During the last 5-year period aggressive surgical debulking was performed in 19 of 21 consecutive patients with the midgut carcinoid syndrome. Two patients were excluded due to severe cardiac disease. Fourteen of the patients had hepatic metastases. Carcinoid symptoms can occur also in patients without proven liver disease with sole lymph node metastases or retroperitoneal tumours. In 4 patients all metastatic tumour tissue could be removed resulting in biochemical cure and no symptoms. In patients with multifocal hepatic metastases surgical debulking was followed by transarterial embolisations of the hepatic arteries. All patients had good symptomatic relief of the combined surgical and radiological treatment. Five patients had currently stable disease anatomically and biochemically, 2 slowly progressive disease and one patient has a more rapid progression. Three patients have just undergone debulking and are waiting for further treatment. During the observation period 4 patients have died. Of these deaths one was related to the surgical procedures. After the introduction of somatostatin analogues major surgery can be performed safely in these patients with little risk of carcinoid crises. The role of additional drug therapy in these rare patients must be evaluated critically in randomized multicenter trials using a common surgical primary treatment.