Severe biliary complications after hepatic artery embolization

Safety and Feasibility of Transarterial Bleomycin-Lipiodol Embolization in Patients with Giant Hepatic Hemangiomas

Giant hepatic hemangiomas present a significant clinical challenge, and effective treatment options are warranted. This study aimed to assess the safety and feasibility of transarterial bleomycin-lipiodol embolization in patients with giant hepatic hemangiomas. A retrospective analysis was conducted on patients with giant hepatic hemangiomas (>5 cm). Transarterial chemoembolization (TACE) was performed using 7-20 cc of lipiodol mixed with 1500 IU of bleomycin. Safety outcomes, including post-embolization syndrome (PES), hepatic artery dissection, systemic complications, and access site complications, were evaluated. Radiation doses were also measured. Feasibility was assessed based on the achieved hemangioma coverage. Seventy-three patients (49 female, 24 male) with a mean age of 55.52 years were treated between December 2014 and April 2023. The average hospitalization duration was 3.82 days, and 97.3% of lesions were limited to one liver lobe. The average bleomycin dose per procedure was 1301.5625 IU, while the average lipiodol dose was 11.04 cc. The average radiation dose was 0.56 Gy. PES occurred after 45.7% of TACE procedures, with varying severity. Complications such as hepatic artery dissection (three cases), access site complications (two cases), and other complications (one case) were observed. No treatment-related mortality occurred. Hemangioma coverage exceeding 75% was achieved in 77.5% of cases. The study results suggest that transarterial bleomycin-lipiodol embolization is a safe and feasible treatment option for a heterogeneous group of patients with giant hepatic hemangiomas. This approach may hold promise in improving outcomes for patients with this challenging condition.

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.

[Radiation therapy of hepatic haemangiomas: Review from a case report]

Haemangioma is the most frequent benign hepatic tumour. Haemangioma is generally asymptomatic but it can sometimes cause disabling symptoms depending on its size and location. Surgery and interventional radiology are the cornerstone of the treatment in this situation. Radiation therapy, already used with good efficacy and safety to treat hepatic malignant lesions as hepatocarcinoma and metastases, is a relevant option in case of contraindication to surgery because of multiple or very large lesions. In this context, we report the case of a patient presenting with multiple symptomatic hepatic haemangiomas, successfully treated by radiation therapy in our department. These good results justified a review of the literature to report series of patients treated in this indication and to describe the main treatment regimens used.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

Emergency endovascular treatments for delayed hemorrhage after pancreaticobiliary surgery: indications, outcomes, and follow-up of a retrospective cohort

PURPOSE

To evaluate the outcomes of emergency endovascular treatments for delayed bleeding after pancreaticobiliary surgery.

METHODS

We retrospectively evaluated 21 patients (M:F = 13:8, median age = 64 years) undergoing 23 endovascular treatments, performed from 2010 to 2017 in a single center. Data collected were patient characteristics; surgery; pathology; incidence of postoperative pancreatic fistulas (POPF); bleeding signs on CT and angiography; damaged artery; endovascular tools used; technical and clinical success; intervals between surgery, endovascular treatment, and discharge; survival rates.

RESULTS

Sixteen patients had pancreatoduodenectomy, three hepaticojejunostomy, two distal pancreatectomy. Indications for surgery were mainly biliary (33%), pancreatic (19%), or duodenal (10%) malignancies. Seventeen patients had "grade C" POPF, three suffered a biliary leak, one had no POPF. Active bleeding was present in 17/23 CTs and in 22/23 angiographies, mostly from hepatic (43%), gastroduodenal (22%), and splenic (13%) arteries. The endovascular treatments were performed with coils (26%), glue (22%), stent-graft (22%), and their combinations (30%). Sixteen patients had a single endovascular treatment, one underwent a second embolization, three had subsequent surgery, one had repeat embolization followed by surgery. Relaparotomy rate was 19%. Median hospital stay was 37 days (range 12-75); median intervals among pancreaticobiliary surgery, endovascular treatment, and discharge were 21 (2-36) and 12 (8-47) days, respectively. We observed 4/21 intrahospital deaths (median: 31 days from endovascular treatment, 4-53); 1-year survival rate of discharged patients was 71%.

CONCLUSIONS

Endovascular treatment using embolization and/or stent-graft placement is a useful first-line intervention to halt postoperative hemorrhage after pancreaticobiliary surgery and decreases the need for urgent relaparotomy.

Pediatric cystic artery pseudoaneurysm embolization

Cystic artery pseudoaneurysm is an exceedingly rare complication of biliary interventions, such as cholecystectomy, or cholecystitis [1]. Prompt intervention is often required due to their predisposition to bleeding. Ideal diagnosis and treatment would have the patient go directly to Interventional Radiology for angiography and embolization, followed by a short interval cholecystectomy [2, 3]. However, due to their low incidence patients often undergo several less invasive diagnostic tests prior to diagnosis [4]. Here we describe what we believe is the first reported pediatric case of a cystic artery pseudoaneurysm secondary to cholecystitis.

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.

Radiological findings in ischaemic cholangiopathy

Ischaemic cholangiopathy occurs as a consequence of deficient arterial blood flow to the bile duct wall. Bile duct ischaemia can lead to full-thickness necrosis, bile leakage, biloma formation, and sepsis. It is an important cause of graft failure post-orthotopic liver transplantation. In the native liver, the causes of biliary ischaemia are diverse and include vasculitis or a complication of endovascular procedures. The present review describes the pathology and radiological findings of ischaemic cholangiopathy and outlines the role of interventional radiology in its management.

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.

Stable gastric pentadecapeptide BPC 157 in the therapy of the rats with bile duct ligation. Eur J Pharmacol. 2019;847:130-142. [PMID: 30690000 DOI: 10.1016/j.ejphar.2019.01.030]

Recently, stable gastric pentadecapeptide BPC 157 reversed the high MDA- and NO-tissue values to the healthy levels. Thereby, BPC 157 therapy cured rats with bile duct ligation (BDL) (sacrifice at 2, 4, 6, 8 week). BPC 157-medication (10 μg/kg, 10 ng/kg) was continuously in drinking water (0.16 μg/ml, 0.16 ng/ml, 12 ml/rat/day) since awakening from surgery, or since week 4. Intraperitoneal administration was first at 30 min post-ligation, last at 24 h before sacrifice. Local bath BPC 157 (10 µg/kg) with assessed immediate normalization of portal hypertension was given immediately after establishing portal hypertension values at 4, 6, 8 week. BPC 157 therapy markedly abated jaundice, snout, ears, paws, and yellow abdominal tegmentum in controls since 4th week, ascites, nodular, steatotic liver with large dilatation of main bile duct, increased liver and/or cyst weight, decreased body weight. BPC 157 counteracts the piecemeal necrosis, focal lytic necrosis, apoptosis and focal inflammation, disturbed cell proliferation (Ki-67-staining), cytoskeletal structure in the hepatic stellate cell (α-SMA staining), collagen presentation (Mallory staining). Likewise, counteraction includes increased AST, ALT, GGT, ALP, total bilirubin, direct and indirect and decreased albumin serum levels. As the end-result appear normalized MDA- and NO-tissue values, next to Western blot of NOS2 and NOS3 in the liver tissue, and decreased IL-6, TNF-α, IL-1β levels in liver tissue. Finally, although portal hypertension is sustained in BDL-rats, with BPC 157 therapy, portal hypertension in BDL-rats is either not even developed or rapidly abated, depending on the given BPC 157's regimen. Thus, BPC 157 may counteract liver fibrosis and portal hypertension.

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.

Transarterial Bleomycin-Lipiodol Embolization (B/LE) for Symptomatic Giant Hepatic Hemangioma. Cardiovasc Intervent Radiol. 2018;41:1674-1682. [PMID: 29922860 DOI: 10.1007/s00270-018-2010-4]

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.

Transarterial Embolization for Treatment of Symptomatic Polycystic Liver Disease: More than 2-year Follow-up

Background:

Currently, treatment of symptomatic polycystic liver disease (PLD) is still a challenging problem, especially for these patients who are not feasible for surgery. Minimally invasive options such as laparoscopic fenestration and percutaneous cyst aspiration with sclerotherapy demonstrated disappointing results due to multiple lesions. Because the cysts in PLD are mostly supplied from hepatic arteries but not from portal veins, transcatheter arterial embolization (TAE) of the hepatic artery branches that supply the major hepatic cysts can lead to shrinkage of the cyst and liver size, relieve symptoms, and improve nutritional status. This study aimed to evaluate the effectiveness of TAE with a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized oil for patients with severe symptomatic PLD during a more than 2-year follow-up.

Methods:

Institutional review board had approved this study. Written informed consent was obtained from all patients. From February 2007 to December 2014, twenty-three patients (20 women and 3 men; mean age, 49.0 ± 14.5 years) infeasible for surgical treatments underwent TAE. Changes in the abdominal circumferences, volumes of intrahepatic cysts, hepatic parenchyma volume, and whole liver, clinical symptoms, laboratory data, and complications were evaluated after TAE.

Results:

Technical success was achieved in all cases. No procedure-related major complications occurred. The median follow-up period after TAE was 48.5 months (interquartile range, 30.0–72.0 months). PLD-related severe symptoms were improved remarkably in 86% of the treated patients; TAE failed to benefit in four patients (four patients did not benefit from TAE). The mean maximum abdominal circumference decreased significantly from 106.0 ± 8.0 cm to 87.0 ± 15.0 cm (P = 0.021). The mean intrahepatic cystic volume reduction rates compared with pre-TAE were 36% at 12 months, 37% at 24 months, and 38% at 36 months after TAE (P < 0.05). The mean liver volume reduction rates were 32% at 12 months, 31% at 24 months, and 33% at 36 months (P < 0.05).

Conclusions:

TAE with the mixture of NBCA and iodized oil appears to be a safe and effective treatment method for patients with symptomatic PLD, especially for those who are not good candidates for surgical treatments, to improve both hepatic volume and hepatic cysts volume.

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.

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.

Histological and Clinicopathological Evaluation of Liver Allograft Biopsy: An Initial Experience of Fifty Six Biopsies

INTRODUCTION

Liver biopsy is gold standard for diagnosis of allograft dysfunction.

AIM

The aim of study was to evaluate liver allograft biopsies performed for graft dysfunction, study the pattern of injury and intensity, and timeline of occurrence of graft dysfunction.

MATERIALS AND METHODS

Retrospective study was carried out of 56 liver allograft biopsies and their histological findings with clinical presentation were correlated. Totally 56 needle liver allograft biopsies from January 1210 to July 2014, obtained from 35 patients were studied for histological and clinicopathological evaluation.

RESULTS

The mean age was 53.2±5.48 years. The most common original disease was alcoholic cirrhosis. The most common histological lesion was acute cellular rejection (ACR) in 31 (55.36%) biopsies followed by preservation-reperfusion injury (PRI) in 10 (17.86%) biopsies and drug toxicity in 8 (14.29%) biopsies. Chronic rejection was reported in 2 (3.57%) and recurrence of HCV in 3 (5.36%). Ischemic coagulative necrosis and acute cholangitis were seen in 1 (1.79 %) case each.

CONCLUSION

Alcoholic cirrhosis was the most common etiology for end stage liver disease. ACR and PRI were the major complications in liver allograft biopsies at our centre.

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.

Management of liver hemangioma using trans-catheter arterial embolization

BACKGROUND

Hemangioma, a congenital vascular malformation, is the most common benign liver lesion that is usually remain stable subsequently requiring not treatment; however, complications such as abdominal pain or fullness, coagulation disturbances, and inflammatory syndrome may occur, demanding a specific treatment of hemangioma.

OBJECTIVES

To assess the safety, feasibility and efficacy of trans-catheter arterial embolization (TAE) for the treatment of Liver hemangioma.

PATIENTS AND METHODS

TAE was performed on 20 patients with liver hemangioma. The embolic agent used was polyvinyl alcohol (PVA) particles (300-400 micron, Jonson and Johnson Cordis, USA). All patients were followed up for 6 months. Imaging was carried out and patients were also evaluated symptomatically through telephone interview by a physician.

RESULTS

Twenty patients aged from 21 to 63 years (mean: 46.8, SD: 10.26) were included in this study. Post embolization syndrome, including abdominal pain, fever, and leukocytosis occurred in one patient 1 week after TAE and lasted for 3 days. No serious adverse event and TAE-related death was observed. None of the patient underwent another intervention including surgery. During follow up interval, decreased episode of abdominal pain was documented in all patients who had pain. Tumor enlargement was also stopped during the follow up. The average diameter of tumors was 97.00 mm (range: 25-200 SD: 47.85) and 88.95 mm (range: 23-195 SD: 43.27) before and after embolization, respectively. Comparison of images before and after TAE revealed statistically significant decrease in the size of lesion (P value: 0.004, t: 3.31).

CONCLUSIONS

Our findings indicate that TAE is a safe and efficient procedure for the treatment of liver hemangioma. Further studies with larger sample sizes are required to support therapeutic effects of TAE.

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.

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

AIM

To describe initial clinical experience with bipolar radiofrequency ablation (RFA) for symptomatic giant hepatic haemangiomas.

MATERIALS AND METHODS

Four consecutive patients with a large-volume, symptomatic hepatic cavernous haemangioma of >10 cm were treated with bipolar RFA during laparotomy with ultrasound guidance. Complications were carefully noted. Clinical and radiological effectiveness were evaluated comparing baseline with 3 and 6 months follow-up of symptom assessments and upper abdominal magnetic resonance imaging (MRI) or computed tomography (CT).

RESULTS

RFA was successfully performed for all four giant haemangiomas. No major complications were observed. Peri-procedural shrinking was remarkable and intermediate-term volume reduction ranged from 58-92% after 6 months. Symptom relief after 6 months was complete in two patients and considerable in the other two.

CONCLUSION

Preliminary results suggest intra-operative bipolar RFA to be a safe, feasible, and effective technique for treatment of giant symptomatic hepatic cavernous haemangiomas.

Radiofrequency ablation for large hepatic hemangiomas: initial experience and lessons

OBJECTIVE

We aimed to assess the feasibility, safety, and efficacy of radiofrequency (RF) ablation for the treatment of large (≥5 cm in greatest diameter) hepatic hemangiomas.

METHODS

Thirty-six patients (15 male, 21 female; mean age 50 years) with 41 hepatic hemangiomas ≥5 cm in diameter were enrolled and treated with RF ablation attributable to the presence of enlargement tendency and/or persistent hemangioma-associated symptoms. Twenty patients had 24 hemangiomas <10 cm, and 16 patients had 17 hemangiomas ≥10 cm. Technical success, complications related to RF ablation, completed ablation, symptom relief, change in size of ablation zone, and recurrence of the residual tumor were analyzed.

RESULTS

Of the 41 hemangiomas with a mean diameter 10 ± 4 cm (range, 5-22 cm), 26 subcapsular lesions were treated with a laparoscopic approach, and 15 lesions located in liver parenchyma underwent a computed tomography-guided percutaneous approach. RF ablation was performed successfully in all patients. There were 62 complications related to the ablation in 22 patients, including 6 of 20 patients with hemangiomas <10 cm and all the 16 patients with hemangiomas ≥10 cm. According to the Dindo-Clavien classification, 2 complications (lower esophageal fistula and acute respiratory distress syndrome, Grade III and Grade IV, respectively) were major in 2 patients with hemangiomas ≥10 cm; all the other were minor in 20 patients (Grade I). All the complications were recovered by conservative treatment. Thirty-eight (93%) of 41 hepatic hemangiomas were ablated completely, including all the 24 lesions <10 cm and 14 of 17 lesions ≥10 cm. All the symptoms related to hemangiomas disappeared (n = 22) or were ameliorated (n = 4) after ablation. The mean diameter of ablation zone was decreased to 6 ± 3 cm (2-12 cm) in a mean follow-up period (X ± SD) of 15 ± 6 months (range, 6-24 months), without recurrence or enlargement of the 3 residual tumors.

CONCLUSION

The present study supports RF ablation as an alternative treatment for hepatic hemangiomas ≥5 cm (but smaller than 10 cm) for the low risk of complications and likelihood of complete ablation, but, in contrast, RF ablation appears to be an inappropriate method for hepatic hemangiomas ≥10 cm because of the high occurrence rate of complications.

Visceral arteriography in trauma

The nonoperative management including endovascular treatment of traumatic injuries to most abdominal solid viscera is increasingly gaining acceptance as treatment of choice in a select group of patients. The indications, techniques, and principles of endovascular management of hepatic, splenic, and renal injuries are discussed in this review.

Symptomatic-enlarging hepatic hemangiomas are effectively treated by percutaneous ultrasonography-guided radiofrequency ablation

BACKGROUND & AIMS

We aimed to evaluate the feasibility, efficacy, and safety of percutaneous ultrasonography-guided radiofrequency ablation for the management of symptomatic-enlarging hepatic hemangiomas.

METHODS

Twenty-four patients (5 male and 19 female, with mean age of 49.5±2.2) with 25 hemangiomas over 4 cm underwent percutaneous RFA due to either the presence of symptoms or the enlargement of hemangioma compared with previous imaging studies.

RESULTS

The mean diameter of hemangioma was 7.2±0.7 cm (4.0-15.0 cm) with 16 hemangiomas in right and 9 hemangiomas in left lobe. Twenty-three hemangiomas (92.0%) were successfully treated by radiofrequency ablation. The mean diameter of hemangiomas was decreased to 4.5±2.4 cm (p<0.001) in serial follow-up CT scans over mean period of 23±3.8 months (23-114 months). Symptoms related to hemangioma disappeared without enlargement of hemangiomas in all successfully treated patients. There were 14 adverse events in 10 patients including abdominal pain, indirect hyperbilirubinemia (>3.0 mg/dl), fever (38.3°C), anemia (<10 g/dl), and ascites, which were successfully managed by conservative treatment.

CONCLUSIONS

Percutaneous ultrasonography-guided radiofrequency ablation is an effective, minimally invasive, and safe procedure for the management of symptomatic-enlarging hepatic hemangioma.

Seeking beyond rejection: an update on the differential diagnosis and a practical approach to liver allograft biopsy interpretation

Pathologic evaluation of liver allograft biopsies plays an integral role in the management of patients after liver transplantation. This review summarizes the clinical context and classical histology of different types of allograft rejection and also the common entities that enter the differential diagnosis of allograft rejection, and provides practical approaches to liver allograft biopsy interpretation. In addition, some of the new developments in the field of liver transplant pathology are updated. The purpose of this review is to provide guidance for pathologists interpreting liver allograft biopsies, particularly those interested in developing expertise in the field of liver transplant pathology.

Experimental evaluation of early and long-term effects of microparticle embolization in two different mini-pig models. Part II: liver

PURPOSE

To evaluate trisacryl-gelatin microspheres (40-120 microm) for acute and chronic tissue embolization in mini-pig livers.

METHODS

Thirteen animals were divided into four groups: group 1 (n = 3), total arterial bed occlusion with acute procedure; groups 2 to 4, chronic superselective embolization with follow-up of 1 week (group 2, n = 1), 4 weeks (group 3, n = 4) or 14 weeks (group 4, n = 5). Key endpoints were homogeneity and particle distribution in acute embolizations (group 1) and necrosis and inflammation in chronic embolizations (groups 2-4) as assessed microscopically and angiographically.

RESULTS

After liver embolization, parenchymal necrosis did not occur; only signs of vessel wall disintegration were evident. The bile ducts remained intact. A distinct foreign body reaction with sparse leukocytic infiltration and giant cells was found at 14 weeks, but no signs of major inflammation were found. Particles were seen at the presinusoidal level, but no particle transportation into the sinusoids was observed.

CONCLUSIONS

Embolization in mini-pig livers, using small trisacryl-gelatin microspheres, results in vessel fibrosis without parenchymal or bile duct necrosis. The most likely explanation for preservation of the parenchyma is portal inflow. Small trisacryl-gelatin microspheres may be ideal as an adjunct for chemoembolization.

Arterial embolization for hemorrhage caused by hepatic arterial injury

Fewer than 10% of patients with major liver trauma have life-threatening bleeding. Laparoscopic operations, endoscopic procedures, and percutaneous interventions such as drainages, vascular or tumor sclerosis, biopsies, and transjugular intrahepatic portocaval shunt (TIPS) have increased the number of iatrogenic vascular and bile duct injuries. Due to its therapeutic success, arterial embolization (AE) has become the standard treatment for late complications of hepatic injury. In some cases, this procedure may be used as the first approach on accidental or iatrogenic arterial trauma and in several hepatic arterial diseases. The result of this method depends on physician experience, size of the wound, and stability of the patient. Persistent hemorrhage and rebleeding may be treated with a new AE or an operation. Precise indication and a correctly performed AE are key factors for a successful treatment. Rebleeding episodes are a rare occurrence, which may be treated with AE as well.

Hypoxia-induced changes in the expression of rat hepatobiliary transporter genes

Cholestatic disorders may arise from liver ischemia (e.g., in liver transplantation) through various mechanisms. We have examined the potential of hypoxia to induce changes in the expression of hepatobiliary transporter genes. In a model of arterial liver ischemia subsequent to complete arterial deprivation of the rat liver, the mRNA levels of VEGF, a hypoxia-inducible gene, were increased fivefold after 24 h. The pattern of VEGF-induced expression and ultrastructural changes, including swelling of the endoplasmic reticulum, indicated that hypoxia affected primarily cholangiocytes, but also hepatocytes, predominantly in the periportal area. Serum and bile analyses demonstrated liver dysfunction of cholestatic type with reduced bile acid biliary excretion. Fluorescence-labeled ursodeoxycholic acid used as a tracer displayed no regurgitation, eliminating bile leakage as a significant mechanism of cholestasis in this model. In liver tissue, a marked reduction in the mRNA levels of Na(+)-taurocholate-cotransporting polypeptide (Ntcp), bile salt export protein (Bsep), and multidrug resistance-associated protein 2 (Mrp2) and an increase in those of Cftr were detected before bile duct proliferation occurred. In cultured hepatocytes, a nontoxic hypoxic treatment caused a decrease in the mRNA and protein expression of Ntcp, Bsep, and Mrp2 and in the mRNA levels of nuclear factors involved in the transactivation of these genes, i.e., HNF4alpha, RXRalpha, and FXR. In bile duct preparations, hypoxic treatment elicited an increase in Cftr transcripts, along with a rise in cAMP, a major regulator of Cftr expression and function. In conclusion, hypoxia triggers a downregulation of hepatocellular transporters, which may contribute to cholestasis, whereas Cftr, which drives secretion in cholangiocytes, is upregulated.

Enucleation of centrally located giant hepatic hemangioma: report of two cases

Two centrally located giant hepatic hemangiomas were referred with severe pain, one of which had a protruding abdominal mass was listed for transplantation at another center. Tumors were 35 and 30 cm at their longest diameter. One was centrally located involving the hilum and segments VI/VII and II/III were partially spared. Volumetric analysis and imaging suggested enucleation is feasible if the left lateral segment and the right posterior sector are left intact. Operation was straightforward except few breaks in enucleation technique in an effort to secure the venous drainage of the remnant liver. She had an uneventful recovery except a biliary fistula through the operatively severed left hepatic duct, which was repaired over a stent. This was managed by lateral segmentectomy and resection of the fistula after the enlargement of the right posterior sector was confirmed volumetrically. The other tumor-involved segments II, III, IV, V, and VIII and the hilum were totally hemangiomatic. Enucleation and postoperative recovery was uneventful. The era of liver transplantation enhanced our knowledge about complex liver surgery and these cases are good examples about the feasibility of enucleation even in extremely complicated liver hemangiomas saving both the patients and a donor liver.

Laparoscopic radiofrequency ablation of hepatic cavernous hemangioma. A preliminary experience with 27 patients

BACKGROUND

Radiofrequency ablation (RFA), currently used extensively for liver tumors, also has been applied successfully to hepatic cavernous hemangioma (HCH) percutaneously. The aim of this study was to assess the feasibility, safety, and efficacy of laparoscopic RFA for patients with HCHs.

METHODS

Between March 2001 and March 2004, 27 patients with symptomatic and rapid-growth lesions were treated by laparoscopic RFA using the RF-2000 generator system. The treatment-related complications were observed. All the patients were followed up with helical computed tomography scans and ultrasonography at regular intervals to assess the therapeutic efficacy of laparoscopic RFA.

RESULTS

This study assessed 9 men and 18 women with a mean age of 41.6 +/- 8.3 years. Three additional intrahepatic lesions missed preoperatively were found in three patients on intraoperative ultrasound. A total of 27 patients with 50 liver lesions were treated successfully with laparoscopic RFA. The mean maximum tumor diameter was 5.5 +/- 2.0 cm. The mean length of time for RFA per lesion was 20.7 +/- 11.9 min, and the mean blood loss was 134.4 +/- 88.9 ml. Laparoscopic cholecystectomy was performed simultaneously for gallstones in 13 patients and for abutting of gallbladder from hemangioma in 2 patients. In addition, 3 patients also had a laparoscopic deroofing of simple hepatic cysts. Although postoperative low-grade fever and transient elevation of serum transaminase levels were observed in 13 patients, there were no complications related to laparoscopic RFA. During a median follow-up period of 21 months (range, 12-42 months), complete lesion necrosis was achieved for all the patients.

CONCLUSIONS

Laparoscopic RFA therapy is a safe, feasible, and effective treatment option for patients with symptomatic and rapid-growth HCHs located on the surface of the liver or adjacent to the gallbladder. Intraoperative ultrasonography is a useful adjunct for detecting additional liver lesions and offering more accurate targeting for RFA.

Ultrasonography guided percutaneous radiofrequency ablation for hepatic cavernous hemangioma

AIM: Hepatic cavernous hemangioma (HCH) is the most common benign tumor of the liver and its management is still controversial. Recent success in situ radiofrequency ablation of hepatic malignancies has led us to consider using this technique in patients with HCH. This study was to assess the efficacy, safety, and complications of percutaneous radiofrequency ablation (PRFA) under ultrasonography guidance in patients with HCH.

METHODS: Twelve patients (four men and eight women, age ranged 33-56 years, mean age was 41.7 years) with 15 hepatic cavernous hemangiomas (2.5 cm to 9.5 cm) were treated using the RF-2000 generator and 10-needle LeVeen electrode percutaneously guided by B-ultrasound. Lesions larger than 3 cm were treated by multiple overlapping ablations that encompass the entire lesion as well as a rim of normal liver tissue (approximately 0.5 cm).

RESULTS: All the patients who received PRFA therapy had no severe pain, bleeding or bile leakage during and after the procedures. Nine to 34 months’ follow-up (mean, 21 months) by ultrasound and/or spiral CT scan demonstrated that the ablated lesions in this group were shrunk remarkably, and the shrunken range was 38%-79% (mean, 67% per 21 months). The contrast enhancement was disappeared within the tumor or at its periphery in all cases on spiral CT scans obtained 3 to 6 months after treatment.

CONCLUSION: The results of this study suggest that PRFA therapy is a mini-invasive, simple, safe, and effective method for the treatment of selected patients with HCH.

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40%. Unfortunately, only 25% of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.