In Group 1, 9% of patients spent a week or less in the hospital preoperatively after diagnosis; no patients spent 0 or 1 day. In Group 2, 77% of patients spent a week or less in the hospital preoperatively (P < 0.001): 23% spent 0 days and 23% spent 1 day (P < 0.01 for spending 0 or 1 day).
No patient died postoperatively (within 30 days). There was no stroke, neurologic dysfunction, myocardial infarction, or renal dysfunction (defined as an increase of serum creatinine by 1.0 mg/dL or greater) in either group. Fewer patients in Group 2 were found to have one or more perioperative complications (18% vs 36%, not significant). This reduction in complication rate was probably more pronounced, as less complete records were obtained before the prospective analyses of each patient in Group 2. Complications in Group 1 included three patients with pneumonia and one with thrombophlebitis. Complications in Group 2 included two patients with pneumonia, one with congestive heart failure, and one with atrial fibrillation.
Because of the slow metastatic spread of pheochromocytoma and the benefits of optimal preoperative patient condition, most studies recommend that patients receive α-adrenergic blockers preoperatively for at least 10 to 14 days. This time is needed to stabilize blood pressure, expand intravascular volume, normalize myocardial performance, and ameliorate symptoms (10–12).
In 1987, we shifted our management of pheochromocytomas to a shorter preoperative hospital stay and longer preoperative treatment with α-adrenergic blockers (1). Patients monitored their own arterial blood pressure and heart rate at home daily and communicated by telephone with the anesthesiologist, who adjusted their medications as needed. Seventy-three percent of patients in Group 2 were deemed to be stable preoperatively and were given home management, compared with only 22% of patients in Group 1. No patient needed hospital care after being sent home for preoperative management.
Postoperative length of stay was significantly reduced in Group 2 patients, even though we did not aim to discharge patients any sooner than in the past. In recent years, this trend has been even more apparent.
There was also a trend toward fewer complications in Group 2. We would need similar data in 97 patients to show significance at the P < 0.05 level. The preoperative ambulatory freedom attributable to treating patients on an outpatient basis may be partly responsible for the smaller incidence of pneumonia postoperatively in Group 2 (3 of 11 versus 2 of 22, not significant).
Hence, this study indicates that outpatient preoperative management is acceptable for many pheochromocytoma patients. All patients in our study were deemed acceptable except three whose social situation precluded outpatient management, and one with intercurrent sepsis.
The change in management of patients with pheochromocytoma not only drastically cut costs (a 50% reduction in total days of hospitalization in this study) (2), but also allowed patients to prepare for surgery in a comfortable and familiar environment and, in many cases, to continue working until shortly before the operation.
This study indicates that pheochromocytoma patients can usually be safely prepared for surgery on an outpatient basis. These results are in concordance with national trends for the management of many other diseases (which often pose less of a challenge for the anesthesiologist). The changes in management of patients were initiated before the introduction of managed care in this geographic area.
In this era of cost-containment, it is significant that this new care pattern reduced hospital stay while improving outcomes and quality of life between diagnosis and surgery for the patients. 2 Although no study in the recent literature has addressed this issue, we believe this study reflects a trend present in other hospitals across the country and merits a larger multi-institution study of the effects of outpatient preoperative management of pheochromocytoma.
1 The standard preoperative preparation that we use is a titration of phenoxybenzamine starting at 10 mg bid, and increasing doses as needed to control blood pressure (including 1 h unsedated in the recovery room with automated blood pressure taken every minute) to have no systolic reading greater than 160 mm Hg or diastolic reading greater than 90 mm Hg in the 3 days before surgery. β-Blockers are not used unless needed to control tachycardia and have been used in only 3 of the last 22 patients. Although agents newer than phenoxybenzamine are currently being used, all treatment in this time frame was done with phenoxybenzamine. Only one patient required pressor treatment after tumor removal as a result of prolonged hypotension.
2 If one calculates the average drug cost of $100/mo versus a copayment amount of $200/hospital day, there is a direct patient savings of more than $1800 and a total savings (assuming $1000/hospital day) of approximately $12,000 per patient. Readers are encouraged to substitute numbers reflecting their own sites of practice.
1. Lucon AM, Pereira MA, Mendonca BB, et al. Pheochromocytoma: study of 50 cases. J Urol 1997; 157:1208–12.
2. Malone MJ, Libertino JA, Tsapatsaris NP, Woods BO. Preoperative and surgical management of pheochromocytoma. Urol Clin North Am 1989; 16:567–82.
3. Orchard T, Grant CS, van Heerden JA, Weaver A. Pheochromocytoma: continuing evolution of surgical therapy. Surgery 1993; 114:1153–9.
4. Sheps SG, Jiang NS, Klee GG. Diagnostic evaluation of pheochromocytoma. Endocrinol Metab Clin North Am 1988; 17:397–414.
5. Samaan NA, Hickey RC, Shutts PE. Diagnosis, localization, and management of pheochromocytoma: pitfalls and follow-up in 41 patients. Cancer 1988; 62:2451–60.
6. Sutton MG, Sheps SG, Lie JT. Prevalence of clinically unsuspected pheochromocytoma: review of a 50-year autopsy series. Mayo Clin Proc 1981; 56:354–60.
7. Loh KC, Shlossberg AH, Abbott EC, et al. Phaeochromocytoma: a ten-year survey. QJM 1997; 90:51–60.
8. Geoghegan JG, Emberton M, Bloom SR, Lynn JA. Changing trends in the management of phaeochromocytoma. Br J Surg 1998; 85:117–20.
9. Sand J, Salmi J, Saaristo J, Auvinen O. Preoperative treatment and survival of patients with pheochromocytomas. Ann Chir Gynaelcol 1997; 86:230–2.
10. Roizen MF, Hunt TK, Beaupre PN, et al. The effect of alpha-adrenergic blockade on cardiac performance and tissue oxygen delivery during excision of pheochromocytoma. Surgery 1983; 94:941–5.
11. Roizen MF, Schreider BD, Hassan SZ. Anesthesia for patients with pheochromocytoma. Anesthesiol Clin North Am 1987; 5:269–75.
12. Jovenich JJ. Anesthesia in adrenal surgery. Urol Clin North Am 1989; 16:583–7.
13. Ito Y, Obara T, Yamashita T, et al. Pheochromocytomas: tendency to degenerate and cause paroxysmal hypertension. World J Surg 1996; 20:923–7.
14. Bravo EL, Gifford RW Jr. Pheochromocytoma: diagnosis, localization and management. N Engl J Med 1984; 311:1298–303.
15. Modlin IM, Farndon JR, Shepherd A, et al. Pheochromocytomas in 72 patients: clinical and diagnostic features, treatment and long term results. Brit J Surg 1979; 66:456–65.
16. Meyer M, Mellicow MD. One hundred cases of pheochromocytoma (107 tumors) at the Columbia-Presbyterian Medical Center, 1926–1976. Cancer 1977; 40:1987–2004.
17. Pruszczyk P, Januszewicz W, Feltynowski T, et al. Long term follow-up after surgical removal of pheochromocytoma: observations in 61 patients. Clin Exper Hypertens 1991; A13:1179–94.