Chapter 3

In 2001 Terkivatan et al. study aimed to prove that surgical treatment may not be justifi ed during long term follow up of patient with benign tumors of the liver. This study involved other benign liver tumor s and a total of 208 patients were analyzed of which 49.5 % (103) were hemagiomas and 24.2 % (25) of those patients under­went surgical resection . The main indication for resection in this subset of patients was abdominal pain (60 %) followed by suspected metastases. Non-anatomic resec­tion (40 %) and segmental resections (28 %) were the most common procedures utilized. In terms of postoperative morbidity 24 % (6) had a reportable complica­tion. The mean follow up for this group was 39 months. Of the conservative arm (non operative) a mean follow up of 45 months showed no mortality or coagulation, although there’s no mention on growth or increased pain in the follow up [ 18 ].

In 2003 Yoon et al . at MSKCC published a large series where only hemangiomas where included. A total of 115 patients in the 8 year cohort were analyzed, 45.3 % (52 patients) presented with symptoms (abdominal pain ) and underwent surgical resection , whereas 54.7 % (63) where observed. Inability to exclude malignancy was the indication in 29 %.

The median size of the resected group was 11 cm vs 4 cm unresected group, and of those more than half (58 %) had tumors larger than 10 cm. Enucleation was the treatment of choice in 60 %. Their complication rate was 25 %. In the observation arm only four patients had persistent symptoms without major complications [ 5 ].

In the Amsterdam experience a cohort of 34 patients were identifi ed and surgical resection was undertaken in 14 (41 %) after a mean follow up of 36.5 months due to progressive abdominal pain and suspected malignancy. Fifty eight percent of a group of tumors >5 cm underwent surgical treatment whereas in the group of smaller hemangiomas (<5 cm) only 20 %. The observation arm did not show any complications with a mean follow-up of 19.6 month [ 20 ].

A retrospective cohort from the Mayo Clinic in 2010 evaluated the rate of hemangioma- associated complications in patients with giant hemangioma s after clinical observation and after operative management to identify the optimal treat­ment algorithm. This series was based in a survey examination. A total of 233 patient (80.6 %) fell in the nonoperative group and 56 (19.4 %). Only 11 % of the nonopera­tive group had symptoms whereas 52 % on the operative group had abdominal pain . Nine percent of patient in the observation group developed symptoms or complica­tions after diagnosis . Of the operative arm 34 patients had partial hepatectomy (60.7 %), 22 patients underwent enucleation (1 laparoscopic ). The survey revealed that 93 % of patients undergoing surgery had good or better health status and there was no statistical signifi cant difference in the overall rate of adverse events between the two groups. The long term risk of adverse events associated with non operative management is similar to the short term risk of operative intervention.

Another series of 2001 demonstrated the relationship between tumor size and presence of symptoms, this series included 155 patient with benign liver tumor s, of which 63 % (97 patients) had been diagnosed with hemangiomas, 40 % of those patients underwent resection with the main indication being persistent symptoms (23 %). The majority (53 %) underwent enucleation , followed by segmentectomy (20 %). The median follow-up was 16 months and the series complication rate was 21 % [ 25 ].

This study is the only one to compare a crucial factor when deciding on resection of hemangiomas, the location of the hemangioma. As seen on previous papers, peripherally located lesions are more amenable for laparoscopic resection [ 8 ].

In 2011 a cohort of 74 patients was analyzed and were divided in two groups, for their management , operative (54.1 %) and nonoperative (45.9 %) with a median follow-up of 77.3 months. Abdominal pain was present in 37.8 % of the total cohort and in 62 % of the patients undergoing resection compared to 8.8 % in the nonop­erative group. The mean size of the lesions was larger in the operative group (11.9 vs 6 cm). A total of 28 formal liver resection s were made and 12 enucleations. This cohort includes a change after year 2000 when 50 % were resected by enucleations, size not being any different for enucleation vs formal resection. The decision was based on the location and the relationship with major vascular and biliary structures. The resection group had more pedicle clamping time than the enucleation subset, the rest of the intraoperative parameter did not show any statistical difference [ 29 ].

Minimal invasive techniques include laparoscopic and robotic resection with adju­vant technical instruments that facilitate the procedure [ 30 ].

A most recent study from Ho et al. addressed factors determining surgical out­comes . The series includes 61 patients undergoing resection for giant hemangioma s (>4 cm), postoperative complications were associated with larger tumors, symp­tomatic presentation, increased blood loss and operative time and greater use of intraoperative infl ow control. A Pringle maneuver was used in 50.8 %. The patients who had complications the majority had central tumors and required lobectomy. The complication rate was 4 % for enucleation and 19.4 % for resection [ 34 ].

A study by Yang et al. aimed to compare an important technical aspect of the surgical resection of hemangiomas, selective hepatic vascular exclusion (SHVE). A total of 273 patients had a hemangioma at least compressing one of the major hepatic veins from. Either SHVE (n = 120) or Pringle maneuver (n = 153) was used. No protocol was used for the selection. There was a signifi cant difference favoring SHVE in the following intraoperative data: Blood loss (600 vs 1,000), blood trans­fusion units (2 vs 4). Major blood loss of 2000 L only happened in the Pringle group and 85 % in this group did not undergo a blood transfusion compared to 76 % in the Pringle group, also there was no air embolism and no conversion to total hepatic vascular exclusion (7.2 % in the Pringle group). The operative time was longer in the SHVE group (139.8 vs 124.2) The overall complication rate was higher in the Pringle group (30.7 % vs 20.8 %) [ 35 ].