The complicated management of a patient following transarterial chemoembolization for metastatic carcinoid

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Abstract

Background

Transarterial Chemoembolization (TACE) has been recognized as a successful way of managing symptomatic and/or progressive hepatic carcinoid metastases not amenable to surgical resection. Although it is a fairly safe procedure, it is not without its complications.

Case presentation

This is a case of a 53 year-old woman with a patent foramen ovale (PFO) and mild pulmonary hypertension who underwent TACE for progressive carcinoid liver metastases. She developed acute heart failure, due to a severe inflammatory response; this resulted in pneumatosis intestinalis due to non-occlusive mesenteric ischemia. We describe the successful non-operative management of her pneumatosis intestinalis and the role of a PFO in this patient's heart failure.

Conclusion

TACE remains an effective and safe treatment for metastatic carcinoid not amenable to resection, this case illustrates the complexity of complications that can arise. A multi-disciplinary approach including ready access to advanced critical care facilities is recommended in managing such complex patients.

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Most cited references 14

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Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome.

W Wiesner, K J Mortelé, J N Glickman … (2001)

The purpose of this study was to analyze the correlation between pneumatosis or portomesenteric venous gas, or both, the severity of mural involvement, and the clinical outcome in patients with small- or large-bowel ischemia. CT scans of 23 consecutive patients presenting with pneumatosis or portomesenteric venous gas caused by bowel ischemia were reviewed. The presence and extent of both CT findings were compared with the clinical outcome in all patients and with the severity and extent of ischemic bowel wall damage as determined by surgery (15 patients), autopsy (three patients), or follow-up (five patients). Seven patients showed isolated pneumatosis, and 16 patients showed portomesenteric venous gas with or without pneumatosis (11 and five patients, respectively). Pneumatosis and portomesenteric venous gas were associated with transmural bowel infarction in 14 (78%) of 18 patients and 13 (81%) of 16 patients, respectively. Nine patients (56%) with portomesenteric venous gas died. Of seven patients with infarction limited to one bowel segment (jejunum, ileum, or colon), only one patient (14%) died, whereas of the 10 patients with infarction of two or three bowel segments, eight patients (80%) died. CT findings of pneumatosis intestinalis and portomesenteric venous gas due to bowel ischemia do not generally allow prediction of transmural bowel infarction, because they may be observed in patients with only partial ischemic bowel wall damage. The clinical outcome of patients with bowel ischemia with these CT findings seems to depend mainly on the severity and extent of their underlying disease.

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Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality.

Jonathan Lee, A Greenstein, Thai Q. Nguyen … (2007)

Pneumatosis intestinalis (PI) is an unusual finding that can exist in a benign setting but can indicate ischemic bowel and the need for surgical intervention. We present a series of cases of PI in adults to illustrate factors associated with death and surgical intervention. We reviewed the radiology database of the Mount Sinai Medical Center for cases of PI between 1996-2006 in adult patients. Chi-square and multivariable logistic regression analyses were used to identify factors significant for surgery and death. Forty patients developed PI over a 10-year span. The overall in-hospital mortality rate was 20%, and the surgical rate was 35%. Factors independently associated with surgical management on multivariable analysis were age >or= 60 years (p = 0.03), the presence of emesis (p = 0.01), and a WBC > 12 c/mm3 (p = 0.03). Pre-existing sepsis was independently associated with mortality (p = 0.03) while controlling for surgery. Patients with the concomitant presence of PI, a WBC > 12 c/mm3, and/or emesis in the >60-year-old age group were most likely to have surgical intervention, whereas PI patients with sepsis had the highest risk for death. A management algorithm is proposed, but further research will be needed to determine which patients with PI may benefit most from surgery.

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Complications of hepatic chemoembolization.

Timothy Clark (2006)

Transarterial hepatic chemoembolization continues to evolve as an integral therapy for unresectable primary and secondary liver tumors. Despite relatively low morbidity, major complications may be seen. This article provides an overview of the spectrum of vascular and nonvascular complications related to this therapy.

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Author and article information

Journal

Journal ID (nlm-ta): World J Surg Oncol

Title: World Journal of Surgical Oncology

Publisher: BioMed Central

ISSN (Electronic): 1477-7819

Publication date Collection: 2008

Publication date (Electronic): 25 November 2008

Volume: 6

Page: 125

Affiliations

[1 ]Department of Surgery, Doctors' Hospital West, Columbus, Ohio, USA

[2 ]Department of Surgery, Ohio State University Medical Center, Columbus, Ohio, USA

[3 ]Division of Hematology and Oncology, Ohio State University Medical Center, Columbus, Ohio, USA

Article

Publisher ID: 1477-7819-6-125

DOI: 10.1186/1477-7819-6-125

PMC ID: 2605455

PubMed ID: 19032771

SO-VID: 82224aca-4909-4454-8d0b-0a51f8908d7d

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The complicated management of a patient following transarterial chemoembolization for metastatic carcinoid

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Abstract

Background

Case presentation

Conclusion

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ScienceOpen Clinical Case Reports Collection

Most cited references 14

Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome.

Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality.

Complications of hepatic chemoembolization.

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