DISCUSSION
The elderly population (i.e., the group of patients aged 65 years or
older) is growing all over the world. Demographic estimates show that
the human population aged 65 years or older will exceed 1.5 billion in
2050 (10). Increasing life expectancies and improvements in medical
technology and healthcare lead to an increase in the number of elder
patients undergoing complex surgical procedures (11). Elderly patients
have several physiologic changes such as cardiovascular, pulmonary and
hepatorenal that impact their response to anaesthesia, surgical stress
and postoperative rehabilitation (12). In this context, laparoscopic
approaches with benefits, including less postoperative pain or more
rapid return to regular daily activities are well suited to the
challenges of elderly individuals (13). On the other hand, the increased
physiologic demands of laparoscopic approaches may present particular
challenges on elderly patients (11). This situation may be more
critical, especially in surgeries that hemodynamic parameters are
affected, such as PHEO.
Pheochromocytoma is a tumour that originates from adrenomedullary
chromaffin cells and releases one or more of the following
catecholamines: epinephrine, norepinephrine and dopamine (14). The most
clinical characteristics such as sweating, headache, palpitations and
episodic hypertension are secondary to the secretion of these
catecholamines (14). Surgical management is considered the gold standard
treatment of PHEO (1-3). Although the laparoscopic resection of PHEO was
reported as feasible and safe, there is a conviction as the fluctuation
of catecholamine levels during operation makes this surgery as
challenging (15). The incidence of hemodynamic instability during
resection of PHEO ranges between 17% to 83% (16). Studies that
specifically investigated this topic is limited in the literature. Thus,
whether the hemodynamic changes during laparoscopic treatment of PHEO
constitutes a more surgical risk for elderly patients than youngers and
the comparison of the outcomes according to the ages deserves additional
study.
There is no standard definition of intraoperative hemodynamic
instability in the literature (17). In this study, we defined
hemodynamic instability as the difference between max and min systolic
and diastolic blood pressures. Additionally, we compared the ratio of
SBP >200 mmHg, MAP <60mmHg, HR >110
and the ratio of 30% above and below baseline measurements of blood
pressures between two groups to evaluate hemodynamic changes more
accurately. According to our findings, there was no difference between
elder and young patients in terms of hemodynamic instability during
laparoscopic PHEO surgery. Bruynzeel et al. reported that age was not
associated with hemodynamic instability during surgery of PHEO; however,
in this study, laparoscopic and open surgeries were included and
patients were not stratified by age (18). Similarly, Srougi et al.
reported that being older than 60 years did not affect hemodynamic
instability; however, their study included open and laparoscopic
adrenalectomies and also partial and bilateral adrenalectomies (8). In
this context, our study differs from previous reports by analyzing the
pure laparoscopic and complete resections between elder and young
patients.
The length of hospitalization of elderly patients that undergo surgery
may be expected as to be longer due to physiological changes of ageing.
Colins et al. reported that advanced age is a predicting factor for
length of hospital stay; however, intraoperative and postoperative
factors are more predictive than age (19). This may be also valid for
elderly patients that undergo a challenging surgery such as PHEO. In our
study, we found that the length of hospital stay was similar between
elderly and young patients. We think that being no difference between
the groups in terms of hemodynamic instability and complication rates
are the most important reason for our these finding. Because, most
simply, even the elevated blood pressure due to catecholamines may cause
haemorrhage either intra or postoperatively (20). This is a major
complication that may affect the duration of hospitalization. The
postoperative period is usually smoothly in intraoperatively
uncomplicated, calmly cases. Our results indicate that laparoscopic PHEO
surgery has successful results in the elderly, just like in young
individuals, in the absence of HI.
The similarity of complication rates and length of hospital stay between
elderly and younger individuals in our study also reveals the importance
of premedication and anaesthetic management indirectly. The mortality
after surgery of PHEO can reach up to almost 50% in unprepared patients
(21). Therefore, the pre-requisite of the obtain successful outcomes in
PHEO surgery is the close co-ordination and co-operation between
anesthesiologist, surgeon and endocrinologist (21). The
multidisciplinary approach provides faster recovery with no or minimal
complications in the postoperative period (20). According to our
institution’s management of PHEO patients, all individuals are evaluated
by the collaboration of endocrinologist, anesthesiologist and a
urologist. Indeed, in the well pre-medicated cases, intraoperative
problems such as hemodynamic stabilities or bleeding were not usual,
even in elderly patients as presented in our results. Consequently, it
can be said that well premedication has a positive feedback effect; it
reduces the hemodynamic instability and risk of complications such as
bleeding, and this decrement reduces the stress on the surgeons’
shoulders and more reduces the risk of complications by leading him/her
to do the job more meticulously.
Additionally, our findings demonstrate that the ratio of leaving anti-HT
treatment in the postoperative period is found as similar between
elderly and young patients. According to our results, LA in the
management of PHEO gives effective results in elderly patients as well
as young individuals, in terms of HT control in the postoperative
period.
Although our study is the first which comparing the surgical outcomes of
pure LA between elderly and young patients with PHEO in the literature,
it has some limitations. First, it is a retrospective designed study.
Second, although the conduction of the present study in the single
centre is an advantage, on the other hand as a natural result of PHEO
incidence being as 3 to 8 per 1 million adults, it has a small sample
size (14). Third, we performed all the LAs with a transperitoneal
approach, so we don’t have the data of the retroperitoneal approach.