piperidines and Malignant-Carcinoid-Syndrome

Topics: Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Intravenous; Female; Humans; Ileal Neoplasms; Intestinal Obstruction; Malignant Carcinoid Syndrome; Middle Aged; Piperidines; Propofol; Remifentanil; Treatment Outcome

Carcinoid syndrome creates many challenges during anaesthesia, including hypertension, hypotension and bronchospasm. These challenges are less common and less severe after the routine use of octreotide. We describe the use of remifentanil as part of the anaesthetic management of a 67-yr-old man undergoing resection of a carcinoid tumour of the terminal ileum. The combination of perioperative octreotide administration, intraoperative remifentanil infusion and sevoflurane anaesthesia, with postoperative epidural analgesia proved satisfactory. We review the recent literature and suggest that remifentanil is a useful addition to the armamentarium of the anaesthetist in the management of a patient with carcinoid syndrome.

Topics: Aged; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Humans; Ileal Neoplasms; Male; Malignant Carcinoid Syndrome; Methyl Ethers; Piperidines; Remifentanil; Sevoflurane

This report describes the successful use of ketanserin, a 5-HT2 receptor antagonist, for the acute control of systemic blood pressure in a patient with the carcinoid syndrome, undergoing hepatic artery embolisation. Serial measurements of plasma 5-hydroxyindoles, platelet 5-hydroxytryptamine and plasma catecholamines are also given.

Topics: Aged; Antihypertensive Agents; Embolization, Therapeutic; Female; Hepatic Artery; Humans; Hypertension; Intraoperative Period; Ketanserin; Malignant Carcinoid Syndrome; Piperidines

Drugs are not absolute in their specificity; the mechanisms by which many agents reduce blood pressure remain disputed. Ketanserin has been shown to have both 5-HT2-serotonergic and alpha 1-adrenergic antagonist activity. Its pharmacological profile makes its designation as a serotonergic antagonist appropriate; however, the relative contributions of at least these two, and perhaps other, mechanisms to the hypotensive effect of ketanserin during long-term oral treatment remain obscure.

Topics: Adrenergic alpha-Agonists; Adrenergic alpha-Antagonists; Animals; Blood Pressure; Humans; Ketanserin; Malignant Carcinoid Syndrome; Phenylephrine; Piperidines; Platelet Aggregation; Serotonin; Serotonin Antagonists

Serotonin (5-HT) and substance P (SP) were assayed in peripheral blood in patients with known midgut carcinoids and hepatic metastases. All patients had supranormal basal levels of 5-HT and SP. The clinical and hormonal response was evaluated by two provocation tests, pentagastrin (PG) injection or calcium infusion. Pentagastrin caused flushing and gastrointestinal symptoms and elevated levels of circulating 5-HT, but not of SP. Pretreatment with a 5-HT2 receptor blocking agent (ketanserin) alleviated gastrointestinal symptoms but had no influence on either 5-HT release or PG-induced flushing. Calcium infusion induced carcinoid symptoms in only two of six patients, which were associated with elevated 5-HT levels (whereas elevated SP levels were seen in only one patient). We conclude that 5-HT is important for the development of gastrointestinal symptoms but not of flushing. Ketanserin may alleviate gastrointestinal symptoms but does not influence PG-induced release of 5-HT. Substance P and 5-HT do not seem to share a common release mechanism. It appears that PG testing is superior to calcium infusion as a provocative test in patients with the carcinoid syndrome.

Topics: Carcinoid Tumor; Female; Gastrointestinal Neoplasms; Humans; Hydroxyindoleacetic Acid; Ketanserin; Male; Malignant Carcinoid Syndrome; Pentagastrin; Piperidines; Receptors, Serotonin; Serotonin Antagonists; Substance P; Time Factors

The levels of 5-hydroxytryptamine (serotonin, 5-HT) and substance P (SP) were assayed (using high performance liquid chromatography-electron capture and radioimmunoassay methods) in the peripheral blood of 17 patients with known mid-gut carcinoids, 16 of whom had hepatic metastases. All patients had supranormal basal levels of 5-HT and SP. The clinical and hormonal changes induced by two provocation tests, intravenous pentagastrin (PG) and calcium infusion, were compared. Pentagastrin caused flushing in all the patients, induced gastrointestinal symptoms in all but one of the patients with hepatic involvement, and universally elevated circulating 5-HT levels. Pretreatment with a 5-HT2-receptor blocking agent, ketanserin, abolished the gastrointestinal effects but had virtually no influence on either 5-HT levels or flushing induced by intravenous pentagastrin. In contrast, calcium infusion induced carcinoid symptoms in only two of six patients, and this was consistently associated with stimulation of circulating serotonin levels. The authors conclude that 1) 5-HT may be responsible for the gastrointestinal symptoms in carcinoid patients, but it does not seem to play any role in flushing; 2) ketanserin may be a useful therapeutic agent in alleviating gastrointestinal symptoms in carcinoid patients; 3) differential responses to PG suggests that SP is released from a site different from that of 5-HT; 4) it is possible that SP may contribute to the mediation of flushing, but it cannot be the sole agent causing this symptom; and 5) the pentagastrin test with measurements of 5-HT levels in peripheral blood seems to be superior to calcium infusion as a provocative test in documenting the diagnosis of carcinoid disease.

Topics: Aged; Calcium; Digestive System; Female; Humans; Ketanserin; Liver Neoplasms; Male; Malignant Carcinoid Syndrome; Middle Aged; Pentagastrin; Piperidines; Serotonin; Serotonin Antagonists; Substance P; Vasomotor System

Topics: Female; Humans; Hypertension; Intraoperative Complications; Ketanserin; Malignant Carcinoid Syndrome; Middle Aged; Piperidines; Serotonin Antagonists