Management and follow-up of 78 giant haemangiomas of the liver

Hepatic Hemangioma: Review of Imaging and Therapeutic Strategies

Hepatic hemangiomas are the most common benign liver tumors. Typically, small- to medium-sized hemangiomas are asymptomatic and discovered incidentally through the widespread use of imaging techniques. Giant hemangiomas (>5 cm) have a higher risk of complications. A variety of imaging methods are used for diagnosis. Cavernous hemangioma is the most frequent type, but radiologists must be aware of other varieties. Conservative management is often adequate, but some cases necessitate targeted interventions. Although surgery was traditionally the main treatment, the evolution of minimally invasive procedures now often recommends transarterial chemoembolization as the treatment of choice.

Transarterial Bleomycin-Lipiodol Chemoembolization for the Treatment of Giant Hepatic Hemangiomas: An Assessment of Effectiveness

This study evaluates the effectiveness of superselective transcatheter arterial chemoembolization (TACE) using a bleomycin-lipiodol emulsion in treating giant hepatic hemangiomas. A retrospective review included 31 patients with a mean age of 53 ± 10.42 years who underwent TACE from December 2014 to October 2022, with follow-up imaging examinations to assess outcomes. Technical success was defined as successful embolization of all feeding arteries, and clinical success was defined as a reduction in hemangioma volume by 50% or more on follow-up imaging. This study observed a 100% technical success rate. Post-embolization syndrome was common, and two cases of asymptomatic hepatic artery dissection were noted. Clinical success was achieved in 80.6% of patients, with significant volume reduction observed in the majority. Conclusively, superselective transcatheter arterial chemoembolization with bleomycin-lipiodol emulsions is presented as a viable and effective treatment option for giant hepatic hemangiomas. With no procedure-related mortality and significant volume reduction in most cases, this method offers a promising alternative to surgical intervention. This study's findings suggest a need for further exploration and validation in larger-scale prospective studies.

The Natural History and Management of Hepatic Hemangioma

BACKGROUND

Knowledge of the natural history and management of hepatic hemangiomas is lacking. The aim of this study was to investigate the natural history of hemangiomas and to elucidate the factors that determine tumor growth and optimal management.

METHODS

A total of 211 adult patients were enrolled, with follow-up for more than three years. Follow-up was performed with repeated ultrasonography (US) and laboratory tests for liver function and coagulation factors (platelets, prothrombin time (PT), fibrinogen, thrombin-antithrombin III complex (TAT), D-dimer, and fibrin and fibrinogen degradation products (FDP)).

RESULTS

Tumor size decreased in 38.9% of patients, showed no change in 31.3%, and increased in 29.8%. The incidence of a size increase was very high in patients under 40 years of age and decreased gradually with age, whereas the incidence of a size decrease increased with age and increased markedly over 60 years of age. The incidence of an increase in size decreased gradually with size enlargement, whereas the incidence of a decrease in size increased markedly with tumor size and further increased rapidly when hemangiomas became larger than 60 mm. Values of TAT, D-dimer, FDP, and Mac-2 binding protein glycosylation isomer (M2BPGi) were closely related to the change in size of hemangiomas.

CONCLUSIONS

Hemangiomas in older patients (>60 years of age) and larger tumors (>60 mm in size) had a tendency to decrease in size, resulting from the reduction in coagulation disorders and the progression of liver fibrosis. Therefore, the majority of patients with hemangiomas can be safely managed by clinical observation.

Perioperative outcomes of robot-assisted versus laparoscopic liver resection for cavernous hemangioma: a propensity score matching study

BACKGROUND

Minimally invasive techniques have increasingly been adopted for liver resection. This study aimed to compare the perioperative outcomes of robot-assisted liver resection (RALR) with laparoscopic liver resection (LLR) for liver cavernous hemangioma and to evaluate the treatment feasibility and safety.

METHODS

A retrospective study of prospectively collected data was conducted on consecutive patients who underwent RALR (n = 43) and LLR (n = 244) for liver cavernous hemangioma between February 2015 and June 2021 at our institution. Patient demographics, tumor characteristics, and intraoperative and postoperative outcomes were analyzed and compared using propensity score matching.

RESULTS

The postoperative hospital stay was significantly shorter (P = 0.016) in the RALR group. There were no significant differences between the two groups in overall operative time, intraoperative blood loss, blood transfusion rates, conversion to open surgery or complication rates. There was no perioperative mortality. Multivariate analysis showed that hemangiomas located in posterosuperior liver segments and those in close proximity to major vascular structures were independent predictors of increased intraoperative blood loss (P = 0.013 and P = 0.001, respectively). For patients with hemangioma in close proximity to major vascular structures, there were no significant differences in perioperative outcomes between the two groups, with the exception that intraoperative blood loss in the RALR group was significantly less than that in the LLR group (350 ml vs. 450 ml, P = 0.044).

CONCLUSIONS

Both RALR and LLR were safe and feasible for treating liver hemangioma in well-selected patients. For patients with liver hemangioma in close proximity to major vascular structures, RALR was better than conventional laparoscopic surgery in reducing intraoperative blood loss.

Prevalence and Characteristics of Hepatic Hemangioma Associated with Coagulopathy and Its Predictive Risk Factors

Background: Knowledge of the relationships between hepatic hemangiomas and coagulopathy and the risk factors for hemangiomas is lacking. The aim of this study was to investigate the prevalence and characteristics of hepatic hemangiomas associated with coagulopathy, elucidate the causes of coagulopathy, and identify the predictive factors for hemangioma-related complications. Methods: In 281 consecutive patients with hepatic hemangiomas, we performed ultrasonography and conducted serum laboratory tests for liver function and six coagulation factors, i.e., platelets, as well as five coagulation fibrinolytic markers (prothrombin time (PT), fibrinogen, thrombin-antithrombin III complex (TAT), d-dimer, and fibrin and fibrinogen degradation products (FDP)) as indicators of coagulation disorder. Results: Among 281 patients, 56 (19.9%) had abnormal coagulation factors. Abnormal values of d-dimer were most frequently found among the six coagulation factors. The number of abnormal coagulation factors was significantly correlated with tumor size, M2BPGi, and HDL cholesterol, among which tumor size was the most significant independent predictor of the number of abnormal coagulation factors. Conclusions: The prevalence of hepatic hemangiomas associated with coagulopathy was relatively high and became more frequent with increases in tumor size. Predictive factors of hemangioma-related complications were found to be a tumor size of >5 cm in diameter and coagulopathy, especially the elevation of d-dimer.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach-Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.

RESULTS

Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach-Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.

CONCLUSION

The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.

Spontaneous Rupture of a Hepatic Cavernous Hemangioma: A Rare Case of Sudden Unexpected Death

Cavernous hemangiomas represent the most common benign tumors affecting the liver. They are more often asymptomatic and usually diagnosed through radiological examinations performed for other reasons. When there are symptomatic, they may cause digestive disorders such as abdominal pain, nausea, vomiting, or a palpable mass. Sudden death may occur as a result of rupture and bleeding. Spontaneous rupture of cavernous hepatic hemangioma is a rare complication, but the mortality rate is high. We report a rare case of sudden unexpected death of a 46-year-old woman due to a spontaneous rupture of a giant hepatic cavernous hemangioma discovered at autopsy.

Giant intrahepatic venous malformation with localized intravascular coagulopathy. Follow-up and treatment during pregnancy

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints?

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.

Impact of open and minimally invasive resection of symptomatic solid benign liver tumours on symptoms and quality of life: a systematic review

BACKGROUND

The value of open and minimally invasive liver resection for symptomatic solid benign liver tumours (BLT) such as hepatocellular adenoma, focal nodular hyperplasia and haemangioma is being debated. A systematic review on symptom relief, quality of life (QoL) and surgical outcome after both open and minimally invasive surgery for solid BLT is currently lacking.

METHODS

A systematic search in PubMed and EMBASE was performed according to the PRISMA guidelines (January 1985-April 2018). Articles reporting pre-and postoperative symptoms or QoL in patients undergoing open or minimally surgery for BLT were evaluated. Methodological quality was assessed using the MINORS tool.

RESULTS

Forty-two studies were included with 4061 patients undergoing surgery for BLT, 3536 (87%) open and 525 (13%) laparoscopic resections. Randomized and propensity-matched studies were lacking. Symptoms were the indication for resection in 56% of the patients. After a weighted mean of 28.5 months follow-up after surgery, symptoms were relieved in 82% of symptomatic patients. Validated QoL tools were used in eight studies, of which two found significant better QoL scores following laparoscopic compared to open surgery.

DISCUSSION

Resection of symptomatic BLT seems safe and relieves symptoms in the vast majority of selected patients. Comparative studies are needed before more firm conclusions can be drawn.

Rupture of hepatic hemangioma with hemoperitoneum due to spontaneous gallbladder perforation: A unique case report

INTRODUCTION

Hemangiomas are common benign tumors of the liver. Spontaneous rupture is a rare complication, occurring most commonly in giant hemangiomas. Rupture of a hemangioma with hemoperitoneum is a serious development and can be fatal if not managed promptly.The present study reports the unique case of a man who experienced rupture and hemorrhage of a hepatic hemangioma (HH) due to perforation of the gallbladder fundus. After en block resection of the hemangioma and gallbladder using the Pringle maneuver, the patient made an uneventful recovery without complications.To our knowledge, spontaneous rupture of HH secondary to gallbladder perforation has not been reported in the literature. This case highlights a unique, rare cause of ruptured HH and the need to consider appropriate treatment for some hemangiomas to avoid this potentially fatal complication.

CONCLUSION

The current case may provide additional support for treatment of HH due to the potential for spontaneous rupture. For patients with ruptured HH, enucleation with the Pringle maneuver is recommended.

Infrahepatic inferior vena cava clamping with Pringle maneuvers for laparoscopic extracapsular enucleation of giant liver hemangiomas

Background

This study aimed to determine the feasibility of the extracapsular enucleation method for giant liver hemangiomas by infrahepatic inferior vena cava (IVC) clamping and the Pringle maneuver to control intraoperative bleeding under laparoscopic hepatectomy.

Methods

From January 2012 to January 2016, 36 patients underwent laparoscopic extracapsular enucleation of giant liver hemangiomas. Patients were divided into two groups: infrahepatic IVC clamping + Pringle maneuvers group (IVCP group, n = 15) and the Pringle maneuvers group (Pringle group, n = 21). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.

Results

The mean size of liver hemangiomas was 13.3 cm (range 10–25 cm). Infrahepatic IVC clamping + the Pringle maneuvers with laparoscopic extracapsular enucleation significantly reduced intraoperative blood loss (586.7 vs 315.3 mL, p < 0.001) and transfusion rates (23.8 vs 6.7%, p = 0.001), compared with the Pringle maneuver alone. The gallbladder was retained in both groups. The mean arterial pressure (MAP) in Pringle group remained virtually stable before and after clamping of hepatic portal, while it was significantly decreased after IVC clamping in IVCP group than that pre-clamping (p < 0.001). The heart rate of all patients was significantly increased after clamping when compared to pre-clamping heart rates (p < 0.001). Once vascular occlusion was released, MAP returned to normal levels within a few minutes. There were no significant differences in postoperative complications between two groups. The vascular occlusion techniques in both groups had no serious effect on postoperative of hepatic and renal function.

Conclusions

Extracapsular enucleation with infrahepatic IVC clamping + the Pringle maneuver is a safe and effective surgical treatment to control bleeding for giant liver hemangiomas in laparoscopic hepatectomy.

New recognition of the natural history and growth pattern of hepatic hemangioma in adults

AIM

Surgical indications for hepatic hemangiomas are still not clearly defined due to limited data on their natural history. This study aimed to investigate the natural history and growth pattern of hepatic hemangiomas in adults.

METHODS

From April 2010 to March 2013, adult patients with hepatic hemangioma who had no prior treatment were enrolled. A routine follow up was performed to observe the natural history of the lesions and their tendency to cause complications.

RESULTS

A total of 236 patients were enrolled in the study. The median size of hemangiomas was 4.5 cm (range, 0.6-19.2). During a median follow-up period of 48 months (range, 3-266), 61.0% patients had hemangiomas that increased in size, 23.7% patients had stable lesions and 8.5% patients had hemangiomas that decreased in size. The peak growth period of hemangiomas was in patients of less than 30 years of age (0.46 ± 0.41 cm/year) and the growth rate decreased significantly after 50 years of age (0.21 ± 0.40 cm/year). Hemangiomas of less than 2 cm had the lowest growth rate (0.16 ± 0.42 cm/year). The peak growth rate of hemangioma size was 8-10 cm (0.80 ± 0.62 cm/year), then decreased rapidly to 0.47 ± 0.91 cm/year while the hemangiomas were of more than 10 cm. Only nine patients had severe symptoms caused by hemangioma. No patients presented with hemangioma-related complications.

CONCLUSION

The majority of hepatic hemangiomas have the tendency to increase in size but rarely cause complications. All the hemangiomas can be safely managed by observation, and surgery is only considered for patients with severe complications.

Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: A large retrospective cross-sectional study

BACKGROUND

Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications.

AIMS

The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture.

METHODS

We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course.

RESULTS

Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding.

CONCLUSION

Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases.

Enucleation of a Giant Hemangioma of Liver: Old School Revisited

Hemangiomas are the most frequent benign hepatic tumours and are usually found in patients aged between 40 and 60 years, more frequently in women. In 30-35% of patients, the lesions are multiple. If the lesions are larger than 4-10 cm, they are coined as "giant" hemangioma. Here, we present a case of giant hemangioma treated with enucleation of the lesion and the advantages of the procedure.

Surgical Treatment of Giant Liver Hemangioma Larger Than 10 cm: A Single Center's Experience With 86 Patients

The ideal surgical treatment of giant liver hemangioma is still controversial. This study aims to compare the outcomes of enucleation with those of resection for liver hemangioma larger than 10 cm in different locations of the liver and establish the preoperative predictors of increased intraoperative blood loss.Eighty-six patients underwent enucleation or liver resection for liver hemangioma larger than 10 cm was retrospectively reviewed. Patient demographic, tumor characteristics, surgical indications, the outcomes of both surgical treatment, and the clinicopathological parameters influencing intraoperative blood loss were analyzed.Forty-six patients received enucleation and 40 patients received liver resection. Mean tumor size was 14.1 cm with a range of 10-35 cm. Blood loss, blood product usage, operative time, hepatic vascular occlusion time and frequency, complications and postsurgical hospital stay were similar between liver resections and enucleation for right-liver and left-liver hemangiomas. There was no surgery-related mortality in either group. Bleeding was more related to adjacency of major vascular structures than the size of hemangioma. Adjacency to major vascular structures and right or bilateral liver hemangiomas were independently associated with blood loss >550 mL (P = 0.000 and 0.042, respectively).Both enucleation and liver resection are safe and effective surgical treatments for liver hemangiomas larger than 10 cm. The risk of intraoperative blood loss is related to adjacency to major vascular structures and the location of hemangioma.

What is changing in indications and treatment of hepatic hemangiomas. A review

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

Impact on liver cancer treatment of a first erroneous diagnosis of hemangioma

BACKGROUND

Most liver hemangioma (HA) diagnoses are presumptive and based on radiological features and growth trend. The goal of this study was to analyze the impact of a false diagnosis of hemangioma upon the overall therapeutic course and upon the prognosis of a liver malignancy.

METHODS

Twenty-eight patients with liver cancer who were observed in the period 2001-2007 after an initial erroneous diagnosis of HA were retrospectively evaluated. We studied their radiological workup after blind revision of the images by two radiologists with specific expertise in liver imaging, analyzing the relationship between overall management and center volume, mean delay from the first test to the curative treatment, and clinical consequences of this diagnostic mistake.

RESULTS

The diagnosis of false HA occurred in a low-volume center (LVC) in 75 % of cases. A specific risk for liver cancer was present in 71.4 % of patients. US gave a false diagnosis of HA in 25/27 patients, a CT scan in 18/25 patients, and MRI in 6/16 patients. The final diagnosis was reached with a mean delay of 22 months. Liver resection was possible in 22 patients; in the 17 hepatocellular carcinoma cases, the survival rate was 69.4 % at 5 years after the first observation.

CONCLUSIONS

A false diagnosis of HA in the presence of malignancy is not rare nowadays and significantly reduces the chances of cure. In situations at risk of having the error occur (poor technical quality of imaging, low specific experience, doubtful diagnosis, and high-cancer-risk patient), the rationale approach is to discuss the case with a multidisciplinary team skilled in the field of liver cancer.

Management of hemangioma of the liver: surgical therapy or observation?

BACKGROUND

Elective surgery for liver hemangioma is controversial. We reviewed long-term outcomes following elective hepatectomy or observation only for symptomatic and asymptomatic liver hemangioma.

METHODS

All patients (n = 307) with liver hemangioma referred to our hospital for surgical evaluation from January 1988 to December 2009 were identified, and imaging results, tumor characteristics, surgical indication, surgical mode, outcome of observation, clinical and/or postoperative outcome, and adverse events were retrospectively evaluated.

RESULTS

Complete median follow-up for 246 patients was 124 months. Elective surgery was performed in 103 patients (symptomatic [n = 62] and asymptomatic [n = 41]). Postoperative morbidity occurred in 17 % of the patients and was significantly lower in asymptomatic patients (p = 0.002). No perioperative mortality was registered. Surgery relieved complaints in most (88 %) patients. In the observation group (n = 143), 56 % of patients had persistent or new onset of hemangioma-associated symptoms. Major hemangioma-related complications occurred in 12 patients (9 %) during the follow-up period, and 2 patients died after traumatic hemangioma rupture. Overall the rate of adverse events was by trend lower in the surgical group than in the observation group (35 versus 57 %; p = 0.08).

CONCLUSIONS

The majority of patients with liver hemangioma can be safely managed by clinical observation. In a subset of patients, especially those with giant hemangioma and/or occurrence of symptoms, surgical treatment could be considered and is justified in high-volume centers.

Minimally invasive treatment of giant haemangiomas of the liver: embolisation with bleomycin

PURPOSE

The management of patients with giant haemangioma of the liver remains controversial. Although the usual treatment method for symptomatic giant haemangioma is surgery, the classical paradigm of operative resection remains. In this study, we evaluated the symptomatic improvement and size-reduction effect of embolisation with bleomycin mixed with lipiodol for the treatment of symptomatic giant hepatic haemangioma.

METHODS

This study included 26 patients [21 female, five male; age 41-65 years (mean 49.83 ± 1.53)] with symptomatic giant haemangioma unfit for surgery and treated with selective embolisation by bleomycin mixed with lipiodol. The patients were followed-up (mean 7.4 ± 0.81 months) clinically and using imaging methods. Statistical analysis was performed using SPSS version 16.0, and p < 0.05 was considered to indicate statistical significance.

RESULTS

Embolisation of 32 lesions in 26 patients was performed. The mean volume of the haemangiomas was 446.28 ± 88 cm(3) (range 3.39-1559 cm(3)) before intervention and 244.43 ± 54.38 cm(3) (range 94-967 cm(3)) after intervention. No mortality or morbidity related to the treatment was identified. Symptomatic improvement was observed in all patients, and significant volume reduction was achieved (p = 0.001).

CONCLUSION

The morbidity of surgical treatment in patients with giant liver hemangioma were similar to those obtained in patients followed-up without treatment. Therefore, follow-up without treatment is preferred in most patients. Thus, minimally invasive embolisation is an alternative and effective treatment for giant symptomatic haemangioma of the liver.

Management of giant liver hemangiomas: an update

Liver hemangiomas are the most common benign liver tumors and are usually incidental findings. Liver hemangiomas are readily demonstrated by abdominal ultrasonography, computed tomography or magnetic resonance imaging. Giant liver hemangiomas are defined by a diameter larger than 5 cm. In patients with a giant liver hemangioma, observation is justified in the absence of symptoms. Surgical resection is indicated in patients with abdominal (mechanical) complaints or complications, or when diagnosis remains inconclusive. Enucleation is the preferred surgical method, according to existing literature and our own experience. Spontaneous or traumatic rupture of a giant hepatic hemangioma is rare, however, the mortality rate is high (36-39%). An uncommon complication of a giant hemangioma is disseminated intravascular coagulation (Kasabach-Merritt syndrome); intervention is then required. Herein, the authors provide a literature update of the current evidence concerning the management of giant hepatic hemangiomas. In addition, the authors assessed treatment strategies and outcomes in a series of patients with giant liver hemangiomas managed in our department.

Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study

OBJECTIVE

The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease.

METHODS

We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries.

RESULTS

Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma.

CONCLUSION

Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.

Management of giant hemangioma of the liver: resection versus observation

BACKGROUND

Management of patients with giant hemangiomas of the liver encounters persistent controversy. Although recent case series suggest a low complication rate with nonoperative management, the classic paradigm of preventive operative resection remains.

STUDY DESIGN

A retrospective cohort study was conducted of 492 patients with giant hepatic hemangioma (>4 cm in size) diagnosed between 1985 and 2005 at Mayo Clinic Rochester. Long-term outcomes were assessed by patient survey, with a follow-up of 11 ± 6.4 years.

RESULTS

Of 492 patients, 289 responded to the survey. In the nonoperative group (n = 233), 20% had persistent or new onset of hemangioma-associated symptoms, including potentially life-threatening complications in 2%. In the operative group (n = 56), perioperative complications occurred in 14%, including potentially life-threatening complications in 7%. None of the operative patients had persistent or new onset of hemangioma-associated symptoms after resection of the dominant hemangioma. In group comparison, the rate of adverse events was similar (20% versus 14%; p = 0.45) with an overall low risk for potentially life-threatening complications (2% versus 7%; p = 0.07). Size of hemangiomas was not associated with adverse events in either group. Subjective health status and quality of life at follow-up were similar in both groups (p > 0.54).

CONCLUSIONS

Clinical observation of patients with giant hemangioma of the liver has a similar rate of complications compared with operative management, but might prevent the need for invasive interventions in some patients. Clinical observation is preferred in most patients and operative treatment should be reserved for patients with severe symptoms or disease-associated complications.

Reappraisal of surgical indications and approach for liver hemangioma: single-center experience on 74 patients

BACKGROUND

Liver hemangiomas are rarely large, symptomatic, or presenting atypical imaging patterns. Surgery is rarely needed; indications and choice of the best technique remain not precisely defined.

METHODS

Features of hemangiomas and surgical indications were assessed in 74 patients (mean follow-up 63.2 months). In 40 operated patients, the results of liver resection versus enucleation were compared.

RESULTS

Most hemangiomas (60/74, 81.1%) showed no size increment. In 40 operated patients (40/74, 54.1%) the mean tumor size (11.9 cm, range 2.6-46.0) was larger than in nonoperated patients (11.9 vs 6.0 cm, P = .0002). Surgical indications were specific symptoms, tumor enlargement, Kasabach-Merritt syndrome, and uncertain diagnosis. Mortality (nil), morbidity (10.0%), and transfusion rate (15.0%) were similar for 28 liver resections versus 12 enucleations; bleeding was more related to large hemangioma size than to the choice of either technique. Liver ischemia techniques, autotransfusion, and intraoperative blood salvage reduced the risk of transfusion.

CONCLUSIONS

Surgery is rarely indicated, has a low risk, and has similar results for liver resection versus enucleation. Risk of bleeding is related more to the large size of the hemangioma than to the type of surgery (resection or enucleation). In these patients, management, the need for surgery, and the choice of technique should be carefully individualized.

Recurrent pulmonary embolism due to giant hepatic hamangioma treated with hepatectomy under vascular exclusion

Giant hepatic hemangiomas are benign tumors that measure more than 4 cm and are usually asymptomatic. Pulmonary embolism (PE) is an extremely rare manifestation of giant hepatic hemangiomas. We report a case of a 44-year-old woman who suffered of recurrent pulmonary emboli that, after thorough work up, were attributed to thrombi formation inside a giant hepatic hemangioma. A right hepatectomy under vascular exclusion was performed and the hemangioma, measuring 17 cm, was resected. Two years later the patient remains asymptomatic. The report highlights the value of investigating giant liver hemangiomas in case of PE. In such cases, the hemangioma should be resected preferably under occlusion of the venous outflow of the liver to avoid PE intraoperatively.

Spontaneous rupture of a giant hepatic hemangioma - sequential management with transcatheter arterial embolization and resection

Hemangioma is the most common benign tumor of liver and is often asymptomatic. Spontaneous rupture is rare but has a catastrophic outcome if not promptly managed. Emergent hepatic resection has been the treatment of choice but has high operative mortality. Preoperative transcatheter arterial embolization (TAE) can significantly improve outcome in such patients. We report a case of spontaneous rupture of giant hepatic hemangioma that presented with abdominal pain and shock due to hemoperitoneum. Patient was successfully managed by TAE, followed by tumor resection. TAE is an effective procedure in symptomatic hemangiomas, and should be considered in such high risk patients prior to surgery.

Diagnosis and treatment of benign focal liver lesions

BACKGROUND

With the routine use of improved imaging modalities, more benign liver lesions are detected nowadays. An accurate characterization of these incidental lesions may be a challenge, and frequently a biopsy or even unnecessary surgery is being performed. However, these interventions are not always to the benefit of the patient.

METHODS

A Medline search of studies relevant to imaging diagnosis and management of the most common, benign, solid and non-solid liver lesions was undertaken. References from identified articles were handsearched for further relevant articles. The authors' own experiences with benign liver lesions were also taken into account.

RESULTS

Although atypical imaging features are the exception rather than the rule, it is sometimes difficult to differentiate between benign and malignant lesions, and knowledge of their imaging features is essential if unnecessary work-up is to be avoided. The use of tissue-specific contrast media, which has clearly improved the accuracy of highly advanced radiological techniques, may be helpful during differential diagnosis. Once having established an accurate diagnosis, surgery is rarely indicated for a benign liver lesion because of its asymptomatic nature.

CONCLUSION

Knowledge of imaging features and a clear management strategy during diagnostic work-up, emphasizing the indications for surgery, will minimize the number of patients who have to undergo biopsy or unnecessary surgery.

Review article: the evaluation of solitary liver masses

BACKGROUND

The increasing use of imaging modalities has led to the detection of more liver masses. The differential diagnosis of a focal liver mass includes a host of benign as well as malignant conditions.

AIM

To provide a comprehensive review on the commonly encountered liver masses, and to help guide an approach to their evaluation and management.

METHODS

Pertinent literature that was identified through PubMed search and senior author's experience formed the basis of this review.

RESULTS

While most incidentally noted liver masses are benign, it may be difficult to differentiate them from those that are malignant. Furthermore, some benign lesions have malignant potential. Certain lesions such as focal nodular hyperplasia, haemangiomas and focal steatosis are often distinctly diagnosed by an imaging modality alone. The less frequently encountered hepatic adenomas are diagnosed radiologically in those with the appropriate clinical background and the absence of radiological features to suggest haemangioma or focal nodular hyperplasia.

CONCLUSIONS

A reasonable approach to the diagnosis, follow-up and management of liver masses is based on a rudimentary knowledge of their presentation, associated clinical and laboratory features, natural history and available treatment options. Most often, the so called 'incidentalomas' are benign and require patient reassurance.

Indicações e resultados da ressecção cirúrgica do hemangioma hepático: indications and results

OBJETIVO: Apresentar os resultados do tratamento cirúrgico em pacientes portadores de hemangioma hepático. MÉTODO: Foram estudados 20 pacientes portadores de hemangioma hepático cavernoso, operados entre fevereiro de 1991 e fevereiro de 2005. A idade dos pacientes variou de 16 a 72 anos (média de 42 anos) com predomínio do sexo feminino (80%), sendo que 85% deles eram sintomáticos. Todos os pacientes foram submetidos à ultrassonografia abdominal (US) e à tomografia computadorizada contrastada (TC). Utilizou-se incisão abdominal subcostal bilateral associada à incisão mediana. RESULTADOS: Durante o período de seguimento clínico não se constataram recidiva de sintomas ou de hemangioma. A morbidade pós-operatória representada por infecção da ferida cirúrgica foi observada em um (5%) paciente, insuficiência hepática leve em 40% e moderada em 15% que apresentaram evolução clínica satisfatória com o tratamento clínico instituido; em um (5%) verificou-se a ocorrência de bilioma que necessitou drenagem por punção abdominal. A maioria dos pacientes retornou as atividades habituais até o 3º. mês de pós-operatório. Não ocorreram óbitos nesta série de pacientes. CONCLUSÃO: A ressecção cirúrgica do hemangioma hepático, gigante ou sintomático, é opção de tratamento segura e eficaz, sendo que a extensão da ressecção varia de acordo com a localização e tamanho.

[Incidentalomas of the liver and gallbladder. Evaluation and therapeutic procedure]

The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of "symptomatic" incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former "absolute" requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.

Surgical treatment of hepatic haemangiomas: a 15-year experience

BACKGROUND

Hepatic haemangiomas are congenital vascular malformations. They are the most common benign tumours of the liver and are often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy and rapid growth are the mandatory surgical indications. We present our experience over the last 15 years with the surgical management of 15 liver haemangiomas to clarify the safety and effectiveness of this treatment.

METHODS

There were 15 patients with hepatic haemangiomas who were surgically treated from 1990 to 2004. Indications for the operation were spontaneous or traumatic rupture, consumption coagulopathy, rapid growth, abdominal pain and uncertain diagnosis. Four of these lesions were located on the left lobe, nine on the right lobe; one lesion was located on the left and the right lobes and one on segments VII and VIII. Methods for diagnosis included ultrasonography, computed tomography scan, magnetic resonance imaging and selective hepatic arteriography or combinations of more than one technique.

RESULTS

The procedures included five right-extended lobectomies, five right lobectomies, one left-extended lobectomy, two left lobectomies and two segmental resections. There was no death. The postoperative morbidity was minimal and was mainly correlated to two subdiaphragmatic collections, one intra-abdominal collection and one wound infection. The postoperative hospital stay was 12.7 days (range, 10-19 days). During the follow-up period, there was no recurrence.

CONCLUSION

The resection of the hepatic haemangioma is safe. The indications for resection, however, should be carefully analysed before embarking on such a major operation.

Laparoscopic treatment of liver hemangioma

Cavernous hemangioma is the most common benign liver tumor. When it becomes symptomatic, enucleation is considered the treatment of choice because of its lower morbidity compared with liver resection. Therefore, although there have been many series of laparoscopic liver resection, only a few cases of laparoscopic enucleation of liver hemangiomas have been reported. We report the case of a 36-year-old woman with a symptomatic 4-cm liver hemangioma of the left lobe who underwent laparoscopic enucleation, with complete relief of the symptoms at the 3-month follow-up. The operating time was 90 minutes. Neither liver mobilization nor ligament division was necessary. The dissection was carried out with minimal blood loss. The postoperative period was uneventful, and the patient was discharged on postoperative day 4. Laparoscopic enucleation is easy to perform in suitable lesions, and its advantage with respect to liver resection is the preservation of healthy parenchyma and liver ligaments. No outflow occlusion is needed, and the intraoperative bleeding is easily controlled. Technical aspects of laparoscopic enucleation are described and a review of the literature is also provided.

Giant hemangiomas of the liver: surgical strategies and technical aspects

The incidence of hemangiomas is 2-7% in the general population. We evaluated more than 300 patients with hepatic hemangiomas. Surgical removal of hepatic hemangiomas was performed in 48 cases due to uncertain diagnosis (2 cases), intractable symptoms (26 cases), size increase (18 cases), and liver failure in 2 cases that were treated by hepatic transplantation. In all, 26 patients underwent enucleation of hemangiomas or segmentectomies, while the remaining 20 patients underwent right lobectomies or left lateral segmentectomies. Blood transfusions were required in four cases (including two liver transplants); mean post-resection hospital stay was 6.3 days. We observed no perioperative mortality and only two cases of major morbidity (bile leaks not requiring reoperation). Our experience confirms that, after adequate patient selection, surgical treatment of hepatic hemangiomas is a very effective therapeutic choice with no mortality and low morbidity.

[Benign solid liver tumors]

Benign solid liver tumors are a heterogeneous group of lesions (adenoma, focal nodular hyperplasia, hemangioma, etc.) with highly varied epidemiological characteristics. Advances in diagnostic methods have improved preoperative diagnosis. Magnetic resonance imaging has become the key test, but there is still a percentage of cases in which definitive preoperative diagnosis is not feasible. The most frequent symptom is abdominal pain, although patients are frequently asymptomatic. Surgery is indicated when diagnosis is uncertain or there are complications (rupture, hemorrhage, etc.). Because of the risk of malignant transformation, adenomas should always be resected. Morbidity and mortality after resection of these tumors is very low since excision is limited, performed in young people without concomitant disease, and in healthy liver.

Adequate symptom relief justifies hepatic resection for benign disease

Background

The purpose of this study was to evaluate the long-term results of partial liver resection for benign liver lesions.

Methods

All patients operated on for benign liver lesions from 1991 to 2002 were included. Information was retrieved from medical records, the hospital registration system and by a telephonic questionnaire.

Results

Twenty-eight patients with a median age of 41 years (17–71) were operated on (M/F ratio 5/23). The diagnosis was haemangioma in 8 patients, FNH in 6, HCA in 13 and angiomyolipoma in 1. Eight patients were known to have relevant co-morbidity. Median operating time was 207 minutes (45–360). The morbidity rate was 25% and no postoperative mortality was observed. Twenty-two patients (79%) had symptoms (mainly abdominal pain) prior to surgery. Twenty-five patients were reached for a questionnaire. The median follow up was 55 months (4–150). In 89% of patients preoperative symptoms had decreased or disappeared after surgery. Four patients developed late complications.

Conclusion

Long-term follow up after liver surgery for benign liver lesions shows considerable symptom relief and patient satisfaction. In addition to a correct indication these results justify major surgery with associated morbidity and mortality.

Hepatic resection for benign non-cystic liver lesions

BACKGROUND

Hepatic resection is indicated for a variety of benign conditions because of persistent symptoms, uncertainty regarding the diagnosis or the risk of malignant transformation. The aim of this study was to assess the indications for and outcome of hepatic resection for benign non-cystic liver lesions in a specialist hepatobiliary unit.

PATIENTS AND METHODS

All patients who had undergone hepatic resection for benign non-cystic hepatic lesions between 1989 and 2001 were identified from a prospective database for analysis.

RESULTS

A total of 49 patients (40 women, 9 men) with a mean age of 43 years (range 21-75 years) underwent resection of non-cystic benign lesions. Indications for operation included suspected liver cell adenoma (n=11), suspicion of malignancy (11), persistent symptoms attributable to the lesion (20) or chronic sepsis (7). The final diagnosis was focal nodular hyperplasia (n=12), haemangioma (12), adenoma (8), sclerosing cholangitis (5), inflammatory pseudotumour (4), intrahepatic cholelithiasis (3), chronic hepatic abscess (3), benign biliary fibrosis (I) and leiomyoma (I). Major anatomical hepatic resections were performed in 44 patients, and 5 patients underwent a segmentectomy or minor atypical resection. Median operating time was 215 min (range 45-450 min) and median blood loss was 875 ml (range 200-4000 ml). Ten patients (20%) required a median blood transfusion of 2 units (range 2-8 units). The median postoperative stay was 10 days (range 4-33 days). There were no deaths, but complications occurred in 15 patients (27%).

CONCLUSIONS

Hepatic resection can be safely recommended for selected patients with a variety of benign non-cystic hepatic lesions. A small group of patients undergo resection as a result of inability to rule out a malignant process, but the large majority will be operated on because of either their malignant potential or related symptoms.

Diagnosis, management, and outcomes of 115 patients with hepatic hemangioma

BACKGROUND

Hepatic hemangiomas are congenital vascular malformations and are the most common benign hepatic tumors. Because the use of cross-sectional imaging has increased, benign hepatic tumors, especially hemangiomas, are encountered more frequently, so clinicians should be familiar with the most appropriate diagnostic tests, management, and outcomes of patients with hepatic hemangioma.

STUDY DESIGN

All patients with a primary diagnosis of hepatic hemangioma referred for surgical evaluation at our institution between January 1992 and December 2000 were identified from a prospective database. Demographics, presentation, tumor characteristics, diagnostic studies, surgical procedures, and outcomes were analyzed. RESULTS; Of 115 patients in the study, nearly half were asymptomatic. In symptomatic patients, abdominal pain or discomfort was the most common presenting symptom. At our institution, the diagnosis of hemangioma was established by ultrasonographic studies in 57% of patients tested, by CT scan in 73%, and by MRI in 84%. In patients with large tumors considered for resection, direct angiography or, more recently, CT angiography, confirmed the diagnosis in 27 of 29 patients (93%). Enucleation was performed in 31 (60%) of the 52 patients who underwent surgical resection; 63 patients were observed. Postoperative complications occurred in 13 patients (25%), and there were no perioperative deaths. Of the patients with symptoms before resection, 96% had resolution of symptoms after operation.

CONCLUSIONS

Hepatic hemangioma can be diagnosed in most patients using noninvasive studies, particularly MRI. Hepatic hemangiomas can be removed safely if patients become symptomatic or when malignancy cannot be excluded. CT angiography can be a valuable preoperative study in patients with large tumors, and enucleation is the procedure of choice. In asymptomatic or minimally symptomatic patients, hepatic hemangiomas usually have a benign course and can be observed.

Size of lesion is not a criterion for resection during management of giant liver haemangioma

BACKGROUND

The unknown natural history and risk of complications of large haemangiomas may pose therapeutic dilemmas. The authors describe their experience with the management of giant haemangiomas.

METHODS

Patients with a giant haemangioma were identified by a survey of the hospital database. Forty-nine patients with a haemangioma of at least 4 cm in diameter presented between January 1990 and December 2000. Medical records were analysed retrospectively.

RESULTS

Eleven patients had surgical treatment and 38 were managed conservatively. The median diameter of the tumours was 8.0 cm in surgically treated patients and 6.0 cm in the group managed by observation. Surgery-related morbidity occurred in three patients, and abdominal complaints persisted in three of ten patients with a symptomatic lesion. During a median follow-up of 52 months, 12 non-operated patients had mild abdominal complaints, considered to be unrelated to the lesion. In these patients symptoms either diminished or became minimal during follow-up. Complications did not occur.

CONCLUSION

Observation of giant haemangiomas can be performed safely. The authors advocate resection of cavernous liver haemangiomas only in patients with persistent severe symptoms.

Hemangioma of the spleen: presentation, diagnosis, and management

Splenic hemangioma is a rare disorder but remains the most common benign neoplasm of the spleen. It often has a latent clinical picture; however, spontaneous rupture has been reported to occur in as many as 25% of this patient population.1 Treatment most often consists of splenectomy. This report reviews an 8-year experience with splenic hemangioma at Mayo Clinic. Thirty-two patients were identified with SH during the 8-year study period. The average age was 63 years (range 23 to 94 years) with 17 women and 15 men. Six patients presented with symptoms potentially related to the SH. The remainder (80%) were asymptomatic, and the SH was discovered incidentally during evaluation for other disorders. A mass or palpable spleen was appreciated in only four patients (12.5%). SHs ranged in size from 0.3 to 7 cm maximum diameter. A diagnosis of SH was made in 11 patients based on the findings of a splenic mass on computed tomography or ultrasound. Each of these SHs was < or =4 cm. Three of the 11 patients had multiple SHs. All 11 patients were managed successfully with observation. All but one of the patients remains asymptomatic, and no complications have developed during follow-up (range 0.6 to 7 years, mean 2.9 years). The diagnosis of splenic hemangioma was made at the time of surgery in the remaining 21 patients (65%). Splenectomy was performed for suspicion of primary or secondary splenic pathology. There were no instances of spontaneous rupture of the SH. Small splenic lesions, which meet the radiologic criteria for hemangiomas, may be safely observed.