Laparoscopic right hepatectomy for giant hepatic hemangioma with endoscopic nasobiliary drainage-guided biliary confirmation.

Surgical management of giant hepatic hemangiomas : complications and review of the literature

Ischemic cholangiopathy

Giant hepatic hemangioma is a benign liver condition that may be treated using surgery. We studied the digital subtraction angiographic (DSA) characteristics of giant hepatic hemangioma, and the effectiveness of transcatheter arterial embolization (TAE) alone for its treatment. This was a retrospective study of 27 patients diagnosed with giant hepatic hemangioma and treated with TAE alone (using lipiodol mixed with pingyangmycin) at the Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, between January 2010 and March 2013. The feeding arteries were identified using DSA. All patients were followed up for between three weeks and 12 months. Changes in tumor diameter and symptoms were observed. The 27 patients included had giant hepatic hemangiomas ranging from 5.3 to 24.5 cm (mean, 11.24±5.08 cm) in the right (n = 13), left (n = 1) or both (n = 13) lobes. Preoperative hepatic angiography showed multiple abnormal vascular lakes in the early phase, known as the “early leaving but late returning, hanging nut on a twig” sign. On the day after TAE, hepatic transaminase levels were increased (ALT: 22.69±17.95 to 94.88±210.32 U/L; ALT: 24.00±12.37 to 99.70±211.54 U/L; both P<0.05), but not total bilirubin. Six patients complained of abdominal pain, and 12 experienced transient fever. In the months after TAE, tumor size decreased (baseline: 11.24±5.08; 3 months: 8.95±4.33; 6 months: 7.60±3.90 cm; P<0.05), and the patients’ condition improved. These results indicated that TAE was effective and safe for treating giant hepatic hemangioma. TAE may be a useful alternative to surgery for the treatment of hepatic hemangioma.

Hepatic hemangiomas are the most common benign tumor of the liver. Most hepatic hemangiomas remain asymptomatic and require no treatment. Giant hepatic hemangiomas with established complications, diagnostic uncertainty and incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. We present a case of a giant hemangioma with intestinal obstruction following transcatheter arterial embolization, by which the volume of the hemangioma was significantly reduced, and it was completely resected by a left hepatectomy. A 21-year-old Asian man visited our hospital for left upper quadrant pain. Examinations at the first visit revealed a left liver hemangioma occupying the abdominal cavity, with a maximum diameter of 31.5 cm. Embolization of the left hepatic artery was performed and confirmed a decrease in its size. However, the patient was readmitted to our hospital one month after embolization for intestinal obstruction. A left hepatectomy was completed through a herringbone incision, and safely removed a giant hemangioma of 26.5 cm × 19.5 cm × 12.0 cm in size and 3690 g in weight. Pre-operative arterial embolization is effective for reducing tumor size, but a close follow-up to decide the time for hepatectomy is important.

The use of pure laparoscopic donor hepatectomy has been increasing, with various advantages reported. However, the Glissonean approach has not been adopted despite its usefulness. The aim of this study was to introduce the Glissonean pedicle approach for laparoscopic living donor hepatectomy. We retrospectively reviewed data from 11 patients who underwent pure laparoscopic donor hepatectomy for adult living donor liver transplantation. In this novel operative procedure, after mobilization of the liver, the right or left Glissonean pedicle was encircled, and then the liver parenchymal transection was completed. Next, the right or left hepatic artery, portal vein, and hepatic duct were dissected out. The right or left hepatic duct was divided under intraoperative cholangiography guidance using indocyanine green fluorescence, and the hepatic artery and the portal vein were cut. Finally, the hepatic vein was divided using the laparoscopic stapler, and the graft liver was procured via a suprapubic incision. The overall median surgical time was 387min (range 280-563min), and the volume of blood loss was 75mL (21-1228mL). The warm ischemic time was 5min (2-10min). A conversion to open procedure was occurred in 1 patient. A complication, a grade IIIa bile leakage according to the Clavien-Dindo classification, was noted in 1 patient. This is the first report of the Glissonean pedicle approach for pure laparoscopic donor hepatectomy; our results demonstrate the safety and feasibility of this technique.

BackgroundThe surgical indications for liver hemangioma remain unclear.MethodsData 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.ResultsMost (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.ConclusionThe 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.

Objective: To compare the interventional curative effect of liver hemangioma patients with different types of blood supply treated by transcatheter arterial embolization (TAE) and portal vein interventional therapy. Methods: From January 2008 to December 2013, 324 patients definitely diagnosed as liver hemangioma were retrospectively analyzed. The patients were classified by blood supply as follows: hypervascular (128 cases) , moderate (104 cases) , hypovascular (90 cases) and portal vein type (2 cases) . The first three groups were treated by TAE with the injection of pingyangmycin-lipiodol emulsion and gelatin sponge, while the patients in last group were treated by portal vein embolization. The drug dosage of different types of hemangioma during operation, change of tumor size and curative effect after different follow-up periods were comparatively analyzed. Results: The two portal vein cases were not involved in the statistical analysis. The dose of pingyangmycin-lipiodol emulsion was the highest in hypervascular type and moderate type was the following and the least was in hypovascular type. In the follow-up of 3 to 6 months, the changes in tumor size of each group were compared with one another. The reduction of tumor size was the most in hypervascular type, moderate type was following and the least is in hypovascular type. The tumor reduction of hypervascular type had no difference with that of the moderate type in the follow-ups of 6 to 12 months, 1 to 2 years and 2 to 3 years. However, the hypovascular type, with the least tumor reduction, had obvious difference from the first two groups in all follow-ups. The effective rates of hyper-and moderate blood supply types were up to 100% and were higher than those of hypovascular group 2 or 3 years after the treatment, with significant difference. Conclusions: The curative effect of TAE for treatment of liver hemangioma has a obvious relationship with blood supply type that the hypervascular and moderate types were better than hypovascular type. Key words: Liver hemangioma; Interventional treatment; Embolization; Blood supply type

Laparoscopic major hepatectomy remains a challenging procedure [1, 2]. In the case of giant tumors in the right liver, conventional approach (complete mobilization of the right liver before parenchymal transection) could be dangerous during mobilization because of large volume and weight [3, 4]. We present the case of a pure laparoscopic right hepatectomy for a giant hemangioma using an anterior approach. We achieved the informed consent with this patient and approved by the Ethics Committee of the Asan Medical Center. Giant hemangioma (13×11×14cm) was located in right liver. After glissonean approach [5], Pringle maneuver was performed during the hepatic parenchymal transection. For the transection, the Cavitron Ultrasonic Surgical Aspirator was used. Small hepatic vein branches along the middle hepatic vein and small glissonean pedicles were sealed and divided with a THUNDERBEATTM (Olympus), which is the device with integration of both bipolar and ultrasonic energies delivered simultaneously. iDriveTM Ultra Powered Stapling device (Medtronic) was used for division of right glissonean pedicle and large hepatic veins. Hemangioma was removed through the lower abdominal transverse incision using the endo-bag. This technique has the advantage of avoiding excessive bleeding caused by avulsion of the hepatic vein and caval branches, iatrogenic tumor rupture [3]. By means of the anterior approach, pure laparoscopic right hepatectomy was performed successfully without intraoperative complications and transfusions. The operation time was 202min, and the estimated blood loss was less than 150ml. On postoperative day 3, computed tomographic scan showed no pathological findings. The patient was discharged on postoperative day 5 without complications. Laparoscopic approach has good results because of the view with magnification enabling meticulous hemostasis and the small wounds that give patients less pain [6, 7]. The authors recommend that the laparoscopic anterior approach is safe and feasible for right hepatectomy, even for giant tumors.

IntroductionLiver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.Case presentationA 38-year-old Asian man was referred to our hospital with complaints of severe abdominal distension and pancytopenia. Examinations at the first visit revealed a right liver hemangioma occupying the abdominal cavity, protruding into the right diaphragm up to the right thoracic cavity and extending down to the pelvic cavity, with a maximum diameter of 43 cm, complicated with "asymptomatic" Kasabach-Merritt syndrome. Based on the tumor size and the anatomic relationship between the tumor and hepatic vena cava, primary resection seemed difficult and dangerous, leading us to first perform transcatheter arterial embolization to reduce the tumor volume and to ensure the safety of future resection. The tumor volume was significantly decreased by two successive transcatheter arterial embolizations, and a conventional right trisectorectomy was then performed without difficulty to resect the tumor.ConclusionsTo date, there have been several reports of aggressive surgical treatments, including extra-corporeal hepatic resection and liver transplantation, for huge hemangiomas like the present case, but because of its benign nature, every effort should be made to avoid life-threatening surgical stress for patients. Our experience demonstrates that a pre-operative arterial embolization may effectively enable the resection of large hemangiomas.

Purpose: To evaluate the medium and long-term efficacy of superselective transcatheter arterial embolization (TAE) with lipiodol–bleomycin emulsions (LBE) for giant hepatic hemangiomas. Methods: A total of 241 patients who had underwent TAE with LBE for hepatic hemangiomas from January 2010 to December 2016 were retrospectively reviewed. Blood tests were performed 3 and 7 days after TAE and procedural-related complications were recorded. The patients were followed up by enhanced CT or MRI imaging at 6, 12, 36, and 60 months post-TAE, respectively. Technical success of TAE was defined as successful embolization of all identifiable arteries supplying to the hemangiomas. Clinical success was defined as improvement of the abdominal symptoms and indications on the imaging examinations that the hemangiomas had decreased by more than 50% in maximum diameter. Results: TAE was performed successfully in all patients without serious complications. Improvement of the abdominal symptoms was recorded in 102/102 cases (100%). The reduction rate of the tumor maximum diameter with >50% at 6, 12, 36, and 60 months was 88.1% (190/210), 86.7% (170/196), 85.2% (124/142), and 86.5% (45/52), respectively. There was a significant change from pre-TAE to follow-up values in maximum diameter (p < 0.05). Conclusion: TAE with LBE was feasible and effective for giant hepatic hemangiomas. The reductions of the tumor maximum diameter with >50% at medium (≥3 years) and long-term (≥5 years) follow-up were satisfactory, with 85.2% and 86.5%, respectively.

Pure laparoscopy for living donor hepatectomy is gaining popularity due to its advantages. However, despite the long-standing application of laparoscopic donor left lateral sectionectomy, the dissection of the Glisson branch, portal vein, and biliary ducts, particularly those of the caudate lobe, remains insufficiently described. Although the Glissonean approach offers easy standardization for hilar dissection, clear landmarks for parenchymal transection, and reduces postoperative bile leakage, it has not been widely adopted in laparoscopic donor hepatectomy. Here, we introduce a modified Glissonean pedicle approach to address the movement restrictions in laparoscopic surgery. After liver mobilization, the Glisson of Spiegel lobe (G1L) was divided, followed by encircling the left Glissonean pedicle. A tape for the liver hanging maneuver was placed from the right edge of the left Glissonean pedicle, along the Arantius plate, to the left edge of the left hepatic vein. When the parenchymal transection was completed, the left hepatic vein was automatically taped. The left hepatic artery and left portal vein were exposed, and some branches of P1 were divided to lengthen for anastomosis. The left hepatic duct was taped by removing the left hepatic artery and left hepatic vein from the left Glissonean pedicle. The left hepatic duct was divided under intraoperative cholangiography. Next, the left hepatic artery, left portal vein, and left hepatic vein were sequentially divided, and the graft liver was retrieved. Our Glissonean approach can help standardize donor left lateral sectionectomy, minimize the exposure of the left hepatic duct, and clarify B1 branch dissection.

Objective To investigate the clinical efficacies of different treatment methods and evaluate the application value of clinical grading system for liver hemangioma. Methods The clinical data of 514 patients with liver hemangioma who were admitted to the First Affiliated Hospital of Xinjiang Medical University from January 2002 to December 2013 were retrospectively analyzed. The surgical resection, transcatheter arterial embolization (TAE) , radiofrequency ablation (RFA) and follow-up observation were selectively applied to patients. The treatment, operation time, level of ALT at postoperative week 1, duration of postoperative hospital stay and incidence of complications in all patients were observed. The clinical grading system for liver hemangioma was proposed based on the clinical effects and symptoms of patients, diameter, location, diametral growth rate of tumor and related factors. The surgical treatment method was selected for the patients with score≥4, and TAE or follow-up observation was selected for the inoperable patients. The follow-up observation was selected for the patients with score <4 and without other risk factors. The patients with score <4 and other risk factors received the individual follow-up based on conditions of patients, and then underwent surgical resection or TAE or RFA after reevaluation. All the patients were followed up via outpatient examination and telephone interview up to June 2014. Results (1) The results of treatment showed as follows: ①Of 380 patients undergoing complete resection, 195 had symptoms remission and 17 had no obvious symptoms remission. The operation time, level of ALT at postoperative week 1 and duration of postoperative hospital stay were (175 ± 15) minutes, (139 ± 14) U/ L and (11. 5 ± 1. 4) days, respectively. Fifty-eight patients had complications. ②Of 37 patients undergoing TAE, the results of postoperative CT showed that no enhancement was detected in 1 patient and partial enhancement in 36 patients, with the loss of volume of 25% -90%. Thirteen patients had symptoms remission and 10 had no obvious symptoms remission. The operation time, level of ALT at postoperative week 1 and duration of postoperative hospital stay were (67 ± 13) minutes, (64 ± 13) U/ L and (6. 8 ± 0. 7) days, respectively. Two patients had complications. ③Of 16 patients undergoing RFA, the results of postoperative CT showed that no enhancement was detected in 2 patients and partial enhancement in 14 patients, with the loss of volume of 29% -72%. Three patients had symptoms remission and 1 had no symptoms remission. The operation time, level of ALT at postoperative week 1 and duration of postoperative hospital stay were (75 ± 26) minutes, (41 ± 18) U/ L and (5. 3 ± 2. 7) days, respectively. ④Of 81 patients undergoing follow-up observation, 24 had symptoms remission, 8 had no symptoms remission and 49 had no symptoms. Twenty had slow enlarging tumor and 3 received surgical resection of rapid enlarging tumor without complications. (2) The results of clinical grading system showed as follows: of 176 patients with score≥4, 159 patients received surgical resection, 8 received TAE and 9 received follow-up observation. Of 338 patients with score <4, 221 patients received surgical resection, 29 received TAE, 16 received RFA and 72 received follow-up observation. (3) All the patients were followed up for 6-150 months (mean, 89 months) with full recovery. Conclusions Surgical resection is an effective method for the treatment of liver hemangioma. TAE and RFA have an advantage of minimal surgery wounds with poor efficacy, and follow-up observation could be applied to patients without surgical indications. The selection of treatment may depend on the clinical grading system for liver hemangioma, and combining with the individual conditions. Key words: Liver hemangioma; Hepatectomy; Transcatheter arterial embolization; Radiofrequency ablation

Giant pedunculated hepatic hemangiomas, mostly seen in women, are considered a rare type of giant hepatic hemangioma, with challenging diagnosis. Unlike other types of liver hemangiomas, they can manifest different kinds of symptoms, and are prone to life-threatening manifestations like rupture or torsion. Hemangioma is the most common benign liver primary tumor. Hepatic hemangioma >4 cm (some studies suggest >10 cm) is referred to as a giant hemangioma. Although hepatic hemangioma does not manifest symptoms in most cases, a giant hepatic hemangioma can manifest different kinds of symptoms. Giant pedunculated hepatic hemangiomas are considered a rare type of giant hepatic hemangioma, with challenging diagnosis, as the thin pedicle could be hard to be detected on imaging. A 41-year-old woman was admitted to our hospital, with dull discomfort of the right upper quadrant and epigastric region and early satiety for the past 7 months, with the history of taking oral contraceptive (OCP) for 10 years. Ultrasound and computed tomography revealed a 130 × 124 × 76 mm solid mass, with central cystic lesion, located in the midline of the epigastric region, attaching to the inferior surface of the third segment of the left lobe of the liver. Due to the potential risk for torsion, and rupture of the hemangioma, the management of the patient proceeded to surgical excision. Pathological examination of the specimen confirmed the diagnosis of hepatic hemangioma. Giant pedunculated hepatic hemangioma is a rare benign tumor. It demonstrates higher incidence rate in women, as some hemangiomas have estrogen receptors, and estrogen can lead to endothelial cell proliferation and organization in vascular structure. Most hemangiomas do not express any symptoms; therefore, no treatment is needed except for the patients who manifest symptoms, or in giant pedunculated hemangiomas, as they are prone to rupture or torsion. In this review most cases were female, and most of them presented with abdominal pain, in most cases the tumor located in the left lobe of the liver. Almost all the reviewed cases underwent surgery. Giant hepatic hemangioma is a differential diagnosis of palpable mass, or other symptoms of the right upper quadrant, and epigastric region specially in women taking OCP. Imaging is needed to rule out these tumors, and most often, pedunculated hemangioma is harder to be defined on imaging. It requires surgery because of the risk of acute problems, such as torsion and rupture.

Laparoscopic right hepatectomy and distal MHV resection after portal vein embolization for intraductal papillary neoplasm of bile duct

Here we report a case of a 76-year-old man with a giant cavernous hepatic hemangioma of more than 20 cm in diameter. Since the hepatic hemangioma was actually growing and might possibly rupture and he complained of abdominal symptoms, we decided to perform interventional therapy. First we performed transcatheter arterial embolization (TAE) of the hepatic arteries. However, since this was not sufficiently effective, we added sorafenib (600 mg/day). As a result, the tumor shrank with symptomatic improvement. Subsequently, an adverse event occurred, and we suspended the sorafenib therapy. Then, the tumor began to grow, and we resumed administering sorafenib at 400 mg/day. The tumor shrank again, and we continued the sorafenib therapy thereafter. The tumor shrinkage, although possibly induced by the effect of TAE, is considered primarily due to the effect of treatment with sorafenib, because (1) TAE did not sufficiently reduce the blood supply to the inside of the tumor; (2) other tumors shrank in the area not targeted by TAE; and (3) the tumor grew during suspension of sorafenib therapy and shrank again after resuming the treatment.