title: Preoperative Metyrosine Improves Cardiovascular Outcomes for Patients Undergoing Surgery for Pheochromocytoma and Paraganglioma.
abstract: BACKGROUND
  The goal of preoperative pharmacotherapy for pheochromocytoma (PCC) and paraganglioma (PGL) resection is to minimize intraoperative hemodynamic instability and perioperative cardiovascular complications, but no standard preoperative regimen exists. Historically, treatment used metyrosine and phenoxybenzamine (MP). The recent metyrosine shortage required that phenoxybenzamine alone (PA) be used for treatment. The authors examined their experience to determine the impact of preoperative metyrosine treatment on patient outcomes.
  
  
  METHODS
  A retrospective cohort study investigated patients who underwent initial PCC/PGL resection (2000-2014). The primary outcome was intraoperative hemodynamics, measured by heart rate (HR) and systolic blood pressure (SBP). The secondary outcomes included perioperative complications and cardiovascular-specific complications (CVC). Univariate analysis was performed, and adjusted risk differences were estimated after confounding was taken into account.
  
  
  RESULTS
  Of 174 patients, 142 (81.6 %) were in the MP group. The MP and PA patients had comparable intraoperative use of antihypertensives (83.9 vs 78.1 %; p = 0.443), vasopressors (74.6 vs 87.5 %; p = 0.120), and fluid resuscitation (mean, 24.4 vs 24.8 ml/min; p = 0.761). Although the perioperative complication rate did not differ significantly between the MP and PA groups (respectively 23.4 vs 34.4 %; p = 0.198), the PA patients had a 15.8 % higher rate of CVC even after controlling for confounders (p = 0.034). Compared with the MP patients, the PA patients had significantly more hemodynamic instability intraoperatively, with a greater range in HR (7.4 bpm; p = 0.034) and SBP (14.8 mmHg; p = 0.020).
  
  
  CONCLUSIONS
  In this study, preoperative metyrosine improved intraoperative hemodynamic stability and decreased CVC rates in patients undergoing PCC/PGLresection. These data suggest that the addition of preoperative metyrosine may improve operative outcomes.
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. heather.wachtel@uphs.upenn.edu.
authors.forename: Heather
authors.initials: H
authors.lastname: Wachtel
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Edward H
authors.initials: EH
authors.lastname: Kennedy
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Salman
authors.initials: S
authors.lastname: Zaheer
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Edmund K
authors.initials: EK
authors.lastname: Bartlett
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Lauren
authors.initials: L
authors.lastname: Fishbein
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.affiliation: Division of Renal, Electrolytes, and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Debbie L
authors.initials: DL
authors.lastname: Cohen
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy / Q000009:adverse effects*; D002318:Cardiovascular Diseases / Q000209:etiology / Q000517:prevention & control*; D004791:Enzyme Inhibitors / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010235:Paraganglioma / Q000473:pathology / Q000601:surgery*; D010673:Pheochromocytoma / Q000473:pathology / Q000601:surgery*; D011300:Preoperative Care; D011379:Prognosis; D012189:Retrospective Studies; D019805:alpha-Methyltyrosine / Q000627:therapeutic use*
chemical_list: D004791:Enzyme Inhibitors; D019805:alpha-Methyltyrosine