466 Resection or Enucleation for Extremely Giant Hepatic Haemangiomata? A Case Report and Review of The Literature

Background

Cavernous hepatic haemangiomas are benign liver tumours and although common when small, giant haemangiomas (usually accepted as being greater than 10cm) are infrequent. Treatment is indicated in patients who are symptomatic or if diagnosis is unclear, although with giant haemangiomas, many support expectant management of asymptomatic lesions due to the risk of major complications. Traditionally hepatic resection has been the primary treatment option for these lesions, but a variety of other techniques, including enucleation, have been described as safe and effective alternatives. There remains equipoise in respect of the best management of giant haemangiomas above 10cm. Cases of such size are rare and so there is a paucity of data available.

Case presentation

We present a case of a 65-year-old male who underwent successful anatomical liver resection for a 5kg giant cavernous haemangioma of 26cm diameter following its incidental identification during an ultrasound scan. We also discuss and compare the role of resection and enucleation for the treatment of haemangiomata greater than 20cm in diameter.

Conclusions

This case demonstrates successful resection of an unusually giant haemangioma which, in contrast to the majority of literature, provides a valuable addition to the limited evidence base for management of this condition by anatomical resection.

Combined microneurosurgical and thoracoscopic removal of neurogenic dumbbell tumors

The resection of posterior mediastinal dumbbell tumors has until now required laminectomy and some form of open access to the thoracic cavity. Over a 1-year period, a novel surgical approach combining posterior microneurosurgical and anterior video-assisted thoracoscopy techniques was used in 4 patients. In 3 patients, the tumor was removed successfully with minimal postoperative discomfort and rapid recovery. In the fourth patient, limited thoracotomy became necessary to control bleeding. This new approach, which combines modern-day neurosurgical and general thoracic surgical techniques, appears safe and could become the preferred method for removing most benign posterior mediastinal dumbbell tumors.

Open tube thoracoscopy: does it have a role in modern thoracic surgery?

To determine the role of open tube thoracoscopy in the diagnosis and management of thoracic diseases, a retrospective review of 48 patients was conducted. A mediastinoscope was used for open tube thoracoscopy. Eleven patients underwent diagnostic thoracoscopy, and 4 patients had thoracoscopy for cancer staging. All 11 diagnostic procedures yielded a diagnosis, and thoracic malignancies were staged accurately in all patients. Thirty-three patients underwent therapeutic thoracoscopy. Twelve therapeutic thoracoscopies were done for pneumothorax, 9 for loculated parapneumonic effusion or empyema, 4 for malignant effusions, 2 for traumatic hemothorax, 2 for wedge resection of peripheral lung cancers, and 4 for other indications. All but 1 therapeutic procedure were successful. Three patients experienced complications specific to thoracoscopy (empyema 1, prolonged air leak 1, chest tube site leakage 1). There were 5 deaths, but none were related to thoracoscopy. Open tube thoracoscopy is very effective for evacuation of loculated pleural fluid, pus, or blood, and it appears to have advantages over video thoracoscopy in these settings. Although open tube thoracoscopy is satisfactory for other simple pleural procedures and wedge resections of lung are possible, video thoracoscopic techniques are now preferred for these indications.

Cystic hydatid lung disease in northwest Canada

OBJECTIVE

To determine the optimal treatment of sylvatic cystic hydatid lung disease.

DESIGN

Retrospective case study.

SETTING

Five Edmonton hospitals serving northern Alberta and parts of the Northwest Territories.

PATIENTS

Fourteen patients with cystic (Echinococcus granulosus) hydatid lung disease.

INTERVENTIONS

Cyst enucleation, wedge resection and pulmonary lobectomy.

MAIN OUTCOME MEASURES

Eradication of pulmonary hydatid disease and complications of treatment.

RESULTS

Mean patient age was 32 years. Eight patients were symptomatic. Liver cysts were present in three patients. One of the three patients managed by observation required surgery for an expanding cyst. Surgery (13 procedures in 12 patients) was successful in eradicating pulmonary hydatid disease: 8 cyst enucleations, 3 wedge resections and 2 lobectomies were done. There was only one major postoperative complication (pneumatocele requiring repeat surgery). Intraoperative cyst rupture occurred in five cases, but anaphylaxis or seeding did not result. There were no bronchopleural fistulae.

CONCLUSIONS

Sylvatic cystic hydatid lung disease is more benign than pastoral hydatid disease. Patients with asymptomatic cysts should be managed by observation. Surgery, consisting of endocyst enucleation or wedge resection, is indicated for symptomatic, enlarging or infected cysts.

Turnover of hyaluronan in the rabbit pleural space

Hyaluronan influences lung fluid balance. The clearance of lung hyaluronan by way of the pulmonary lymphatics and the pleural space is increased when fluid flux into the interstitium is increased. The purpose of this study was to determine the rate at which hyaluronan is removed from the pleural space. We injected hyaluronan, labeled with tritium in the acetyl group, into the pleural space of six rabbits. The appearance of [3H]H2O in serum was measured over time to calculate the turnover rate of hyaluronan. We found that the half-lives ranged between 8 and 15 h and were positively related to the amount of hyaluronan injected. At the end of the experiment, the contralateral pleural space was irrigated to determine the amount of pleural space hyaluronan, which was 0.3 micrograms/kg body wt.