HPB, 2006; 8: 200
201

Giant hemangiomas of the liver: surgical strategies and technical

aspects

P. BERLOCO, P. BRUZZONE, G. MENNINI, F. DELLA PIETRA, M. IAPPELLI,

G. NOVELLI & M. ROSSI

Division of General Surgery and Transplantation, Department of General Surgery, Surgical Specialties and Organ
Transplantation ‘‘Paride Stefanini’’, Rome, Italy

Abstract
The incidence of hemangiomas is 2
7% in the general population. We evaluated more than 300 patients with hepatic
hemangiomas. Surgical removal of hepatic hemangiomas was performed in 48 cases due to uncertain diagnosis (2 cases),
intractable symptoms (26 cases), size increase (18 cases), and liver failure in 2 cases that were treated by hepatic
transplantation. In all, 26 patients underwent enucleation of hemangiomas or segmentectomies, while the remaining 20
patients underwent right lobectomies or left lateral segmentectomies. Blood transfusions were required in four cases (including
two liver transplants); mean post-resection hospital stay was 6.3 days. We observed no perioperative mortality and only two
cases of major morbidity (bile leaks not requiring reoperation). Our experience confirms that, after adequate patient selection,
surgical treatment of hepatic hemangiomas is a very effective therapeutic choice with no mortality and low morbidity.

Key Words: Hemangioma, hepatectomy, Kasabach-Merritt, Budd-Chiari

Introduction
The incidence of hemangiomas is 2
7% in the general
population. Hemangiomas are the most frequent
benign hepatic tumors and are usually found in
patients aged between 40 and 60 years, more fre-
quently in women. In 30
35% of patients the lesions
are multiple. If larger than 4
10 cm, they are termed
‘giant’ hemangiomas [1].
Patients and methods
We evaluated more than 300 patients with hepatic
hemangiomas. Surgical removal of hepatic hemangio-
mas was performed in 48 cases due to uncertain
diagnosis (2 cases), intractable symptoms (26 cases),
size increase (18 cases), and liver failure in 2 cases that
were treated by hepatic transplantation. In all, 26
patients underwent enucleation of hemangiomas or
segmentectomies, while the remaining 20 patients
underwent right hepatectomies or left lateral segmen-
tectomies [2].
Results
Blood transfusions were required in four cases (in-
cluding two liver transplants); mean post-resection
hospital stay was 6.3 days. We routinely used a CUSA
Cavitron Ultrasonic Surgical Aspirator (CUSA Sys-
tem 200; Valleylab Inc., Boulder, CO, USA) together
with the TissueLink Floating BallTM device. The
Pringle maneuver was never required.
We observed no perioperative mortality and only
two cases of major morbidity (bile leaks not requiring
reoperation).
All patients (including the recipients of liver trans-
plantation) were completely cured of their symptoms
and remain alive and in good health, without long-
term complications, after a follow-up period ranging
from 2 months to 8 years.
Discussion
Surgical treatment of hepatic hemangiomas is re-
quired in case of complications such as platelet
sequestration (Kasabach-Merritt syndrome) [3],
Budd-Chiari syndrome, and rupture.
We agree with Cameron [4] that surgical treatment
of hemangiomas is indicated in case of severe,
intractable symptoms, absence of another etiology
for symptoms, diagnostic uncertainty, and intrapar-
enchymal or intraperitoneal hemorrhage.
The influence of estrogens and hormone replace-
ment therapy on hemangiomas is still under debate; in
pregnancy a conservative approach with serial ultra-
sound (US) monitoring is recommended.
Hemangiomas in newborns and infants grow ra-
pidly and can cause coagulopathy or high-output
cardiac failure. Therapy may require corticosteroids,

Correspondence: Paolo Bruzzone, MD, Via Santa Maria Goretti 38/10, 00199 Rome, Italy. Tel: /39 338 5369744. E-mail: paolo.bruzzone@fastwebnet.it

accepted 22 December 2005

ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis
DOI: 10.1080/13651820500539610

hepatic arterial embolization, a-interferon, cyclopho-
sphamide, external beam irradiation, and surgical
excision in case of rupture or failure of conservative
therapy.
The differential diagnosis between hemangioma
and hemangioendothelioma may be difficult, particu-
larly in children. Although we agree again with
Cameron [4] that fine needle cytology and core needle
biopsy (18 gauge), either percutaneously or laparos-
copically performed, is associated with a low risk
(0.03
0.04%) of hemorrhage and may be a useful
diagnostic tools, we usually avoid it.
Complications or diagnostic doubts are uncommon
indications for surgical treatment, while other intra-
abdominal diseases should be ruled out in sympto-
matic patients.
In fact, Farges et al. found additional intra-abdom-
inal diseasesin 42% of 163 patients with symptomatic
hepatic hemangiomas [5], while, according to Pietra-
bissa et al., 50% of patients remained symptomatic
after surgery [6].
Our experience confirms that, after adequate pa-
tient selection, surgical treatment of hepatic heman-
Giant hemangiomas of the liver 201
giomas is a very effective therapeutic choice with no
mortality and low morbidity [7,8].
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