Successful liver resection in a giant hemangioma with intestinal obstruction after embolization

Abstract

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

Preoperative Trans-Arterial Embolization and Surgical Resection for Giant Liver Hemangioma: A Multidisciplinary Approach

“…Our outcomes are consistent with those from Vassiou et al, Bailey et al, and Kayan et al, who performed a similar technique with minimal blood loss, improved mobilization, and without inflow vascular occlusion [19][20][21]. Our quantified blood loss was also similar to the 400 mL reported by Zhou et al, who also reported a much longer post-operative stay than our patient (16 days vs. 7 days) [23]. We believe that TAE alone would not be an appropriate treatment option for this patient due to the side effects of TAE monotherapy, risk of future hemangioma complications, and insufficient evidence the patient's symptoms would resolve.…”

“…Due to the risks associated with TAE and a possible inflammation in the portal triad, some authors advocate for surgical resection either on the same day or within days of the embolization [19,21,34]. Conversely, Zhou et al argue that the timing of surgery should be based on close follow-up with the surgeon and interval imaging, ensuring that the hemangioma has decreased in size [23].…”

“…Risks associated with TAE include pain, inoperability, non-target embolization, bile duct injury, pyrexia, leukocytosis, and nausea [15,19,34,35]. When performed before surgical resection, TAE can improve hepatic mobility and reduce intraoperative blood loss [19,20,23]. Due to the risks associated with TAE and a possible inflammation in the portal triad, some authors advocate for surgical resection either on the same day or within days of the embolization [19,21,34].…”

“…Although traditionally treated with surgical resection or enucleation alone, recent treatment modalities include trans-arterial embolization (TAE), radiotherapy, radiofrequency ablation, transplant, chemotherapy, or multi-modal therapy [13]. Trans-arterial embolization has been proposed as a treatment option in giant symptomatic hemangiomas, both alone and in combination with resection [15][16][17][18][19][20][21][22][23].…”

Therapeutic Options of Giant Liver Hemangioma

“…In complicated hemangioma, transarterial embolization is used before surgery to stabilize ruptured lesion. In an extremely large lesion, Preoperative TAE is widely performed to decrease blood supply and to reduce tumour size making thus definitive surgery easier and less risked [22][23][24][25][26][27]. Radiofrequency ablation was successful to control symptomatic smaller lesions (5-10cm diameter) [28].…”