Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
Division of General Surgery, Section Endocrine Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
Surg Endosc. 2020 Jan;34(1):368-376. doi: 10.1007/s00464-019-06777-z. Epub 2019 Apr 11.
Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications.
Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters.
Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg h, p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min m, p = 0.005; HIAT: 2.08 vs. 2.56 l min m, p = 0.225).
As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course.
ClinicalTrials.gov, Identifier: NCT01425710.
在嗜铬细胞瘤（PCC）的肾上腺切除术期间，经常观察到血流动力学不稳定。指南建议术前进行自由的容量管理。然而，尚不清楚是液体不足还是血管麻痹导致血流动力学变化，以及使用食管多普勒（EDM）进行微创血流动力学监测是否有助于可视化术中变化，避免容量过负荷和并发症。
10 例经生化证实的 PCC 患者和 5 例激素无活性肾上腺肿瘤（HIAT；对照组）患者按照严格的方案进行治疗。在腹腔镜肾上腺切除术期间，使用 EDM 进行目标导向的液体治疗。记录血流动力学和生化数据。主要观察变量为液体需求和血流动力学参数。
应用 EDM，PCC 患者的总术中液体给药量略高于 HIAT 患者（2100±516 比 1550±622 ml，p=0.097；12.9±4.8 比 8.3±0.7 ml·kg·h，p=0.014）。PCC 组的血流动力学变化较大，并与分泌儿茶酚胺的类型和水平相关。动脉血压和全身血管阻力指数在 PCC 切除后 10 分钟内达到最低。在没有自由液体给药的情况下，两组的心脏指数在与手术结束时的基线测量值相比均有所增加。仅在 PCC 患者中，这种增加具有统计学意义（PCC：2.31 比 3.15 l·min·m，p=0.005；HIAT：2.08 比 2.56 l·min·m，p=0.225）。
由于在肿瘤切除后记录到血管麻痹，而不是低血容量，因此没有证据表明腹腔镜肾上腺切除术中 PCC 患者从自由液体给药中获益。为避免容量过负荷，应常规使用非侵入性技术，如 EDM，以可视化术中变化。
ClinicalTrials.gov，标识符：NCT01425710。
