Witteles, Ronald M. BA*†; Kaplan, Edwin L. MD†; Roizen, Michael F. MD*
Departments of *Anesthesia and Critical Care and †Surgery, The University of Chicago Hospitals, Chicago, Illinois
Address correspondence and reprint requests to Michael Roizen, MD, Chairman, Department of Anesthesia and Critical Care, University of Chicago Hospitals, 5841 S. Maryland Ave., MC 4028, Chicago, IL 60637.
Pheochromocytomasare one of the most dangerous types of tumors encountered in clinical medicine because of their paroxysmal release of catecholamines and the risk for rapid changes in arterial blood pressure, arrhythmias, shock, and disseminated intravascular coagulation (1–7).
Although no controlled, randomized, prospective clinical studies have evaluated the benefits and risks of preoperative use of α-adrenergic receptor-blocking drugs, the use of such drugs has been generally recommended before surgery (8–17).
In our institution, a change in personnel for preoperative preparation after 1986 led to a change in management decisions for pheochromocytoma patients. The purpose of this study was to determine whether, after stabilization, selected patients could be maintained safely at home as outpatients before elective operations for pheochromocytoma.
After institutional review board approval, we obtained the complete medical records of 33 nonpregnant patients who were operated on for primary pheochromocytomas at the University of Chicago Hospitals between 1962 and 1997.
The patients were divided into two groups: pre-January 1, 1987 (Group 1), and post-January 1, 1987 (Group 2). Patients in Group 1 had many different surgeons and anesthesiologists, and their data were collected by retrospective chart review. Almost all patients in Group 2 were cared for by one anesthesiologist (MR) and one surgeon (ELK), and their data were collected as part of an institutional review board-approved, prospective study. 1
When appropriate, statistical evaluation was performed by using independent t-test analysis with separate variances, χ2 analysis, Mann-Whitney U-test, and power analysis;P values < 0.05 were considered significant.
Group 1 consisted of 7 men and 4 women, mean age 33.8 ± 19.7 yr. Group 2 consisted of 10 men and 12 women, mean age 44.0 ± 18.3 yr. All patients had open operations: laparotomies (n = 32) or flank incisions (n = 1). No tumors were excised laparoscopically.
The hospital course of the 33 nonpregnant patients who underwent surgery for pheochromocytoma is summarized in Table 1 and Figure 1.
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. Cited Here...
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. Cited Here...
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