Combined Liver Resection and Roux-en-Y Gastric Bypass for a Giant Hepatic Hemangioma: A case report and review of the literature

by Manuel Cáceres, MD; David. A. Geller, MD, FACS; and Carol A. McCloskey, MD, FACS

Drs. Cáceres and McCloskey are from University of Pittsburgh Medical Center Division of Minimally Invasive Bariatric and General Surgery Pittsburgh, Pennsylvania. Dr. Geller is from University of Pittsburgh Medical Center Liver Cancer Center.

Background
The obesity epidemic and the evolution of minimally invasive surgical techniques have dramatically increased the number of bariatric procedures performed annually. Roux-en-Y gastric bypass (RYGB) is the most frequently performed bariatric procedure in the United States. Based on incidental pathology, it is estimated that 2 to 2.5 percent of patients undergoing bariatric surgery will have an unexpected pathology found during surgery or during preoperative workup.[1,2] These unexpected findings rarely interfere with the completion of the planned bariatric surgery. Hepatic hemangiomas are the most common benign liver lesions. The prevalence of this hepatic lesion is between 5 and 20 percent.[3] Usually these benign tumors are asymptomatic and are found incidentally on screening radiological images, intraoperatively, or at autopsy. Controversy still exists about the excision of giant hemangiomas, defined as lesions larger than 4cm in diameter,[4,5] and resection is often limited to lesions that have an uncertain diagnosis, rapid growth, or associated symptoms.

Giant left lobe hemangiomas can significantly hinder exposure and increase the risk of bleeding during a RYGB. However, in the setting of a giant lesion that meets criteria for resection, a liver resection can be performed safely in combination with RYGB. Therefore, such a lesion should not preclude performing bariatric surgery in centers where liver resections can safely be performed.

We present a case report of a 61-year-old, morbidly obese man who presented for bariatric surgery and safely underwent a combined major liver resection and RYGB. He had a known history of multiple hepatic hemangiomas, including a giant lesion on the left lateral lobe of the liver. The location and size of this liver lesion required a liver resection in order to treat the lesion as well as to safely expose and perform the RYGB. To our knowledge, there has not been a reported case in the literature of a RYGB performed simultaneously with a major liver resection.

Case Report
The patient is a 61-year-old, morbidly obese man, with a body mass index (BMI) of 48 and multiple comorbidities, including non-insulin-dependent diabetes mellitus, depression, hypertension, coronary artery disease, hyperlipidemia, asthma, obstructive sleep apnea, and a history of deep venous thrombosis. The patient also had a known history of multiple, asymptomatic, hepatic hemangiomas, which were discovered incidentally several years prior to his bariatric evaluation.

The patient was referred for a consultation with a liver surgeon at our institution. He underwent a computed tomography (CT) scan of the abdomen that revealed an 11.5 by 6.7cm mixed hyper- and hypoattenuating lesion in the left lobe of the liver (Figure 1) and a 5.2 by 2.7cm lesion on the anterior aspect of the right lobe (Figure 2), suggestive of a hemangioma. Given the somewhat atypical CT appearance, a magnetic resonance imaging scan (MRI) was performed, and both lesions were felt to be probable hemangiomas. The left-sided lesion had increased in size from a scan performed a year earlier. Serum tumor markers (CEA, AFP, CA 19-9) were sent to confirm that these lesions were not malignant. The liver function tests (LFTs) were normal.

After the initial evaluation, it was determined that, despite the large size of the lesion, the overall size of the left lateral lobe was not extremely large. Therefore, it was felt that a laparoscopic RYGB (LRYGB), in the absence of a liver resection, was still a possible option that would have allowed his liver lesions to be addressed at a later time following weight loss. Preoperatively, the patient was well informed that the size and location of the liver lesion could possibly prevent a successful procedure if adequate liver retraction could not be obtained. During the laparoscopic exploration, the left lateral lobe mass was found to be very pedunculated and appeared to have surrounding inflammation, making it densely adherent to the underlying tissues of the lesser sac (Figure 3). The friable nature of the mass made laparoscopic manipulation and separation from the underlying tissues difficult and prevented the exposure necessary to complete a RYGB. It was decided that additional dissection and placement of a liver retractor would be a significant risk for intraoperative and/or postoperative bleeding. The procedure was aborted with the intention of planning a later combined procedure, as previously discussed with the patient as a possible outcome.

Given the enlarging size and atypical appearance of the mass, it was decided that a simultaneous left lobe resection and RYGB was an acceptable approach. It was also felt that initially doing a liver resection alone would make a later RYGB procedure more difficult due to adhesions. Also, this would significantly delay the timing of the bariatric procedure in a patient with advanced age and numerous obesity-related comorbidities. The liver lesions were not amenable to laparoscopic liver resection; therefore, the combined procedure was planned as an open midline approach.

Intraoperative findings consisted of a giant, exophytic mass with a gross hemangioma appearance on the left lateral lobe of the liver (Figure 4). There was an additional hemangioma to the left of the gallbladder at the junction of segments IV and V. A third lesion was seen on the right lobe at the junction of segments V and VI. The remaining liver was evaluated with intraoperative ultrasound, which did not reveal any additional lesions. The gallbladder was thickened and appeared chronically inflamed.

The liver surgery team performed a complete left lobectomy, resection of the right hepatic lesion, and excision of segments IVb and V for the third lesion encountered. An open cholecystectomy with intraoperative cholangiogram was performed, which did not reveal leaks at the cut edges of the liver, and the extrahepatic bile ducts were intact. The bariatric surgery team was called after the completion of the liver resection to perform the RYGB. An open antecolic, antegastric RYGB was performed, with a 150cm Roux limb and a 30cc capacity gastric pouch. Two drains were left at the end of the case, one near the gastrojejunal anastomosis and the other near the cut liver surface. Total operating room (OR) time was 350 minutes.

Postoperatively, the patient was progressed to a Phase I clear liquid diet after a negative gastrograffin upper gastrointestinal (UGI) study. The overall postoperative course was uncomplicated and the patient was discharged home on postoperative Day (POD) 6. The pathologic evaluation of the three liver specimens confirmed that the lesions were cavernous hemangiomas. There was also diffuse micro-macro vesicular steatosis of the liver parenchyma. The gallbladder had localized adenomyomatosis hyperplasia and cholesterol polyps. The patient was followed in the bariatric clinic for one year, and he has lost a total of 110 pounds. His midline incision healed well with no evidence of an incisional hernia. His LFTs were normal, and follow-up MRI of his liver revealed no recurrence of his liver lesions.

Review of the Literature
Hemangiomas are the most common benign tumors of the liver. The origin of hemangiomas is a matter of debate. Some theorize that they are slow-growing congenital lesions, while others feel that they are spontaneously occurring new neoplasms. They arise from the mesoderm and are composed of blood-filled cavernous spaces of varying sizes lined with a single layer of flat endothelial cells, which may be separated by fibrous septa of variable thickness. The majority of these lesions are completely asymptomatic and are found incidentally on imaging studies or intraoperatively. Large hemangiomas may become symptomatic and may present with upper abdominal pain, obstructive jaundice, or early satiety. On rare occasions, larger lesions can be associated with abcess formation, spontaneous rupture, or a diffuse intravascular coagulopathy known as the Kasabach-Merrit syndrome.

These lesions can be diagnosed using ultrasound, CT scan, MRI, and red blood cell scintigraphy. The sensitivity of these imaging studies is high, and percutaneous biopsy is not generally performed due to the risk of bleeding.

Controversy still exists about the indications for surgical excision of liver hemangiomas. Most hemangiomas are less than 4cm, but when greater than 4cm, are classified as giant hemangiomas.[4,5] Giant hemangiomas that cause intractable abdominal pain or compression of adjacent structures are indications for surgical resection. In the setting of diagnostic uncertainty of a hemangioma, resection may also be indicated. Overall size of the hemangioma should not be the sole indication for resection, but rapidly enlarging tumors are also considered for resection.

If a hemangioma is small and superficial, it can be enucleated from the liver parenchyma. Giant hemangiomas, often replacing the majority of a lobe, can require an anatomical resection, such as segmentectomy or hemihepatectomy.[6] Complications associated with major liver resections are bleeding and biliary fistula. These occur in about eight percent of liver resections for hemangiomas.[4,7] Major liver resections should be performed in high-volume centers by experienced surgeons. Embolization is not an effective treatment of giant hemangiomas, but can be used preoperatively in combination with resection to reduce intraoperative blood loss. There have been no prior published reports of a major liver resection simultaneously performed in the setting of
a LRYGB.

Conclusion
Roux-en-Y gastric bypass has become a frequently performed surgical procedure in the United States. The preoperative or intraoperative finding of a giant, left-sided, liver hemangioma may interfere with the appropriate exposure necessary to perform bariatric surgery. Therefore, combined liver resection at the time of RYGB is a feasible option to consider for lesions that meet resection criteria. This approach allows definitive treatment of the liver lesion while allowing the necessary exposure to safely perform a bariatric procedure. Such a complex procedure should be considered only at institutions with high volumes and significant experience with both procedures.

References
1.    Finnell CW, Madan AK, Ternovits CA, et al. Unexpected pathology during laparoscopic bariatric surgery. Surg Endosc. 2007;21:867–869.
2.    Gonzalez R, Haines K, Gallagher SF, et al. Management of incidental ovarian tumors in patients undergoing gastric bypass. Obes Surg. 2004;14:1216–1221.
3.    Erdogan D, Busch OR, van Delden OM, et al. Management of liver hemangiomas according to size and symptoms. J Gastroenterol Hepatol. 2007;22:1953–1959.
4.    Herman P, Costa ML, Machado MA, et al. Management of hepatic hemangiomas: A 14 year experience. J Gastrointest Surg. 2005;9(6)853–859.
5.    Mungovan JA, Cronan JJ, Vacarro J. Hepatic cavernous hemangiomas: lack of enlargement over time. Radiology. 1994;191:111–113.
6.    Hamaloglu E, Altun H, Ozdemir A, et al. Giant liver hemangioma therapy by enucleation or liver resection. World J Surg. 2005;29:890–893.
7.    Yoon SS, Charny CK, Fong Y, et. al. Diagnosis, management and outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg. 2003;197:392–402.

Category: Case Report, Past Articles