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Giant hemangiomas of the liver: surgical strategies and technical aspects
HPB, 2006; 8: 200 201
Giant hemangiomas of the liver: surgical strategies and technical aspects
P. BERLOCO, P. BRUZZONE, G. MENNINI, F. DELLA PIETRA, M. IAPPELLI, G. NOVELLI & M. ROSSI Division of General Surgery and Transplantation, Department of General Surgery, Surgical Specialties and Organ Transplantation ‘‘Paride Stefanini’’, Rome, Italy
Abstract 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.
Key Words: Hemangioma, hepatectomy, Kasabach-Merritt, Budd-Chiari
Introduction The incidence of hemangiomas is 27% in the general population. Hemangiomas are the most frequent benign hepatic tumors 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 larger than 410 cm, they are termed ‘giant’ hemangiomas [1].
with the TissueLink Floating BallTM device. The Pringle maneuver was never required. We observed no perioperative mortality and only two cases of major morbidity (bile leaks not requiring reoperation). All patients (including the recipients of liver transplantation) were completely cured of their symptoms and remain alive and in good health, without longterm complications, after a follow-up period ranging from 2 months to 8 years.
Patients and methods 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 hepatectomies or left lateral segmentectomies [2]. Results Blood transfusions were required in four cases (including two liver transplants); mean post-resection hospital stay was 6.3 days. We routinely used a CUSA Cavitron Ultrasonic Surgical Aspirator (CUSA System 200; Valleylab Inc., Boulder, CO, USA) together
Discussion Surgical treatment of hepatic hemangiomas is required in case of complications such as platelet sequestration (Kasabach-Merritt syndrome) [3], Budd-Chiari syndrome, and rupture. We agree with Cameron [4] that surgical treatment of hemangiomas is indicated in case of severe, intractable symptoms, absence of another etiology for symptoms, diagnostic uncertainty, and intraparenchymal or intraperitoneal hemorrhage. The influence of estrogens and hormone replacement therapy on hemangiomas is still under debate; in pregnancy a conservative approach with serial ultrasound (US) monitoring is recommended. Hemangiomas in newborns and infants grow rapidly and can cause coagulopathy or high-output cardiac failure. Therapy may require corticosteroids,
Correspondence: Paolo Bruzzone, MD, Via Santa Maria Goretti 38/10, 00199 Rome, Italy. Tel: /39 338 5369744. E-mail: [email protected]
accepted 22 December 2005 ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820500539610
Giant hemangiomas of the liver hepatic arterial embolization, a-interferon, cyclophosphamide, external beam irradiation, and surgical excision in case of rupture or failure of conservative therapy. The differential diagnosis between hemangioma and hemangioendothelioma may be difficult, particularly in children. Although we agree again with Cameron [4] that fine needle cytology and core needle biopsy (18 gauge), either percutaneously or laparoscopically performed, is associated with a low risk (0.03 0.04%) of hemorrhage and may be a useful diagnostic tools, we usually avoid it. Complications or diagnostic doubts are uncommon indications for surgical treatment, while other intraabdominal diseases should be ruled out in symptomatic patients. In fact, Farges et al. found additional intra-abdominal diseasesin 42% of 163 patients with symptomatic hepatic hemangiomas [5], while, according to Pietrabissa et al., 50% of patients remained symptomatic after surgery [6]. Our experience confirms that, after adequate patient selection, surgical treatment of hepatic heman-
201
giomas is a very effective therapeutic choice with no mortality and low morbidity [7,8].
References [1] Adams RB. Liver hemangioma In: Cameron JL, ed. Current surgical therapy, 8th edn. [2] IHPBA Brisbane 2000 Terminology of Liver Anatomy & Resections. HPB 2000;2:333 9. [3] Ferraz AA, Sette MJ, Maia M, Lopes EP, Godoy EP, Petribu AT, et al.Liver transplant for the treatment of giant hepatic hemangioma Liver Transpl 2004;10. [4] Cameron JL, ed. Current surgical therapy, 8th edn. Philadelphia: Elsevier Mosby, 2004. [5] Farges O, Daradkeh S, Bismuth H.Cavernous hemangiomas of the liver: are there any indications for resection? World J Surg 1995;19. [6] Pietrabissa A, Giulianotti P, Campatelli A, Di Candio G, Farina F, Signori S, et al.Management and follow up of 78 giant hemangiomas of the liver Br J Surg 1996;83. [7] Liu CL, Fan ST, Lo CM, Chan SC, Tso WK, Ng IO, et al.Hepatic resection for incidentaloma J Gastrointest Surg 2004;8. [8] Charny CK, Jarnagin WR, Schwartz LH, Frommeyer HS, DeMatteo RP, Fong Y, et al.Management of 155 patients with benign liver tumours Br J Surg 2001;88; 2001:808 13. /
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Giant hemangiomas of the liver: surgical strategies and technical aspects
P. BERLOCO, P. BRUZZONE, G. MENNINI, F. DELLA PIETRA, M. IAPPELLI, G. NOVELLI & M. ROSSI Division of General Surgery and Transplantation, Department of General Surgery, Surgical Specialties and Organ Transplantation ‘‘Paride Stefanini’’, Rome, Italy
Abstract 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.
Key Words: Hemangioma, hepatectomy, Kasabach-Merritt, Budd-Chiari
Introduction The incidence of hemangiomas is 27% in the general population. Hemangiomas are the most frequent benign hepatic tumors 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 larger than 410 cm, they are termed ‘giant’ hemangiomas [1].
with the TissueLink Floating BallTM device. The Pringle maneuver was never required. We observed no perioperative mortality and only two cases of major morbidity (bile leaks not requiring reoperation). All patients (including the recipients of liver transplantation) were completely cured of their symptoms and remain alive and in good health, without longterm complications, after a follow-up period ranging from 2 months to 8 years.
Patients and methods 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 hepatectomies or left lateral segmentectomies [2]. Results Blood transfusions were required in four cases (including two liver transplants); mean post-resection hospital stay was 6.3 days. We routinely used a CUSA Cavitron Ultrasonic Surgical Aspirator (CUSA System 200; Valleylab Inc., Boulder, CO, USA) together
Discussion Surgical treatment of hepatic hemangiomas is required in case of complications such as platelet sequestration (Kasabach-Merritt syndrome) [3], Budd-Chiari syndrome, and rupture. We agree with Cameron [4] that surgical treatment of hemangiomas is indicated in case of severe, intractable symptoms, absence of another etiology for symptoms, diagnostic uncertainty, and intraparenchymal or intraperitoneal hemorrhage. The influence of estrogens and hormone replacement therapy on hemangiomas is still under debate; in pregnancy a conservative approach with serial ultrasound (US) monitoring is recommended. Hemangiomas in newborns and infants grow rapidly and can cause coagulopathy or high-output cardiac failure. Therapy may require corticosteroids,
Correspondence: Paolo Bruzzone, MD, Via Santa Maria Goretti 38/10, 00199 Rome, Italy. Tel: /39 338 5369744. E-mail: [email protected]
accepted 22 December 2005 ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820500539610
Giant hemangiomas of the liver hepatic arterial embolization, a-interferon, cyclophosphamide, external beam irradiation, and surgical excision in case of rupture or failure of conservative therapy. The differential diagnosis between hemangioma and hemangioendothelioma may be difficult, particularly in children. Although we agree again with Cameron [4] that fine needle cytology and core needle biopsy (18 gauge), either percutaneously or laparoscopically performed, is associated with a low risk (0.03 0.04%) of hemorrhage and may be a useful diagnostic tools, we usually avoid it. Complications or diagnostic doubts are uncommon indications for surgical treatment, while other intraabdominal diseases should be ruled out in symptomatic patients. In fact, Farges et al. found additional intra-abdominal diseasesin 42% of 163 patients with symptomatic hepatic hemangiomas [5], while, according to Pietrabissa et al., 50% of patients remained symptomatic after surgery [6]. Our experience confirms that, after adequate patient selection, surgical treatment of hepatic heman-
201
giomas is a very effective therapeutic choice with no mortality and low morbidity [7,8].
References [1] Adams RB. Liver hemangioma In: Cameron JL, ed. Current surgical therapy, 8th edn. [2] IHPBA Brisbane 2000 Terminology of Liver Anatomy & Resections. HPB 2000;2:333 9. [3] Ferraz AA, Sette MJ, Maia M, Lopes EP, Godoy EP, Petribu AT, et al.Liver transplant for the treatment of giant hepatic hemangioma Liver Transpl 2004;10. [4] Cameron JL, ed. Current surgical therapy, 8th edn. Philadelphia: Elsevier Mosby, 2004. [5] Farges O, Daradkeh S, Bismuth H.Cavernous hemangiomas of the liver: are there any indications for resection? World J Surg 1995;19. [6] Pietrabissa A, Giulianotti P, Campatelli A, Di Candio G, Farina F, Signori S, et al.Management and follow up of 78 giant hemangiomas of the liver Br J Surg 1996;83. [7] Liu CL, Fan ST, Lo CM, Chan SC, Tso WK, Ng IO, et al.Hepatic resection for incidentaloma J Gastrointest Surg 2004;8. [8] Charny CK, Jarnagin WR, Schwartz LH, Frommeyer HS, DeMatteo RP, Fong Y, et al.Management of 155 patients with benign liver tumours Br J Surg 2001;88; 2001:808 13. /
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