Anästhesiologisches Vorgehen
bei Hemihepatektomie bei einem Patienten mit Karzinoid-Syndrom

Zusammenfassung.

Karzinoide sind seltene Tumore enterochromaffiner Zellen insbesondere des Darmtraktes. Das Karzinoid-Syndrom mit systemischer Ausschüttung von Serotonin und anderen vasoaktiven Substanzen führt zur typischen Symptomkonstellation Hyper- oder Hypotension, Bronchospasmus, Tachykardie, Durchfall und/oder Flush und tritt vor allem bei hepatischer Metastasierung der Karzinoide auf, fatale perioperative „Karzinoid-Krisen” sind möglich. Wir berichten über einen Patienten mit Karzinoid-Syndrom bei Lebermetastasen, bei dem eine Hemihepatektomie durchgeführt wurde. Zur Prophylaxe erhielt der Patient präoperativ Antihistaminika, Kortikosteroide und eine kontinuierliche Somatostatininfusion. Neben invasivem Monitoring erfolgte intermittierend die Messung der Serotonin- und Katecholaminkonzentration. Unter Somatostatininfusion fielen zwar im Verlauf die anfangs erhöhten Serotoninkonzentrationen ab, trotz Abklemmen der Leberpforte (Pringle-Manöver) trat jedoch ein Serotonin-Konzentrationsanstieg während Leberresektion auf, verbunden mit einem Abfall des Blutdrucks, des peripheren Gefäßwiderstands und des zentralvenösen Druckes, welcher durch Volumengabe und Noradrenalininfusion beherrschbar war. Trotz Somatostatin-Infusion scheint daher die Serotoninfreisetzung unter chirurgischer Manipulation nicht vollständig supprimierbar.

Anaesthetic Management for Hemihepatectomy in a Patient with Carcinoid-Syndrome.

Carcinoids are rare tumors of enterochromaffin cells. The carcinoid-syndrome most often occurs with hepatic metastases of carcinoids and is evoked by release of serotonin and other vasoactive substances, leading to typical symptoms such as hyper- or hypotension, bronchospasm, tachycardia, diarrhoe, and flushing. A lethal perioperative ”carcinoid-crisis“ may occur. We report on a patient with carcinoid-syndrome due to liver metastases undergoing hemihepatectomy. For prophylaxis, the patient preoperatively received H 1- and H 2-histamine-receptor antagonists, corticosteroids, and a continuous somatostatin infusion. Besides monitoring cardiovascular variables we intermittently measured serotonin- and catecholamine concentrations. Initially increased serotonin concentration decreased during the course of anaesthesia. However, it increased again during liver resection despite Pringle's manoeuvre and was associated with a decrease in arterial pressure, systemic vascular resistance, and central venous pressure. Hypotension was treated by volume and noradrenaline infusion. Thus, despite somatostatin infusion serotonin release is still possible, especially during surgical manipulation.

Leber - endokriner Tumor - Somatostatin - Katecholamintherapie

Liver - endocrine tumor - somatostatin - catecholamine therapy

Literatur

• 1 Modlin J M, Sandor A. An analysis of 8305 cases of carcinoid tumors.  Cancer. 1997;  79 813-829
• 2 Oberndorfer S. Karzinoide Tumoren des Dünndarms.  Frankf Z Pathol. 1907;  1 425-429
• 3 Kulke H M, Mayer R J. Carcinoid Tumors.  New Engl J Med. 1999;  340 858-868
• 4 Thorson A, Biörck G, Björkmann G, Waldenström J. Malignant carcinoid of the small intestine with metastases to the liver, valvular disease of the right side of the heart (pulmonary stenosis and tricuspid regurgitation without septal defects), peripheral vasomotor symptoms, bronchoconstriction, and an unusual type of cyanosis: a clinical and pathological syndrome.  Am Heart J. 1954;  47 795-817
• 5 Marlink R G, Lokich J J, Robins J R. Hepatic arterial embolization for metastatic hormone-secreting tumours.  Cancer. 1990;  65 2227-2231
• 6 Norton J A. Surgical management of carcinoid tumors: role of debulking and surgery for patients with advanced disease.  Digestion. 1994;  55 98-103
• 7 Claure R E, Drover D D, Haddow G R, Esquivel C O, Angst M S. Orthotopic liver transplantation for carcinoid tumour metastatic to the liver: anesthetic management.  Can J Anesth. 2000;  47 334-337
• 8 Sarantopoulos C, Fassoulaki A, Alexandris A. Anesthetic management of two patients undergoing laparotomy & hepatectomy for carcinoid syndrome.  Acta Anaesth Belg. 1994;  45 93-87
• 9 Veall G RQ, Peacock J E, Bax N D, Reilly C S. Review of the anaesthetic management of 21 patients undergoing laparotomy for carcinoid syndrome.  Br J Anaesth. 1994;  72 335-341
• 10 Ahlman H, Ahlund L, Nilsson O, Skolnik G, Theodorsson E, Dahlström A. Carcinoid tumour cells in long-term culture: release of serotonin but not of tachykinins on stimulation with adrenoceptor agonists.  Int J Cancer. 1988;  42 506-510
• 11 Grönstad K, Nilsson O, Dahlström A, Skolnik G, Ahlman H. Adrenergic control of serotonin release from carcinoid tumor cells in vitro and in vivo.  J Surg Res. 1987;  42 141-146
• 12 Holdcroft A. Hormones and the gut.  Br J Anaesth. 2000;  85 58-68
• 13 Houghton K, Carter J A. Peri-operative management of carcinoid syndrome using ketanserin.  Anaesthesia. 1986;  41 596-599
• 14 Lawrence J, Ishizuka J, Haber B, Townsend C, Thompson J. The effect of somatostatin on 5-hydroxytryptamine release from a carcinoid tumor.  Surgery. 1990;  108 1131-1135
• 15 Parris W, Oates J, Kambam J, Shmerling R, Sawyer J. Pre-treatment with somatostatin in the anaesthetic management of a patient with carcinoid syndrome.  Can J Anaesth. 1988;  35 413-416
• 16 Hughes E W, Hodkinson B P. Carcinoid syndrome: The combined use of Ketanserin and Octreotide in the management of an acute crisis during anaesthesia.  Anaesth Intensive Care. 1989;  17 367-370
• 17 Monteith K, Roaseg O. Epidural anaesthesia for transurethral resection of the prostate in a patient with carcinoid syndrome.  Can J Anaesth. 1990;  37 349-352
• 18 Vaughan D, Brunner M. Anesthesia for patients with carcinoid syndrome.  Int Anesthesiol Clin. 1997;  35 129-142
• 19 Brinkmann M, Günnicker M, Freund U, Schieffer M, Peters J. Histamine plasma concentration and cardiovascular effects of non-depolarizing muscle relaxants: Comparison of atracurium, vecuronium, pancuronium and pipecuronium in coronary surgical patients at risk.  Anaesthesiol Intensivmed Notfallmed Schmerzther. 1998;  33 362-366