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“数智化”及微创外科时代肝血管瘤规范化治疗
Standardized treatment of hepatic hemangioma in the era of digital intelligence and minimally invasive surgery
肝血管瘤作为常见肝脏良性肿瘤，其诊治理念已由以瘤体大小为核心的经验判断，转向以症状、增长速度、并发症风险、诊断确定性及全身状况为基础的综合评估，多学科综合治疗协作组（MDT）成为规范决策的重要前提。治疗目标强调在确保疗效的同时，最大限度保护正常肝实质，减少过度治疗。手术仍是重要手段，血管瘤剥除术因更符合良性病变的解剖特点被作为优先术式，肝切除则适用于病灶深在、范围广或难以保留周围肝组织者。围手术期管理重在控制出血风险，依赖血流阻断、肝脏悬吊、低中心静脉压及精细化器械应用。微创外科持续发展，腹腔镜与机器人技术在复杂病灶处理中显示出减少创伤、加快恢复和提升精准性的优势。基于CT、MRI的三维重建、吲哚菁绿（ICG）荧光导航、增强现实（AR）及人工智能（AI）辅助决策，推动手术由经验外科走向精准外科。介入治疗方面，经导管动脉化疗栓塞（TACE）已成为重要微创选择，对缩小病灶、缓解症状具有较好疗效，也可作为巨大肿瘤手术前的桥接措施，但其长期效果和适应范围仍需个体化判断。消融治疗以射频消融（RFA）和微波消融（MWA）为主，具有微创、高效特点，其中微波消融在缩短时间、减轻热沉效应和降低溶血相关风险方面更具优势。未来诊疗将沿着数智化整合、联合治疗优化、标准体系推广和个体化精准干预方向发展，以更小创伤换取更优临床结局。
As a common benign liver tumor, the diagnostic and therapeutic paradigm for hepatic hemangioma has shifted from experience-based judgment centered primarily on tumor size to a comprehensive assessment based on symptoms, growth rate, risk of complications, diagnostic certainty, and general condition. Multidisciplinary team (MDT) collaboration has become an important prerequisite for standardized decision-making. The therapeutic goal is to ensure efficacy while maximizing preservation of normal liver parenchyma and minimizing overtreatment. Surgery remains an important treatment modality. Enucleation is preferred because it is more consistent with the anatomical characteristics of benign lesions, whereas hepatectomy is more suitable for deeply located lesions, extensive lesions, or lesions in which preservation of the surrounding liver tissue is difficult. Perioperative management focuses on the control of bleeding risk and relies on vascular inflow occlusion, liver hanging maneuver, low central venous pressure, and the application of refined surgical devices. With the continuous development of minimally invasive surgery, laparoscopic and robotic techniques have shown advantages in the management of complex lesions, including reduced surgical trauma, faster postoperative recovery, and improved procedural precision. Three-dimensional reconstruction based on computed tomography (CT) and magnetic resonance imaging (MRI), indocyanine green (ICG) fluorescence navigation, augmented reality (AR), and artificial intelligence-assisted decision-making are driving the transition from experience-based surgery to precision surgery. In the field of interventional therapy, transcatheter arterial chemoembolization (TACE) has become an important minimally invasive option, showing favorable efficacy in reducing lesion size and relieving symptoms, and it can also serve as a bridging treatment before surgery for giant hemangiomas; however, its long-term efficacy and indications still require individualized evaluation. Ablative therapy mainly includes radiofrequency ablation (RFA) and microwave ablation (MWA), both of which are minimally invasive and efficient. Among them, MWA may offer advantages in shortening procedure time, reducing the heat-sink effect, and lowering the risk of hemolysis-related complications. In the future, diagnosis and treatment are expected to advance toward the integration of digital intelligence, optimization of combined treatment strategies, promotion of standardized systems, and individualized precision intervention, thereby achieving better clinical outcomes with less trauma.
肝血管瘤 / 肝切除术 / 血管瘤剥除术 / 经导管动脉化疗栓塞 / 热消融 / 微创外科 / 机器人手术 / 人工智能辅助决策
hepatic hemangioma / hepatectomy / hemangioma enucleation / transcatheter arterial chemoembolization / thermal ablation / minimally invasive surgery / robotic surgery / artificial intelligence-assisted decision-making
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Benign hepatic tumors include a broad spectrum of regenerative and true neoplastic processes. Because of advances in imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) as well as progress in immunohistochemistry, accurate diagnosis can now be made in a large percentage of patients without surgical laparotomy or resection. This article will focus on the pathogenesis, diagnosis, and management of focal benign lesions of the liver. Many of these tumors present with typical features in various imaging studies. On occasions, biopsies are required and/or surgical removal is needed. The most common benign hepatic tumors include cavernous hemangioma, focal nodular hyperplasia, hepatic adenoma, and nodular regenerative hyperplasia. In the majority of cases of benign hepatic tumors, patients are asymptomatic, and no treatment is indicated. The main indication for treatment is the presence of significant clinical symptoms or suspicion of malignancy or fear of malignant transformation.
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国际肝胆胰协会中国分会肝血管瘤专业委员会. 肝血管瘤诊断和治疗多学科专家共识(2019版)[J]. 中国实用外科杂志, 2019, 39(8): 761-765. DOI:10.19538/j.cjps.issn1005-2208.2019.08.01.
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Liver resection (LR) and enucleation (EN) are the main surgical treatment for giant hepatic hemangioma (HH), but how to choose the type of surgery is still controversial. This study aimed to explore the efficacy and the factors affecting the choice of open procedure for HH.The data for patients with pathologically confirmed HH who underwent open surgery from April 2014 to August 2020 were analyzed retrospectively. Univariate and multivariate analyses with logistic regression were performed to disclose the factors associated with the choice of EN or LR. Propensity score matching (PSM) analysis was used to compare the efficacy of the two procedures.A total of 163 and 110 patients were enrolled in the EN and LR groups. Following 1:1 matching by PSM analysis, 66 patients were selected from each group. Centrally located lesions (OR: 0.131, 95% CI 0.070-0.244), tumors size > 12.1 cm (OR: 0.226, 95% CI 0.116-0.439) and multiple tumors (OR: 1.860, 95% CI 1.003-3.449) were independent factors affecting the choice of EN. There was no significant difference in the median operation time (156 vs. 195 min, P = 0.156), median blood loss (200 vs. 220 ml, P = 0.423), blood transfusion rate (33.3% vs. 33.3%, P = 1.000), mean postoperative feeding (3.1 vs. 3.3 d, P = 0.460), mean postoperative hospital stay (9.5 vs. 9.0 d, P = 0.206), or the major complication rates between the two groups.Peripherally located lesions, tumors size ≤ 12.1 cm and multiple tumors were more inclined to receive EN. There was no significant difference in the efficacy of EN or LR.
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To compare the safety and efficacy of enucleation and hepatectomy for the treatment of hepatic hemangioma (HH).
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Laparoscopic treatment has been increasingly adopted for giant hepatic hemangioma (HH), but the role of liver resection or enucleation remains uncertain. The aim of this study is to compare the laparoscopic resection (LR) with laparoscopic enucleation (LE) for HH, and to provide evidence on how to choose the most suitable approach for HH.A retrospective analysis of HH patients underwent laparoscopic treatment between March 2015 and August 2022 was performed. Perioperative outcomes were compared based on the surgical approaches, and risk factors for increased blood loss was calculated by logistic regression analysis.A total of 127 patients in LR group and 287 patients in LE group were enrolled in this study. The median blood loss (300 vs. 200 mL, P < 0.001) was higher in LE group than that in LR group. Independent risk factors for blood loss higher than 400 mL were tumor size ≥ 10 cm, tumor adjacent to major vessels, tumor occupying right liver or caudate lobe, and the portal phase enhancement ratio (PER) ≥ 38.9%, respectively. Subgroup analysis showed that LR was associated with less blood loss (155 vs. 400 mL, P < 0.001) than LE procedure in patients with high PER value. Both LR and LE approaches exhibited similar perioperative outcomes in patients with low PER value.Laparoscopic treatment for HH could be feasibly and safely performed by both LE and LR. For patients with PER higher than 38.9%, the LR approach is recommended.© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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Surgical strategies for hepatic hemangiomas remain controversial, particularly concerning the influence of anatomical location and the use of tumor size thresholds. The proximity of tumors to major central hepatic vessels introduces significant surgical complexity and risks, yet its precise effect on perioperative outcomes and the appropriate application of size thresholds under varying anatomical conditions remain understudied. This study aims to evaluate the impact of proximity to major central hepatic vessels on perioperative outcomes and to assess the appropriateness of different size thresholds (8 cm vs. 10 cm) for risk stratification in varied anatomical contexts.
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This study aimed to determine the feasibility of the extracapsular enucleation method for giant liver hemangiomas by infrahepatic inferior vena cava (IVC) clamping and the Pringle maneuver to control intraoperative bleeding under laparoscopic hepatectomy.From January 2012 to January 2016, 36 patients underwent laparoscopic extracapsular enucleation of giant liver hemangiomas. Patients were divided into two groups: infrahepatic IVC clamping + Pringle maneuvers group (IVCP group, n = 15) and the Pringle maneuvers group (Pringle group, n = 21). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.The mean size of liver hemangiomas was 13.3 cm (range 10-25 cm). Infrahepatic IVC clamping + the Pringle maneuvers with laparoscopic extracapsular enucleation significantly reduced intraoperative blood loss (586.7 vs 315.3 mL, p < 0.001) and transfusion rates (23.8 vs 6.7%, p = 0.001), compared with the Pringle maneuver alone. The gallbladder was retained in both groups. The mean arterial pressure (MAP) in Pringle group remained virtually stable before and after clamping of hepatic portal, while it was significantly decreased after IVC clamping in IVCP group than that pre-clamping (p < 0.001). The heart rate of all patients was significantly increased after clamping when compared to pre-clamping heart rates (p < 0.001). Once vascular occlusion was released, MAP returned to normal levels within a few minutes. There were no significant differences in postoperative complications between two groups. The vascular occlusion techniques in both groups had no serious effect on postoperative of hepatic and renal function.Extracapsular enucleation with infrahepatic IVC clamping + the Pringle maneuver is a safe and effective surgical treatment to control bleeding for giant liver hemangiomas in laparoscopic hepatectomy.
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Surgical intervention is the most accurate method for the treatment of hepatic hemangioma. The advantages of laparoscopic surgery on quality of life should be clarified by prospective studies.The sample sizes of the laparoscopic and open surgery groups were calculated based on previous retrospective literature. Intraoperative and postoperative parameters were prospectively collected and analyzed. Quality of life in both groups was predicted by a mixed linear model.Sixty patients were enrolled in the laparoscopic surgery group and open surgery group. The laparoscopic group had a longer operation time (P = 0.040) and more hospitalization expenses (P = 0.001); however, the Clavien-Dindo classification and comprehensive complication index suggested a lower incidence of surgical complications in the laparoscopic group, with P values of 0.049 and 0.002, respectively. After mixed linear model prediction, between-group analysis indicated that the laparoscopic group had little impact on role-physical functioning and role-emotional functioning; in addition, within-group analysis showed a rapid recovery time on role-physical functioning and role-emotional functioning in the laparoscopic group. Quality of life in both groups recovered to the preoperative level within 1 year after the operation.The advantages of laparoscopic hepatectomy for hepatic hemangioma were fewer postoperative complications, lower impact on quality of life and faster recovery from affected quality of life.© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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This study aims to evaluate the safety and efficacy of laparoscopic enucleation for liver hemangioma in special hepatic segments.
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Minimally invasive techniques have increasingly been adopted for liver resection. This study aimed to compare the perioperative outcomes of robot-assisted liver resection (RALR) with laparoscopic liver resection (LLR) for liver cavernous hemangioma and to evaluate the treatment feasibility and safety.
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The purpose of the study is to evaluate the effectiveness and safety of transarterial chemoembolization (TACE) with pingyangmycin-lipiodol emulsion for the treatment of symptomatic giant hepatic haemangioma. Four hospitals (The Second Hospital of Shandong University, Qilu Hospital of Shandong University, Shandong Provincial Hospital and Jinan Municipal Hospital) participated in this study during 2002-2012. A total of 836 patients with symptomatic giant haemangioma were treated with pingyangmycin-lipiodol emulsion via selective TACE. The patients were followed-up for 12 months-10 years. The effectiveness of the treatment was evaluated by symptom assessments and upper abdominal magnetic resonance imaging or computed tomography. TACE was successfully performed for a total of 1120 lesions in 836 patients. Success rate of the procedure was 100 %. The mean diameter of the haemangiomas was significantly reduced after the interventional therapy (mean diameter 9.6 ± 0.8 vs. 3.6 ± 0.5 cm; P < 0.05). Symptom relief was achieved in all the patients during the follow-up period. No mortality was identified. TACE with pingyangmycin-lipiodol emulsion is a safe, feasible, and effective treatment for the giant symptomatic hepatic haemangioma.
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Hepatic hemangiomas (HHs) are the most common benign tumors of the liver. These tumors are mainly asymptomatic and do not require treatment. Nevertheless, there are some special cases that require therapeutic intervention, and surgery and intervention are currently the primary treatment modalities. Despite significant advances in the development of minimally invasive techniques and their popularization, interventional treatment of HH is still the preferred choice. In the present review, we discuss the pathological properties, type of blood supply, and treatment indications for HH and assess the status and progress of the existing interventional treatments.© 2022 Shanghai Journal of Interventional Radiology Press. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.
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Purpose: To evaluate the medium and long-term efficacy of superselective transcatheter arterial embolization (TAE) with lipiodol–bleomycin emulsions (LBE) for giant hepatic hemangiomas. Methods: A total of 241 patients who had underwent TAE with LBE for hepatic hemangiomas from January 2010 to December 2016 were retrospectively reviewed. Blood tests were performed 3 and 7 days after TAE and procedural-related complications were recorded. The patients were followed up by enhanced CT or MRI imaging at 6, 12, 36, and 60 months post-TAE, respectively. Technical success of TAE was defined as successful embolization of all identifiable arteries supplying to the hemangiomas. Clinical success was defined as improvement of the abdominal symptoms and indications on the imaging examinations that the hemangiomas had decreased by more than 50% in maximum diameter. Results: TAE was performed successfully in all patients without serious complications. Improvement of the abdominal symptoms was recorded in 102/102 cases (100%). The reduction rate of the tumor maximum diameter with >50% at 6, 12, 36, and 60 months was 88.1% (190/210), 86.7% (170/196), 85.2% (124/142), and 86.5% (45/52), respectively. There was a significant change from pre-TAE to follow-up values in maximum diameter (p < 0.05). Conclusion: TAE with LBE was feasible and effective for giant hepatic hemangiomas. The reductions of the tumor maximum diameter with >50% at medium (≥3 years) and long-term (≥5 years) follow-up were satisfactory, with 85.2% and 86.5%, respectively.
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Background:Transcatheter arterial embolization (TAE) is regarded as an effective treatment for patients with symptomatic hepatic hemangioma. However, few studies have evaluated the efficacy of TAE alone for treating hepatic hemangioma. The aim of this study was to identify the factors that influence the response to TAE and formulate a quantitative nomogram to optimize the individualized management of hepatic hemangioma.
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Treatment of hepatic hemangiomas is a controversial topic, and traditionally treatment is by surgical excision. Transcatheter arterial embolisation (TAE) and transcatheter arterial chemoembolisation (TACE) have been reported as minimally invasive treatment methods. To our knowledge, there are no studies comparing use of TACE and TAE for hepatic hemangioma treatment. The aim of the study is to compare symptom resolution, size reducing effects and complications of TACE and TAE for the treatment of giant hepatic hemangiomas.104 patients underwent TACE using bleomycin and 108 patients underwent TAE. The patients were followed-up for 2 year and follow-up images at 6 months, 12 months and 24 months were acquired. Lesion volumes in both follow-up images were calculated. The patients were examined for any possible procedure related complications as well as the status of their initial symptoms.The shrinkage period was determined to have ended after 12. month in the both group. The results of the Two-Way Mixed ANOVA showed that there was significant main effect of procedure type (p = <0.001) on hemangioma volumes. Similarly, there was a significant interaction between procedure and time (p = <0.001).Both methods are effective in symptomatic relief in properly selected patients. However, TACE causes greater volume reduction with less pain and therefore is the better endovascular treatment option.
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Liver embolization is a common procedure for management of liver lesions. Embolization can be performed using only an embolic material or along with chemotherapy agents. Infrequent complications seen postliver embolization include pulmonary thromboembolism, hepatic infarct, liver abscess, liver failure, ischemic biliary strictures, and less frequently pancreatic damage (incidence of 1.7%). We describe a case of necrotizing pancreatitis after bland embolization of a large hepatic hemangioma. The exact mechanisms of acute pancreatitis after liver embolization are uncertain, although direct ischemic mechanisms, toxic effects of antineoplastic agents, and volume of embospheres used are believed to play a role.
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Liver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.
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To report the complications of radiofrequency ablation (RFA) for hepatic hemangioma.
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Thermal ablation of large hepatic cavernous hemangiomas may lead to intravascular hemolysis, hemoglobinuria, and even acute renal failure. This study aimed to identify the risk factors associated with hemoglobinuria after ultrasonography-guided percutaneous microwave ablation for large hepatic cavernous hemangiomas. In our study, 11 related risk factors were analyzed using univariate and multivariate binary logistic regression model and Receiver operating characteristic curves to determine the contribution to hemoglobinuria after microwave ablation for 49 patients with 51 hepatic cavernous hemangiomas. By multivariate analysis, the ablation time (= 0.021; Odds Ratio, 1.005), and the number of antenna insertions (= 0.036; Odds Ratio, 3.568) were the independent risk factors associated with hemoglobinuria. The cutoff value for ablation time and the number of antenna insertions in predicting the presence of hemoglobinuria was 1185s (sensitivity, 75%; specificity, 69%) and 4.5 (sensitivity, 55%; specificity, 83%), respectively. Less than 5 of antenna insertions and less than 20 mins of ablation time may therefore be recommended in patients with microwave ablation of large hepatic cavernous hemangiomas, in order to reduce the occurrence of hemoglobinuria. This is the first report about the risk factors analysis associated with hemoglobinuria after thermal ablation for large hepatic cavernous hemangiomas.
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To improve treatment options for acute kidney injury (AKI) after microwave ablation (MWA) of hepatic hemangioma (HH).From January 1, 2021, to October 28, 2024, 117 patients with HH were treated by MWA at our center, and 2 of them occurred AKI after operation. The preoperative and postoperative data of 2 patients were retrospectively analyzed.During the MWA for patients with HH, hemoglobinuria may occur during and after surgery, which may even lead to AKI. A sequential treatment consisting of sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient as early and timely. And their renal function returned to normal.Patients with AKI after MWA of HH can fully recover. It suggested that MWA is an effective and safe treatment for HH patients.© 2025. The Author(s).
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