Disease profileHepatic hemangioma is a common benign tumor of the liver. The clinical features of cavernous hemangioma are the most common.
Hepatic hemangioma is a common benign tumor of the liver. The clinical features of cavernous hemangioma are the most common. The detection rate of autopsy is 0.35-7.3%, which is 5-20%. In recent years, with the improvement of people's awareness of health examination and the progress of various imaging diagnostic techniques, the rate of detection of asymptomatic small hemangioma was significantly increased. The majority of cases have no symptoms or mild symptoms, long course of disease, slow growth and good prognosis. There are not many basic and clinical research on this disease, the lack of mature and strict standard of diagnosis and treatment, treatment and indications of definition there are a lot of ambiguity or even wrong understanding, coexistence of traditional surgical treatment with radiofrequency ablation, hepatic artery embolization, radiotherapy, surgery, intraoperative microwave curing freezing and sclerotherapy a variety of treatment methods, treatment plan has not yet formed a unified clinical pathway for patient choice. [1-2]
Cause of disease
At present, the exact cause of hepatic hemangioma is not clear:
(1) congenital anomalies: at present, most scholars think that the theory of hemangioma is caused by congenital hepatic peripheral vascular malformations, generally during embryonic development due to hepatic vascular abnormalities caused by abnormal proliferation of vascular endothelial cells and the formation of hepatic hemangioma;
(2) the theory of hormone stimulation: some scholars have observed that the growth rate of hemangioma can be accelerated in female adolescence, pregnancy, oral contraceptives, and so on;
(3): other deformation such as capillary tissue after infection, cause telangiectasia, liver tissue necrosis after local vessel expansion formed vacuolated, its peripheral vascular engorgement; hepatic regional blood circulation stagnation, resulting in the formation of vascular sponge Zhuang Kuozhang. [3-4]
According to the number of fibrous tissue, hepatic hemangioma can be divided into 4 types:
(1) cavernous hemangioma is the most common type;
(2) sclerosing hemangioma;
(3) vascular endothelial cell tumor;
(4) capillary hemangioma, rare. The current use of classification according to the diameter size: < 5cm (small hemangioma); 5-10cm (hemangioma); 10cm-15cm (giant hemangioma); > 15cm (large hemangioma), may have a certain guiding hepatic hemangioma treatment, provide effective reference for the diagnosis and treatment of hepatic hemangioma. 
Hepatic hemangioma can occur at any age, with more than 30-50 years old, more women than men reported in the literature, the proportion of male and female 1:3-6. But 53859 healthy cases were the result of data analysis, liver hemangioma incidence rate was 3.11%, the incidence of male and female rate (3.36% VS.2.88%, P> 0.05), this phenomenon and reported different results, analysis from the previous literature reports are outpatient or inpatient exposure cases rather than large sample the population census, the majority of small hemangioma is not included in the relevant statistics. The constituent ratio of in-depth analysis of the census were male and female hemangioma size can be seen in the > hepatic hemangioma were 5cm the proportion of all cases, 2.56 times as many women as men (2.90% VS.1.26%, P> 0.05), the results support the previous assumption.
Further analysis of the relationship between age and incidence can be seen with the increase of age, the incidence has increased to the peak of 40-60 years old, and then decreased. May the explanation of this phenomenon is increased with age, occult hemangioma is difficult to detect because of the initial growth and gradually to be examined, the incidence rate increased; in 40-60 years, the hemangioma growth stopped even part of hemangioma has subsided by incidence has declined.
This phenomenon has been verified in the analysis of more than 131 years after the follow-up of more than 5 years. With the increase of age, the proportion of cases of hemangioma increased significantly, and the degree of enlargement of the largest diameter of hemangioma was significantly reduced. In the analysis of the relationship between gender, age and tumor size were found in the female hemangioma in all ages were lower than male hemangioma is large, and the size of the hemangioma increased with age increased to 40-60 years and reached the peak, then slightly reduced. From the above data is not difficult to get the effect of hemangioma development may be affected by the changes in hormone levels, estrogen may influence is more obvious, this may also explain why in diameter > hemangioma of liver 5cm, the incidence rate of female is higher than male's reason. [6-8]
The majority of liver hemangioma had no obvious symptoms were found in health examination by B-ultrasound or abdominal surgery, there is no evidence that they have the possibility of malignancy, other malignant tumors but occasionally with liver confused lead to misdiagnosis. When the hemangioma increases above 5cm, there may be non-specific abdominal symptoms, including:
(1) abdominal mass: the mass is cystic, no tenderness, smooth or not smooth, in the mass department can sometimes hear auscultation conduction vascular murmur;
(2): gastrointestinal symptoms can appear right upper abdominal pain and discomfort, loss of appetite, nausea and vomiting, belching, indigestion after eating saturated swelling;
(3) compression symptoms: large hemangioma can be generated by pushing and compression of the surrounding tissues and organs. The oppression of the lower esophagus, can appear dysphagia; extrahepatic biliary obstructive jaundice can occur, and the gallbladder effusion; portal vein compression system, there may be splenomegaly and ascites; oppression can appear dyspnea and lung atelectasis; gastric and duodenal compression, digestive tract symptoms can appear etc.;
(4) rupture of hepatic hemangioma, can appear abdominal pain, and bleeding and shock symptoms, is one of the most serious complications, for the growth of hepatic hemangioma in the costal arch following large rupture due to external bleeding, extremely rare;
(5) Kasabach-Merritt syndrome, which is caused by the presence of thrombocytopenia associated with a large number of coagulation factors. Retention of its pathogenesis is the giant hemangioma in the blood, consume a lot of red blood cells, platelets, blood coagulation factor II, V, VI and fibrinogen, caused by abnormal blood coagulation, which can be further developed into DIC;
(6) other: free in the growth of liver hemangioma with pedicle torsion, necrosis, abdominal pain, fever and prostration. There are also individual patients due to the presence of large arteriovenous fistula formation, resulting in an increase in the amount of cardiac blood and increase the burden on the heart, resulting in heart failure and death. There is also a rare biliary bleeding. 
Liver hemangioma is lack of specific clinical manifestations, imaging examination (such as B ultrasound, CT, MRI) is the main method for the diagnosis of hepatic hemangioma. According to the comprehensive literature report, the diagnosis rate of liver hemangioma was 57.0%-90.5%, the contrast of ultrasound was 94%, CT was 73.0%-92.2%, MRI was 84.0-92.7%, and hepatic angiography was.
Ultrasound examination is cheap, easy to operate, high prevalence, no trauma, safe and reliable, can be short-term dynamic observation of changes in focus, get more information, it is CT, MRI less than. The ultrasonic manifestations of hepatic hemangioma are mostly high echo, and the low echo is mostly reticular, with uniform density, regular shape and clear boundary. A large section of hemangioma can be lobulated, internal echo is still to enhance, a pipe network, or nodular or massive irregular hypoechoic areas, sometimes also can appear hyperechoic and calcification of posterior acoustic shadow system, intravascular thrombosis, or calcification caused by machine.
In recent years, the role of contrast enhanced ultrasound in the differential diagnosis of liver space has been recognized by the majority of doctors. Selective hepatic angiography may be considered in patients with atypical hepatic hemangioma. Hemangioma ultrasound typically manifests as artery in surrounding nodular or ring enhancement, with time increasing range gradually extended to the center, the expansion process is slow, the portal venous and delayed phase lesions still in enhancing the state, echo is equal to or higher than the surrounding liver tissue, this kind of "slow in and slow out" enhanced features with similar spiral CT. The sensitivity, specificity and accuracy of contrast-enhanced ultrasonography in the diagnosis of small hepatic hemangioma were 100%, 87%, 94%.
Helical enhancement CT
CT scan showed that the liver parenchyma within the realm of clear circular or circular low density lesions, a small number of irregular shape, CT value of about 30HU. Dynamic CT or multi phase spiral CT contrast enhancement scanning most typical performance: in the fast 20-30s after injection of contrast agent, the early arterial lesion edge showed nodular enhancement, enhanced density enhanced density is higher than that of normal liver; with the extension of time, 50-60s after injection of contrast agent, namely into portal vein enhancement, contrast enhanced mutual integration, gradually advancing to the center of the lesion, the strength decreased gradually; delayed scanning after a few minutes, the whole tumor uniform enhancement, enhanced density also continued to decline, increased higher than or equal to the surrounding normal liver parenchyma density, the contrast enhancement "reappears" characteristics of the process. Part of the cavernous hemangioma, delayed scan tumor center had irregular low density area with no enhancement, but still shows around the tumor characteristic of this kind of "spare".
MRI weighted T1 showed low signal, T2 weighted signal was high, and the intensity is uniform, the edge is clear, and the surrounding liver contrast is obvious, described as the "bulb sign", which is the specific expression of hemangioma in MRI. MRI enhanced dynamic scanning mode with CT. When the characteristic signs of CT and MRI have been clearly diagnosed, they do not have to be expensive or invasive examination, but also to avoid liver biopsy.
The accuracy of liver biopsy is low and can lead to bleeding, and hepatic artery angiography is invasive. Whole body positron emission tomography (PET/CT) has been shown to be valuable for the removal of metabolically active malignant tumors in recent years. [10-11]
The main differential diagnosis of hepatic hemangioma:
Primary or metastatic hepatocellular carcinoma (HCC) usually has a history of chronic hepatitis B and liver cirrhosis, with abnormal liver function and elevated AFP, and metastatic liver cancer;
Liver hydatid disease
With pastoral life history, sheep and dogs have contact history, liver hydatid intradermal test (Casoni test) were positive, eosinophil count increased;
Non parasitic cyst of liver
Solitary hepatic cyst is easy to be identified with hepatic hemangioma, and only a small number of polycystic liver may sometimes be confused with hepatic hemangioma. More than 50% patients of polycystic kidney and polycystic liver disease, since the beginning of the multiple, mostly with liver cysts, ultrasonography and CT examination showed lesions of varying size and boundary smooth and complete, there may be genetic factors;
Hepatic adenoma and hepatic vascular endothelial sarcoma were rare. The former develops slowly, but the tumor is hard like rubber; the latter develops rapidly and has the characteristic of malignant tumor. [12-13]
At present, there are a lot of controversies in the treatment of hepatic hemangioma, including resection of hemangioma, ligation of hemangioma, ligation of hepatic artery, microwave coagulation therapy, radiofrequency ablation, hepatic artery embolization and so on. It is also feasible for liver transplantation to diffuse hepatic hemangioma or unresectable giant hemangioma, such as hepatic decompensation or Kasabach-Merritt syndrome. For hepatic hemangiomas need treatment, should be integrated a variety of factors to consider, in order to benefit patients and safe and effective principle, based on the doctor's level of technology and experience, a variety of factors weigh, choose different treatments.
The following is only a different way to explain the treatment:
Resection of hepatic hemangioma is safe and effective, and complete resection is the only way to cure the disease. With the development of surgical techniques, the incidence and mortality of surgical complications are very low. Nevertheless, the operation still need to master the indications. The common surgical procedures include hepatic resection, tumor resection, laparoscopic liver resection, hemangioma suture, liver transplantation and so on.
With the development of surgical techniques and surgical techniques to improve the liver, liver resection significantly reduce mortality and complications, the application scope has been expanded to benign lesions in the liver, the liver hemangioma is benign liver lesions most commonly used liver resection. Patients with hepatic hemangioma have no history of liver cirrhosis, and have good liver compensation function. For giant hepatic hemangioma or multiple hemangiomas, it is usually possible to have regular hepatic segments, hepatic lobectomy, or even semi hepatectomy, but the liver resection should not exceed 70%-75%. The main problem of liver resection in the treatment of liver hemangioma is to control bleeding, because of hemangiomas with abundant blood supply, the tumor itself easy bleeding, thus increasing the difficulty of operation, and sometimes even operation properly can lead to uncontrollable bleeding, how to control the bleeding is the key to the success of the operation.
Resection of hepatic hemangioma
Liver hemangioma showed expansive growth, oppress the normal liver and bile ducts and blood vessels formed a thin fibrous capsule, the interface can be less vascular, blunt separation along the interface, stripping out of vessel tumor, namely "hemangioma extracapsular enucleation, less bleeding, can achieve completely the purpose of resection of the lesion. In 1988 Alper first reported by this procedure, a large sample of clinical research on liver resection and vascular tumor dissection were compared: operative time, dissection of the bleeding and transfusion were significantly less than the liver resection; liver injury of light, to maximize the retention of the normal liver tissues of patients the recovery of liver function; reduce of hepatic vessels and bile duct injury, reduce bleeding, reduce the incidence of biliary fistula.
At present, many scholars both at home and abroad have been respected, has become the main treatment of liver hemangioma. Regular hepatectomy only for suspected malignancy, or liver tumor was completely occupied a leaf. But some scholars believe that confirmation gap between hemangioma and liver parenchyma is difficult in some cases during operation, stripping may bleed more, especially the hemangioma of the inferior vena cava and other important structures near the hepatic vein and liver after blunt dissection is easy to tear the great vessels or damage the tumor, leading to uncontrollable bleeding.
(1) the tumor was located in the left lateral lobe of the liver, and should be selected for simple operation. In addition, multiple hemangioma confined to one lobe of the liver before hepatectomy, the one by one if the removal of tumor, injury, bleeding and time consuming;
(2) because the technique of right hepatectomy is relatively complicated and the injury is more serious, the removal of the right lobe of the liver is superior to that of hepatectomy;
(3) the middle of liver hemangioma near the hepatic portal vascular access and liver is not only closely related, may also invaded the left and right sides of hepatic lobes, hepatic resection for this tumor is more difficult to handle, peeling can not only avoid the hepatic hilum pipeline damage, also does not need to be cut too much normal the liver tissue and significantly reduce the bleeding during operation;
(4) large hemangioma should be treated with hepatectomy. Because of the huge hemangioma occupying the left hepatic lobe or right lobe or a liver segment, liver tissues, hepatic lobe or segment lesions of the normal liver tissue There is not much left. regular hepatic lobectomy, or liver resection so as not to lose a lot of normal liver tissue, and avoid enucleation may lead to tumor capsule or large vascular laceration bleeding;
(5) patients with suspected liver metastases who had no history of primary liver cancer or other malignant tumors were advised to undergo regular liver resection or local excision of a "safe margin";
(6) multiple hemangiomas located in different hepatic lobes or segments of the liver may be combined with the use of two surgical procedures.
Laparoscopic liver resection
Laparoscopic liver resection has become more and more mature, and it has obvious advantages such as less trauma, fewer complications, faster recovery and so on. The postoperative complications were similar to those of open surgery. Laparoscopic left lateral and left hemi hepatectomy may be a standard surgical procedure for the treatment of hepatic hemangioma. However, because of the special location, the hepatic hemangioma in the right posterior lobe, middle lobe of liver and caudate lobe is prone to massive hemorrhage. Although the scope of laparoscopic hepatectomy in the treatment of liver hemangioma is limited, however, with the development and breakthrough of laparoscopic treatment of hepatic hemangioma, this operation will have the broad application prospect of laparoscopic hepatectomy.
Liver hemangioma is a benign disease, liver transplantation is only used for the resection of giant hepatic hemangioma and serious complications such as Kasabach - Merritt syndrome, has not yet been widely carried out.
Hepatic hemangioma suture ligation of hepatic hemangioma is to make the tumor shrink, machine, or even disappear, so as to achieve the purpose of treatment of hemangioma. Due to lack of understanding of the anatomy of previous liver hemangioma, with banding, the tumor is small, crowded with longer, better effect, and the tumor is bigger, the strapping time shorter, the effect is worse. The recurrence rate after the operation of simple hemangioma is very high.
Ligation of hepatic artery
Hepatic hemangioma is usually supplied by the hepatic artery, and the tumor can be narrowed and soft after ligation of the hepatic artery. Combined with postoperative radiotherapy, the tumor can be hardened, which can improve the symptoms and control the growth of tumor. However, due to the existence of collateral circulation, the effect is more difficult to maintain, long-term effect is limited. Hepatic artery ligation is an important procedure for unresectable giant hemangiomas. Due to the adoption of new technologies in recent years, previously considered unresectable hemangioma has the technical conditions superior department of hepatobiliary surgery safety resection, the simple hepatic artery ligation in the treatment of hepatic hemangioma has been rarely used.
1, postoperative intra-abdominal hemorrhage
The majority of cases occur within 24h, which is a common and serious complication. Patients with liver hemangioma without cirrhosis based and preoperative liver function, postoperative blood coagulation dysfunction leading to less bleeding, mostly due to intraoperative thorough hemostasis or vascular ligation line loss caused by. For the postoperative hemorrhage of hemangioma should be actively laparotomy, with vascular suture tight suture suspected bleeding points, postoperative pay close attention to bleeding.
2, postoperative bile leakage
After the resection of hepatic hemangioma, the wound is large, and the main cause of bile leakage after operation is not found and a small bile duct ligation. Bile leakage after liver hemangioma operation needs to keep the drainage unobstructed, and it can be healed by itself.
3, postoperative liver dysfunction or failure
Often before operation and failed to fully assess other basic diseases, patients with liver remnant liver volume, intraoperative bleeding, long time of hypotension, intraoperative injury to retain liver into the liver or liver blood vessels, occurrence of portal vein thrombosis, postoperative residual liver liver blood flow in the torsion effect. In patients with hepatic vascular surgery using the method of blocking hepatic portal control blood flow into the liver, most patients with elevated aminotransferase, reached the peak at 2-3 days after operation, usually in about 1 weeks and decreased to normal range, some patients may also appear bilirubin increased slightly, can the liver support treatment gradually improved. The only way to do this is to have an emergency liver transplant. [14-16]
Transcatheter arterial embolization (TAE)
TAE treatment of liver hemangioma is a reference to TAE in the treatment of hepatocellular carcinoma, liver hemangioma theory is mainly by the hepatic artery embolization on tumors after arterial thrombosis, thrombus formation and fibrosis of the tumor fibroma like structure to reduce the purpose of hemangioma and hardening. However, the treatment of TAE for liver hemangioma is still controversial, the reason is that the long term effect of large hemangioma is poor, it is difficult to reduce the tumor body. And in intraoperative embolization agent embolization effect of hemangioma, often involving the normal blood supply of hepatic hilar and intrahepatic bile duct, can cause some serious complications, such as bile, tumor necrosis of liver cells, liver abscess, biliary cirrhosis, biliary stricture and biliary duct artery fistula. At the same time, although the side effects of vascular sclerosis, Pingyang, are less, but the side effects caused by pulmonary fibrosis and large doses of arterial injury can not be underestimated.
Microwave coagulation and radiofrequency ablation of hepatic hemangioma
Microwave coagulation therapy and radiofrequency treatment of hepatic hemangioma can be transformed into heat energy, so that the surrounding tissue coagulation, so that the local tumor shrinkage, hardening, to achieve the purpose of curing cancer. This method must be used to block the first porta hepatis in order to reduce the flow of blood in the tumor. It is difficult to completely cure the tumor of the liver hemangioma, and the recurrence rate is high. With the principle of RF and microwave similar to acceptable therapeutic effect of small hemangioma on > 8cm treatment effect is poor, and even lead to bleeding. Especially small aneurysm, tumor puncture and fibrous tissue less prone to uncontrolled bleeding, is the microwave curing or radiofrequency treatment taboo. At the same time, microwave coagulation and radiofrequency ablation can cause a large number of red blood cell destruction to release a large number of hemoglobin, which can cause acute renal failure and blood stasis. Therefore, under the guidance of ultrasound guided microwave coagulation or radiofrequency treatment of hemangioma should be very careful. It is not suitable for radiofrequency catheter ablation to cause the serious complications of adjacent organs, such as the tumor located in the center of the liver near the large blood vessels and adjacent organs such as the stomach and intestines, and adjacent to the diaphragm. [17-18]
With the deep understanding of the natural course of hepatic hemangioma, there is a new understanding of the timing and indications of the operation. Focus on the treatment of hemangioma is how to relieve symptoms and preventive control of huge hemangioma, multiple complications caused by rupture and bleeding may, also should give full consideration to the possible corresponding complications bring different treatment options, especially for the controversial no clinical signs and symptoms were not excessive treatment, unnecessary complications.
Treatment of hepatic hemangioma at present evidence is more chaotic, has determined by the size of the diameter of > 4-5cm; it should have determined by surgical treatment, symptoms and complications. From the data, the majority of hemangioma of the symptoms are not specific, it is difficult to differentiate from the gastrointestinal tract and biliary symptoms, causes symptoms in hemangioma diameter is less than 5cm less, and the left hepatic caudate lobe tumor vascular symptoms began to appear clearly in diameter greater than 6cm, while the right hepatic hemangioma to emerge more than 8cm. Therefore, the indications of surgery:
(1) right hepatic > 8cm, left liver and caudate lobe > 6cm, with definite symptoms or exogenous or growth rate of > 1-2cm/;
(2) hemangioma diameter greater than 10cm;
(3) complications, such as infection, fever, bleeding, and significant hematologic abnormalities;
(4) for patients older than the age of 60, it may be more severe because the vessel may no longer grow or grow slowly.
(5) in view of the fact that the hemangioma of the liver may increase during pregnancy, and can cause massive hemorrhage during delivery, it is necessary to have an aggressive surgical resection of the giant hemangioma of the liver in young women.
(6) for those who are engaged in strenuous exercise, such as boxers and football players, surgical removal may be considered.
(7) it was found that the growth rate of the tumor was faster than that of the others. It is suggested that the clinical symptoms, exogenous, rapid growth rate, and hematologic abnormalities should be the surgical indications for these patients.
In the treatment of hepatic hemangioma, the removal of hemangioma is superior to that of resection in safety, thoroughness, blood loss, blood transfusion and length of stay. Laparoscopic resection can be performed in a number of hemangiomas located at the periphery, the periphery, and the left lateral lobe of the liver in order to achieve minimal trauma and rapid recovery. TAE has certain curative effect and superiority of minimally invasive treatment of hemangioma of small, but < hemangioma 5cm often don't need treatment, but large hemangioma long-term TAE treatment effect is poor, may cause serious complications and increase the difficulty of surgery.
Suggested that even if found in physical examination of hepatic hemangioma, but also refer to the indications for surgery therapy, interventional therapy can be used in special cases selectively, such as old age, systemic complications, surgical contraindication of giant hemangioma surgery and patients with strong demand to.
In short, the diagnosis and treatment of hepatic hemangioma is in progress, as a common and frequently occurring disease of the liver, clinical treatment should be paid attention to, the attitude should be careful and strict, should pay attention to and other liver lesions, especially malignant disease identification.