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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 123-127

Anesthetic management of a giant cavernous hemangioma of liver posted for right hepatectomy

Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission15-Dec-2020
Date of Acceptance12-Jul-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Sivakumar Segaran
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_85_20

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Hepatic hemangiomas (HH) are benign tumors of the liver with an incidence of 0.4%–20%. Most of the HH are asymptomatic with incidental discovery and shows female preponderance. They range from small hemangiomas to large cavernous hemangiomas involving the entire liver. Large hemangiomas will develop symptoms and complications that require prompt surgical intervention or other treatment modalities. Most large liver hemangiomas require hepatic resection which is a complex procedure involving vascular structures and physiological derangements. Hepatic resection requires meticulous anesthetic and surgical management with proper blood replacement therapy. Coagulopathy, hepatic and renal failure and bile leak are some of the important complications of hepatic resection. We present successful management of a case of hepatic hemangioma who underwent right hepatectomy.

Keywords: Consumptive coagulopathy, giant cavernous hemangioma liver, hepatectomy, massive blood and products, replacement

How to cite this article:
Fatima A, Sekar P, Segaran S, Zachariah M. Anesthetic management of a giant cavernous hemangioma of liver posted for right hepatectomy. J Curr Res Sci Med 2021;7:123-7

How to cite this URL:
Fatima A, Sekar P, Segaran S, Zachariah M. Anesthetic management of a giant cavernous hemangioma of liver posted for right hepatectomy. J Curr Res Sci Med [serial online] 2021 [cited 2022 Jun 28];7:123-7. Available from: https://www.jcrsmed.org/text.asp?2021/7/2/123/334467

  Introduction Top

Hepatic hemangiomas (HH) are benign tumors of the liver with clusters of blood-filled cavities, lined by endothelial cells, fed by the hepatic artery with an incidence of 0.4%–20%.[1] The vast majority of HH are asymptomatic, discovered incidentally on imaging. Women are more susceptible, with a reported prevalence of 4.5:1–5:1 ratio of female to male. Typically, hemangioma range from a few mm to >10 cm (most commonly), large hemangiomas will develop symptoms and complications that require prompt surgical intervention or other treatment modalities.

The major concerns during partial hepatectomy include hemodynamic instability, hemorrhage, biliary leak, hepatic failure, pulmonary complications, sepsis, and coagulopathy.[2] However, improvement in surgical and anesthetic techniques with meticulous perioperative care has reduced morbidity and mortality. Here, we report a rare case of giant cavernous hemangioma of the liver in a 40-year-old woman with consumptive thrombocytopenia who underwent partial hepatectomy in our hospital.

  Case Report Top

A 40-year-old female presented to the surgical department with complaints of pain and swelling of upper abdomen on and off for 6 years. On further evaluation, she was diagnosed to have a huge right lobe hemangioma of the liver. She was planned for right hepatectomy in a staged procedure. During preanesthetic workup, she had no known comorbidities except hypothyroidism and was on tablet. Thyronorm 25 mcg/day. She was malnourished, weighing 35 kg. On examination, her vitals, airway and lab investigations were normal [Table 1]. Abdomen was soft with mild tenderness and liver enlargement. Preoperative thyroid function test, electrocardiogram, chest X-ray (CXR), two-dimensional echocardiogram were within normal limits. She belonged to the American Society of Anaesthesiologists Physical Status 2 with METs >4.
Table 1: Laboratory analysis –perioperative period

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She had undergone right side portal vein ligation with open cholecystectomy under general anesthesia and epidural anesthesia 2 months prior to this surgery by the same team as a part of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy[3] and the surgery was uneventful. She was planned for right hepatectomy for removal of the hemangioma. A written informed high risk consent was obtained and the risks of the surgery was explained to the patient. Preoperatively, 4 units of PCV, 4 units of Fresh Frozen Plasma, 4 units of platelets were arranged.

The right hepatectomy was planned under general anesthesia with controlled ventilation. Epidural was deferred for the fear of coagulopathy. Intravenous access was established with two 16 G cannula on right and left forearm. Antibiotic prophylaxis was administered. Trachea was intubated using 7 mm ID Portex Endotracheal tube after induction using midazolam 1 mg, 50 mcg of fentanyl, propofol 80 mg, atracurium 25 mg with sevoflourane and oxygen. Anesthesia was maintained with oxygen: air (50:50) mixture, isoflourane, atracurium boluses and fentanyl was supplemented 0.5 mcg/kg hourly. Right radial artery cannulation for continuous blood pressure (BP) monitoring and right internal jugular vein cannulation for continuous central venous pressure (CVP) monitoring and to deliver inotropes were established. Plan was to maintain CVP <5 cm H2O throughout surgery, urine output of 1 ml/kg/h and to do serial blood sugar and arterial blood gas analysis (ABG) monitoring. Inline fluid warmers and forced air warmers were used to prevent hypothermia.

During intraoperative period, BP remained between 90–120 and 60–90 mm Hg and pulse rate ranged between 90 and 120 bpm. When resection of the right lobe (segment 5–8) started, surgeon requested to decrease BP and CVP to reduce bleeding. In order to reduce BP and CVP pressure, we started propofol infusion at the rate of 10–20 mg/h and isoflurane titration. BP was kept around 90–100/50–60 mm Hg and CVP pressure was kept below 5 cm of H2O. Intraoperative ultrasound was done by radiologist for mapping of the vascular structures and to assess plane of resection. Parenchymal resection of liver was done with the help of harmonic ultrasonic dissector using crush – clamp technique. During this period, there was excessive bleeding. The BP and urine output were maintained with crystalloids, colloids, and blood products. Intraoperatively, 3 serial ABGs [Table 1] were done to look for metabolic acidosis and coagulation profile (prothrombin time [PT], activated partial thromboplastin time and international normalized ratio [INR]) were done to know the coagulation status. In spite of adequate volume infusion and i.v. phenylephrine boluses, BP maintenance required inotropes with noradrenaline infusion 0.15 mcg/kg/min and injection Dopamine at 5 mcg/kg/min.

After resection of liver parenchyma, intrahepatic bile ducts and oozing vessels were ligated. During 8 h of surgery, the patient received 3500 ml crystalloids, 6 units PCV, 500 ml colloid, 8 units of FFP, 6 units of platelets, 2 units of cryoprecipitate. Sodium bicarbonate and calcium gluconate were given as divided boluses to correct metabolic acidosis and to increase ionic calcium. Total blood loss was estimated to be 3000 ml and urine output of 900 ml was measured. Although the patient continued to exhibit mild metabolic acidosis [Table 1], this did not impact her circulatory condition. BP increased up to 110/70 mm Hg. Abdomen was closed in layers after placing portex drains. Later on, BP remained at 100–130/60–90 mm of Hg and heart rate 90–120/min till patient was shifted to postanesthesia care unit.

Postoperatively, the patient was electively ventilated overnight in view of metabolic acidosis, prolonged duration of surgery and excessive volume shifts. Fentanyl infusion was started at the rate of 15 mcg/h for postoperative pain relief. On the 1st Post-Operative Day (POD-1), vitals were stable on minimal inotropic support and extubated after thorough suction. She maintained good ABG on O2 with Hudson mask postextubation. Nebulization, incentive Spirometry, and venous thromboembolism prophylaxis (mechanical) were started. She required dopamine 5 mcg/kg/min and noradrenaline 0.1 mcg/kg/min for the first 24 h. Inotropic supports were tapered and discontinued on POD 2. Postoperative hypokalemia was corrected as required. Hematological parameters showed anemia, severe thrombocytopenia with abnormal liver enzymes and minimally deranged coagulation profile [Table 1].

She received PCV (6 units), platelets (8 units), cryoprecipitate (2 units), and FFP (8 units) along with 100 ml of 20% albumin. The patient developed pulmonary edema on the 4th postoperative day evidenced clinically on auscultation and chest X-ray, with drop-in saturation from 98% to 93% due to fluid overload state. She was started on tablet Aldactone 75 mg and injection Lasix 20 mg with negative fluid balance targeted to 500 ml. She maintained urine output at the rate of 1 ml/kg/h. Her liver enzymes, platelet count, and coagulation profile returned to normal by 5th POD. The patient was mobilized, started on oral feeds and shifted to ward on POD-5. She was discharged on POD-12 uneventfully [Figure 1] and [Figure 2].
Figure 1: Contrast-enhanced computed tomography scan revealed 13.2 × cm 14.5 × cm 20 cm well defined heterogeneous hypo dense lesion in right lobe of the liver with mass effect on common hepatic artery, portal vein, pancreas and adjacent bowel loops

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Figure 2: (a) Final aspect of the liver remnant. (b) Gross image: right hepatectomy specimen of liver haemangioma weighing 890 g, measuring 20 cm × cm 16 × 6 cm

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  Discussion Top

Hepatic resection is indicated in several benign and malignant liver diseases. The surgical aim is to excise the diseased area of the liver, with minimal blood loss and preservation of adequate healthy liver. This patient had only two features of classical Kasabach–Merritt syndrome.[4]

The procedure can be divided into two phases – pre and post resection.[5] During the initial step of mobilizing the liver, there may be a sudden fall in cardiac output and CVP. During isolation of portal vein and hepatic artery, there may be massive hemorrhage. A delicate balance is needed between delivering organ protective anesthesia and providing hemodynamic stability which will allow for optimal surgical results. Vascular occlusion techniques will minimize intraoperative bleeding during liver resection. Pringle's maneuver provides total inflow occlusion of the portal vein and hepatic artery which decreases the cardiac output up to 10% and increases the left ventricular afterload by 20%–30% and low CVP (0–5 cm of H2O) reduces the hepatic venous congestion.[6],[7] However, a low CVP during parenchymal resection may predispose to venous air embolism. Therefore, beneficial effects must be carefully weighed against adequate hydration and volume status optimization. In our case, surgical team did not perform any vascular exclusion technique due to adhesions and distorted anatomy because of previous surgery. This might have contributed to the massive bleeding intraoperatively.

Meticulous plan of anesthesia, fluid administration, good knowledge of the surgical techniques, and anticipated problems with good discussion with the surgeons are essential during hepatic resection. Any intraoperative fall in systemic BP must be rapidly treated to preserve liver blood flow and minimize postoperative liver dysfunction. Nitrous oxide should be avoided to prevent gut distension and risk of air embolism. Invasive hemodynamic monitoring should be instituted. Noninvasive cardiac output monitoring and (point of care) coagulation monitoring would have been beneficial in this setting of dynamic hemodynamic changes and massive blood transfusion, but it was not available. The triad of acidosis, hypothermia and hypocalcaemia is well known for aggravation of bleeding so they should be monitored and treated.

Posthepatectomy liver failure is impairment in the liver's ability to maintain its synthetic, excretory and detoxifying functions as characterized by an increased INR, elevated liver enzymes, and hyperbilirubinemia after surgery.[8] The use of epidural catheter for postoperative pain control is highly controversial because of complex nature of coagulopathy. PT usually rises postoperatively, peaks in the 2nd day and normalizes in 4–6 days. Such impairment of coagulation could theoretically increase the risk of spinal/epidural hematoma. Hence, we avoided epidural analgesia.[9]

The common postoperative complications are coagulopathy, renal and liver dysfunction, intra-abdominal infection, sepsis, pulmonary complication. The incidence of postoperative hepatic insufficiency is around 3%. Hypophosphatemia is the most common electrolyte imbalance causing cardiac dysrhythmias, hence require correction.[10] Insulin resistance is a feature which necessitates tight sugar control.[11] In this case, phosphate and sugar levels stayed within normal limits.

  Conclusion Top

Partial hepatectomy causes significant morbidity and mortality due to physiological and biochemical changes that occur in the perioperative period. The perioperative management should start with the detailed preoperative assessment involving both the physical and psychosocial aspects of the patient till the postoperative rehabilitation and pain management. A sound knowledge regarding the pathophysiological changes of the disease process and changes during the surgery is necessary for the successful management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kim KW, Kim TK, Han JK, Kim AY, Lee HJ, Park SH, et al. Hepatic hemangiomas: Spectrum of US appearances on gray-scale, power Doppler, and contrast-enhanced US. Korean J Radiol 2000;1:191-7.  Back to cited text no. 1
Bhayani NH, Hyder O, Frederick W, Schulick RD, Wolgang CL, Hirose K, et al. Effect of metabolic syndrome on perioperative outcomes after liver surgery: A National Surgical Quality Improvement Program (NSQIP) analysis. Surgery 2012;152:218-26.  Back to cited text no. 2
Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 2012;255:405-14.  Back to cited text no. 3
Hall GW. Kasabach-Merritt syndrome: Pathogenesis and management. Br J Haematol 2001;112:851-62.  Back to cited text no. 4
Lentschener C, Ozier Y. Anaesthesia for elective liver resection: Some points should be revisited. Eur J Anaesthesiol 2002;19:780-8.  Back to cited text no. 5
Eid EA, Sheta SA, Mansour E. Low central venous pressure anesthesia in major hepatic resection. Middle East J Anaesthesiol 2005;18:367-77.  Back to cited text no. 6
Chen H, Merchant NB, Didolkar MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anaesthesia improves morbidity and mortality. J GastrointestSurg 2000;4:162-7.  Back to cited text no. 7
Rahbari NN, Garden OJ, Padbury R, Brooke-Smith M, Crawford M, Adam R, et al. Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011;149:713-24.  Back to cited text no. 8
Redai I, Emond J, Brentjens T. Anesthetic considerations during liversurgery. In: Khatri VP, Schneider PD, editors. Liver Surgery: Modern Conceptsand Techniques. Vol. 84. Surgical Clinics of North America; 2004. p. 401-11.  Back to cited text no. 9
Cho SW, Marsh JW, Steel J, Holloway SE, Heckman JT, Ochoa ER, et al. Surgical management of hepatocellular adenoma: Take it or leave it? Ann Surg Oncol 2008;15:2795.  Back to cited text no. 10
Okabayashi T, Hnazaki K, Nishimori I, Sugimoto T, Maeda H, Yatabe T, et al. Continuous postoperative blood glucose monitoring and control using a closed loop system in patients undergoing hepatic resection. Dig Dis Sci 2008;53:1405.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]


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