From the Research
Bradycardia during resection of small bowel neuroendocrine tumor with liver metastases is a significant concern that requires prompt recognition and management, even in the absence of right heart disease, as it can lead to increased morbidity and mortality. The most recent and highest quality study on the management of neuroendocrine tumor liver metastases, published in 2023 1, highlights the importance of a multi-disciplinary approach in treating these patients.
Clinical Significance of Bradycardia
The bradycardia is likely due to vasoactive substances released during tumor manipulation, particularly serotonin, bradykinin, and histamine from the neuroendocrine tumor cells. These substances can cause significant hemodynamic changes including bradycardia and hypotension.
Treatment Approach
Treatment should begin with atropine 0.5-1 mg IV for symptomatic bradycardia, with repeated doses up to 3 mg total if needed. If bradycardia persists, consider epinephrine (2-10 mcg/min) or dopamine (2-10 mcg/kg/min) infusions. Preoperative preparation with octreotide (100-500 mcg subcutaneously or IV) can help prevent carcinoid crisis and associated bradycardia.
Surgical Considerations
During surgery, careful tumor handling is essential to minimize hormone release. Anesthesiologists should maintain vigilant monitoring of heart rate and blood pressure, with vasopressors readily available. The role of primary tumor resection for metastatic small bowel neuroendocrine tumors is supported by recent studies, including one published in 2021 2, which suggests that resection of the primary tumor can help prevent potentially debilitating complications associated with mesenteric fibrosis and may improve survival.
Postoperative Care
Postoperatively, continued monitoring is necessary as delayed hormone release can occur. The absence of right heart findings suggests that the bradycardia is not due to carcinoid heart disease but rather an acute response to hormone release during surgical manipulation.
Key points to consider:
- Prompt recognition and management of bradycardia during resection of small bowel neuroendocrine tumor with liver metastases
- Use of atropine, epinephrine, or dopamine for symptomatic bradycardia
- Preoperative preparation with octreotide to prevent carcinoid crisis
- Careful tumor handling during surgery to minimize hormone release
- Vigilant monitoring of heart rate and blood pressure during and after surgery.