Surgical Treatment of Symptomatic Cavernous Hemangiomas of the ...

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(Kasabach-Merritt syndrome) resulting from sequestra- tion and destruction of platelets related to giant heman- giomas can be seen (4, 5). Even giant hepatic ...
Acta chir belg, 2004, 104, 172-174

Surgical Treatment of Symptomatic Cavernous Hemangiomas of the Liver H. A. Kayaoglu*, S. Hazinedaroglu**, N. Ozkan*, M. A. Yerdel** *Gaziosmanpasa University, School of Medicine, Department of General Surgery, Tokat, Turkey; **Ankara University, School of Medicine, Department of General Surgery, Ankara, Turkey.

Key words. Hemangioma ; liver ; surgery. Abstract. Background : Elective surgery for liver hemangiomas is still controversial. Material and Methods : Twenty-one patients, all symptomatic, underwent surgery for liver hemangiomas between August 1986 and June 2001. The primary indications for surgery were abdominal pain in 12 patients, pain and enlargement in 4, bleeding after needle biopsy in 1 and diagnostic uncertainty and suspicion of malignancy in 4. Results : Enucleation was the choice of operation in 18 patients. Hospital mortality and morbidity were 0% and 9.52 % respectively. Mean follow-up period was 58.55 months (2-180). Mean hospitalization time was 15.6 days (8-75) and mean transfusion requirement was 2.1 units (0-18) of erythrocyte suspension. The median largest dimension of the major lesions was 12.71 cm (2-30). Conclusion : Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, diagnostic uncertainty and bleeding after needle biopsy. The results of surgery without any mortality and minimal morbidity are safe and effective. Enucleation is the preferred operation and can be performed rapidly and safely.

Introduction Cavernous hemangioma is the most common tumour of the liver and is present in 0.7% to 7% of population (1). Because most lesions are asymptomatic and small, the true prevalence is unknown and is diagnosed incidentally or at autopsy (2). Those with a diameter more than 4 cm are called giant hemangiomas and may present as a symptomatic abdominal mass (3). Patients may present with slight discomfort in the upper abdomen, abdominal pain, early satiety or spontaneous rupture of hemangioma. More rarely, consumption coagulopathy (Kasabach-Merritt syndrome) resulting from sequestration and destruction of platelets related to giant hemangiomas can be seen (4, 5). Even giant hepatic hemangiomas can be asymptomatic (6). Pain, diagnostic uncertainty, enlargement, profound thrombocytopenia and rupture are indications for surgery (7, 8). Surgical methods are enucleation, liver resection, hepatic artery ligation and liver transplantation (9-12). Hemangiomas must be differentiated from malignant lesions to make appropriate diagnostic and therapeutic decisions (2). In this article, we report the results of 21 patients that underwent surgical therapy. Material and methods Between August 1986 and June 2001, 73 patients with hepatic hemangioma were admitted to the Hepatobiliary

Unit of the Surgery Department of the Faculty of Medicine, Ankara University. Among these 73 patients, 21 underwent surgical therapy by either anatomic resection (n = 3) or enucleation (n = 18). Patient medical records were reviewed for operation indications, tumour localization and size, removal technique, operation variables (transfusion requirement), hospital length of stay, postoperative morbidity and mortality rates. Results There were 17 women and 4 men varying in age from 37 to 77 years with an average age of 51. Hemangioma was single in 18 patients, double in 2 patients and quadruple in 1 patient. The median largest dimension of main lesions was 12.71 cm (2-30) . Mean hospitalisation time was 15.6 days (8-75). Methods for diagnosis included ultrasonography, computerised tomography, magnetic resonance imaging and angiography, or a combination of these. Indications for surgery were pain in 12, pain and increasing diameter of hemangioma in 4, suspicion of malignancy in 4, bleeding after needle biopsy in 1. There was Kasabach Merritt Syndrome in 2 patients. The increase in diameter of hemangiomas was 4 cm / 48 months, 13 cm / 84 months, 3 cm / 12 months, 2 cm / 14 months at pre-operative follow-up of 4 patients. Hepatic function tests were normal in all patients. Complete blood counts except for two patients with mild thrombocytopenia were normal.

Treatment of Liver Hemangiomas

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Fig. 1 Pre-operative computerized tomography images of the patient who had the only serious complication : that of left hepatic duct injury.

Enucleation was the preferred operation and was performed in 18 patients. A right hepatic lobectomy was performed in one patient and left hepatic lobectomy in two patients. A second hemangioma was enucleated in the patient who had undergone left hepatic lobectomy for a giant hemangioma. In June 1990 Hepatic artery ligation had been performed in one of the patients whose hemangioma was enucleated in April 2000. Twelve patients required transfusion of up to 18 units of erythrocyte suspension (mean 2.1). Two patients had postoperative complications, one wound infection was treated with drainage and antibiotic therapy and a left hepatic duct injury was treated in another patient whose hemangioma was 30 cm at its widest diameter. The injured left main hepatic duct was repaired after the placement of a stent inside the injured portion. Segments II and III which are vitally important to the patient were protected in this way (Fig. 1). At postoperative followup period a biliary fistula had developed via this injured duct. This controlled fistula persisted even after restenting with ERCP. After two mounts, the right hepatic lobe hypertrophied and became enough for patients survival. The patient was then re-operated and a left lateral segmentectomy was performed. At the follow-up period no fistula discharge was observed. There is no permanent morbidity in the patients followed-up between 2 months and 16 years and no surgical deaths.

The diagnosis of benign hepatic cavernous hemangioma was histologically confirmed without any malignant component in all specimens. The other 52 patients (18 Male) were all asymptomatic, except for 5 patients with slight abdominal pain, and their hemangiomas were detected incidentally at ultrasonographic examination for other reasons e.g. cholelithiasis. Their mean age was 49.69 and the median largest dimension of main lesions was 7.78 cm (120). The pain in these patients could easily be controlled with analgesics so did not necessitate any operation. Discussion Hemangiomas occur in people of all ages but are frequently diagnosed in adults (13). Most hepatic hemangiomas are small (≤ 4 cm in diameter) and asymptomatic. They have no clinical relevance but can be mistaken for primary or metastatic tumours of the liver. A complete diagnostic work-up must be done in such patients (14). Hemangiomas with a diameter of more than 4 cm. are called giant hemangiomas (3). Ultrasonography, computerised tomography, angiography, magnetic resonance imaging and labelled red blood cell scintigraphy can be used for diagnosis (1520). Of these ultrasonography, computerised tomography, magnetic resonance imaging and labelled red blood cell scintigraphy are effective, non-invasive methods and

174 sufficient for diagnosis in nearly all cases. Angiography and needle biopsy are invasive methods and should not be used as a routine procedure. Angiography is invaluable in the determination of the surgical anatomy and strategy. Radiologically guided needle biopsy may be very dangerous and may result in massive haemorrhage (21). We have performed needle biopsy on 3 patients and bleeding was seen in one of them. Although we have limited experience, we believe it should be done only in selected patients. These last two methods can be used particularly in cases with ongoing diagnostic uncertainty and a suspicion of malignancy despite all non-invasive diagnostic approaches. Pain, enlargement in diameter, diagnostic uncertainty, Kasabach Merritt syndrome and rupture are indications for the surgical removal of the liver hemangiomas (7, 8). In our series, there is a statistical sensitivity difference between operated and non-operated patient groups according to mean hemangioma diameter. So, uncontrolled pain seems to be related to the diameter of the hemangioma. Enucleation is the preferred method of surgical treatment and anatomic liver resections are rarely necessary. The advantages of enucleation are : 1. There is a dissection plane between liver parenchyma and hemangioma, so enucleation is simpler than resection through solid liver parenchyma. 2. There are no bile ducts at this plane so resection from here carries a low risk of biliary leakage. 3. Enucleation avoids unnecessary loss of healthy parenchyma (22). When uncontrolled symptoms are present or diagnosis is uncertain, surgical excision plays an important therapeutic role, to relieve the symptoms that are nearly 100 per cent related to the presence of the hemangioma and to confirm the diagnosis in all the patients. The results of our experience support these data, indicating that surgical resection of giant hemangiomas is a safe and definitive radical therapy when performed in specialized centres. Eighteen minor hepatic resections and 3 lobectomies were carried out without mortality and with little morbidity.

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H. A. Kayaoglu Bosna Caddesi Yesilırmak Mahallesi Mevlana Sitesi Blok : 4 Kat : 2 Daire : 8 60030 Tokat / Turkey Tel. : +90 356 2142589 E-mail : [email protected]