{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T17:18:42Z","timestamp":1787678322199,"version":"build-2784847793"},"reference-count":25,"publisher":"Bioscientifica","issue":"8","license":[{"start":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T00:00:00Z","timestamp":1786060800000},"content-version":"vor","delay-in-days":6,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["journals.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,8,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Adrenalectomy without preoperative dose escalation of \u03b1-blockade is gaining popularity for managing phaeochromocytoma, showing comparable outcomes but shorter hospital stays and less postoperative hypotension. However, recent data showed an initial significant increase in intraoperative hypotension after transitioning to this approach, suggesting a learning curve. We evaluated this learning curve for the safe use of our \u03b1-blockade non-escalation workflow employing a risk-adjusted CUSUM (RA-CUSUM) analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>This single-centre cohort study included phaeochromocytoma resections without preoperative \u03b1-blockade dose escalation from 2019 until 2023. All procedures were performed by an experienced operating theatre team, including anaesthesiologists and surgeons dedicated to phaeochromocytoma treatment. Intraoperative hypotension (time-weighted average (TWA) of mean arterial pressure (MAP) &amp;lt; 60 mmHg) was identified as primary learning curve outcome. RA-CUSUM analysis consisted of predicting intraoperative hypotension using a multivariable linear regression model corrected for established risk factors and modelling the relationship between the number of procedures and the cumulative difference in predicted and observed outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 44 procedures were evaluated employing the new preoperative \u03b1-blockade non-escalation strategy. RA-CUSUM analysis showed that the learning curve was completed after 19 surgeries. The median TWA of MAP &amp;lt; 60 mmHg was 2.29 (IQR: 0.45\u20134.16) mmHg. No perioperative complications related to haemodynamic instability occurred in the cohort. Time in the operating theatre and length of hospital stay remained consistent over time.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Our results confirm that transitioning to phaeochromocytoma resection without \u03b1-blockade dose escalation follows a learning curve. To ensure safe implementation, centres adopting the non-escalation workflow should meet certain conditions, with structured guidance or proctoring as possible measures.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1530\/ec-26-0158","type":"journal-article","created":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T11:52:01Z","timestamp":1786103521000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-10","source":"Crossref","is-referenced-by-count":0,"title":["Learning curve of blood pressure management during phaeochromocytoma surgery without preoperative alpha-blockade dose escalation"],"prefix":"10.1530","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0585-1889","authenticated-orcid":true,"given":"Isabelle","family":"Holscher","sequence":"first","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Surgery 1 , ,","place":["Amsterdam, The Netherlands"]},{"name":"Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam 2 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahsoem","family":"Ali","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Surgery 1 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3140-3502","authenticated-orcid":true,"given":"Koen M A","family":"Dreijerink","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Endocrinology and Metabolism 3 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus W","family":"Hollmann","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Anesthesiology 4 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tijs J","family":"van den Berg","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Anesthesiology 4 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wouter D","family":"Lubbers","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Anesthesiology 4 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Els J M","family":"Nieveen van Dijkum","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Surgery 1 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anton F","family":"Engelsman","sequence":"additional","affiliation":[{"name":"Amsterdam UMC Location University of Amsterdam, Department of Surgery 1 , ,","place":["Amsterdam, The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","published-online":{"date-parts":[[2026,8,7]]},"reference":[{"key":"2026082512265377800_bib1","doi-asserted-by":"crossref","first-page":"e102","DOI":"10.1002\/bjs.11348","article-title":"Meta-analysis of \u03b1-blockade versus no blockade before adrenalectomy for phaeochromocytoma","volume":"107","author":"Schimmack","year":"2020","journal-title":"Br J Surg"},{"key":"2026082512265377800_bib2","doi-asserted-by":"crossref","first-page":"1470","DOI":"10.1097\/JS9.0000000000000390","article-title":"Preoperative \u03b1-blockade versus no blockade for pheochromocytoma-paraganglioma patients undergoing surgery: a systematic review and updated meta-analysis","volume":"109","author":"Wang","year":"2023","journal-title":"Int J Surg"},{"key":"2026082512265377800_bib3","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1136\/bmj.1.5534.191","article-title":"Preoperative and operative management of patients with phaeochromocytoma","volume":"1","author":"Ross","year":"1967","journal-title":"Br Med J"},{"key":"2026082512265377800_bib4","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1213\/00000539-197201000-00010","article-title":"The anesthetic management of pheochromocytoma effect of preoperative adrenergic blocking drugss","volume":"51","author":"Perry","year":"1972","journal-title":"Anesth Analg"},{"key":"2026082512265377800_bib5","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1002\/bjs.1800660704","article-title":"Phaeochromocytomas in 72 patients: clinical and diagnostic features, treatment and long term results","volume":"66","author":"Modlin","year":"1979","journal-title":"Br J Surg"},{"key":"2026082512265377800_bib6","doi-asserted-by":"crossref","first-page":"1915","DOI":"10.1210\/jc.2014-1498","article-title":"Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline","volume":"99","author":"Lenders","year":"2014","journal-title":"J Clin Endocrinol Metab"},{"key":"2026082512265377800_bib7","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1097\/MPA.0b013e3181ebb4f0","article-title":"The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer","volume":"39","author":"Chen","year":"2010","journal-title":"Pancreas"},{"key":"2026082512265377800_bib8","doi-asserted-by":"crossref","first-page":"2381","DOI":"10.1210\/clinem\/dgz188","article-title":"Efficacy of alpha-blockers on hemodynamic control during pheochromocytoma resection: a randomized controlled trial","volume":"105","author":"Buitenwerf","year":"2020","journal-title":"J Clin Endocrinol Metab"},{"key":"2026082512265377800_bib9","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1530\/EJE-11-0162","article-title":"Point of controversy: perioperative care of patients undergoing pheochromocytoma removal-time for a reappraisal?","volume":"165","author":"Lentschener","year":"2011","journal-title":"Eur J Endocrinol"},{"key":"2026082512265377800_bib10","doi-asserted-by":"crossref","first-page":"613","DOI":"10.3949\/ccjm.57.7.613","article-title":"Perioperative management of 63 patients with pheochromocytoma","volume":"57","author":"Boutros","year":"1990","journal-title":"Cleve Clin J Med"},{"key":"2026082512265377800_bib11","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1111\/cen.13252","article-title":"Is there an optimal preoperative management strategy for phaeochromocytoma\/paraganglioma?","volume":"86","author":"Challis","year":"2017","journal-title":"Clin Endocrinol"},{"key":"2026082512265377800_bib12","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1210\/jc.2009-1051","article-title":"Risk factors for hemodynamic instability during surgery for pheochromocytoma","volume":"95","author":"Bruynzeel","year":"2010","journal-title":"J Clin Endocrinol Metab"},{"key":"2026082512265377800_bib13","doi-asserted-by":"crossref","DOI":"10.1186\/s12871-020-01066-y","article-title":"Intraoperative hypotension is associated with increased postoperative complications in patients undergoing surgery for pheochromocytoma-paraganglioma: a retrospective cohort study","volume":"20","author":"Li","year":"2020","journal-title":"BMC Anesthesiol"},{"key":"2026082512265377800_bib14","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1093\/bja\/aew414","article-title":"Preoperative \u03b1-blockade in catecholamine-secreting tumours: fight for it or take flight?","volume":"118","author":"Keegan","year":"2017","journal-title":"Br J Anaesth"},{"key":"2026082512265377800_bib15","doi-asserted-by":"crossref","first-page":"e170","DOI":"10.1002\/bjs.11378","article-title":"International multicentre review of perioperative management and outcome for catecholamine-producing tumours","volume":"107","author":"Groeben","year":"2020","journal-title":"Br J Surg"},{"key":"2026082512265377800_bib16","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1093\/bja\/aew392","article-title":"Perioperative \u03b1-receptor blockade in phaeochromocytoma surgery: an observational case series","volume":"118","author":"Groeben","year":"2017","journal-title":"Br J Anaesth"},{"key":"2026082512265377800_bib17","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1097\/SLA.0000000000006493","article-title":"Omitting the escalating dosage of alpha-adrenergic blockade before pheochromocytoma resection: implementation of a treatment strategy in discordance with current guidelines","volume":"280","author":"Holscher","year":"2024","journal-title":"Ann Surg"},{"key":"2026082512265377800_bib18","article-title":"Intraoperative hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma without preoperative medical preparation compared with nonsecreting tumor","volume":"177","author":"Nomine-Criqui","year":"2024","journal-title":"Surgery"},{"key":"2026082512265377800_bib19","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1002\/bjs.10740","article-title":"Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy","volume":"105","author":"Vrielink","year":"2018","journal-title":"Br J Surg"},{"key":"2026082512265377800_bib20","first-page":"e178","article-title":"Criticism of learning curve in laparoscopic adrenalectomy: a systematic review","volume":"171","author":"Tarallo","year":"2020","journal-title":"Clin Ter"},{"key":"2026082512265377800_bib21","doi-asserted-by":"crossref","first-page":"4167","DOI":"10.1245\/s10434-023-13406-6","article-title":"Adoption of robotic adrenalectomy: a two-institution study of surgeon learning curve","volume":"30","author":"Collins","year":"2023","journal-title":"Ann Surg Oncol"},{"key":"2026082512265377800_bib22","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.0040296","article-title":"The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"4","author":"von Elm","year":"2007","journal-title":"PLoS Med"},{"key":"2026082512265377800_bib23","doi-asserted-by":"crossref","first-page":"4531","DOI":"10.3390\/jcm10194531","article-title":"Risk factors for perioperative hemodynamic instability in pheochromocytoma: a systematic review and meta-analysis","volume":"10","author":"Urabe","year":"2021","journal-title":"J Clin Med"},{"key":"2026082512265377800_bib24","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1016\/j.bja.2019.01.013","article-title":"Perioperative quality initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery","volume":"122","author":"Sessler","year":"2019","journal-title":"Br J Anaesth"},{"key":"2026082512265377800_bib25","doi-asserted-by":"crossref","DOI":"10.1093\/bjsopen\/zraa018","article-title":"Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis","volume":"5","author":"Wijnberge","year":"2021","journal-title":"BJS Open"}],"container-title":["Endocrine Connections"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.bioscientifica.com\/ec\/article-pdf\/doi\/10.1530\/EC-26-0158\/523335\/ec-26-0158.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/journals.bioscientifica.com\/ec\/article-pdf\/doi\/10.1530\/EC-26-0158\/523335\/ec-26-0158.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T16:27:02Z","timestamp":1787675222000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.bioscientifica.com\/ec\/article\/15\/8\/e260158\/77966\/Learning-curve-of-blood-pressure-management-during"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,1]]},"references-count":25,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,8,1]]}},"URL":"https:\/\/doi.org\/10.1530\/ec-26-0158","relation":{},"ISSN":["2049-3614"],"issn-type":[{"value":"2049-3614","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,1]]},"article-number":"e260158"}}