Obviously, the patient with advanced carcinoid disease requires a more
complex approach than stated in this report. The authors place emphasis
on aggressive volume replacement and IV somatostatin for the treatment
of hypotension and cardiac arrest. In such cases, this therapy may be
too little, too late. Volume replacement, with adequate IV fluids and
meticulous attention to the addition of electrolytes, is mandatory.
This should include supplemental sodium chloride, magnesium, potassium
chloride, and calcium—all of which are generally depleted in the
patient with advanced carcinoid disease who is suffering from multiple
bouts of diarrhea daily, which is still only partially controlled by
the patient’s usual daily subcutaneous injections of octreotide.
Volume and electrolyte replacement should be given (in appropriate
amounts, dependent on the clinical status of the patient) even when the
levels of the electrolytes, ascertained by laboratory testing, are
normal, as cellular imbalance is often present especially if these
supplements have not been prescribed for use on a daily basis.
Preoperative, intraoperative, and postoperative therapy must not only
involve the use of fluids, electrolytes, and subcutaneous and/or IV
adminstration of octreotide, but, in my opinion, should also include
bolus IV injections of methylprednisolone based on an individually
selected regimen. Such therapy should be started the day before surgery
and not merely as a last-minute, preoperative endeavor, except in
emergency situations requiring immediate intervention. The carcinoid
syndrome is, indeed, a true diagnostic and therapeutic dilemma.