Surgical management of gastrointestinal carcinoid tumors

While carcinoid tumors of the gastrointestinal tract continue to intrigue physicians and surgeons, the medical and surgical management of these tumors continues to evolve. Summarizing the current literature, patients should undergo local excision for incidental tumors of the stomach, rectum, and appendix, provided the tumor measures less than 2 cm in greatest dimension and does not demonstrate muscular invasion or lymph node metastases. Curative radical resection should be attempted, even in the presence of hepatic metastases, in patients with symptomatic or incidentally discovered carcinoid tumors of the small intestine, or in patients with large (> 2 cm) or invasive tumors. Palliative radical resection should be performed for patients with metastatic carcinoid tumors in light of the indolent tumor growth characteristics and the incapacitating symptoms related to tumor bulk and hormone production. Liver dearterialization should be considered only if resection cannot be safely accomplished. Carcinoid heart disease can be safely managed surgically and early intervention prior to the development of irreversible myocardial dysfunction is advocated. Medical therapy, primarily octreotide, should be offered to patients with disseminated tumors, and should be administered and available during the perioperative period to patients undergoing resection or liver dearterialization. With the use of new radioimmunoimaging techniques, earlier diagnosis, improved follow-up, and potentially targeted chemotherapy will be possible. As is evident, the treatment for gastrointestinal carcinoid tumors can be simple, as with small appendiceal tumors, or complex, as with disseminated small intestinal tumors. All surgeons should be familiar with the treatment options for these patients, as most can be treated by simple endoscopic excision or appendectomy. For the unusual patient with a disseminated carcinoid tumor, a multidisciplinary approach is required, combining the expertise of surgeons, oncologists, anesthesiologists, and radiologists for effective results.