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.