What Is Riskier for the Patient with an Asymptomatic Large Hepatic Hemangioma: Observation or the Surgeon?
- PDF / 108,568 Bytes
- 2 Pages / 595.276 x 790.866 pts Page_size
- 0 Downloads / 165 Views
INVITED COMMENTARY
What Is Riskier for the Patient with an Asymptomatic Large Hepatic Hemangioma: Observation or the Surgeon? Michael D’Angelica
Published online: 12 April 2013 Ó Socie´te´ Internationale de Chirurgie 2013
Hemangiomas, the most common benign tumor of the liver, can grow, compress critical structures, and cause symptoms necessitating resection. There is not much controversy over observing small asymptomatic hemangiomas. Furthermore, there is not much controversy over resecting symptomatic hemangiomas given that the symptoms are clearly related. Although there seems to be some consensus in recent years that large (with some variation in the definition of ‘‘large’’) asymptomatic hemangiomas should be observed, there may be an element of controversy regarding the role of prophylactic resection in these patients. Historically, the inability to exclude malignancy and concerns about rupture resulted in resection of hepatic hemangiomas. With modern imaging, including triphasic contrast-enhanced computed tomography and magnetic resonance imaging, the inability to diagnose a hemangioma is rare [1]. With the ability to diagnose hemangiomas reliably on imaging studies, what remains is to define the risk associated with observation, particularly with large hemangiomas. Three modern, adequately powered series have addressed this issue in more than 600 patients [2–4]. In sum, these series demonstrated that observation of asymptomatic hemangiomas, regardless of size, is safe. No ruptures were documented, and fewer than 20 % of patients developed any symptoms, most of which were minor. In one of the three series, there was a 2 % rate of life-threatening, hemangioma-specific complications [2], although none was documented in the other two series. In general, the morbidity rate associated with surgery in patients undergoing resection was greater than or similar to M. D’Angelica (&) Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA e-mail: [email protected]
the rate of symptoms or adverse events among patients being observed. The lesson was clear. No matter how big, asymptomatic hemangiomas do not require resection. In this edition of the World Journal of Surgery, Yedibela et al. [5] report a large series of resected and observed hepatic hemangiomas. Although in the end they found that the morbidity due to the surgery was similar to the morbidity associated with the observed large hemangiomas, there were some surprising outcomes in the observed patients. One finding was that nine patients (of 307) presented with ruptured hemangiomas: five spontaneous and four traumatic. Given the other recent publications that reported zero ruptures in more than 600 followed patients, this new finding seems to be an extraordinary clinical or statistical aberration. I have never seen or heard of a ruptured hemangioma in my surgical career (including 5 years of training at a major trauma center), and I wonder how many of the readers have. Two of these ruptures from trauma resulted in death, but we do not
Data Loading...
