Characteristics and operative treatment of extremely giant liver hemangioma >20 cm

A novel and effective strategy for the treatment of large hepatic hemangioma: combining preoperative embolization with laparoscopic-assisted and ultrasound-guided ablation

BACKGROUND

Hepatic hemangioma is the most common benign liver tumor. This study aims to evaluate the feasibility, safety and efficacy of Trans-arterial embolization (TAE) combined with thermal ablation in the treatment of large hepatic hemangioma (> 5 cm).

METHODS

From January 2018 to December 2021, 82 patients and 112 large HH with a maximum mean diameter of 8.24 ± 0.26 cm (range: 4.3-16.0 cm) and a cumulative diameter of 9.45 ± 0.45 cm (range:5.0-29.6 cm) were treated with laparoscopic-assisted and ultrasound (US)-guided percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) during a single general anesthesia episode following TAE. After surgery, therapeutic efficacy was assessed by contrast-enhanced imagings during follow-up. Median follow-up time was 14 months (range: 2-48 months).

RESULTS

All patients have a mean operating time of 79.10 ± 2.59 min. The plain CT revealed that 112 treated lesions were totally covered (100%). Hemoglobinuria was detected in 28 patients (34.1%), and there were no cases of acute renal failure. Abdominal pain occurred in 40 patients (48.8%), while peritoneal effusion in six (7.3%). Acute cholecystitis developed in 11 patients (13.4%), constipation in five (6.1%), and nausea and vomiting in 14 (17.1%). According to the Clavien-Dindo classification, 54 patients (65.9%) had minor complications, while none had severe complications. The follow-up, no Hepatic hemangioma growth was observed.

CONCLUSION

Preoperative TAE combined with thermal ablation is a novel therapeutic strategy for large HH. This strategy is simple, less risky, and feasible.

Clinical impact and role of major vessels involvement in laparoscopic resection for hepatic hemangioma

BACKGROUND

Severe bleeding remains a significant concern in laparoscopic resection for hepatic hemangioma. It is rarely reported that how the degree of major vessels involvement impacts on severe bleeding. The present study primarily aimed to analyze the impacts of the number of involved major vessels (NIMV) during laparoscopic surgery for hepatic hemangioma and evaluate the risk factors associated with increased bleeding.

METHODS

A database search was carried out for consecutive patients who underwent laparoscopic resection for liver hemangiomas at our department from January 2018 to December 2023. The collected data included demographics, characteristics of the hemangiomas, laboratory data, operation method, surgical and postoperative variables.

RESULTS

A total of 72 patients were enrolled in the study. 42 patients were categorized into the group with NIMV < 2, while 30 patients were divided into the group with NIMV ≥ 2. The group with NIMV ≥ 2 demonstrated a significant correlation with special segments, involved multiple segments and diameter of the hemangiomas (P < 0.01). And the perioperative variables including the extent of resection, operative time, blood loss, Pringle maneuver times, postoperative stay, drainage tube duration, and postoperative liver function (ALT, AST) also showed significant differences between the two groups (P < 0.05). Notably, NIMV ≥ 2 was identified as the most important independent risk factor for intraoperative blood loss ≥ 500 ml in laparoscopic surgery for hepatic hemangioma (P = 0.011). For NIMV ≥ 2, the independent risk factor was special segments in multivariate analysis (P = 0.000).

CONCLUSION

The involvement of multiple major vessels (NIMV ≥ 2) was significantly associated with special segments, resulting in increased intraoperative blood loss, operation difficulty, and delayed postoperative recovery. Moreover, it was identified as the single independent risk factor with a considerable risk for increased blood loss during laparoscopic resection for hepatic hemangioma.

Transarterial embolization with bleomycin-lipiodol emulsion: a successful minimal invasive approach for giant liver hemangioma

Hemangiomas are most common benign liver tumor. Most patients have an excellent prognosis because of the small size and benign nature of tumor. On some occasions, giant liver hemangioma may cause symptoms and significant challenges due to its complication. We report a case of giant liver hemangioma treated with minimal invasive approach by transarterial embolization (TAE). Following three TAE sessions over a specific timeframe, the patient was successfully managed, addressing that TAE may be a useful alternative to hepatic surgery in such cases.

Management of Neonatal Hepatic Hemangiomas: A Single-Center Experience Focused on Challenging Cases

Background: Management of hepatic hemangioma (HH) in infancy ranges from close monitoring to surgical resection. We analyzed the clinical characteristics and outcomes of HH according to its treatment options, with particular focus on challenging cases. Methods: Data of patients diagnosed with HHs in their first year of life and followed up for at least 1 year were retrospectively reviewed and divided into treatment and observation groups. Serial imaging results, serum alpha-fetoprotein (AFP) levels, medications, and clinical outcomes were compared. The detailed clinical progress in the treatment group was reviewed separately. Results: A total of 87 patients (75 in the observation group and 12 in the treatment group) were included. The median HH size at the initial diagnosis and the maximum size were significantly larger in the treatment group than the observation group (2.2 [0.5-10.3] cm vs. 1.0 [0.4-4.0] cm and 2.1 [0.7-13.2] vs. 1.1 [0.4-4.0], respectively; all p < 0.05]. The median initial and last serum AFP levels were significantly higher in the treatment group than in the observation group (76,818.7 vs. 627.2 and 98.4 vs. 8.7, respectively; all p < 0.05). Serum AFP levels in both groups rapidly declined during the first 3 months of life and were almost undetectable after 6 months. Among the challenging cases, a large (14 × 10 × 6.5 cm sized) focal HH was successfully treated using stepwise medical-to-surgical treatment. Conclusions: Patients with large HH and mild symptoms can be treated using stepwise pharmacotherapy. More aggressive surgical treatment of tumors unresponsive to initial pharmacotherapy may help shorten the treatment period and improve outcomes.

Surgery for a symptomatic massive liver haemangioma

Liver haemangiomas are the most common benign hepatic tumours, but secondary portal hypertension resulting from haemangiomas is exceedingly uncommon. We present a case of a man in his 50s who presented with a progressively enlarging mass in the right upper abdomen. CT of the liver revealed a large hypodense lesion involving the right lobe, with two smaller lesions in the left lobe. The portal vein was compressed by the tumour, causing portal hypertension. The patient underwent right hepatectomy. Postoperatively, the patient had an uneventful course, and a 3-month follow-up demonstrated resolution of the oesophageal varices, portal gastropathy, with hypertrophy of the left lobe. This case report highlights the successful surgical management of a rare massive hepatic haemangioma causing portal hypertension with surgical resection, emphasising the potential benefits of surgical intervention with minimal complications.

Hepatic hemangioma: proportion and predictor of surgical treatment with emphasis on its growth rate

BACKGROUND/AIMS

There are limited studies on the management of hepatic hemangiomas (HHs). We investigated the proportion and predictors of surgical resection and analyzed HH growth rates in addition to associated factors.

METHODS

A retrospective case-control study of patients treated in 2 centers was conducted. Thirty-six patients who underwent surgical resection were assigned to the case group. Patients who did not undergo surgical treatment were randomly sigselected at a 1:10 ratio and assigned to the control group (n = 360). Baseline characteristics, clinical course and surgical outcomes were analyzed.

RESULTS

The proportion of surgically treated HH patients was 0.3% (36 per 11,049). The longest diameter at diagnosis (mean ± standard deviation) was 7.7 ± 5.2 cm in the case group and 2.4 ± 1.8 cm in the control group (p < 0.001). In the multivariate analysis, the presence of more than 2 HHs (odds ratio [OR] 7.64, 95% confidence interval [CI] 1.40-41.72) and a growth rate of more than 4.8%/year (OR 30.73, 95% CI 4.86-194.51) were independently associated with surgical treatment. Symptom development during follow-up was related to HH size > 10 cm (OR 10.50, 95% CI 1.06-103.77, p = 0.04). The subgroup analysis showed substantial growth in 41.3% with an overall mean annual growth rate of 0.14 cm.

CONCLUSION

Approximately one in 300 patients with an HH underwent surgical treatment. Multiple HHs and a growth rate of more than 4.8%/year were indications for surgical treatment. Nearly half of the HHs showed growing pattern in our study.

Feasibility of laparoscopic enucleation for hemangioma in special hepatic segments

Background and aim

This study aims to evaluate the safety and efficacy of laparoscopic enucleation for liver hemangioma in special hepatic segments.

Methods

We retrospectively reviewed 58 patients who underwent laparoscopic surgery for hepatic hemangioma at a single center from January 2016 to January 2022. Segments I, IVa, VII, and VIII are defined as special hepatic segments, attributing to the bad visualization and adjacent to important vessels such as hepatic veins and inferior vena cava that lead to a high risk in laparoscopic surgery. Patients were categorized into a special location group (SLG) and a normal location group (NLG) according to the location of hemangioma. General data, intraoperative and postoperative outcomes, and postoperative complications of the two groups were compared and analyzed.

Results

There were no significant differences in age (p = 0.288), gender (p = 0.331), body mass index (p = 0.168), the maximum diameter of hemangioma (p = 0.330), ASA risk grading (p = 0.615), and comorbidities (p > 0.05) between the two groups. The operation time (p < 0.001), intraoperative blood loss (p < 0.001), and intraoperative blood transfusion rate (p = 0.047) were significantly higher in the SLG. The rate of conversion to laparotomy was higher in the SLG, but there was no significant difference (p = 0.089). In addition, the exhaust time (p = 0.03) and postoperative hospital stay (p < 0.01) were significantly shorter in the NLG. The postoperative complications were comparable between the two groups, and there were no perioperative deaths.

Conclusion

Laparoscopic enucleation of hemangioma in special hepatic segments is difficult and has a critical risk of massive bleeding during surgery. Meanwhile, it is also safe, feasible, and effective.

The surgical outcomes and risk factors of giant hepatic haemangiomas: a single centre experience

Objective

To evaluate the safety of performing surgery on cavernous haemangiomas in the liver larger than 10 cm and establish preoperative predictors of intraoperative blood transfusion and morbidity.

Methods

A total of 373 patients with haemangiomas larger than 10 cm who underwent surgery in our hospital were retrospectively analysed. According to tumour diameter, the patients were divided into a giant haemangioma (GH) group (241 cases) (10 cm ≤ diameter < 15 cm) and an enormous haemangioma (EH) group (132 cases) (diameter ≥ 15 cm). Clinical parameters were then compared between the two groups.

Results

Compared with the GH group, the EH group had higher rates of leukopenia (10.6% vs. 4.5%), anaemia (26.5% vs. 15.7%), and thrombocytopenia (13.6% vs. 6.2%). The occlusion time in the EH group was longer than that in the GH group (26.33 ± 14.10 min vs. 31.85 ± 20.09 min, P < 0.01). The blood loss and blood transfusion in the EH group were greater than those in the GH group (P < 0.05). Moreover, the morbidity in the EH group was higher than that in the GH group (17.4% vs. 9.13%, P < 0.05). According to the results of the multivariable analysis, the operation time and size of the haemangioma may be independent risk factors for blood transfusion (P < 0.05). Additionally, the size of the haemangioma may be an independent risk factor associated with complications (P < 0.05).

Conclusion

Enormous haemangioma is more likely to cause haematologic abnormalities than giant hepatic haemangioma. The risks of the operation and postoperative complications of enormous haemangioma are higher than those of giant hepatic haemangioma.

Computed Tomography Fluoroscopy-Guided Percutaneous Transhepatic Bleomycin/Ethiodized Oil Sclerotherapy for Symptomatic Giant Hepatic Hemangioma

PURPOSE

To determine the safety and efficacy of computed tomography (CT) fluoroscopy-guided percutaneous transhepatic sclerotherapy with a bleomycin/ethiodized oil emulsion for symptomatic giant hepatic hemangiomas.

MATERIALS AND METHODS

The procedure was performed on 22 patients with symptomatic giant hepatic hemangiomas in an outpatient setting between 2018 and 2020. All patients were followed clinically and underwent contrast-enhanced magnetic resonance imaging after 1 month and again at a mean time of 15 months ± 2. Adverse events were classified according to the Common Terminology Criteria for Adverse Events (CTCAE, v5.0), in which a severe adverse event was defined as an adverse event with a grade of ≥3. The desired radiologic response (volume and index size) and improvement of pain intensity (visual analog scale [VAS]) and other symptoms were recorded as outcomes.

RESULTS

Overall, patients showed a 36.4% ± 8.6 reduction in volume and a 14% ± 1.6 reduction in index size after 1 month, with P values of .002 and .001, respectively. The final follow-up volume and index size were 194.7 cm³ ± 25.8 and 77 mm ± 36, respectively. Moreover, a 53.0% ± 7 reduction in volume and 22% ± 3.7 reduction in index size during the final imaging were reported, with the P values of .001 and .001, respectively. Significant reductions in the mean pain intensity (90% of patients with lower VAS scores after intervention) and symptoms were reported. Four patients were classified as clinically unsuccessful, and were recommended further procedures for residual pain.

CONCLUSIONS

CT fluoroscopy-guided transhepatic sclerotherapy is an effective, safe, and minimally invasive method to manage giant hepatic hemangiomas in an outpatient setting.

Liver transplantation for giant hemangioma of the liver: A case report and review of the literature

Large benign hepatic masses as a rare indication for liver transplantation have been reported less frequently. These liver transplantations are complex, with high intraoperative bleeding, high perioperative complication rates, and high mortality rates due to difficulties in visualization, especially when they have undergone various percutaneous operations or open surgery, resulting in severe perihepatic adhesions. Here is a case report of a patient admitted to our hospital who underwent liver transplantation after suffering from a giant hemangioma in liver transplantation for 10 years and who had received multiple interventional treatments ineffective in the past.

Individualized risk estimation for postoperative pulmonary complications after hepatectomy based on perioperative variables

BACKGROUND

At present, there is no perfect system to evaluate pulmonary complications of liver surgery using perioperative variables.

AIM

To design and verify a risk assessment system for predicting postoperative pulmonary complications (PPCs) after hepatectomy based on perioperative variables.

METHODS

A retrospective analysis was performed on 1633 patients who underwent liver surgery. The variables were screened using univariate and multivariate analyses, and graded scores were assigned to the selected variables. Logistic regression was used to develop the liver operation pulmonary complication scoring system (LOPCSS) for the prediction of PPCs. The LOPCSS was verified using the receiver operating characteristic curve.

RESULTS

According to the multivariate correlation analysis, the independent factors which influenced PPCs of liver surgery were age [≥ 65 years old/< 65 years old, odds ratio (OR) = 1.926, P = 0.011], medical diseases requiring drug treatment (yes/no, OR = 3.523, P < 0.001), number of liver segments to be removed (≥ 3/≤ 2, OR = 1.683, P = 0.002), operation duration (≥ 180 min/< 180 min, OR = 1.896, P = 0.004), and blood transfusion (yes/no, OR = 1.836, P = 0.003). The area under the curve (AUC) of the LOPCSS was 0.742. The cut-off value of the expected score for complications was 5. The incidence of complications in the group with ≤ 4 points was significantly lower than that in the group with ≥ 6 points (2.95% vs 33.40%, P < 0.001). Furthermore, in the validation dataset, the corresponding AUC of LOPCSS was 0.767.

CONCLUSION

As a novel and simplified assessment system, the LOPCSS can effectively predict PPCs of liver surgery through perioperative variables.

Management of hepatic haemangioma in pregnancy

Hepatic cavernous haemangioma is a benign tumour of vascular origin found within the liver. Often incidentally diagnosed, the management of these vascular masses is frequently determined by the size of the mass and symptoms associated with its compression of adjacent structures. Tumours >10 cm are known as giant haemangiomas and are associated with increased risks of compression symptoms, coagulopathies and haemorrhage. Known to express hormone receptors for oestrogen, intervention for these masses remains controversial in the setting of pregnancy where concerns for tumour growth and life-threatening complications are increased. Here we present the case of a woman in her 30s recently diagnosed with a giant haemangioma who is found to be pregnant, their management and a review of the literature.

The Two-Step Treatment for Giant Hepatic Hemangiomas

The aim of the present study is to analyze the feasibility and the impact of a two-step approach in the treatment of giant hemangiomas (GH) i.e., exceeding 10 cm in maximum diameter, consisting of transarterial embolization (TAE) followed by laparoscopic liver resection (LLR). Ten patients with 11 GH were treated with TAE and subsequent LLR between 2017 and 2020 (Group A). A matched cohort of 10 patients with GH treated with upfront LLR between 2014 and 2017 was identified for comparison (Group B). Data were analyzed regarding intraoperative and postoperative outcomes, including successful completion of LLR, morbidity, and mortality. Successful microparticle embolization of the GH-feeding arteries was performed in all patients in group A. In three cases a liquid embolic agent (Squid-18) was also injected to obtain complete embolization. No complications were observed after TAE. Successful surgery was performed after a mean time interval of 2.2 days from TAE without any case of conversion to laparotomy. Statistically significant differences between group A and group B were found in intraoperative blood loss (250 ± 200 vs. 400 ± 300 mL, p = 0.039), operative time (245 ± 60 vs. 420 ± 60 min, p = 0.027), and length of stay (5 ± 1 vs. 8 ± 2 days, p = 0.046). Our data suggest that two-step TAE + LLR might be a safe and effective option for surgical treatment of GH >10 cm.

Real-world data on the clinicopathological traits and outcomes of hospitalized liver hemangioma patients: a multicenter study

Background

There is currently a lack of consensus regarding the clinical features, diagnosis, treatment indications and options, and risk assessment of hepatic hemangioma patients.

Methods

This was a multicenter, real-world study that analyzed a large number of hepatic hemangioma cases in China and included patient data on epidemiology, diagnosis, treatment methods, and outcomes.

Results

A total of 5,143 patients hospitalized for hepatic hemangioma were included, of whom 34.42% were male and 65.58% were female. The age distribution was concentrated between 30 and 60 years old, accounting for 87.41% of the patients. Among the hepatic hemangioma patients, 60.8% had only one tumor, with the most common pathological type being cavernous hemangioma (96.07% of cases). The treatment motivations and indications included anxiety, obvious clinical symptoms, rapid tumor growth, unclear diagnoses and acute emergencies. Overall, 41.4% of the patients were treated for psychological reasons, while 30.59% were treated because they presented obvious (primarily nonspecific) clinical symptoms. Hepatic resection was the main therapeutic method and was based on various indications. There were a small number of patients with Kasabach-Merritt syndrome, according to its generally recognized definition.

Conclusions

Most patients in this study who were hospitalized for hepatic hemangioma did not meet the indications for requiring treatment. Surveillance is the recommended course of action for definitively diagnosed hepatic hemangioma, and a new classification system is needed to standardize the diagnosis of this condition.

Proton beam therapy for a giant hepatic hemangioma: A case report and literature review

Background

Hepatic hemangiomas are benign tumors with a favorable prognosis, but giant hepatic hemangiomas can cause abdominal symptoms and are indicated for treatment. Most cases are treated with surgery, but radiotherapy has also been used. However, to date, there have been no reports of proton beam therapy for a hepatic hemangioma.

Case presentation

A 46-year-old woman had a tumor of 80 × 80 mm in the left medial lobe of the liver, which was diagnosed as a giant hemangioma based on the contrast pattern. Therapy was required for a giant hepatic hemangioma with symptoms, but the patient refused blood transfusion due to religious reasons, which made surgical resection difficult. Therefore, she was referred to our hospital for proton beam therapy. At her first visit, liver function was Child-Pugh A (5 points) and there was no elevation of tumor markers. Proton beam therapy of 28.6 Gy (RBE) given in 13 fractions was performed without interruption. The only observed acute radiation toxicity was Grade 1 dermatitis. One year after proton beam therapy, the hemangioma had significantly decreased, and a complete response has been maintained for 15 years based on ultrasound and MRI.

Conclusion

This case is the first reported use of proton beam therapy for a hepatic hemangioma. The outcome suggests that this treatment may be effective for a giant liver hemangioma.

Efficacy and factors affecting the choice of enucleation and liver resection for giant hemangioma: a retrospective propensity score-matched study

Background

Liver resection (LR) and enucleation (EN) are the main surgical treatment for giant hepatic hemangioma (HH), but how to choose the type of surgery is still controversial. This study aimed to explore the efficacy and the factors affecting the choice of open procedure for HH.

Methods

The data for patients with pathologically confirmed HH who underwent open surgery from April 2014 to August 2020 were analyzed retrospectively. Univariate and multivariate analyses with logistic regression were performed to disclose the factors associated with the choice of EN or LR. Propensity score matching (PSM) analysis was used to compare the efficacy of the two procedures.

Results

A total of 163 and 110 patients were enrolled in the EN and LR groups. Following 1:1 matching by PSM analysis, 66 patients were selected from each group. Centrally located lesions (OR: 0.131, 95% CI 0.070–0.244), tumors size > 12.1 cm (OR: 0.226, 95% CI 0.116–0.439) and multiple tumors (OR: 1.860, 95% CI 1.003–3.449) were independent factors affecting the choice of EN. There was no significant difference in the median operation time (156 vs. 195 min, P = 0.156), median blood loss (200 vs. 220 ml, P = 0.423), blood transfusion rate (33.3% vs. 33.3%, P = 1.000), mean postoperative feeding (3.1 vs. 3.3 d, P = 0.460), mean postoperative hospital stay (9.5 vs. 9.0 d, P = 0.206), or the major complication rates between the two groups.

Conclusions

Peripherally located lesions, tumors size ≤ 12.1 cm and multiple tumors were more inclined to receive EN. There was no significant difference in the efficacy of EN or LR.

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.

Giant Liver Hemangiomas: A Plea for Early Surgical Referral and Resection

Hepatic hemangiomas are the most common benign hepatic tumor. Current guidelines recommend surveillance imaging and reserving surgical intervention for symptomatic patients with giant liver hemangiomas (>5 cm). We present the case of a patient with a rapidly enlarging giant hepatic hemangioma initially managed by surveillance. During her observation period, she developed weight loss, constipation, and pancytopenia concerning for Kasabach-Merritt Syndrome. Resection of the hemangioma was complicated by its large size (28.0×18.0×11.4 cm). Patients with rapidly growing giant liver hemangiomas, even when asymptomatic, should be promptly referred to specialized surgical centers for evaluation and management.

Totally Laparoscopic Resection of an Extremely Giant Hepatic Hemangioma

Risk of massive intraoperative hemorrhage and the difficulty to control it makes the laparoscopic treatment of giant hepatic hemangiomas (GH) a challenge for minimally invasive hepatobiliary surgeons. Symptomatic GHs of more than 20 cm (extremely giant hepatic hemangiomas) are typically treated with an open resection. There is a paucity of literature on laparoscopic resection of extremely giant hepatic hemangiomas. We describe (with video), here, the technical nuances of pure laparoscopic resection of an extremely giant hepatic hemangioma using modified port positions and the anterior approach.

Impact of open and minimally invasive resection of symptomatic solid benign liver tumours on symptoms and quality of life: a systematic review

BACKGROUND

The value of open and minimally invasive liver resection for symptomatic solid benign liver tumours (BLT) such as hepatocellular adenoma, focal nodular hyperplasia and haemangioma is being debated. A systematic review on symptom relief, quality of life (QoL) and surgical outcome after both open and minimally invasive surgery for solid BLT is currently lacking.

METHODS

A systematic search in PubMed and EMBASE was performed according to the PRISMA guidelines (January 1985-April 2018). Articles reporting pre-and postoperative symptoms or QoL in patients undergoing open or minimally surgery for BLT were evaluated. Methodological quality was assessed using the MINORS tool.

RESULTS

Forty-two studies were included with 4061 patients undergoing surgery for BLT, 3536 (87%) open and 525 (13%) laparoscopic resections. Randomized and propensity-matched studies were lacking. Symptoms were the indication for resection in 56% of the patients. After a weighted mean of 28.5 months follow-up after surgery, symptoms were relieved in 82% of symptomatic patients. Validated QoL tools were used in eight studies, of which two found significant better QoL scores following laparoscopic compared to open surgery.

DISCUSSION

Resection of symptomatic BLT seems safe and relieves symptoms in the vast majority of selected patients. Comparative studies are needed before more firm conclusions can be drawn.

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.

Pure laparoscopic liver resection for giant liver hemangioma with extrahepatic growth based on preoperative 3-dimensional simulation: A case report

Background

Performing laparoscopic liver resection for giant hemangiomas is challenging, and careful preoperative planning is essential. Controlling intraoperative bleeding and handling surgical instruments within a limited workspace is necessary.

Case presentation

In the present case, the patient was a 38-year-old woman diagnosed with a 16-cm giant liver hemangioma in segment 5/6, with extrahepatic growth. Preoperative three-dimensional simulations for port placement and the laparoscopic view from the left upper abdomen were performed to complete the pure laparoscopic liver resection. The laparoscopic resection was then safely performed on the same way.

Conclusions

Pure laparoscopic resection could be applied to giant hemangiomas with extrahepatic growth, and the preoperative three-dimensional simulation of port placement and the laparoscopic view might be helpful when the intraabdominal workplace is restricted.

Electronic supplementary material

The online version of this article (10.1186/s40792-019-0607-8) contains supplementary material, which is available to authorized users.

Enormous haemangioma of the liver

Haemangiomas are the most common benign tumours of the liver. Their origin lies in the proliferation of the vascular endothelium. Their growth mechanism is by dilation. They are considered giant when they exceed 5 cm at their greatest diameter. Very uncommon presentations surpass 15 cm; these are known as enormous haemangiomas. We present a case of a 54-year-old woman with an enormous haemangioma of 30 cm in diameter. A mass was present in her right upper quadrant along with dull abdominal pain for several years. It is unknown for how long the tumour had been developing. She underwent surgical management due to evident mass effect. Clinicians should be aware of the importance of early diagnosis in these types of tumours. Its erratic growth pattern, mass effect-related complications and the capacity of producing haematological abnormalities makes it an entity to be considered.

Transarterial Bleomycin-Lipiodol Embolization (B/LE) for Symptomatic Giant Hepatic Hemangioma

BACKGROUND

Large hepatic hemangiomas can cause symptoms such as pain and bleeding. No consensus currently exists on the optimal management of large and symptomatic hemangiomas. The purpose of this study was to evaluate the role of transarterial bleomycin-lipiodol embolization (B/LE) in the treatment of symptomatic large hepatic hemangioma.

MATERIALS AND METHODS

We retrospectively reviewed 23 patients (29 hemangiomas) treated between July 2011 and August 2017. Transarterial B/LE was performed using 7-15 cc of Lipiodol mixed with 30-45 IU of bleomycin by standard three-way stopcocks. All patients were followed clinically and by imaging for an average of 7.5 months. Patterns of bleomycin-lipiodol distribution in the periphery of hemangiomas were categorized into four different grades. Technical success was defined as proper delivery of bleomycin-lipiodol into the hemangioma confirmed by post-embolization computed tomography. Clinical success was defined as more than 50% reduction of hemangioma volume and symptom improvement during follow-ups.

RESULTS

Technical success and clinical success were 100 and 73.9% (17 patients), respectively. Six patients (26.08%) experienced transient post-embolization syndrome. Significant size reduction was seen in patients with grade 4 hemangioma border coverage (P = 0.042).

CONCLUSION

Transarterial B/LE is a safe and efficient alternative for controlling symptoms related to large hemangiomas.

Surgical Management of Giant Hepatic Hemangioma: Single Center's Experience with 144 Patients

BACKGROUND

Hepatic hemangioma (HH) is the most common benign solid tumor of the liver. The aim of this study is to review our experiences of surgical treatment for giant HH and to show the impact of HH size and type of surgical resection on surgical outcomes.

PATIENTS AND METHODS

This is a retrospective study of the cases who underwent surgery for giant HH during the period from January 2000 to April 2017.

RESULTS

Elective surgery was performed for 144 patients who had giant HH. The median diameter of resected HH was 10 cm (5-31 cm). Enucleation was performed for 92 (63.9%) patients and anatomical resection was required in 52 (36.1%) patients. No statistical difference between enucleation and resection as regards intraoperative and postoperative findings. The amount of intraoperative blood loss is significantly more in HH > 10 cm (300 vs. 575 ml, P = 0.007), the need of blood transfusion was significantly more in HH > 10 cm (P = 0.000), and the operation time was significantly longer in HH > 10 cm (120 vs. 180 min, P = 0.000). The size of HH had no significant effect as regards the development of postoperative complications.

CONCLUSION

Giant hemangioma can be treated surgically with low incidence of morbidity and mortality. No statistical difference between enucleation and resection as regards surgical outcomes. In left lobe HH, HH located deeper in posterior hepatic segments and in multiple HH, hepatic resection is preferred. The size of the HH had significant impact intraoperative blood loss and operative time.

Fever of Unknown Origin Caused by Giant Hepatic Hemangioma

CASE PRESENTATION

A 33-year-old man had fever for 2 months. He was admitted by the physician with the suspicion of pneumonia. However, both chest X-ray and computed tomography (CT) showed no abnormality. Tuberculosis and hematological and autoimmune diseases were all excluded. A giant hepatic lesion (20 cm) was detected by ultrasonography with the diagnosis of hemangioma. Contrast enhanced CT scan was conducted and hepatic hemangioma was confirmed. Some areas of the hepatic lesion had lower density compared to surrounding tissues and necrosis of the tumor was suspected.

TREATMENT

Right trisectionectomy was then performed and the symptom of fever disappeared after the operation. No bacteria grew in the culture of the necrosis tissue. Pathological examination confirmed the diagnosis of hemangioma and the necrosis.

RESULTS

He was followed up for 5 months and no fever occurred.

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.