpha} blocker has not yet been determined. Metyrosine reduces the biosynthesis of catecholamines without establishing haemodynamic stability, thereby causing possible cardiovascular collapse after tumour gland removal.11 Phenoxybenzamine, a non-selective {alpha} adrenoreceptor antagonist, has a long duration of action and a pharmacological half-life of about 24 h. Its chronotropic and inotropic effects can be controlled with ß-blockers.11 Prazosin is a selective, competitive {alpha}1 adrenoreceptor blocker that, given orally, improves the management of phaeochromocytoma only in the preoperative phase.11 All these drugs may exert delayed effects that can increase the incidence of severe hypotension after tumour removal. An alternative treatment is urapidil, a competitive and selective short-acting {alpha}1 blocker, administered by continuous i.v. infusion preoperatively and throughout anaesthesia, to block {alpha}1 adrenergic receptors before any acute catecholamine release during surgery.1 Its pharmacological profile renders it effective in this situation. If severe rises in blood pressure occur, nicardipine at low doses is an effective adjuvant treatment, whose action is potentiated by sevoflurane.12 13 Desflurane should be avoided as it is associated with catecholamine release if given rapidly in high concentrations.14

We totally share Dr Lippmann's conclusions that the unprepared patient is most at risk, and we believe that the use of urapidil represents a modern, pathophysiological approach to the perioperative management of phaeochromocytoma.

P. Tauzin-Fin, M. Sesay, P. Gosse and P. Ballanger

Bordeaux, France

References

1 Tauzin-Fin P, Sesay M, Gosse P, et al. Effects of perioperative {alpha}1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 2004; 92: 512–17[Abstract/Free Full Text]

2 Mann C, Boccara G, Pouzeratte Y, et al. The relationship among carbon dioxide pneumoperitonium, vassopressin release and hemodynamic changes. Anesth Analg 1999; 89: 278–83[Abstract/Free Full Text]

3 Leighton TA, Bongard FS, Liu SY. Comparative cardiopulmonary effects of carbon dioxide vs. helium pneumoperitoneum. Surg J 1993; 113: 527–31

4 Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991; 236: 997–1001

5 Lippmann M. Ford M, Lee CM, et al. Use of desflurane during resection of phaeochromocytoma. Br J Anaesth 1994; 72: 707–9[Abstract]

6 Lentschener C, Axler O, Fernandez H, et al. Haemodynamic changes and vasopressin release are not consistently associated with carbon dioxide pneumoperitoneum in humans. Acta Anaesthesiol Scand 2001; 45: 527–35[CrossRef][ISI][Medline]

7 Myre K, Rostrup M, Buanes T, Stokland O. Plasma catecholamine and haemodynamic changes during pneumoperitoneum. Acta Anaesthesiol Scand 1998, 42: 343–7[ISI][Medline]

8 Fernandez-Cruz L, Taura P, Saenz A, Benaroch G. Laparoscopic approach to pheochromocytoma: hemodynamic changes and catecholamine secretion. World J Surg 1996; 20: 762–8[CrossRef][ISI][Medline]

9 McMahon AJ, Baxter JN, Murry W, Imrie CW, Kenny G, O'Dwyer. Helium pneumoperitonium for laparoscopic cholecystectomy: ventilatory and blood gas changes. Br J Surg 1994; 81: 1033–6[ISI][Medline]

10 Junghans T, Bohm B, Meyer E. Influence of nitrous oxide anaesthesia on venous gas embolism with carbon dioxide and helium during pneumoperitonium. Surg Endoscopy 2000; 14: 1167–70[CrossRef][ISI]

11 Prys-Robert C. Phaeochromocytoma-recent progress in its management. Br J Anaesth 2000; 85: 44–57[Free Full Text]

12 Nishiyama T, Matsukawa T, Hanaoka K, Conway C. Interactions between nicardipine and enflurane, isoflurane, and sevoflurane. Can J Anaesth 1997; 44: 707–9[Abstract]

13 Van de Low A, Plaud B, Debaene B. Utilisation du sevoflurane pour la chirurgie du phéochromocytome. Ann Fr Anesth Reanim 1998; 17: 301–5[CrossRef][ISI][Medline]

14 Ebert TJ, Muzi M. Sympathetic activity during desflurane anesthesia in healthy volunteers. A comparison to isoflurane. Anesthesiology 1993; 78: 444–53





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