REPEATED HEPATIC ISCHEMIA AS A TREATMENT FOR CARCINOID LIVER METASTASES

Hepatic ischemia has been used in the treatment of bilobar malignant carcinoid tumors in the liver. Hepatic artery ligation, hepatic dearterialization, and embolization with nondegradable micromaterial have been followed by collateral formation and are associated with a high complication rate. To reduce this, an implantable vascular occluder permitting intermittent occlusion of the hepatic artery was used in 3 patients with bilateral malignant carcinoid in the liver, with high urinary excretion of 5-hydroxyindoleacetic acid (5-HIAA). Following a thorough dearterialization of the liver and division of all attachments, except for the hepatic artery, portal vein, and common duct, the vascular occluder was placed around the hepatic artery and connected to an implantable subcutaneous port. The hepatic artery was occluded by injecting a few milliliters of saline into the port and flow was released by withdrawal of the same amount of saline. Two patients had an anomalous blood supply to the right lobe and the arterial branch was transposed to the proper hepatic artery. One patient had the hepatic artery regularly occluded for 16 hours at 4–6 week intervals. Two patients managed to do the occlusions by themselves at home for 1 hour twice daily. Two patients had a normalization of the urinary excretion of 5-HIAA after 4 and 9 months. On follow-up with computed tomographic scanning, tumor regression was noted in one, however, there was no change in the other. The third patient has already had a 75% reduction of urinary excretion of 5-HIAA after 2 months of treatment. This new technique has the advantage of being performed on repeated occasions and on an ambulant basis over a long period of time.