Orthotopic liver transplantation for carcinoid tumour metastatic to the liver: anesthetic management

Abstract

Purpose: To report the anesthetic management of a patient with carcinoid tumour metastatic to the liver who presented for orthotopic liver transplantation. Anesthetic implications of metastatic carcinoid tumour on liver transplantation and the use of octreotide are discussed.Clinical features: A 51-yr-old woman with intestinal carcinoid tumour metastatic to the liver presented for orthotopic liver transplantation, a recent treatment option for patients with extensive hepatic carcinoid metastases and disabling symptoms unresponsive to conventional therapy. Despite continuous administration of the somatostatin analogue octreotide via a hepatic artery infusate pump, the patient suffered from daily break through symptoms, which included flushing, palpitations, paroxysmal hypertension, and dyspnea. The patient presented to the operating room with sinus tachycardia and severe arterial hypertension. Octreotide and phentolamine were used to prevent further mediator release and to control the paroxysmal hypertension. Midazolam, fentanyl, thiopental, succinylcholine, vecuronium, and isoflurane were used to induce and maintain anesthesia safely. An intravenous octreotide infusion was initiated after induction and continued throughout the case. Infrequent and non-threatening peaks in arterial blood pressure were readily treated with small intravenous doses of vasoactive drugs and octreotide. No other manifestations of the carcinoid syndrome occurred. The patient had an uneventful recovery and was discharged on postoperative day #6. Conclusion:The patient safely underwent orthotopic liver transplantation for treatment of symptomatic carcinoid tumour metastatic to the liver. The anesthetic management followed recent recommendations favouring the use of octreotide to prevent patients from becoming symptomatic. Outlined dosing regimen for octreotide provided satisfactory hemodynamic stability.Objectif : Présenter le traitement anesthésique d'une patiente atteinte d'une tumeur carcinoïde, avec métastase au foie, admise pour une transplantation hépatique orthotopique. Les implications anesthésiques de la tumeur sur la transplantation du foie et l'usage d'octréotide sont étudiées. Éléments cliniques : Une femme de 51 ans souffrant d'une tumeur intestinale carcinoïde, avec métastase au foie, s'est présentée pour une transplantation du foie orthotopique, une nouvelle option thérapeutique pour les patients chez qui les métastases carcinoïdes du foie sont étendues et les symptômes invalidants ne sont pas éliminés par la thérapie traditionnelle. Malgré l'administration continue d'un analogue de la somatostatine, l'octréotide, au moyen d'une perfusion insérée dans l'artère hépatique, la patiente souffrait d'une poussée quotidienne de symptômes qui comprenaient des bouffées vasomotrices, des palpitations, de l'hypertension paroxystique et de la dyspnée. À son arrivée à la salle d'opération, la patiente présentait une tachycardie sinusale et une hypertension artérielle sévère. Conclusion : La patiente a subi en toute sécurité une transpla...

Carcinoid Heart Disease

“…Perioperative octreotide, aimed at reducing serotonin release, is the most efficacious treatment for preventing crises during surgery and is the mainstay treatment of carcinoid crisis. 47,48 Intravenous octreotide (50 to 100 g/h) should be started at least 2 hours before surgery. The infusion should continue for 48 hours after surgery.…”

“…Avoiding or minimizing the use of drugs known to precipitate mediator release such as opioids, the neuromuscular relaxant atracurium, and catecholamine producers like dopamine and epinephrine may reduce the risk of carcinoid crisis. 48,49 …”

Carcinoid and Other Neuroendocrine Tumors of the Colon and Rectum

“…For major procedures, a preoperative SQ dose of 250-500 mg is given, followed by a continuous infusion of 50-500 mg/h, then weaned by 50% each day until the patient no longer manifests symptoms is recommended. 16,18,19 Short-acting steroid preparations and antihistamines have been recommended as adjuncts to octreotide by some authors. 20 Pressor agents should be avoided, as they are associated with the release of serotonin and other vasoactive amines from NETs.…”

“…6 All lesions are termed neuroendocrine tumors (heretofore referred to as ''NETs'') and are separated on the basis of histologic aggressiveness and location within the GI tract. Grade 1 NETs are considered low-grade malignancies (<2 mitoses per high-powered field [HPF] ), grade 2 NETs are considered to be intermediate in behavior (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) mitoses/ HPF), and grade 3 are considered high grade (>20 mitoses/HPF). The original term ''carcinoid'' equates to NETs that are both grade 1 and 2 (well differentiated), whereas grade 3 NETs are mostly small cell carcinomas with a minority component being large cell type (poorly differentiated).…”

Cardiac Surgery for Carcinoid Heart Disease: A Weapon Not to Be Misused

“…The perioperative administration of intravenous octreotide has been shown to prevent the appearance of carcinoid crisis [44]. Another challenge in these patients is the differentiation between intraoperative hypotension of this origin and that attributable to myocardial dysfunction.…”