Anesthetic key points in a patient with a terminal ileum neuroendocrine tumor and a rare carcinoid left heart disease presented for non-cardiac surgery: case report.

BACKGROUND: Carcinoid tumors are rare neuroendocrine malignancies presenting in an increasing number in our center. The incidence of carcinoid tumors is approximatively between 2.5 and 5 cases per 100,000 people of whom about 50% develop carcinoid syndrome. Once the carcinoid syndrome has developed, a carcinoid cardiomyopathy can occur. Carcinoid heart disease (CaHD) remains a serious and rare complication associated with a significant increase in morbidity and mortality. Although carcinoid tumors have been known and studied for several years, there are still scarce data on the anesthetic management and the peri operative period. CASE PRESENTATION: We describe a case of a Caucasian 44-year-old woman with an unusual presentation of left CaHD with an ileal neuroendocrine tumor and liver metastases. Our preoperative somatostatin administration protocol, limit the cardiac damage. The maintenance of stable hemodynamics, the use of balanced anesthetic technique, all along with a good understanding of the pathology, played a major role in the successful management of anesthesia. This case report allows us to introduce our decision algorithm for the management of this type of pathology in our tertiary hospital, Cliniques Universitaires Saint-Luc. CONCLUSION: Despite the paucity of data, anesthetic management of patients with carcinoid tumor can be safely performed with effective hemodynamic monitoring and a good understanding of the pathophysiology. Knowledge and application of a clear institutional algorithm for octreotide administration and multidisciplinary consultation at a referral center are essential for the management of these patients.

Advanced Age and Sex Influence Baseline Regional Cerebral Oxygen Saturation as Measured by Near-Infrared Spectroscopy: Subanalysis of a Prospective Study.

OBJECTIVES: The aging brain shows decreased venous oxygenation predominantly in the frontal cortex, which seems sex- dependent. The authors hypothesized that age and sex would influence baseline regional cerebral oxygen saturation (rScO2) measured by the INVOS 5100. DESIGN: Subanalysis of published data. SETTING: Tertiary hospital. PARTICIPANTS: A total of 1,616 adults undergoing cardiac interventions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline rScO2 was recorded at room air and calculated as mean of the left and right rScO2. Patients were divided into 3 groups: 18- to- 49 years: young; 50- to- 74 years: middle-aged; and ≥75 years: elderly. The rScO2 was significantly different in the middle-aged (63 [56-69]) compared with the young participants (67 [59-74]; p < 0.001) and elderly participants (60 [55-66]; p < 0.001]. Women were significantly older compared with men (72 [62-79] v 66 [56-74]; p < 0.001]) and showed lower hemoglobin values (p < 0.001) and lower rScO2 (58 [52-63] v 65 [58-70]; p < 0.001]). Multiple regression analysis revealed age, sex, and hemoglobin as significant determinants of rScO2: 26.665 - (0.030 × age) + (2.581 × hemoglobin) + (2.799 × 0 for female sex). CONCLUSIONS: Baseline rScO2, as measured by the INVOS 5100, decreases with advanced age and is lower in women. New definitions of cerebral oxygen desaturation need to be analyzed in future trials that will evaluate neurologic outcome in the aging population or in women.

When laparoscopy for fertility preservation prior to gonadotoxic treatment of an anterior mediastinal mass is a dilemma: A case report.

INTRODUCTION: The management of anterior mediastinal masses is a challenge for anesthesiologists. Recommendations for their management in the context of diagnostic or curative surgery are well described. The added risk of laparoscopic surgery for fertility preservation has however never been discussed in the literature. PRESENTATION OF CASE: We present the case of a 32-year-old female patient with a large malignant anterior mediastinal mass. She was referred for anesthesia evaluation before laparoscopic ovarian tissue harvesting as part of fertility preservation prior to gonadotoxic treatment. The patient presented dyspnea at rest. Chest computed tomography revealed a tracheal deviation and a partial obstruction of the left mainstem bronchus. Transthoracic echocardiography showed a pericardial effusion. Proceeding to high risk anesthesia for a non-curative surgery in a patient with a highly symptomatic mass was considered unacceptable and the procedure was postponed. The patient received a single cycle of neoadjuvant chemotherapy. Clinical and radiological improvement were shown after this single dose and laparoscopic surgery was performed under general anesthesia without complications. CONCLUSION: In the context of an anterior mediastinal mass and fertility preservation a thorough benefit-risk analysis must be undertaken before non-curative laparoscopic surgery. In case of severe symptoms, surgery should be postponed until the patient's condition improves after the minimum necessary chemotherapy treatment. So far it is impossible to say whether the risk exceeds the expected benefit in this difficult situation. Further studies need to be conducted in this area.