Diagnosis and Surgical Treatment of Liver Hemangiomas

The dissertation is dedicated to the relevant issues of diagnosis and surgical treatment of liver hemangiomas. The research analyzes modern instrumental examination methods, such as ultrasonography and computed tomography, and develops a rational treatment-diagnostic algorithm. The study improves the techniques of anatomical liver resection, creates an absorbable hemostatic agent for the wound surface, and investigates the efficacy of intraoperative sclerotherapy. The practical significance of the dissertation lies in proving the feasibility of extensive resections with preservation of the parenchyma, developing a T-shaped access, and a method for determining the functional reserve of the liver.

Relevance of the Problem.

The rapid development of liver surgery began in the mid-1960s, facilitated by studies of its segmental structure, the intrahepatic architecture of tubular structures, the development of new technologies in resection, and the introduction of a number of technical means to prevent massive bleeding, but despite this, benign liver diseases remained an operative or autopsy finding [47,73].

The introduction of highly informative non-invasive instrumental research methods (ultrasonography and computed tomography) into wide clinical practice contributed to a significant increase in the number of patients diagnosed with benign liver diseases, with the number of hemangiomas growing annually. Thus, by the end of the 1970s, the literature contained information about hundreds of such patients, more than 50% of whom were operated on. Nevertheless, an analysis of domestic and foreign literature indicates a lack of unity of views on the issues of diagnosis, indications and contraindications for operative treatment, and the feasibility of using minimally invasive non-operative or alternative treatment methods [6,21].

Liver hemangioma is a disease requiring critical analysis for the development of differential-diagnostic criteria and indications for surgical treatment. The absence of pathognomonic symptoms and the paucity of the clinical picture do not always allow timely and accurate diagnosis of the disease. A complex differential-diagnostic search requires the creation of a sequential research algorithm. If a liver hemangioma is not recognized in a timely manner, it often becomes inoperable or harbors the danger of complications. Mortality from spontaneous and traumatic ruptures of hemangiomas ranges from 63 to 83% [13, 95].

The relative rarity of cavernous liver hemangiomas, difficulties in preoperative diagnosis, the development of dangerous complications for the patient's life (tumor rupture with bleeding, pulmonary trunk or its branch thromboembolism, possible malignant transformation of the tumor), the development of portal blood flow disorders when the tumor is located near the hepatic hilum even at small sizes, as well as the absence of clear indications for operative and conservative treatment and unified tactical criteria indicate the unresolved and relevant nature of this problem. In connection with the above, it seems relevant to search for ways to diagnose and treat liver hemangiomas.

Research Objective

To improve the treatment outcomes for patients with liver hemangiomas by refining their diagnostic methods and surgical interventions.

Research Tasks

1. To determine the diagnostic value of modern examination methods for patients with liver hemangiomas, and based on their analysis, develop a tactical-diagnostic algorithm.

2. To improve the technique of anatomical resection in liver hemangiomas.

3. To develop an absorbable hemostatic wound dressing for liver resections and evaluate its efficacy.

4. To study the possibility of sclerotherapy of liver hemangiomas. Develop methods, determine indications, and evaluate the efficacy of sclerotherapy of liver hemangiomas.

5. To conduct a comparative analysis of the early and late results of traditional and improved liver resection methods.

Scientific Novelty

Based on the conducted analysis of the diagnostic value of modern instrumental examination methods in liver hemangiomas, the determining importance of ultrasonography (including in duplex scanning mode) as a screening method, and computed tomography, liver scintigraphy, and angiography of the hepatic vessels as methods for differentiating hemangiomas from other focal liver lesions has been shown. A rational treatment-diagnostic algorithm has been developed. Indications for choosing operative intervention in patients with liver hemangiomas have been formulated. A new absorbable agent for covering the wound surface of the liver during its resection has been introduced, contributing to effective hemostasis. Morphological changes in the tissue of the liver hemangioma subjected to sclerotherapy with the drug 'Ethoxysclerol' have been studied.

Practical Significance

1. Based on our data, the feasibility of performing extensive liver resections with maximum preservation of functioning parenchyma in giant hemangiomas has been proven.

2. The developed T-shaped access used in right-sided liver resections allows for a full revision of the hepatoduodenal zone and operative treatment. In combination with costal arch retractors, the access allows abandoning the previously proposed more traumatic thoracoabdominal accesses.

3. It has been proven that sclerotherapy in combination with other technical means and operative procedures contributes to a reduction in blood loss during extensive resections and provides more favorable conditions for preserving liver parenchyma. Sclerotherapy in isolation is effective in treating tumors located near the Glissonian or caval portals of the liver, given the high risk of their resection.

4. The developed absorbable hemostatic material, due to its large specific surface area and the presence of blood coagulation system components, exhibits a pronounced hemostatic effect, easily absorbs blood, and, adhering to the wound, forms a reliable protective coating on its surface, creating conditions for stopping parenchymal bleeding and reducing the possibility of bile leakage.

5. The developed method for determining the functional reserve of the liver in hemangiomas allows for an adequate choice of treatment course and predicting the immediate risk of surgical intervention and the treatment outcome in patients with hemangiomas.

Propositions Submitted for Defense

• Surgical treatment of patients with liver hemangiomas remains a serious problem of modern hepatology. If liver hemangiomas are not recognized in a timely manner, they often become inoperable or harbor the danger of complications.

• The application of the developed wound dressing significantly reduces the time to achieve final hemostasis, the volume of blood loss at the stage of achieving final hemostasis, the volume of intraoperative hemotransfusion, and prevents the development of the adhesive process.

• The use of intraoperative sclerotherapy helps to incise the liver parenchyma along the tumor margin, which reduces the volume of blood loss and facilitates the performance of a peritumoral resection, during which greater preservation of the functioning parenchyma of the organ is possible.

Testing and Implementation of the Dissertation Results

The main provisions of the dissertation were reported and discussed at the X Anniversary International Conference of Hepatic Surgeons of Russia and the CIS (Moscow, 2003), the IV International Conference of Students and Young Scientists (Dnepropetrovsk, 2003), the 68th Republican Final Scientific-Practical Conference of Students and Young Scientists of the RB (Ufa, 2003), the International Surgical Congress 'New Technologies in Surgery' (Rostov-on-Don, 2005), the International Congress of Hepatic Surgeons of the CIS (Tashkent, 2005), and the Association of Surgeons of the Republic of Bashkortostan (Ufa, 2005, 2006).

The results of the work have been implemented in the complex treatment of patients at the Republican Center for Surgical Hepatology based on the Department of Gastrointestinal Surgery of the Republican Clinical Hospital named after G. G. Kuvatov.

The theoretical provisions and practical recommendations of the dissertation are used in the training program for students, resident physicians, clinical residents, and postgraduate students at the Department of General Surgery of the Bashkir State Medical University.

Based on the dissertation materials, 9 printed works have been published (5 of them in the central and international press), a Russian Federation patent 'Method of obtaining a powdery biomaterial for endoscopic covering of wound surfaces' No. 2243777 dated 10.01.05, and 3 certificates of rationalization proposals have been obtained.

The work was carried out in the clinic of general surgery (director - Honored Scientist of the RB, Doctor of Medical Sciences, Professor, M.A. Nartaylakova) of the Bashkir State Medical University (rector - Corresponding Member of the RAMS, Doctor of Medical Sciences, Professor, V.M. Timirbulatov), based on the Republican Center for Surgical Hepatology of the RK named after G. G. Kuvatov (chief physician, Candidate of Medical Sciences, Z.Ya. Murtazin).

I express my gratitude to the employees of the Bashkir State Medical University, Doctor of Medical Sciences, Professor M.A. Nartaylakova, Associate Professor R.S. Mingazov, employees of the RK named after G.G. Kuvatova: the Department of Gastrointestinal Surgery (head N.V. Peskov), the Department of Ultrasonic Diagnosis (head Candidate of Medical Sciences N.N. Kalimullin), the Pathological Anatomy Department (head Candidate of Medical Sciences V.N. Tkachenko) for their assistance in carrying out the work.