Surgical treatment of carcinoid heart disease

Right heart failure in patients with carcinoid heart disease is a serious prognostic sign. Consideration and adequate timing of valvular operations seem essential for the postoperative outcome. Without any relation to duration or progression of the metastasizing tumor disease, right heart failure developed and increased rapidly for a period of 12 to 17 months in four patients with classic carcinoid syndrome. Invasive hemodynamic and cardiac ultrasound investigations revealed severe carcinoid heart disease, and medical decompensation treatment gradually failed. Tricuspid and pulmonic valve replacement operations resulted in dramatic improvement in three of the patients, and these patients were still free of cardiac symptoms 10, 12, and 38 months postoperatively. One patient died 5 days postoperatively probably of septicemia. The preoperative and postoperative development of the cardiac disease is evaluated clinically, by cardiac ultrasound and plasma atrial natriuretic peptide concentrations, and related to the tumor disease. Surgical anatomy and operative technique are reported, and the beneficial value of prophylactic treatment of the effects of tumor-released vasoactive substances by a somatostatin analog is emphasized.     

Surgical management of carcinoid heart disease

Metastatic carcinoid tumor is often seen with flushing, diarrhea, and cardiac symptoms--the carcinoid syndrome. Cardiac failure is often associated with major morbidity and mortality in carcinoid disease. In this report, a case of successful cardiac valvar surgical intervention has resulted in prolonged alleviation of cardiac symptoms and survival.     

Surgical treatment of bronchial carcinoid

84 patients with bronchial carcinoid tumors were analysed on during of 28 years. 26 of them were detected by radiography and 58 by symptoms. The bronchoscopy with biopsy is the most important diagnostic procedure. The preoperative histological or cytological diagnosis was correct in 25 cases. The suspicion was given only in 39 patients. The surgical therapy was carried out in all cases with conventional resection of lung as well as parenchyma preserving methods. We used atypical or typical segmental lung resections, bronchotomy with direct suture, sleeve or wedge resection of the bronchus and fenestration of bronchus with closure of the window with free skin graft. The prognosis after surgical treatment is very good. The 5-year-survival was 89%.     

重症心脏瓣膜病的外科治疗

目的总结重症心脏瓣膜病的外科治疗结果,探讨提高早期生存率的措施。方法自2000年6月至2005年7月,对78例重症心脏瓣膜病患者施行瓣膜替换术。其中单纯二尖瓣置换12例,二尖瓣置换 三尖瓣成形22例,单纯主动脉瓣置换8例,二尖瓣 主动脉瓣置换 三尖瓣成形35例,二尖瓣置换 冠状动脉旁路移植术1例。结果死亡6例,其中术后并发低心排血量5例,心室颤动治疗无效死亡1例,死亡率7.69%。随访53例,平均随访2.5年,死亡5例。结论对重症心脏瓣膜病患者,注重改善术前心功能,掌握手术时机,尽量保留瓣下组织,选择合适瓣膜,重视围手术期处理,可提高手术成功率。     

Palliation of carcinoid heart disease

The clinical manifestations of the carcinoid syndrome have been known for 35 years. Median survival in patients with carcinoid syndrome, although dependent on several factors, including the extent of liver metastases, is in the range of four years. In this setting, a frequent cause of death is right-sided cardiac dysfunction. When this occurs, the only definitive palliation is surgical in patients with this slow-growing tumor. Successful palliation was provided by tricuspid valve replacement and pulmonary valvoplasty in a patient with carcinoid heart disease and extensive liver metastases. This emphasizes the importance of surgery in selected patients with this slow-growing tumor.     

Surgical treatment of mid-gut carcinoid tumors

Coincident with medical antitumor treatment of 138 patients suffering from mid-gut carcinoid tumors, 51 patients were subjected to surgery with the principal aims of removing primary tumors and debulking mesenteric or liver metastases. Sixteen patients had previously been operated with intestinal resection or, when the tumors had been considered inexcisable, with intestinal bypass or laparotomy alone. Apart from exhibiting symptoms related to the carcinoid syndrome, the majority (approximately 60%) of the 51 patients had generally intermittent, subileus-like abdominal pain and weight loss. In 18 patients, these symptoms were pronounced and associated with intestinal obstruction or severe malnutrition. Computed tomography and arteriography efficiently demonstrated mesenteric and liver metastases. At laparotomy, the primary intestinal tumors were small, mainly less than 1 cm in diameter, and they were multiple in 39% of the patients. Mesenteric metastases measuring up to 12 cm in diameter were present in 86% of the patients. These metastases were frequently associated with a pronounced mesenteric and retroperitoneal fibrosis causing fixation, angulation, and obstruction of the bowel as well as incipient intestinal gangrene in 8 patients. In all but 6 patients, the primary tumors could be removed by comparatively limited intestinal resections although bulky mesenteric metastases were often dissected from the mesenteric vessels. Liver metastases, found in 49% of the patients, were generally bilateral and multiple, and major hepatic metastases were resected in 6 patients. The results support a role for surgery also in the more compromised patients with mid-gut carcinoid tumors and that such intervention may be associated with considerable symptomatic relief and substantial periods of survival.

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Resumen Coincidente con el tratamiento médico antitumoral de 138 pacientes con tumores carcinoides del intestino medio, 51 pacientes fueron sometidos a cirugía con el propósito principal de remover los tumores primarios y disminuir la masa tumoral de metástasis mesentéricas o hepáticas. Dieciseis pacientes habían sido operados previamente con realización de resección intestinal o, cuando el tumor fue considerado no resecable, derivación intestinal o sólo laparatomía. Además de los síntomas relacionados con el síndrome carcinoide, la mayoría (60%) de los 51 pacientes presentó dolor abdominal intermitente y pérdida de peso, en 18 casos estos síntomas fueron severos y aparecieron asociados con obstrucción intestinal o con malnutrición severa. La tomografía computadorizada y la arteriografía demonstraron bien las metástasis mesentéricas y hepáticas. En la laparotomía los tumores intestinales primarios aparecieron como de tamaño pequeño, la mayoría de menos de un centimetro de diámetro, y múltiples en 39% de los casos. Metástasis mesentéricas hasta de 12 cm de diámetro ocurrieron en 86% de los pacientes. Tales metástasis con frecuencia aparecieron asociadas con marcada fibrosis mesentérica y retroperitoneal, produciendo fijación, angulación, y obstructión del intestino, así como gangrena intestinal incipiente en ocho pacientes. En todos los pacientes, menos en 6, se pudo resecar los tumores primarios mediante resecciones intestinales relativamente limitadas, aunque tumores muy voluminosos tuvieron que ser disecados de los vasos mesentéricos. Las metástasis hepáticas, presentes en 49% de los pacientes, generalmente fueron bilaterales y múltiples; en 6 pacientes se efectuó la resección de metástasis hepáticas mayores. Los resultados dan apoyo a la conducta de tratamiento quirúrgico también para los pacientes más comprometidos con tumores carcinoides del intestino medio y demuestran que la intervención puede resultar en considerable mejoría sintomática y sustanciales períodos de supervivencia.

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Résumé Parmi 138 patients traités par chimiothérapie pour tumeurs carcinoïdes intestinales, 51 ont eu une résection de leur tumeur primitive ou une chirurgie de réduction des métastases mésentèriques ou hépatiques. Seize patients avaient déjà été opérés d'une résection intestinale ou, quand on avait considéré les tumeurs comme inextirpables, d'une dérivation intestinale ou d'une laparotomie exploratrice. Mis à part les symptômes en rapport avec le syndrome carcinoïde, la plupart (60%) des 51 patients se plaignaient en général d'une douleur abdominale intermittente semblable à celle de l'occlusion intestinale et une perte de poids. Chez 18 patients ces symptômes étaient aigus et associés à une occlusion intestinale ou à une malnutrition sévère. Tomodensitométrie et artériographie ont été employés pour mettre en évidence les métastases du mésentère et du foie. A la laparotomie, les tumeurs intestinales primitives étaient petites, avec en général moins d'un cm de diamètre, et il y en avait plusieurs chez 39% des patients. Des métastases du mésentère mesurant plus de 12 cm de diamètre étaient présentes chez 86% des patients. Ces métastases était souvent associées à une importante fibrose mésentérique et rétropéritonéale provoquant adhérences, angulation et occlusion de l'intestin et un début de gangrène intestinale chez 8 patients. Chez tous les patients sauf 6, nous avons pu enlever les tumeurs primitives avec une résection de l'intestin relativement limitée alors qu'il existait de grosses métastases du mésentère, souvent dissociables des vaisseaux mésentériques. Les métastases du foie, retrouvées chez 49% des patients, étaient en général bilatérales et multiples, et, chez 6 patients, réséquables. Nos résultats parlent en faveur de la chirurgie même chez les patients avec des tumeurs carcinoïdes de l'intestin, même évoluées, et confirment que cette intervention peut être associée à d'importantes améliorations symptomatiques et à des périodes de survie conséquentes.

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Presented at the International Association of Endocrine Surgeons in Toronto, Ontario, Canada, September, 1989.

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Supported by the Swedish Cancer Society.     

Carcinoid heart disease and carcinoid syndrome: successful surgical treatment

Tumor debulking can greatly improve quality of life for patients with malignant carcinoid syndrome, but hepatic cytoreduction is confounded by carcinoid heart disease, which can cause postsinusoidal portal hypertension, thereby increasing the risk of death from hemorrhage during hepatic resection. We describe a patient with metastatic carcinoid syndrome and carcinoid heart disease who had repair of his carcinoid heart disease and, after improvement of right-sided heart function, had successful hepatic debulking of carcinoid metastases.     

Surgical treatment of valvular heart disease.

Surgeons are presently able to choose from a variety of satisfactory valve prostheses, depending on the individual situation. The durability, thromboembolic potential, and hemodynamic properties of any valve must be balanced against specific anatomic and clinical factors. Thus, if a surgeon is most concerned about durability, he might choose the bare strut Starr-Edwards ball valve or the Smeloff-Cutter valve, the most proven valves by length of service. However, the Bjork-Shiley, Lillehei-Kaster, and Hancock valves all have good durability records to seven years.Thromboembolic potential is markedly decreased with tissue valves such as the Hancock porcine xenograft, Carpentier-Edwards porcine xenograft, Ionescu-Shiley pericardial valve, or dura mater valve. Patients with these valves do not usually require chronic anticoagulation, which is associated with significant morbidity and mortality. In clinical situations that contraindicate long-term anticoagulation or when the threat of thromboembolism or bleeding is very high, the use of a tissue valve is particularly indicated.Hemodynamic considerations may be paramount in some patients with restrictive anatomy; the small diameter, tilting disc valves have the best hemodynamic performance, although new modifications in the Hancock porcine heterograft may reduce the hemodynamic obstruction in these small diameter valves and allow their implantation without long-term anticoagulation.A number of durable and effective devices exist today for valve replacement, and the type of valve used can be individualized according to the valve characteristics, clinical indications, and anatomic considerations.     

Surgical treatment of chronic ischemic heart disease

The authors suggest a new complex approach to the surgical treatment of ischemic heart disease. Operation of coronary shunting for the restoration of the coronary blood flow, operation of partial ileoshunting for correction of hyperlipoproteinemia, plexotomy for removal of the vasospastic component. The sequence of the operations may vary, each one can also be undertaken independently. The operations were conducted on 315 patients. The follow-up period is up to 8 years. Patency of the mammary-coronary shunts was 93.5%, of autologous veins shunt--65%. Disappearance of the signs of coronary spasm++ and stable normalization of the lipid spectrum are noted.     

Surgical treatment of functioning metastatic carcinoid tumors

Thirteen patients with functioning carcinoid syndrome and hepatic metastases were surgically treated. Localized hepatic metastases were resected in five patients, and diffuse hepatic metastases were treated with hepatic artery ligation in eight. There were no postoperative deaths, and follow-up ranged from six to 46 months. All patients were symptom-free after operation. In all patients with resection, levels of 5-hydroxyindoleacetic acid (5-HIAA) returned to normal or near normal, whereas in patients who underwent hepatic artery ligation, the average reduction in 5-HIAA level was 76%. Three patients died during the follow-up period--two of metastatic carcinoids and one without evidence of disease. The mean duration of response was 36 months for resection and 4.8 months for hepatic artery ligation. The addition of postoperative intra-arterial chemotherapy and sequential systemic chemotherapy may enhance the response to hepatic artery ligation.     

先天性心脏病三尖瓣关闭不全的外科治疗

目的为提高先天性心脏病三尖瓣关闭不全外科治疗的疗效,总结其外科治疗经验.方法 1995～2001年,共收治16例先天性心脏病三尖瓣关闭不全患者,三尖瓣中度反流3例,重度反流13例.行单纯DeVega环缩术7例,DeVega环缩加前叶腱束缩短、隔叶腱束转移、裂修补和前叶自体心包扩大术各1例,应用三尖瓣人工瓣环3例,三尖瓣置换术2例.结果全组无手术死亡.随访所有患者,平均随访38个月,1例单纯DeVega环缩术患者于术后4年出现中至重度三尖瓣关闭不全.结论先天性心脏病三尖瓣关闭不全患者的外科治疗首选三尖瓣成形术,DeVega成形术环缩瓣环方法简便、有效.     

婴幼儿先天性心脏病外科治疗

目的 总结50例婴幼儿先天性心脏病的外科治疗经验。方法 年龄4～36m,平均14±3月,男性39例,女性20例。体重4.5～18kg,平均13±2.5kg,心胸比率0.45～0.80,平均0.55±0.10。其中30例有不同程度肺动脉高压。25例有2种以上病变。5例常温下行动脉导管结扎术,其余45例均在全身麻醉,浅低温,体外循环下行心内畸形根治术。结果 术后30d内死亡5例(10％),发生各种并发症5例(10％),无远期死亡病例及并发症。结论 婴幼儿先天性心脏病早期治疗可明显减轻症状,一般均可根治,手术效果令人满意。     

Surgical treatment of ischemic heart disease combined with hypothyroidism

Treatment for patients with ischemic heart disease and hypothyroidism contains many difficulties, such as a dilemma that thyroid hormone to hypothyroid patients may worsen angina. The purpose of this study is to propose an appropriate control of thyroid function in these patients before coronary artery bypass grafting (CABG), and to clarify the change of thyroid function during postoperative period. Because of progressive angina pectoris, five hypothyroidism patients underwent CABG. Preoperatively, minimal dose of L-Thyroxine (0-75 micrograms, daily) was administered orally to keep thyroid function at slightly low level before CABG. Ten consecutive CABG patients with normal thyroid function were selected as control group. Between both groups, there was no significant difference in age, coronary artery disease, and the number of bypass grafts. Serum T4, free-T4, T3, free-T3, and TSH were measured at 1st, 2nd, 3rd, and 7th P.O.D. In control group, pituitary-thyroid function was suppressed transiently. In hypothyroid group, T4 revealed no change and was kept at slightly low level during observed period. There was no significant difference in postoperative hemodynamics between both groups. Postoperatively all of hypothyroid patients got free from angina and received an adequate thyroid hormone replacement therapy without complications. It is concluded that CABG for patients with angina and hypothyroidism can be performed safely by keeping preoperative thyroid function at slightly low level.