Bipolar radiofrequency ablation for symptomatic giant (>10 cm) hepatic cavernous haemangiomas: initial clinical experience

Ablation for Benign Liver Tumors: Current Concepts and Limitations

Percutaneous ablation under imaging guidance is a curative treatment that can induce complete tumor necrosis with advantages of minimal invasiveness and a low risk of complications. Thermal ablation, which includes radiofrequency ablation and microwave ablation, is a representative technique that has sufficient antitumor effects in cases of hepatocellular carcinoma with ≤3 lesions measuring ≤3 cm and preserved liver function. The short- and long-term outcomes of patients are comparable with those achieved with surgical resection. Despite their nonmalignant nature, some benign liver tumors require treatment for symptoms caused by the presence of the tumor and/or continuous enlargement. Ablation may be the treatment of choice because it has lower burden on patients than surgical treatment. This review describes the recent concepts, progress, and limitations of ablation-based treatment for benign liver tumors.

Dual-Applicator MR Imaging-Guided Microwave Ablation with Real-Time MR Thermometry: Phantom and Porcine Tissue Model Experiments

PURPOSE

To investigate the effect of simultaneous use of dual applicators on the image quality of real-time magnetic resonance (MR) thermometry and to characterize the dual-applicator treatment zone pattern during MR imaging-guided microwave ablation (MWA).

MATERIALS AND METHODS

MWA experiments were performed on a 1.5-T MR scanner with 2 commercial microwave systems (902-928 MHz). Phantom experiments were first performed to evaluate the effect of dual-applicator MWA on the image quality of MR. Then, porcine tissue model experiments were conducted with real-time MR thermometry using either a single applicator or dual applicators inserted 2.6, 3.6, and 4.6 cm apart. Fiberoptic thermal probes were used to measure the temperature changes at the tissue surface.

RESULTS

Simultaneous use of dual applicators resulted in a decrease in the relative signal-to-noise ratio (SNR) in the MR thermometry images to 55% ± 2.9% when compared with that of a single applicator (86.2% ± 2.0%). Despite the lower SNR, the temperature and ablation zone maps were of adequate quality to allow visualization of the ablation zone(s). The extents of increase in the temperature at the tissue surface using dual applicators (19.7 °C ± 2.6 °C) and a single applicator (18.2 °C ± 3.3 °C) were not significantly different (P = .40). Treatment zones were significantly larger (P < .05) in dual-applicator ablations (29.4 ± 0.4, 39.9 ± 0.6, and 42.6 ± 0.9 cm² with 2.6-, 3.6-, and 4.6-cm spacing, respectively) at the end of the ablation procedure than in the single-applicator MWA (18.6 ± 0.9 cm²).

CONCLUSIONS

MR imaging-guided dual-applicator MWA produced larger ablation zones while allowing adequate real-time MR thermometry image quality for monitoring the evolution of the treatment zone.

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.

Natural history of hepatic hemangiomas as a guide for surgical indication

Background

Generally, hemangiomas are asymptomatic and most lesions are incidentally diagnosed on abdominal ultrasonography. The indications for surgery are still debated mainly due to limited data about the natural history of hepatic hemangiomas. The aim of this study is to investigate the natural history of hepatic hemangiomas, the effects of age and sex on their growth, and their tendency to increase in size or causing symptoms or complications as a guide for surgical indication. In this current study, combined retrospective and prospective analysis was conducted on 186 Egyptian adult patients having 244 hepatic hemangiomas who attended to the outpatient clinics. Follow-up was performed to observe the accurate site, size, number, rate of growth of the lesions, and their tendency to cause symptoms or complications.

Results

Ninety-one percent of patients were asymptomatic and 9% were symptomatic. During follow-up, 48% of patients showed an increase in tumor diameter, 22% decreased, and 30% were stable. The growth rate at 18–45-year group showed an increasing trend that was higher in females; it was 3.3 ± 2 mm/year for males and 3.9 ± 1.8 mm/year for females. At ˃ 45 year group, the female patients showed a decreasing trend (− 2.1 ± 1.1 mm/year) while in males showed an increasing trend that was slower than in 18–45-year group (2.6 ± 1.7 mm/year).

Conclusion

Growth pattern of liver hemangiomas is affected by age and sex. The majority of hemangiomas are asymptomatic and complications are rare. Hemangioma size alone is not an indication for surgery in asymptomatic patients. Surgical indications are limited to patients with severe symptoms, complications, or suspicious lesions. Most hemangiomas can be managed conservatively even giant hemangiomas.

Percutaneous ultrasound-guided 'three-step' radiofrequency ablation for giant hepatic hemangioma (5-15 cm): a safe and effective new technique

Purpose: To evaluate the safety and efficacy of percutaneous ultrasound-guided 'three-step' radiofrequency ablation (RFA) for the treatment of giant hepatic hemangioma.Materials and methods: Patients with giant hepatic hemangioma who underwent percutaneous ultrasound-guided 'three-step' RFA (n = 52) and conventional RFA (n = 54) at our center from June 2013 to December 2017 were retrospectively analyzed. The 'three-step' RFA proceeds as follows. Step 1: Ablate the feeding artery of the hemangioma. Step 2: Aspirate blood from the tumor. Step 3: Ablation the lesion. Intraoperative information, postoperative recovery, therapeutic effects, and complications were compared between the two groups.Results: The duration of RFA was significantly shorter (19.2 ± 0.8 min versus 44.5 ± 2.8 min, p < 0.001), the number of punctures was significantly lower (3.2 ± 0.1 versus 4.7 ± 0.3, p = 0.002), and the duration of hospital stay was significantly shorter (9.0 ± 0.5 versus 11.5 ± 0.7, p = 0.013) in the TS-RFA group than in the C-RFA group. The complete ablation rate (86.5% versus 40.7%), the maximum postoperative pain score (2.5 ± 1.3 versus 4.1 ± 2.0) and symptom relief were also significantly better in the TS-RFA group than in the C-RFA group (p < 0.05). No postoperative death occurred in either group. There were no grade III or higher complications in the TS-RFA group, but one patient in the C-RFA group developed the grade III complication of postoperative abdominal bleeding.Conclusions: 'Three-step' RFA is a safe and effective minimally invasive treatment for giant hepatic hemangioma. It is worthy of further promotion and application.

Outcomes of ultrasound-guided percutaneous microwave ablation versus surgical resection for symptomatic large hepatic hemangiomas

Purpose: Microwave ablation (MWA) has become increasingly popular as a minimally invasive treatment for benign and malignant liver tumors. However, few studies have demonstrated the benefits and disadvantages of MWA compared to surgical resection (SR) for large hepatic hemangiomas. This study aimed to evaluate the safety and effectiveness of MWA compared to SR for large (5-10 cm) hepatic hemangiomas. Methods and materials: This retrospective comparative study included 112 patients with large, symptomatic hepatic hemangiomas who had been treated with MWA (n = 44) or SR (n = 68) and followed up for a median of 44 months using enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Intraoperative information, postoperative recovery time, postoperative discomfort and complications and treatment effectiveness between groups were compared using a chi-square test or an independent t-test. Results: The operative time was significantly shorter (31.3 ± 21.76 versus 148.1 ± 59.3 min, p < .001) and the blood loss (10.2 ± 60.6 versus 227.9 ± 182.9 mL, p < .0001) and rate of prophylactic abdominal drainage [1 (2.3%) versus 57 (83.8%), p < .001] were significantly lower in the MWA group than in the SR group. Postoperative recovery of the MWA group in regard to indwelling catheter time, normal diet time, incision cicatrization time and hospital stay (p < .001) was significantly better than the SR group. However, no statistically significant difference in effectiveness was noted between the groups (p = .58). Conclusions: MWA may be as effective as SR, and potentially safer for treating large, symptomatic hepatic hemangiomas. To confirm our findings, large-sample, multicentered, randomized controlled trials are needed.

Invasive management of symptomatic hepatic hemangioma

Hepatic hemangioma is common among benign liver tumors and usually grows slowly. About 50-70% of hepatic hemangiomas are asymptomatic, and management is not necessary; however, management should be considered in symptomatic patients. The optimal management of symptomatic hepatic hemangioma depends on multiple factors. Invasive management of symptomatic hepatic hemangioma mainly consists of surgery and interventional radiology, including transarterial embolization, ablation, percutaneous sclerotherapy, and percutaneous argon-helium cryotherapy. Although both surgery and interventional radiology are promising in the management of symptomatic hepatic hemangioma, multiple and/or giant hemangiomas represent a clinical dilemma because the complication rate and recurrence rate are relatively high, and symptom relief is not always achieved. However, a review of recent advances in treatment is lacking. We therefore summarized the current invasive management techniques for symptomatic hepatic hemangioma to potentially facilitate clinical decision-making.

The value of 3D visualization operative planning system in ultrasound-guided percutaneous microwave ablation for large hepatic hemangiomas: a clinical comparative study

Background

To evaluate the value of a three dimension (3D)visualization operative planning system in ultrasound-guided percutaneous microwave ablation (US-PMWA) for large hepatic hemangiomas (LHHs).

Methods

Fifty-eight patients with LHHs were divided into 3D and 2D groups. The therapeutic efficacy was assessed by contrast-enhanced imaging during follow-up. Hepatic and renal function were examined. The complete ablation, tumor volume shrinkage, and complication rates were analyzed.

Results

The ablation time and energy of the 3D group were lower than those of the 2D group (1152.0 ± 403.9 s vs. 1379.7 ± 375.8 s and 87,407.2.9 ± 50,387.0 J vs. 117,775.8 ± 46,245.6 J, P = 0.031 and 0.021, respectively). The 3D group had a higher complete ablation rate than the 2D group (97.7 ± 2.4% vs. 94.5 ± 3.7%, P < 0.001). The incidence of hemoglobinuria after ablation in the 3D group was lower than that in the 2D group (32.0% vs. 57.6%, P = 0.047). The levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and creatinine (Cre) after ablation in the 3D group were lower than those in the 2D group (126.7 ± 56.4 U/L vs. 210.9 ± 96.2 U/L, P < 0.001; 141.0 ± 60.8 U/L vs. 211.4 ± 90.0 U/L, P = 0.001; 57.3 ± 17.6 U/L vs. 80.8 ± 41.9 U/L, P = 0.010; and 66.6 ± 16.6 mmol/L vs. 84.5 ± 39.6 mmol/L, P = 0.037, respectively). There were no significant differences in antenna insertion and the volume reduction rate between the groups. One patient developed acute kidney injury shortly after ablation in the 2D group and recovered after hemodialysis. No other severe complications occurred during the follow-up period.

Conclusions

The 3D visualization operative planning system has a relatively high clinical application value in providing scientific, reasonable, quantifiable, and individualized therapy for LHHs by US-PMWA.

Feasibility, safety, and efficacy of ultrasound-guided percutaneous microwave ablation for giant hepatic hemangioma

BACKGROUND

Hepatic hemangioma is a common benign liver tumor. The majority of cases are asymptomatic and require no specific treatment. The aim of this study was to evaluate the feasibility, safety and efficacy of microwave ablation (MWA) for symptomatic or enlarging giant hepatic hemangioma (≥10 cm).

METHODS

From December 2013 to June 2016, 12 patients with giant hepatic hemangioma (≥10 cm) underwent ultrasound-guided percutaneous MWA, and ablation-related complications were observed. All patients were followed up with magnetic resonance or enhanced CT imaging at one month postoperatively to evaluate efficacy.

RESULTS

This study included a total of 13 giant hepatic hemangiomas (mean: 11.7 ± 1.6 cm) in 12 patients who initially underwent 16 sessions of MWA; three lesions were treated with two sessions of planned ablation. The average ablation time for a single hepatic hemangioma was 39.0 ± 14.4 minutes. Two patients had acute postoperative non-oliguric renal insufficiency without intra-abdominal hemorrhage, liver failure or other complications. Initially, complete ablation was achieved in ten lesions in nine patients (76.9%, 10/13). One patient underwent a second session of MWA at 5 months postoperatively due to fast growing residual tissue; complete necrosis was achieved after treatment. The remaining two cases did not receive any invasive treatment due to small residual volumes. The total complete ablation rate was 84.6% (11/13).

CONCLUSION

Image-guided MWA is a safe, feasible, effective treatment for giant hepatic hemangioma; these findings may open a new avenue for treatment.

Extracapsular excision of hepatic hemangioma: A single centre experience

Backgrounds/Aims

Hepatic hemangioma is a common non-epithelial neoplasm of the liver. Presence of symptoms and uncertainty in diagnosis are the most common indications for surgery.

Methods

Eighteen patients with hepatic hemangioma, operated on from January 2011 to December 2016 at the Hepato-pancreato-biliary surgical unit of Tata Memorial Hospital, were retrospectively analyzed.

Results

Main indications for operation were presence of symptoms, the most common being pain and diagnostic uncertainty. The median size of hemangioma was 9.9 cm (range 3.2 to 24 cm). All patients underwent extra-capsular excision of hemangioma. The median operating time was 180 minutes (range 75 to 460 minutes) and median blood loss was 950 ml (range 100 to 3,500 ml). Median post-operative stay was 5.5 days (range 3 to 10 days). One (5.6%) patient required re-exploration for post-operative hemorrhage, Clavien Dindo (CD) grade IIIb, and one (5.6%) had postoperative purulent intra-abdominal collection requiring percutaneous cutaneous drainage CD grade IIIa. There was no postoperative mortality. Postoperative day 3 liver function tests were within normal limits. Size of the tumor did not correlate significantly with postoperative complications (p=0.135).

Conclusions

Surgical treatment of hemangioma should be guided by presence of symptoms or by the presence of diagnostic uncertainty, not by size alone. The size had no correlation with perioperative complications. The technique of extra-capsular excision is safe and technically feasible in most of the hemangiomas. This technique preserves maximum liver parenchyma, resulting in early postoperative recovery with minimal morbidity.

Patient age affects the growth of liver haemangioma

BACKGROUND

The aim of this study was to report the prevalence of liver haemangioma and describe growth rates by age.

METHODS

A retrospective study of people undergoing a health examination. The collected data included gender, age, presence or absence and size of liver haemangioma. A second database of liver haemangioma patients with a minimum follow up period of 5 years was analysed. The collected data included gender, initial age at diagnosis, follow-up period, initial and final size.

RESULTS

Patients were divided into four age groups: 20-29 years, 30-39 years, 40-49 years and ≥50 years. Patients in the 20-29 years group had the lowest prevalence of liver haemangioma (1.78%) and the smallest size (1.3 ± 0.7 cm), while 40-49 years group had the highest prevalence (3.94%) and largest size (1.9 ± 1.3 cm). Patients between 30 and 39 years had the greatest increase in haemangioma size (4.0 cm, (3.0, 6.0) cm), while patients of ≥50 years had the least (1.4 cm (0.5, 3.8) cm). The proportion of patients without an increase in haemangioma size increased with age (P = 0.031).

CONCLUSION

Age is an important factor affecting the prevalence and growth rate of liver haemangioma.

Long-term result of transcatheter arterial embolization for liver hemangioma

Transcatheter arterial embolization (TAE) is a method for the treatment of liver hemangioma, but fewer studies reported the long-term result.Retrospective study was conducted to liver hemangioma patients who received TAE. The inclusion criteria included the following: the period of follow-up was more than 5 years; and patients were followed up for less than 5 years, but received surgical treatment due to the enlargement of tumor or severe complications of TAE. The collected data included sex, age, size of the tumor, times of TAE, complications, period of follow-up, long-term result, and whether or not surgery was finally performed.Fifty-five patients were included, and the average age was 43.1 ± 8.6 years. The average size of liver hemangioma was 9.0 ± 4.3 cm. Four patients (7.3%) had severe complications after TAE, including 2 cases of biloma which were cured by surgery. The tumor size was smaller or the same in 19 patients after 5 years follow-up, and the long-term effective rate was 35.8%. The size of tumor became larger in the other 34 patients (64.2%), and 29 patients (54.7%) received surgery finally. The long-term effective rate for patients with ≥10 cm tumor and <10 cm tumor were 12.5% and 45.9%, respectively, and the difference was significant (P = .019).The long-term result of TAE for liver hemangioma was not satisfying, and the treatment had the risk of severe complication. For patients with asymptomatic liver hemangioma, TAE should not be conducted.

Radiofrequency ablation for hepatic hemangiomas: A consensus from a Chinese panel of experts

Recent studies have shown that radiofrequency (RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the treatment of hepatic hemangiomas: minimal invasiveness, definite efficacy, high safety, fast recovery, relatively simple operation, and wide applicability. It is necessary to formulate a widely accepted consensus among the experts in China who have extensive expertise and experience in the treatment of hepatic hemangiomas using RF ablation, which is important to standardize the application of RF ablation for the management of hepatic hemangiomas, regarding the selection of patients with suitable indications to receive RF ablation treatment, the technical details of the techniques, therapeutic effect evaluations, management of complications, etc. A final consensus by a Chinese panel of experts who have the expertise of using RF ablation to treat hepatic hemangiomas was reached by means of literature review, comprehensive discussion, and draft approval.

Giant liver hemangioma with adult Kasabach-Merritt syndrome: Case report and literature review

RATIONALE

Adult Kasabach-Merritt syndrome associated with giant liver hemangioma is rare; to date, most reports have been single-case reports, and no multi-case reports or literature reviews are available.

DIAGNOSES

We conducted a retrospective analysis of 5 cases of adult Kasabach-Merritt syndrome associated with giant liver hemangioma treated at our hospital between 2011 and 2016. All 5 patients had varying severities of leukopenia, anemia, thrombocytopenia, prolonged prothrombin time, and hypofibrinogenemia.

INTERVENTIONS

All the patients underwent surgery: 2 patients had left hemihepatectomy; 1 had enucleation; 1 had a right hemihepatectomy; and 1 had a left trisectionectomy.

OUTCOMES

The 5 patients had an average operative time of 6.9 hours and an average blood loss of 3200 mL. One patient developed a biliary fistula (grade II) after the operation. There was no mortality among 5 patients. The white blood cell counts, hemoglobin, platelets, and prothrombin times of all 5 patients returned to normal after the operation. To date, a total of 11 cases of adult Kasabach-Merritt syndrome associated with giant liver hemangioma have been reported, of which 8 patients underwent surgery, and their platelets and coagulation returned to normal after the operation.

LESSONS

Adult Kasabach-Merritt syndrome associated with giant liver hemangioma is uncommon, and surgical treatment is risky. However, resection of the tumor corrected the abnormalities in hematological and coagulative systems.

Transarterial Chemoembolization of Giant Liver Haemangioma: A Multi-center Study with 836 Cases

The purpose of the study is to evaluate the effectiveness and safety of transarterial chemoembolization (TACE) with pingyangmycin-lipiodol emulsion for the treatment of symptomatic giant hepatic haemangioma. Four hospitals (The Second Hospital of Shandong University, Qilu Hospital of Shandong University, Shandong Provincial Hospital and Jinan Municipal Hospital) participated in this study during 2002-2012. A total of 836 patients with symptomatic giant haemangioma were treated with pingyangmycin-lipiodol emulsion via selective TACE. The patients were followed-up for 12 months-10 years. The effectiveness of the treatment was evaluated by symptom assessments and upper abdominal magnetic resonance imaging or computed tomography. TACE was successfully performed for a total of 1120 lesions in 836 patients. Success rate of the procedure was 100 %. The mean diameter of the haemangiomas was significantly reduced after the interventional therapy (mean diameter 9.6 ± 0.8 vs. 3.6 ± 0.5 cm; P < 0.05). Symptom relief was achieved in all the patients during the follow-up period. No mortality was identified. TACE with pingyangmycin-lipiodol emulsion is a safe, feasible, and effective treatment for the giant symptomatic hepatic haemangioma.

Diagnosis and treatment of benign liver nodules: Brazilian Society of Hepatology (SBH) recommendations

Space-occupying lesions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenomas and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenomas are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenomas may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenomas growth, particularly of the hepatocyte nuclear factor-1alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of the liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the absence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agents are indicated.

Radiofrequency ablation for huge hepatic hemangiomas: How far from being the first-line treatment

Huge hepatic hemangiomas (≥ 10 cm) are often growthful and harmful. Surgical resection is the traditional treatment for this disease, however, this treatment modality is rather invasive and the operative morbidity and mortality are relatively high. To avoid surgical risk, many minimally invasive procedures have been developed to treat hepatic hemangiomas. In the recent decade, radiofrequency ablation (RFA) has been performed successfully in patients with huge hepatic hemangiomas, showing many advantages over resection, including minimal invasiveness, low complication rate, reduced cost, short hospital stay and increased patient compliance. The treatment strategy for huge hepatic hemangioma is changing from the traditional surgical resection to the minimally invasive treatment with RFA. In the current review, we discuss the present situation and prospect of RFA application in the treatment of huge hepatic hemangiomas.

Laparoscopic Radiofrequency Ablation for Large Subcapsular Hepatic Hemangiomas: Technical and Clinical Outcomes

Objectives

The aim of this study was to evaluate the technical and clinical outcomes of using laparoscopic radiofrequency (RF) ablation for treating large subcapsular hepatic hemangiomas.

Methods

We retrospectively reviewed our sequential experience of treating 124 large subcapsular hepatic hemangiomas in 121 patients with laparoscopic RF ablation.

Results

The mean diameter of the 124 hemangiomas was 9.1 ± 3.2 cm (5.0–16.0 cm). RF ablation was performed successfully in all patients. There were 55 complications related to the ablation in 26 patients, including 5 of 69 (7.3%) patients with hemangioma <10 cm and 21 of 52 (40.4%) patients with hemangiomas ≥10 cm (P < 0.001). No injuries to abdominal viscera occurred in all the 121 patients. According to the Dindo–Clavien classification, all the complications were minor in 26 patients (Grade I). Out of 124 hepatic hemangiomas, 118 (95.2%) were completely ablated, including 70 of 72 (97.2%) lesions < 10 cm and 48 of 52 (92.3%) lesions ≥ 10 cm (P = 0.236).

Conclusion

Laparoscopic RF ablation therapy is a safe, feasible and effective procedure for large subcapsular hepatic hemangiomas, even in the hepatic hemangiomas ≥ 10 cm. Its use avoids thermal injury to the abdominal viscera.

Giant cavernous liver hemangiomas: is it the time to change the size categories?

BACKGROUND

Four different sizes (4, 5, 8 and 10 cm in diameter) can be found in the literature to categorize a liver hemangioma as giant. The present review aims to clarify the appropriateness of the size category "giant" for liver hemangioma.

DATA SOURCES

We reviewed the reports on the categorization of hemangioma published between 1970 and 2014. The number of hemangiomas, size criteria, mean and range of hemangioma sizes, and number of asymptomatic and symptomatic patients were investigated in patients aged over 18 years. Liver hemangiomas were divided into four groups: <5.0 cm, 5.0-9.9 cm, 10.0-14.9 cm and ≥15.0 cm in diameter. Inclusion criteria were noted in 34 articles involving 1972 (43.0%) hemangiomas (>4.0 cm).

RESULTS

The patients were divided into the following groups: 154 patients (30.0%) with hemangiomas less than 5.0 cm in diameter (small), 182 (35.5%) between 5.0 cm and 9.9 cm (large), 75 (14.6%) between 10.0 and 14.9 cm (giant), and 102 (19.9%) more than 15.0 cm (enormous). There were 786 (39.9%) asymptomatic patients and 791 (40.1%) symptomatic patients. Indications for surgery related to symptoms were reported in only 75 (3.8%) patients. Operations including 137 non-anatomical resection (12.9%) and 469 enucleation (44.1%) were unclearly related to size and symptoms.

CONCLUSIONS

The term "giant" seems to be justified for liver hemangiomas with a diameter of 10 cm. Hemangiomas categorized as "giant" are not indicated for surgery. Surgery should be performed only when other symptoms are apparent.

Outcome using selective hemihepatic vascular occlusion and Pringle maneuver for hepatic resection of liver cavernous hemangioma

Background

Though accumulated evidence proved the advantages of laparoscopic hepatectomy, bleeding still remains the most important challenge in clinical practice. Our study aimed to compare the outcomes of Pringle maneuver (PM) and selective hemihepatic vascular occlusion (SHVO) surgeries for patients with liver cavernous hemangioma (LCH).

Methods

The SHVO (n = 26; mean age, 42) and PM (n = 78; mean age, 43) surgeries were performed in 104 LCH patients from January 2006 to January 2015. The intraoperative (bleeding, arterial pressure, oxyhemoglobin saturation, etc.) and postoperative parameters (anal exhaust time, complications, blood cell numbers, etc.) were measured and compared between the two groups. Liver function of all these patients was detected by blood test at 1-day preoperation, and at 1, 3, and 5 days postoperation.

Results

Both of the two surgeries were successfully performed without any mortality. The intraoperative systolic arterial pressure and pulse in PM group were much higher than that in SHVO group (P < 0.01). The postoperative liver function parameters such as alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin (TBIL) increased much more in the PM group than that in the SHVO group compared with preoperation results (P < 0.05). However, there were no statistical differences in intraoperative bleeding, blood transfusion, hepatic inflow occlusion time, oxygen saturation occlusion, anal exhaust time and incidence of complications between the two groups (P > 0.05).

Conclusions

SHVO is safer with less ischemia reperfusion injury than PM surgery for hemangioma resection on patients with LCH.

Efficacy, safety and feasibility of ultrasound-guided percutaneous microwave ablation for large hepatic hemangioma

OBJECTIVE

To evaluate the efficacy, safety and feasibility of microwave ablation (MWA) for large (5-10 cm in diameter) hepatic hemangioma.

METHODS

In all, 46 patients with 47 large hepatic hemangiomas were treated with ultrasound-guided percutaneous MWA. The effect of MWA for all patients was evaluated by enhanced magnetic resonance imaging or computed tomography within two months after ablation.

RESULTS

A total of 27 male and 19 female patients were enrolled, with an average age of 46 ± 11 years. The average size of hemangiomas was 6.3 ± 1.4 cm (range 5.0-9.6 cm). The initial complete ablation rate was 91.5% (43/47) and the volume of ablated lesions was significantly reduced. The rate of complete necrosis was not associated with the tumor size or location (P = 0.899 and 0.758, respectively). The total complete ablation rate was 95.7% (45/47). Major complications included acute renal dysfunction, hyperbilirubinemia and pleural effusion. No procedure-related death occurred. The average hospitalization stay was 5.7 ± 2.5 days (range 3-17 days). During a follow-up period of 18.2 months (range 4-40 months), one patient developed local tumor progression at the radiofrequency ablation site. Three patients had new hemangiomas in other sites of the liver. At the end of the study all patients were alive and no severe complications occurred.

CONCLUSION

Image-guided MWA is an effective and safe treatment for large hepatic hemangiomas, and can potentially be regarded as the first-line therapy.

"Edgeboost": A Novel Technique to Extend the Ablation Zone Lateral to a Two-Probe Bipolar Radiofrequency Device

BACKGROUND

The dual-electrode bipolar-RFA (B-RFA) is increasingly used to ablate large liver tumours (3-7 cm). However, the challenging aspect of B-RFA is the placement of the two electrodes around the tumour. Realignment often requires the electrodes to be extracted and reinserted.

AIM

The aim of this study is to examine "Edgeboost", a novel technique to increase the lateral ablation dimension without requiring any realignment of the electrodes.

METHODS AND MATERIALS

An egg-white model and an ex vivo calf liver model were used compare the standard bipolar mode ablation to Edgeboost-1 (reaching full impedance in bipolar mode initially, then cycling in unipolar mode between left and right probes) and Edgeboost-2 (similar to Edgeboost-1 but not reaching full impedance initially in bipolar mode in order to minimize charring and, thus, to increase total ablation time).

RESULTS

A significantly larger outer lateral ablation dimension to the probe was achieved with Edgeboost-1 compared to the standard method in the liver model (1.14 cm, SD: 0.16 vs. 0.44 cm, SD: 0.24, p = 0.04). Edgeboost-2 achieved the largest outer lateral ablation dimension of 1.75 cm (SD: 0.35). A similar association was seen in the egg model. Edgeboost-2 almost doubled the mass ablated with standard bipolar alone (mass ratio: 1:1.94 in egg white and 1:1.84 in liver).

CONCLUSION

This study demonstrates that the novel "Edgeboost" technique can increase the outer lateral ablation dimension without requiring the two inserted electrodes to be reinserted. This would be beneficial for interventionists who use the dual B-RFA.

Laparoscopic vs computerized tomography-guided radiofrequency ablation for large hepatic hemangiomas abutting the diaphragm

AIM: To compare safety and therapeutic efficacy of laparoscopic radiofrequency (RF) ablation vs computed tomography (CT)-guided RF ablation for large hepatic hemangiomas abutting the diaphragm.

METHODS: We retrospectively reviewed our sequential experience of treating 51 large hepatic hemangiomas abutting the diaphragm in 51 patients by CT-guided or laparoscopic RF ablation due to either the presence of symptoms and/or the enlargement of hemangioma. Altogether, 24 hemangiomas were ablated via a CT-guided percutaneous approach (CT-guided ablation group), and 27 hemangiomas were treated via a laparoscopic approach (laparoscopic ablation group).

RESULTS: The mean diameter of the 51 hemangiomas was 9.6 ± 1.8 cm (range, 6.0-12.0 cm). There was no difference in the diameter of hemangiomas between the two groups (P > 0.05). RF ablation was performed successfully in all patients. There was no difference in ablation times between groups (P > 0.05). There were 23 thoracic complications in 17 patients: 15 (62.5%, 15/24) in the CT-guided ablation group and 2 (7.4%, 2/27) in the laparoscopic ablation group (P < 0.05). According to the Dindo-Clavien classification, two complications (pleural effusion and diaphragmatic rupture grade III) were major in two patients. All others were minor (grade I). Both major complications occurred in the CT-guided ablation group. The minor complications were treated successfully with conservative measures, and the two major complications underwent treatment by chest tube drainage and thoracoscopic surgery, respectively. Complete ablation was achieved in 91.7% (22/24) and 96.3% (26/27) in the CT-guided and the laparoscopic ablation groups, respectively (P > 0.05).

CONCLUSION: Laparoscopic RF ablation therapy should be used as the first-line treatment option for large hepatic hemangiomas abutting the diaphragm. It avoids thermal injury to the diaphragm and reduces thoracic complications.

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.

Short-term effects of radiofrequency shrinkage treatment for anterior cruciate ligament relaxation on proprioception

OBJECTIVE

Radiofrequency (RF) shrinkage is used in anterior cruciate ligament (ACL) reconstruction. The present study investigated the therapeutic effects of RF on ACL relaxation and the probable influencing factors.

METHODS

Patients with ACL relaxation were included. Participants were randomly divided into two groups: a treatment group, in which patients were treated with RF shrinkage (RF group); a control group, in which patients received conventional surgical treatment. Thermal shrinkage was performed on ACL using an ArthroCare® CAPSure® wand. Lysholm scores, proprioceptive testing and Tegner activity scores were evaluated before and after treatment (at 6 and 12 months).

RESULTS

A total of 38 patients were included. The mean ± SD Lysholm score of those in the RF group at 12 months' post-treatment was significantly higher than in controls. The angle of deviation of the knee joint in RF group was significantly larger than in the control group at 6 months' post-treatment.

CONCLUSIONS

RF shrinkage treatment for ACL laxity could improve knee scores, and may affect proprioception and recovery of activity after surgery.