嗜铬细胞瘤/副神经节瘤术中血压骤升的临床特征分析(附单中心219例报告)

Analysis of clinical characteristics for hypertensive attack during pheochromocytoma and paraganglioma operation: a single center case report of 219 cases

目的分析嗜铬细胞瘤(PHEO)/副神经节瘤(PGL)术中出现血压骤升的临床特征.方法 回顾性分析2016年9月至2018年9月我院收治的219例PHEO/PGL患者的临床资料.男99例,女120例;年龄13 ~76岁,平均47岁.肿瘤直径1.5~ 18.0 cm,平均5.3 cm.单侧PHEO 140例,双侧PHEO 6例,PGL(颈动脉体、纵隔、心脏、腹膜后、盆腔、膀胱)68例,PHEO合并PGL 5例.术前有高血压表现者199例(90.8%),术前收缩压最高240 mmHg(1 mmHg =0.133 kPa),舒张压最高160 mmHg.无高血压表现者20例.217例术前行α受体阻滞剂[酚苄明,起始剂量为5 mg,每12小时1次,极量不超过1 mg/(kg· 24h)]充分药物准备,2例术前未行药物准备.全部患者均接受内镜下或开放PHEO/PGL切除术,按照术中是否出现血压骤升(收缩压>180 mmHg)分为血压骤升组和非血压骤升组.分析两组一般资料及术前药物准备的差异.结果 219例术后病理为PHEO或PGL,其中良性205例,恶性14例.血压骤升组112例,非血压骤升组107例.血压骤升组肿瘤直径大于非血压骤升组[(6.70±2.95) cm与(3.95±1.70) cm,P=0.005],而两组患者年龄[(51.0±10.8)岁与(38.5±17.6)岁,P=0.105]、术前儿茶酚胺水平[去甲肾上腺素(111.20±41.49) μg/24 h与(419.15±154.81)μg/24 h,P=0.075]、α受体阻滞剂使用时间[(53.0±7.5)d与(38.0±6.4)d,P =0.139]及每日使用量[(40.0±7.2) mg与(27.1±1.8)mg,P=0.111]、诊断PHEO/PGL时血压[(173.75±26.69) mmHg与(155.00±20.75) mmHg,P=0.139]差异均无统计学意义.219例中2例术后出血行二次手术探查止血.1例术前未行药物准备的隐匿型嗜铬细胞瘤患者术后出现儿茶酚胺心肌病,经治疗后好转出院;另1例术前未行药物准备的隐匿型嗜铬细胞瘤患者术中未出现血压骤升.无围手术期死亡病例.结论 肿瘤体积大的PHEO/PGL患者术中容易出现血压骤升.

Objective To analyze the clinical characteristics for hypertensive attack during operation and clinical experience of preoperative evaluation and preparation in patients with pheochromocytoma and paraganglioma(PHEO/PGL).Methods A total 219 PHEO/PGL cases from September 2016 to September 2018 were retrospectively reviewed.It included 99 males and 120 females,aged 13 to 76 (average 47) years old.The mean diameter of tumor was 5.3 cm (1.5-18.0 cm).140 cases were unilateral PHEO,6 cases were bilateral PHEO,68 cases were PGL(jugular,mediaphragm,heart,retroperitoneum,pelvic and bladder) and 5 cases were PHEO combined with PGL.Preoperative highest systolic blood pressure (SBP)was 240 mmHg(1 mmHg-0.133 kPa) and highest diastolic blood pressure (DBP) was 160 mmHg.20 cases were occult PHEO without hypertension.217 cases accepted preoperative preparation of alpha-blocker [phenoxy-benzamine,dosage ranging from 5 mg Q12h to 40 mg Q8h,maximum dosage not exceeding 1 mg/(kg· 24 h)].2 cases did not accept preoperative preparation.All cases accepted open or endoscope surgery.The patients were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery.Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack.Results Histopathological results showed that all cases were PHEO or PGL,while 205 cases were benign,14 cases were malignant.Hypertensive attack were recorded in 112 cases(51%).The diameter of tumors in the hypertensive attack group were larger than that in the non-hypertensive attack group[(6.70 ± 2.95)cm vs.(3.95 ± 1.70) cm,P =0.005].There was no significant difference between the two groups among age [(51.0 ± 10.8) years vs.(38.5 ± 17.6) years,P =0.105],preoperative catecholamine level [norepinephrine (111.20 ± 41.49) μg/24 h vs.(419.15 ± 154.81) μg/24 h,P =0.075],time of use of alpha blockers [(53.0 ± 7.5) d vs.(38.0 ± 6.4) d,P =0.139],daily dosage of alpha blocker [(40.0 ±7.2)mg vs.(27.1 ± 1.8) mg,P =0.111] and blood pressure at diagnosis[(173.75 ± 26.69) mmHg vs.(155.0 ± 20.75) mmHg,P =0.139].Among 219 cases,2 case had emergency hemostasis after operation,1 case had catecholamine cardiomyopathy after operation for occult pheochromocytoma,and no perioperative death occurred.Conclusions Patients with large tumor tend to have hypertensive attack during operation so that should be better prepared.