Combining On-Table Embolization With Immediate Resection To Safely Excise Giant Hepatic Hemangiomas

Abstract

Presenter: Ajay Maker MD | University of Illinois at Chicago Background: The management of symptomatic giant hepatic hemangiomas varies in the literature. Multiple approaches have been described, and surgical resection is often used as a last resort due to the risk of major hemorrhage. One of the major difficulties in approaching massive hemangiomas is safe control of the substantial arterial inflow since the porta, feeding vessels, and outflow may be inaccessible to due to tumor size and immobility. Preoperative arterial embolization is an option, however, many patients will experience severe pain, fever, transaminitis, acidosis, recanalization, and collateral inflow that limit its utility. Furthermore, patients will require post-procedure inpatient observation that extends hospital costs and length of stay, and there is no consensus on the appropriate time interval between procedures. We endeavored to approach this clinical situation with on-table angiogram and embolization followed by immediate resection in a hybrid operating room. Methods: Under general anesthesia in a hybrid operating room with on-table angiogram capabilities, the patient underwent a celiac and SMA angiogram followed by hemangioma inflow embolization and immediate hepatic resection. Results: Two large branches of the left hepatic artery were feeding a >20cm hemangioma. The mass replaced the left hepatic lobe and displaced the middle hepatic vein. After coil embolization of the arterial inflow to the tumor, the femoral sheath was removed and the patient was immediately prepped and draped for hepatic resection on the same table. Tumor size was substantially reduced and the hemangioma was compressible, allowing mobilization of the tumor and access to the porta hepatis. Left hepatic arterial and portal inflow were ligated, outflow was controlled, and the parenchyma was divided combining formal resection planes with enucleation of the tumor off the middle hepatic vein at its origin. Blood loss was minimal ( < 150mL) and the patient was discharged home on no pain medicine and free of preoperative symptoms on post-operative day 4. Conclusion: Combining on-table embolization with immediate resection avoids post-procedure pain and many of the pitfalls of preoperative embolization. It is an efficient use of hospital resources and reduces an intervening hospital admission. We have found it to be a preferred approach to enhance the safety and feasibility of resection for massive hepatic hemangiomas with minimal intraoperative blood loss and reduced risk.