| Part 1. The risk of operation for different sized liver hemangiomaObjectives To evaluate the risk of operation for different sized liver hemangioma and to reappraise surgical indications for liver hemangioma. Methods A retrospective cohort study was conducted of patients underwent operation for liver hemangioma in general hospital of PLA, Beijing, China during January 2006 and January 2014. All patients were divided into three groups according to the long diameters (d) of gross specimen, and they were group A (large hemangioma,5cm≤d<10cm), group B (giant hemangioma,10cm≤d<20cm) and group C (extremely large hemangioma, d≥20cm). The medical records of all patients were reviewed to document clinical presentation, characteristics of hemangioma, duration of surgery, intraoperative blood loss, morbidity, mortality and length of hospitalization. Results 362 patients were enrolled in this retrospective study with 217 in group A,119 in group B and 26 in group C. All patients underwent surgery successfully, the major morbidity was 4.7%(17/362), and no mortality was observed. The statistical difference between group A, B and C in intraoperative blood loss (300ml vs.500ml vs.1975ml, χ2=80.94, P<0.01), rate of perioperative blood transfusion (14.3% vs.30.2% vs.76.9%,χ2=53.65, P<0.01), and morbidity (2.3% vs.4.2% vs.26.9%, χ2=31.54, P<0.01) were significant. Further analysis with chi-square test revealed that the difference of morbidity between group A and group B was not statistical significant (x2=0.41, P=0.52). And obviously, these two groups had much lower morbidity than group C (χ2=24.96 and 11.67, P<0.01). Conclusions With the development of surgical techniques, the operation of hemangioma is of great safety. Different size of tumor below 20cm does not have a significant effect on morbidity. But the risk of operation should not be neglect in hemangioma larger than 20 cm and the prophylactic treatment should be reserved for rare situation.Part 2. Surgical approaches of giant hemangioma:enucleation or liver resection?Objectives The aims of this study was to compare the outcomes of giant hemangioma underwent enucleation or liver resection and clarify the rule of preferential approach with the guidance of precision liver surgery. Methods There were 145 patients with hemangioma no less than 10cm in part one, all of them were enrolled in this study. Patients were divided into two groups according to the different approach of operation (Enucleation or Liver Resection), the characteristics of hemangioma and the outcomes of operation were analyzed. Results Of 145 patients with giant liver hemangioma,81 patients underwent enucleation and 64 patients had liver resection. Hemangiomas located in right lobe were most common [53.1%(43/81)] in enucleation while both-lobes hemangiomas were most common [42.2%(27/64)] in liver resection. The differences of tumor size (12.0cm vs.15.5cm, Z=3.71, P<0.01), duration of surgery (210min vs.280min, Z=3.86, P<0.01) and the ratio of inflow control (81.5% vs.56.3%, χ2=10.91, P<0.01) of enucleation and liver resection were significant. The difference of intraoperative blood loss (500ml vs.800ml, Z=1.89, P=0.06) was not significant. There was no hospital mortality and the morbidity was low in both groups (8.6% vs. 7.8%, χ2=0.03, P=0.86). Conclusions Both of enucleation and liver resection are effective approaches for giant liver hemangioma, risk of bleeding and complications are rarely related to the type of operation. Procedures should be carefully individualized based on the bound of liver hemangioma with the guideline of precision liver surgery.Part 3. Surgical management of extremely large hepatic hemangioma Objectives The purpose of present study was to summary our experience of surgical management of extremely large hepatic hemangioma. Methods 26 patients in part one were underwent operation for extremely large hepatic hemangioma (no less than 20cm in size), the clinical characteristics, perioperative management, surgical treatments and outcomes were analyzed. Results Hemangioma-associated symptoms were presented in 19 patients (73.1%). The operations were successfully executed in all cases,13 patients were underwent anatomic liver resection,5 patients were underwent enucleation and 8 patients were treated with combination approaches. The median intraoperative blood loss was 1975ml (800-4000ml), and 16 patients (61.5%) got autologous transfusion with median blood volume 1000ml (500-1500ml), serious postoperative complications occurs in 7 patients which include postoperative bleeding in 5 patients and bile leakage in 2 patients, no hospital mortality was observed. Conclusions The surgical treatment of extremely lager hepatic hemangioma can be performed safely in experienced hands though the risk of bleeding is high. A considered perioperative management and accurate preoperative evaluation is needed in treatment of extremely large hepatic hemangioma, and the approach of operation should be applied individually, liver ischemia techniques and auto-transfusion could be helpful in reducing the risk of operation. |
