Intraoperative carcinoid syndrome during small-bowel neuroendocrine tumour surgery

Abstract

Only few descriptions of intraoperative carcinoid syndrome (ioCS) have been reported. The primary objective of this study was to describe ioCS. A second aim was to identify risk factors of ioCS. We retrospectively analysed patients operated for small-bowel neuroendocrine tumour in our institution between 2007 and 2015, and receiving our preventive local regimen of octreotide continuous administration. ioCS was defined as highly probable in case of rapid (<5 min) arterial blood pressure changes ≥40%, not explained by surgical/anaesthetic management and regressive ≥20% after octreotide bolus injection. Probable cases were ioCS which did not meet all criteria of highly-probable ioCS. Suspected ioCS were detected on the anaesthesia record by an injection of octreotide due to a manifestation which did not meet the criteria for highly-probable or probable ioCS. A total of 81 patients (liver metastases: 59, prior carcinoid syndrome: 49, carcinoid heart disease: 7) were included; 139 ioCS occurred in 45 patients: 45 highly probable, 67 probable and 27 suspected. ioCs was hypertensive (91%) and/or hypotensive (29%). There was no factor, including the use of vasopressors, significantly associated with the occurrence of an ioCS. All surgeries were completed and one patient died from cardiac failure 4 days after surgery. After preoperative octreotide continuous infusion, ioCS were mainly hypertensive. No ioCS risk factors, including vasopressor use, were identified. No intraoperative carcinoid crisis occurred, suggesting the clinical relevance of a standardized octreotide prophylaxis protocol.

Perioperative Carcinoid Crisis: A Systematic Review and Meta-Analysis

“…Authors were contacted and did not have full texts, so the two records were excluded. Eight studies which enrolled 864 patients (943 operations) met all inclusion criteria [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ].…”

“…In 5 studies, all patients had metastatic disease, with 4 studies selecting patients with liver metastasis (with or without other sites) [ 20 , 25 , 26 , 27 ], while the 5th study included patients with metastasis not exclusive of the liver (i.e., metastasis could be at other sites and not include the liver) [ 23 ]. All studies included patients with carcinoid syndrome, with 6 studies reporting the proportion of patients presenting with carcinoid syndrome, ranging between 46.7 and 85.2% [ 21 , 22 , 23 , 24 , 26 , 27 ]. One study excluded patients with carcinoid heart disease [ 26 ], and another did not specify whether carcinoid heart disease patients were included [ 23 ].…”

Surgery and Perioperative Management in Small Intestinal Neuroendocrine Tumors

“…Even if octreotide is the treatment of choice for carcinoid crisis according to its efficacy in carcinoid syndrome, data on its value for both managing and preventing the crisis are still scarce and conflicting [50][51][52][53][54][55][56]. All of the existing data are based on retrospective studies which used heterogenous definitions of carcinoid crisis, primary tumor origins, stages of disease, and octreotide regimens.…”

“…In 2001, Kinney et al published the first and only study with a control group: they reported no complications during surgery in patients treated with octreotide (0/45, 0%) preoperatively, unlike those who did not receive any octreotide (7/67, 10%) [53]. The other publications, without any control group, described a low rate of carcinoid crisis (range from 0% to 3.4%) with the systematic use of octreotide regimen on the one hand, and a high rate of carcinoid crisis (range from 24% to 32%) despite the systematic use of octreotide regimen [50][51][52][54][55][56] on the other hand. Whatever the efficacy of octreotide regarding carcinoid crisis, it does not seem deleterious, as no increased rate of anastomotic leakage has been reported despite the octreotide-induced decrease of visceral perfusion.…”

Postoperative morbidity and mortality after surgical resection of small bowel neuroendocrine neoplasms: A systematic review and meta‐analysis

“…Besides surgical experience, anesthesia management might also be relevant. This is especially the case for patients undergoing surgery for hormonally active NEN because intra‐operative carcinoid syndrome develops in up to 55% of patients, regardless of preoperative prophylactic octreotide infusions 16 . Recently, Hallet et al 17 investigated the association between anaesthesiologist volume and postoperative morbidity after complex gastrointestinal surgery.…”