Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):357-361. 10.14701/ahbps.2020.24.3.357.

Extended liver resection including hypertrophy concept with portal venous embolisation for giant haemangioma. Too much surgery?

• Strohmaier A
• Wagner KC
• Reese T
• Fard-Aghaie M
• Makridis G
• Rittberg Yv
• Horling K
• Oldhafer KJ

• KMID: 2505351
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.357

Abstract

Haemangiomas of the liver are benign tumours, which are often diagnosed randomly. With an increase in size haemangiomas could become symptomatic. In this case therapeutic options, surgical or interventional, have to be weighted to a conservative approach. We present a case of a 36-year old woman with a symptomatic giant haemangioma of the right liver lobe. Because of the size of the tumor and the small future liver remnant we decided to perform a major liver resection after hypertrophy induction with a preoperative portal vein embolization; an option mainly used for major hepatectomies in malignant tumors of the liver. But however, this case shows, that using a hypertrophy concept also for benign liver tumours is the safer approach, if an extended resection is necessary and the future liver remnant is critical.

Keyword

Haemangioma; Liver resection; Portal venous embolization

Figure

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  Fig. 1 Clinical findings. (A) Photograph from the right patient side. Distended abdomen due to enlarged liver. (B) Marking of the palpabel liver.

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  Fig. 2 Portal Vein Embolisation of all right hepatic portal veins. (A) Angiography of the portal vein with a five French- Pigtail-Catheter. The catheter is placed in the main portal vein. (B) Portal vein embolization with Glubran of the right anterior and posterior branch.

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  Fig. 3 CT-Scans. (A) Giant haemangioma in the right lobe of the liver and smaller haemangioma in segment III. (B) Volumetric CT scan of the left liver lobe. (C) CT Scan 2 weeks after PVE showing an enlarged left liver lobe. (D) Volumetric CT scan of the left liver lobe after PVE.

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  Fig. 4 Intraoperative situs. (A) Open abdomen; (B) Left liver lobe with haemangioma, measuring 29.5 cm; (C) Hypertrophied left liver lobe, measuring 23 cm; (D) Ligamentum hepatoduodenale: Gallbladder (1); Ductus hepaticus communis (2); Ductus choledochus (3); Left hepatic arteries (4); Duodenum (5); Segment I haemangioma (6); (E) Situs after extended right resection: Inferior vena cava (1); Left bile duct with inserted T-drain (2); Resection area (3).

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  Fig. 5 Pathological findings. (A) Specimen of the extended right resection (liver segment IV-VIII and I); (B) Cross section with characteristic structure of haemangioma with small streak of regular liver parenchyma on the left margin.

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  Fig. 6 (A) HE-stained sections showed the classic morphology of a cavernous haemangioma with widely dilated vascular channels lined by flattened inconspicuous endothelial cells and fibrous walls, (B) focal organized thrombi (1) and partial sclerotic areas (2) could be recognised.

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  Fig. 7 Adjacent liver parenchyma with peliosis hepatis like sinusoidal dilatation (1) and mild fibrosis of the portal tracts in Elastica van Gieson stain (2).

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