Hepatic hemangioma is a kind of relatively common benign liver tumor, clinically, cavernous hemangioma is the most common, the discovery rate of natural population autopsy is 0.35-7.3%, accounting for 5-20% of the benign liver tumors; in recent years, with the improvement of the awareness of people’s health checkups and various diagnostic imaging technology, the discovery rate of asymptomatic small hemangiomas is significantly higher. Most cases are clinically asymptomatic or have mild symptoms, with a long course of disease, slow growth and good prognosis. Disease Introduction Hepatic hemangioma is a kind of common benign liver tumor, and cavernous hemangioma is the most common one in clinic, with the autopsy detection rate of 0.35-7.3% in the natural population, accounting for 5-20% of benign liver tumors. In recent years, with the improvement of people’s awareness of health checkups and the advancement of various diagnostic imaging techniques, the detection rate of asymptomatic small hemangiomas has increased significantly. Most cases are clinically asymptomatic or have mild symptoms, with a long course, slow growth and good prognosis. At present, there is not much basic and clinical research on this disease, and there is a lack of mature and strict diagnostic and treatment standards, and there are many ambiguities and even mistakes in the definition of treatment plans and indications. Traditional surgical treatment coexists with radiofrequency ablation, embolization of hepatic arteries, radiation therapy, intraoperative microwave curing, freezing and sclerosing agent injection, and the treatment plan has not yet formed a more unified clinical pathway for the doctors and patients to choose. Treatment options have not yet formed a more unified clinical pathway for patients and doctors to choose. At present, the exact cause of hepatic hemangioma is still unclear, and there are mainly the following doctrines: (1) congenital developmental abnormality: most scholars believe that the occurrence of hemangioma is caused by congenital malformation of hepatic blood vessels, and it is generally believed that hepatic hemangiomas are formed due to abnormal hepatic blood vessel development in the process of embryonic development, which causes abnormal proliferation of vascular endothelial cells; (2) hormonal stimulation theory: Some scholars have observed that in female puberty, pregnancy, oral contraceptive pills and so on can accelerate the growth rate of hemangioma, and it is believed that female hormone may also be one of the pathogenic mechanisms of hemangioma; (3) Others: such as capillary tissue deformation after infection, resulting in capillary expansion, vascular expansion after local necrosis of liver tissue to form vacuoles, and its peripheral blood vessels are congested and dilated; the regional stagnation of intrahepatic blood circulation results in the formation of blood vessels and spongy expansion. Spongy expansion. Classification Hepatic hemangioma can be classified into 4 types according to the amount of fibrous tissue: (1) cavernous hemangioma, which is the most common type; (2) sclerosing hemangioma; (3) vascular endothelial cell tumor; (4) capillary hemangioma, which is rare. At present, the classification of hemangiomas according to diameter: <5cm (small hemangiomas); 5-10cm (hemangiomas); 10cm-15cm (giant hemangiomas); >15cm (very large hemangiomas) may have certain significance in guiding the treatment plan of patients with hepatic hemangiomas, and provide an effective reference for the diagnosis and treatment of hepatic hemangiomas. Disease Hazards Hepatic hemangiomas can develop at any age, and are more common in 30-50 years old, and the literature reports that there are more females than males, with a male-to-female ratio of about 1:3-6. However, the analysis of the data from our 53,859 cases of physical examination of the healthy population showed that the incidence of hepatic hemangiomas was 3.11%, with a comparable incidence rate in males and females (3.36% vs. 2.88%, P>0.05), a phenomenon that is different from that reported in the literature. This phenomenon is different from the results reported in the literature and may be related to the fact that previous reports in the literature analyzed outpatient or inpatient exposures rather than a large sample of the population census, and most of the small hemangiomas were not included in the statistics. Deeper analysis of the size composition ratio of hemangiomas in males and females of our census cases showed that females were 2.56 times more likely than males to have cases of hepatic hemangiomas >5 cm as a proportion of all cases (2.90% vs. 1.26%, P>0.05), a result that supports our assumptions. Further analysis of the relationship between age and prevalence showed an increase in prevalence with increasing age, peaking at 40-60 years of age, followed by a decline. A possible explanation for this phenomenon is that with increasing age, the incidence of hidden hemangiomas, which are initially difficult to detect, increases as they grow and are detected; after 40-60 years of age, the incidence of hemangiomas decreases as some of them stop growing and even some of them recede. This phenomenon was verified in our analysis of 131 cases followed up for more than 5 years, in which the proportion of cases with enlarged hemangiomas decreased significantly with increasing age, and the extent of increase in the maximum diameter of hemangiomas also decreased significantly. In the analysis of the relationship between gender, age and hemangioma size, it was found that female hemangiomas were larger than male hemangiomas at all ages, and the size of hemangiomas increased significantly with age, reaching a peak at the age of 40-60 years, and then decreased slightly thereafter. From the above data, it is easy to conclude that the development of hemangiomas may be affected by changes in hormone levels, and the effect of estrogen may be more obvious, which may also explain why the incidence rate of hepatic hemangiomas with a diameter of >5 cm is much higher in women than in men. Symptoms Most hepatic hemangiomas do not have obvious discomfort symptoms, and are mostly detected during routine ultrasound examination during health checkups or abdominal surgery. There is no evidence that they have malignant potentials, but they can occasionally be confused with other malignant tumors of the liver, leading to misdiagnosis. When the hemangioma increases to more than 5cm, non-specific abdominal symptoms may appear, including: (1) abdominal mass: the mass is cystic, without pressure pain, with smooth or non-smooth surface, and sometimes conductive vascular murmur can be heard on auscultation of the mass; (2) gastrointestinal symptoms: vague pain and discomfort in the right upper abdomen, as well as loss of appetite, nausea, vomiting, belching, post-feeding bloating and indigestion, etc; (3) Compression symptoms: huge hemangioma can push and compress the surrounding tissues and organs. Pressing the lower end of esophagus, dysphagia can appear; pressing extrahepatic biliary tract, obstructive jaundice and gallbladder effusion can appear; pressing portal vein system, splenomegaly and ascites can appear; pressing lungs, dyspnea and atelectasis can appear; pressing stomach and duodenum, digestive symptoms can appear, etc.; (4) rupture and bleeding of hepatic hemangioma, which can cause severe pain in the epigastrium as well as symptoms of hemorrhage and shock, and it is one of the most serious complications. It is one of the most serious complications, which is mostly caused by the rupture and bleeding of large hepatic hemangiomas growing below the rib arch due to external force, which is extremely rare; (5) Kasabach-Merritt syndrome, which is a coagulation abnormality caused by hemangioma accompanied by thrombocytopenia and consumption of large amount of coagulation factors. Its pathogenesis is blood retention in huge hemangioma, which consumes a large number of red blood cells, platelets, coagulation factors II, V, VI and fibrinogen, causing abnormal coagulation mechanism, and may further develop into DIC; (6) Others: when free and extrahepatic growth of the tibial hemangioma is torsioned, necrosis may occur, with severe abdominal pain, fever and collapse. There are also individual patients with arteriovenous fistula formation due to huge hemangiomas, resulting in increased blood return and increased cardiac burden, leading to heart failure and death. There are also rare cases of biliary hemorrhage. Auxiliary examination Hepatic hemangioma lacks specific clinical manifestations, and imaging examination (e.g. ultrasound, CT, MRI) is the main method to diagnose hepatic hemangioma. Comprehensive literature reports suggest that the diagnosis rate of hepatic hemangioma is 57.0%-90.5% by ultrasound, 94% by ultrasonography, 73.0%-92.2% by CT, 84.0-92.7% by MRI, and 62.5% by hepatic arteriography. Ultrasound ultrasound examination is cheap, simple and easy to perform, with high prevalence rate, non-invasive and painful, safe and reliable, and can be used for short-term and repeated dynamic observation of lesion changes and obtaining more information, which is not as good as that of CT and MRI. Ultrasound performance of hepatic hemangioma is mostly hyperechoic, and those with low echogenicity have reticular structure, uniform density, regular morphology and clear boundary. Larger hemangioma section can be lobulated, the internal echo is still dominated by enhancement, can be tubular network, or irregular nodular or blocky hypoechoic area, sometimes there can be calcified hyperechoic and posterior acoustic shadows, the Department of vascular luminal thrombosis, mechanization, or calcification caused by. Contrast ultrasound In recent years, the role of contrast ultrasound in the differential diagnosis of liver occupancy has been gradually recognized by the majority of doctors. In cases of hepatic hemangioma with atypical imaging manifestations, selective use of contrast ultrasound of the liver may be considered. Typical ultrasonography of hemangioma shows nodular or ring-like enhancement in the periphery during arterial phase, and the range of enhancement gradually expands to the center with the prolongation of time, and the expansion process is slow, and the lesion is still in the state of enhancement in portal and delayed phases, and the echo is equal to or higher than that of the surrounding hepatic tissues, and this kind of enhancement characteristic of “slow in and slow out” is similar to that of helical-enhanced CT. This “slow in and slow out” enhancement characteristic is similar to that of spiral-enhanced CT. It has been reported that the sensitivity, specificity and accuracy of contrast ultrasound for small hepatic hemangioma reached 100%, 87% and 94%. Spiral-enhanced CT CT scanning examination shows round or round-like low-density foci in the liver parenchyma with clear boundaries, and a few of them may be irregular shaped, with a CT value of about 30 HU. Dynamic CT or spiral CT multi-phase contrast-enhanced scanning most specific typical manifestations: in the rapid injection of contrast agent in 20-30s, the edge of the lesion in the early arterial phase appeared nodular enhancement, enhancement density is higher than that of the normal liver enhancement density; with the prolongation of time, in the injection of contrast agent in the 50-60s; that is, to enter the portal phase of the enhancement, the contrast enhancement foci fused with each other, and gradually to the center of the lesion to promote the intensity of With the prolongation of time, 50-60s after the injection of contrast agent, it will enter the portal vein phase of enhancement, the contrast foci will merge with each other, gradually advancing to the center of the lesion, and the intensity will be gradually reduced. In some cavernous hemangiomas, there may be an irregular hypointense area in the center of the tumor with no enhancement on delayed scanning, however, the peripheral part of the tumor still shows this characteristic of “coming out early and coming back late”. MRI: T1-weighted low signal, T2-weighted high signal, uniform intensity, clear margins, and obvious contrast with the surrounding liver, which is described as the “light bulb sign”, which is the specific manifestation of hemangiomas in MRI.The enhancement pattern of MRI dynamic scanning is the same as that of CT, and it is not necessary to carry out further MRI scanning when the characteristic signs in CT and MRI have already been diagnosed. When the diagnosis is clear from the characteristic signs of CT and MRI, there is no need to perform other expensive or invasive tests, and liver puncture biopsy should be avoided. Hepatic puncture biopsy has low accuracy and can cause bleeding, and hepatic arteriography is invasive and unnecessary. Whole-body positron emission computed tomography (PET/CT), which has emerged in recent years, is valuable in ruling out metabolically active malignant tumors. Differential diagnosis The main differential diagnoses of hepatic hemangioma are: primary or metastatic hepatocellular carcinoma Primary hepatocellular carcinoma often has a history of chronic hepatitis B and cirrhosis, with liver function abnormalities and elevated AFP; metastatic hepatocellular carcinoma, which is multifocal, often has a primary lesion of the gastrointestinal system; hepatocellular echinococcosis The patient has a history of living in a pastoral area, with history of contact with sheep and dogs, a positive intracranial test for hepatic encapsulated worms (Casoni’s test), and increased eosinophilic cell Liver nonparasitic cysts Isolated solitary hepatic cysts are easily differentiated from hepatic hemangiomas, and only a few polycystic livers may sometimes be confused with hepatic hemangiomas. More than 50% of polycystic livers are combined with polycystic kidneys, and the lesions are multiple from the beginning, mostly spreading all over the liver, and ultrasound and CT examinations show that the lesions are cystic cavities of different sizes with smooth and intact borders, and there may be a familial hereditary factor; Other Hepatic adenomas and hepatic hemangioendothelial cell sarcomas are rare. The former develops slowly, but the mass is hard like rubber; the latter develops faster, with malignant tumor characteristics, mostly seen in adolescents. Surgical treatment Currently, there is a big controversy on the treatment of hepatic hemangioma, mainly including hemangioma resection, hemangioma ligation, hepatic artery ligation, microwave curing, radiofrequency treatment, hepatic artery embolization, and so on. For diffuse hepatic hemangiomas, or unresectable giant hemangiomas, such as decompensated liver function or combined Kasabach-Merritt syndrome, liver transplantation is also feasible. For hepatic hemangiomas that require treatment, a combination of factors should be considered, and different treatment modalities should be chosen based on the principles of patient benefit, safety, and effectiveness, and on the balance of factors according to the doctor’s skill level and experience. The following is only an elaboration of different treatment modalities: hepatic hemangioma resection Surgical resection is reliable and safe, and complete resection is the only method that can be cured radically. With the development of surgical techniques, the incidence of surgery-related complications and the morbidity and mortality rates are now very low. Nevertheless, strict indications for surgery are still needed. Common surgical procedures include segmental hepatectomy, hemangioma debulking, laparoscopic hepatectomy, hemangioma ligation and liver transplantation. Segmental hepatectomy With the development of surgical technology and the improvement of hepatic surgical skills, the mortality rate and complications of hepatectomy have been greatly reduced, and the scope of application has been expanded to benign liver lesions, among which hepatic hemangiomas are the benign liver lesions for which hepatectomy is most frequently applied. Most patients with hepatic hemangioma do not have a history of cirrhosis, have good liver compensatory function, and can tolerate a larger range of hepatic resection. For giant hepatic hemangioma or multiple hemangiomas, regular hepatic segmental resection, hepatic lobectomy, or even hemihepatectomy is usually feasible, but the amount of hepatic resection should not be more than 70%-75% of the whole liver. The main problem of hepatic segmental resection for hepatic hemangioma is to control bleeding. Due to the rich blood supply of hemangioma, the tumor itself is easy to bleed, which increases the difficulty of the operation, and even sometimes the improper operation can lead to uncontrollable hemorrhage, so how to control the hemorrhage is the key to the success of the operation. Hepatic hemangioma debulking surgery Hepatic hemangioma mostly shows expansive growth, which can compress normal liver tissue, bile ducts and blood vessels to form a thin fibrous peritoneum, with few blood vessels at the interface, so it can be detached bluntly along the interface and debulked out of the hemangioma, i.e. “hemangioma peritoneal debulking surgery”, which can achieve the purpose of less bleeding and complete resection of the lesion. In 1988, Alper et al. firstly reported this kind of operation, and several large samples of clinical studies on the comparison of hepatectomy and hemangioma debulking found that: the operation time, bleeding and blood transfusion of debulking were significantly less than that of hepatectomy; the damage to the liver was light, and the normal liver tissues were preserved to the maximum extent, and the patients recovered the liver function quickly after the operation; it reduced the damage to the important intrahepatic blood vessels and bile ducts, and the bleeding was reduced, and the incidence of biliary fistulae was reduced. Reduced damage to important intrahepatic vessels and bile ducts, reduced bleeding, and reduced incidence of biliary fistula. At present, many scholars at home and abroad advocate it, and it has become the main procedure for the treatment of hepatic hemangioma. Regular hepatectomy is only used when malignant lesions are suspected or when one lobe of the liver is completely occupied by the tumor. However, some scholars believe that in some cases, it is difficult to confirm the gap between the hemangioma and the liver parenchyma during the operation, and the stripping may cause more bleeding, especially for hemangiomas close to the trunk of the hepatic vein, the posterior hepatic inferior vena cava and other important structures, and blunt stripping may easily tear the large blood vessels or injure the tumor, resulting in uncontrollable hemorrhage. Expert opinion (1) If the tumor is located in the left lobe of the liver, hepatectomy should be chosen due to the simplicity of operation. In addition, hepatectomy is also performed when multiple hemangiomas are confined to a certain lobe of the liver, in which case removing the tumors one by one will cause great damage, bleeding and time-consuming; (2) Due to the relative complexity of right hepatectomy and the greater trauma, right lobe hemangioma debulking is more advantageous than hepatectomy; (3) hemangiomas in the middle lobe of the liver are not only close to the portal of liver and the large blood vessels entering and exiting the liver, they may also encroach upon left and right lobes of the liver, so hepatectomy is more suitable for such tumors. Hepatic resection is more difficult to deal with such tumors. Stripping can not only effectively avoid the damage of the ducts at the hilum, but also not have to remove too much normal liver tissue and significantly reduce intraoperative bleeding; (4) Hepatic resection is preferred for hemangiomas with huge volume. Because huge hemangioma occupies the left or right lobe of liver or a certain liver segment and presses the liver tissue, so there is little normal liver tissue left in the lobe or segment where the lesion is located, regular hepatic resection of the lobe or segment does not cause much loss of normal liver tissue, and it avoids hemorrhage due to the removal of the tumor peritoneum or tearing of large blood vessels that may be caused by the resection procedure; (5) If the patient can not exclude the primary hepatocellular carcinoma before the operation, or if there is the suspicion of metastasis of the liver with the history of malignant tumors in other parts of the liver, it is advisable to perform regular hepatic resection. For those who cannot exclude primary hepatocellular carcinoma before surgery or have history of malignant tumor in other parts of the liver and suspect liver metastasis, regular hepatectomy or local resection with certain “safe margins” is preferred; (6) Multiple hemangiomas distributed in different hepatic lobes or hepatic segments can be combined with two surgical methods.