Perioperative management of pheocromocitoma / paraganglioma: a comprehensive review

  • Alejandro Román-González a. School of Medicine, Universidad de Antioquia. Medellín, Colombia. b. San Vicente Fundación University Hospital. Medellín, Colombia.
  • Huber Padilla-Zambrano Center for Biomedical Research (CIB), School of Medicine, Universidad de Cartagena. Cartagena Colombia.
  • Luis Felipe Vásquez Jimenez Pablo Tobón Uribe Hospital. Medellín, Antioquia.
Keywords: Pheochromocytoma, Preoperative care, Intraoperative care, Drug therapy, Postoperative care


Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this entity and who undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.


Erlic Z, Beuschlein F. Metabolic Alterations in Patients with Pheochromocytoma. Exp Clin Endocrinol Diabetes. 2019;127(02/03):129–36. doi:

Turchini J, Cheung VKY, Tischler AS, De Krijger RR, Gill AJ. Pathology and genetics of phaeochromocytoma and paraganglioma. Histopathology. 2018;72(1):97–105. doi:

Farrugia F, Martikos G, Tzanetis P, Charalampopoulos A, Misiakos E, Zavras N, et al. Pheochromocytoma, diagnosis and treatment: Review of the literature. Endocr Regul. 2017;51(3):168–81. doi:

Tsirlin A, Oo Y, Sharma R, Kansara A, Gliwa A, Banerji MA. Pheochromocytoma: A review. Maturitas. 2014;77(3):229–38. doi:

Mercado-Asis LB, Wolf KI, Jochmanova I, Taïeb D. Pheochromocytoma: a genetic and diagnostic update. Endocr Pract. 2018;24(1):78–90. doi:

Davison AS, Jones DM, Ruthven S, Helliwell T, Shore SL. Clinical evaluation and treatment of phaeochromocytoma. Ann Clin Biochem Int J Lab Med. 2018;55(1):34–48. doi:

Kimura N, Takekoshi K, Naruse M. Risk Stratification on Pheochromocytoma and Paraganglioma from Laboratory and Clinical Medicine. J Clin Med. 2018;7(9):242. doi:

Kiernan CM, Solorzano C. Phaeochromocytoma and Paraganglioma: Diagnosis, Genetics, and Treatment. In: Surg Oncol Clin N Am. Elsevier Inc; 2016. p. 119–138. doi:

Fishbein L. Pheochromocytoma and Paraganglioma: Genetics, Diagnosis, and Treatment. Hematol Oncol Clin North Am. 2016;30(1):135–50. doi:

Thosani S, Ayala-Ramirez M, Román-González A, Zhou S, Thosani N, Bisanz A, et al. Constipation: an overlooked, unmanaged symptom of patients with pheochromocytoma and sympathetic paraganglioma. Eur J Endocrinol. 2015;173(3):377–87. doi:

Gunawardane PTK, Grossman A. Phaeochromocytoma and Paraganglioma. In: Adv Exp Med Biol. 2016. p. 239–59. doi:

Zhou W, Ding SF. Concurrent Pheochromocytoma, Ventricular Tachycardia, Left Ventricular Thrombus, and Systemic Embolization. Intern Med. 2009;48(12):1015–9. doi:

Edafe O, Webster J, Fernando M, Vinayagam R, Balasubramanian SP. Phaeochromocytoma with hypercortisolism and hypercalcaemia. BMJ Case Rep. 2015;2015. doi:

Jain A, Baracco R, Kapur G. Pheochromocytoma and paraganglioma—an update on diagnosis, evaluation, and management. Pediatr Nephrol. 2019; doi:

Lenders JWM, Eisenhofer G. Update on Modern Management of Pheochromocytoma and Paraganglioma. Endocrinol Metab. 2017;32(2):152. doi:

Neumann HPH, Young WF, Eng C. Pheochromocytoma and Paraganglioma. N Engl J Med. 2019;381:552–65. doi:

Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: Review of Perioperative Management of Blood Pressure and Update on Genetic Mutations Associated With Pheochromocytoma. J Clin Hypertens. 2013;15(6):428–34. doi:

Naranjo J, Dodd S, Martin YN. Perioperative Management of Pheochromocytoma. J Cardiothorac Vasc Anesth. 2017;31(4):1427–39. doi:

Ahmed A. Perioperative management of pheochromocytoma: Anaesthetic implications. J Pak Med Assoc. 2007;57(3):140–6.

Schreiner F, Anand G, Beuschlein F. Perioperative Management of Endocrine Active Adrenal Tumors. Exp Clin Endocrinol Diabetes. 2019;127(02/03):137–46. doi:

Connor D, Boumphrey S. Perioperative care of phaeochromocytoma. BJA Educ. 2016;16(5):153–8. doi:

Pacak K. Preoperative Management of the Pheochromocytoma Patient. J Clin Endocrinol Metab. 2007;92(11):4069–79. doi:

Kerstens MN, Wolffenbuttel BHR. Preoperative pharmacological management of phaeochromocytoma. J Med. 2006;64(8):290–5.

Lentschener C, Gaujoux S, Tesniere A, Dousset B. Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal? Eur J Endocrinol. 2011;165(3):365–73. doi:

Ramachandran R, Rewari V. Current perioperative management of pheochromocytomas. Indian J Urol. 2016;(1):19–25. doi:

Groeben H, Walz MK, Nottebaum BJ, Alesina PF, Greenwald A, Schumann R, et al. International multicentre review of perioperative management and outcome for catecholamine-producing tumours. Br J Surg. 2020;107(2):e170–8. doi:

Goldstein DP, Voigt MR, Ruan D. Current Preoperative Preparation of Pheochromocytoma /Paraganglioma Syndrome. Clin Surg - Endocr Surg. 2017;2:1–5.

Martucci VL, Pacak K. Pheochromocytoma and paraganglioma: diagnosis, genetics, management, and treatment. Curr Probl Cancer. 2014/01/15. 2014;38(1):7–41. doi:

Schimmack S, Kaiser J, Probst P, Kalkum E, Diener MK, Strobel O. Meta-analysis of alpha-blockade versus no blockade before adrenalectomy for phaeochromocytoma. Br J Surg. 2020;107(2):e102–8. doi:

Santos JRU, Wolf KI, Pacak K. A necessity, not a second thought: pre-operative alpha-adrenoceptor blockade in pheochromocytoma patients. Endocr Pract. 2019;25(2):200–1. doi:

Lentschener C, Baillard C, Dousset B, Gaujoux S. Dogma is made to be broken. why are we postponing curative surgery to administer ineffective alpha adrenoreceptor blockade in most patients undergoing pheochromocytoma removal? Endocr Pract. 2019;25(2):199. doi:

Isaacs M, Lee P. Preoperative alpha-blockade in phaeochromocytoma and paraganglioma: is it always necessary? Clin Endocrinol (Oxf). 2017;86(3):309–14. doi:

Doenicke A, Soukup J, Hoernecke R, Moss J. The Lack of Histamine Release with Cisatracurium: A Double-Blind Comparison with Vecuronium. Anesth Analg. 1997;84(3):623–8. doi:

Roizen M, Schreider B, Hassan S. Anesthesia for patients with pheochromocytoma. Anesth Clin North Am. 1987;5:269–75.

Scholten A, Cisco RM, Vriens MR, Cohen JK, Mitmaker EJ, Liu C, et al. Pheochromocytoma crisis is not a surgical emergency. J Clin Endocrinol Metab. 2013;98(2):581–91. doi:

Salinas CL, Gómez Beltran OD, Sánchez-Hidalgo JM, Bru RC, Padillo FJ, Rufián S. Emergency adrenalectomy due to acute heart failure secondary to complicated pheochromocytoma: a case report. World J Surg Oncol. 2011;9:49. doi:

Jiang M, Ding H, Liang Y, Tang J, Lin Y, Xiang K, et al. Preoperative risk factors for haemodynamic instability during pheochromocytoma surgery in Chinese patients. Clin Endocrinol (Oxf). 2018;88(3):498–505. doi:

Bruynzeel H, Feelders RA, Groenland THN, van den Meiracker AH, van Eijck CHJ, Lange JF, et al. Risk Factors for Hemodynamic Instability during Surgery for Pheochromocytoma. J Clin Endocrinol Metab. 2010;95(2):678–85. doi:

Lafont M, Fagour C, Haissaguerre M, Darancette G, Wagner T, Corcuff JB, et al. Per-operative hemodynamic instability in normotensive patients with incidentally discovered pheochromocytomas. J Clin Endocrinol Metab. 2015;100(2):417–21. doi:

Gu YW, Poste J, Kunal M, Schwarcz M, Weiss I. Cardiovascular Manifestations of Pheochromocytoma. Cardiol Rev. 2017;25(5):215–22. doi:

Lenders JWM, Duh Q-Y, Eisenhofer G, Gimenez-Roqueplo A-P, Grebe SKG, Murad MH, et al. Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2014;99(6):1915–42. doi:

Shen WT, Sturgeon C, Clark OH, Duh Q-Y, Kebebew E. Should pheochromocytoma size influence surgical approach? A comparison of 90 malignant and 60 benign pheochromocytomas. Surgery. 2004;136(6):1129–37. doi:

Conzo G, Musella M, Corcione F, De Palma M, Ferraro F, Palazzo A, et al. Laparoscopic adrenalectomy, a safe procedure for pheochromocytoma. A retrospective review of clinical series. Int J Surg. 2013;11(2):152–6. doi:

Kulis T, Knezevic N, Pekez M, Kastelan D, Grkovic M, Kastelan Z. Laparoscopic adrenalectomy: lessons learned from 306 cases. J Laparoendosc Adv Surg Tech A. 2012;22(1):22–6. doi:

Lorenz K, Langer P, Niederle B, Alesina P, Holzer K, Nies C, et al. Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbeck’s Arch Surg. 2019;404(4):385–401. doi:

Gumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab. 2006;20(3):483–99. doi:

Callender GG, Kennamer DL, Grubbs EG, Lee JE, Evans DB, Perrier ND. Posterior retroperitoneoscopic adrenalectomy. Adv Surg. 2009;43:147–57. doi:

Prys-Roberts C. Phaeochromocytoma--recent progress in its management. Br J Anaesth. 2000;85(1):44–57. doi:

Pinaud M, Desjars P, Cozian A, Nicolas F. [Fluid loading in the surgical care of pheochromocytoma. Hemodynamic study]. Ann Fr Anesth Reanim. 1982;1(1):53–8. doi:

De Backer D, Bakker J, Cecconi M, Hajjar L, Liu DW, Lobo S, et al. Alternatives to the Swan-Ganz catheter. Intensive Care Med. 2018;44(6):730–41. doi:

Niederle MB, Fleischmann E, Kabon B, Niederle B. The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial. Surg Endosc. 2020;34(1):368–76. doi:

Matsuura T, Kashimoto S, Okuyama K, Oguchi T, Kumazawa T. [Anesthesia with transesophageal echocardiography for removal of pheochromocytoma]. Masui. 1995;44(10):1388–90.

Matsuda Y, Kawate H, Shimada S, Matsuzaki C, Nagata H, Adachi M, et al. Perioperative sequential monitoring of hemodynamic parameters in patients with pheochromocytoma using the Non-Invasive Cardiac System (NICaS). Endocr J. 2014;61:571–5. doi:

Burns JM, Sing RF, Mostafa G, Huynh TT, Jacobs DG, Miles WS, et al. The role of transesophageal echocardiography in optimizing resuscitation in acutely injured patients. J Trauma. 2005;59(1):32–6. doi:

Kanchi M, Nair HC, Banakal S, Murthy K, Murugesan C. Haemodynamic response to endotracheal intubation in coronary artery disease: Direct versus video laryngoscopy. Indian J Anaesth. 2011;55(3):260–5. doi:

Maze M, Smith CM. Identification of receptor mechanism mediating epinephrine-induced arrhythmias during halothane anesthesia in the dog. Anesthesiology. 1983;59(4):322–6. doi:

Lippmann M, Ford M, Lee C, Ginsburg R, Foran W, Raum W, et al. Use of desflurane during resection of phaeochromocytoma. Br J Anaesth. 1994;72:707–9. doi:

Janeczko GF, Ivankovich AD, Glisson SN, Heyman HJ, El-Etr AA, Albrecht RF. Enflurane anesthesia for surgical removal of pheochromocytoma. Anesth Analg. 1977;56(1):62–7. doi:

Kinney MA, Warner ME, vanHeerden JA, Horlocker TT, Young WFJ, Schroeder DR, et al. Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection. Anesth Analg. 2000;91(5):1118–23. doi:

Castillo OA, Vitagliano G, Olivares R, Soffia P, Contreras M. Laparoscopic Resection of an Extra-adrenal Pheochromocytoma. Surg Laparosc Endosc Percutaneous Tech. 2007;17(4):351–3. doi:

Jung J-W, Park JK, Jeon SY, Kim YH, Nam S-H, Choi Y-G, et al. Dexmedetomidine and remifentanil in the perioperative management of an adolescent undergoing resection of pheochromocytoma -A case report-. Korean J Anesthesiol. 2012;63(6):555–8. doi:

Naguib M, Samarkandi AH, Bakhamees HS, Magboul MA, el-Bakry AK. Histamine-release haemodynamic changes produced by rocuronium, vecuronium, mivacurium, atracurium and tubocurarine. Br J Anaesth. 1995;75(5):588–92. doi:

Amaranath L, Zanettin GG, Bravo EL, Barnes A, Estafanous FG. Atracurium and pheochromocytoma: a report of three cases. Anesth Analg. 1988;67(11):1127–30.

Solares G, Ramos F, Blanco J, Blanco E. Alcuronium, pancuronium and phaeochromocytoma. Vol. 42, Anaesthesia. England; 1987. p. 77–8. doi:

Stoner TRJ, Urbach KF. Cardiac arrhythmias associated with succinylcholine in a patient with pheochromocytoma. Anesthesiology. 1968;29(6):1228–9. doi:

Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75(4):509–28. doi:

Breslin DS, Farling PA, Mirakhur RK. The use of remifentanil in the anaesthetic management of patients undergoing adrenalectomy: a report of three cases. Anaesthesia. 2003;58(4):358–62. doi:

Leonard JB, Munir KM, Kim HK. Metoclopramide induced pheochromocytoma crisis. Am J Emerg Med. 2018;36(6):1124.e1-1124.e2. doi:

Nizamoglu A, Salihoglu Z, Bolayrl M. Effects of epidural-and-general anesthesia combined versus general anesthesia during laparoscopic adrenalectomy. Surg Laparosc Endosc Percutan Tech. 2011;21(5):372–9. doi:

Jayatilaka G, Abayadeera A, Wijayaratna C, Senanayake H, Wijayaratna M. Phaeochromocytoma during pregnancy: anaesthetic management for a caesarean section combined with bilateral adrenalectomy. Ceylon Med J. 2013;58(4):173–4. doi:

Lipson A, Hsu T-H, Sherwin B, Geelhoed GW. Nitroprusside Therapy for a Patient With a Pheochromocytoma. JAMA. 1978;239(5):427–8. doi:

Zakowski M, Kaufman B, Berguson P, Tissot M, Yarmush L, Turndorf H. Esmolol use during resection of pheochromocytoma: report of three cases. Anesthesiology. 1989;70(5):875–7. doi:

James MF, Cronjé L. Pheochromocytoma Crisis: The Use of Magnesium Sulfate. Anesth Analg. 2004;99(3). doi:

Erdoğan MA, Uçar M, Özkan AS, Özgül Ü, Durmuş M. Perioperative Management of Severe Hypertension during Laparoscopic Surgery for Pheochromocytoma. Vol. 44, Turkish Journal of Anaesthesiology and Reanimation. 2016. p. 47–9. doi:

Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol. 2015;31(3):317. doi:

Namekawa T, Utsumi T, Kawamura K, Kamiya N, Imamoto T, Takiguchi T, et al. Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2016;159(3):763–70. doi:

Hua J, Chen G, Li H, Fu S, Zhang L-M, Scott M, et al. Intensive intraoperative insulin therapy versus conventional insulin therapy during cardiac surgery: a meta-analysis. J Cardiothorac Vasc Anesth. 2012;26(5):829–34. doi:

Duggan EW, Carlson K, Umpierrez GE. Perioperative Hyperglycemia Management: An Update. Anesthesiology. 2017;126(3):547–60. doi:

Domi R, Sula H. Pheochromocytoma, the Challenge to Anesthesiologists. J Endocrinol Metab. 2011;1(3):97–100. doi:

Garg M, Brar K, Mittal R, Kharb S, Gundgurthi A. Medical management of pheochromocytoma: Role of the endocrinologist. Indian J Endocrinol Metab. 2011;15(8):329. doi:

Bajwa S, Bajwa S. Implications and considerations during pheochromocytoma resection: A challenge to the anesthesiologist. Indian J Endocrinol Metab. 2011;15(8):337. doi:

How to Cite
Román-González A, Padilla-Zambrano H, Vásquez Jimenez LF. Perioperative management of pheocromocitoma / paraganglioma: a comprehensive review. Colomb. J. Anesthesiol. [Internet]. 2020Dec.4 [cited 2021Jan.21];49. Available from:


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How to Cite
Román-González A, Padilla-Zambrano H, Vásquez Jimenez LF. Perioperative management of pheocromocitoma / paraganglioma: a comprehensive review. Colomb. J. Anesthesiol. [Internet]. 2020Dec.4 [cited 2021Jan.21];49. Available from:
Narrative review

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