Happy
Thanksgiving! This will be the last piece for 2013. I wish everyone a great
holiday season and a wonderful year of 2014!
When we, health
care professionals and lay people alike, talk about pheo, we seem to assume all
pheos are the same. In medical textbooks, pheo is mostly discussed in a way
that gives the reader the impression that if one has a pheo, one will have all
the classical signs and symptoms of pheo. In the lay communications, the heterogeneity
of pheo is even less appreciated. One pheo, however, can be very different from
another. I have written about clinically “silent” pheo, pheo associated with
normal blood pressure, pheo that causes frank cardiovascular problems, small
pheo, pheo caused by genetic mutations, etc. Understanding the heterogeneity of
pheo is critical to tailor pheo management to an individual patient with a
particular pheo.
Preoperative
management of pheo has been controversial since the very beginning. I myself
have advocated careful preoperative preparation for every patient with pheo. On
the other hand, there are many different ways of preoperative preparation used
by experts, all with similar excellent outcome. Recently, one review article
proposes risk stratification for pheo, which may help reconcile the paradox.
The article
divides pheos into 3 categories: low-, intermediate-, and high-risk, according
to the risk of heart complications a particular pheo can impose on a patient.
Low-risk pheos are those smaller than 3 cm in diameter. This article proposes
that specific preoperative preparation is not needed for low-risk pheos. High-risk
pheos are those that already cause obvious cardiovascular complications such as
arrhythmia, heart attack, heart failure, or stroke. Careful preparation is
needed for high-risk pheos and the doctors need to coordinate their care so
that the preparation regimen is safe and effective. Intermediate-risk pheos are
those that are none of the above. The preparation regimen should be
individualized. The higher the relative risk of cardiovascular complications a
pheo has, the more careful and longer the preparation it requires.
It needs to be
emphasized that this risk stratification is based on clinical observation and
just a proposal. It has not been prospectively tested. What am I doing? I
currently still carefully prepare everyone. If a patient does have a low-risk
pheo, I am more relaxed with the regimen.
Dr. Pheo