Dear Editor,
We read with great interest the recent case report by Sawada et al. describing the perioperative management of a patient with familial pheochromocytoma after bilateral adrenalectomy.1 The authors successfully highlight the anesthetic challenges posed by the dual risks of adrenal insufficiency and potential catecholamine excess. We commend their meticulous planning and clear description of anesthetic technique.
Nevertheless, a few points merit further consideration. First, while the report is framed around a “blood pressure paradox,” the intraoperative course was characterized primarily by hypotension, without significant hypertensive episodes. This somewhat limits the demonstration of the paradoxical hemodynamic risks. A timeline of blood pressure trends might have illustrated this more effectively.
Second, the chosen perioperative steroid supplementation (hydrocortisone 10 mg preoperatively and dexamethasone 6.6 mg intraoperatively) appears higher than guideline-based recommendations for minor procedures. Although no complications were observed, a critical discussion of potential overtreatment (e.g., hyperglycemia, delayed healing) would have enriched the report.2,3
Third, the rationale for using ephedrine as the primary vasopressor over alternatives such as phenylephrine or norepinephrine was not clearly addressed. Given the patient’s history of catecholamine-secreting tumor, this choice warrants further justification.
Lastly, long-term follow-up regarding recurrence, endocrine status, and functional outcomes would have strengthened the clinical relevance. While the report reinforces established principles—balanced anesthesia, α-blockade, avoidance of epinephrine—it could further differentiate itself by deeper comparison with similar published cases.4,5
In conclusion, this case adds to the literature on perioperative management of pheochromocytoma, but greater emphasis on hemodynamic paradoxes, steroid dosing strategies, and long-term outcomes would enhance its impact.