**7.2 Liver transplantation**

Liver transplantation is an extraordinary choice in a few selected patients, with multiple HAs, giant HAs [69], or recurrent adenomas that are not technically resectable [70]. Those HAs considered unresectable are either in close proximity to major vascular structures or the liver hilum or less than 20% of viable hepatic parenchyma remains after resection. Liver transplantation for recurrent HA is a more technically demanding procedure if compared to the cases with chronic liver disease due to the presence of postoperative adhesions that must be divided before reaching the liver and also due to difficulties in liver implantation when at least a major hepatic vein and hepatic pedicle are absent after major hepatectomy [70]. Transplanted liver is generally harvested from a cadaveric donor but living liver transplantation has also been reported [71]. Due to an expanding armamentarium and experience in angiographically controlling bleeding from a ruptured HA, liver transplantation as an ultimate life-rescue therapy remains exceptionally rare, being reported for spontaneous intra-partum rupture of hepatocellular adenoma [72] (**Algorithm 1**).

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*Challenging Issues in Hepatic Adenoma DOI: http://dx.doi.org/10.5772/intechopen.87993*

**7.3 Management of liver adenomatosis**

The management of cases with liver adenomatosis is cumbersome. All women with adenomatosis must discontinue exogenous hormone therapy and should avoid pregnancies. In the massive pattern of adenomatosis, if larger lesions comprise a single lobe, a hemihepatectomy or more limited hepatic resection (**Figure 19**) could be a wise choice. Laparoscopic left lateral sectionectomy can be a good approach for

those patients expecting a future liver transplantation [73] (**Algorithm 2**).

Even the resection of only the complicated nodule (i.e., hemorrhagic liver nodule) seems appropriate as the first step toward enlisting for liver transplantation. Multiple resections are the preferable options in patients with liver

**Algorithm 2.** Management in liver adenomatosis.

**Algorithm 1.** Management in hepatic adenoma.

*Liver Disease and Surgery*

as large as 180 mm [61].

resections for HA [66].

**7.2 Liver transplantation**

anesthesiologist to stabilize the patient.

hemodynamic stable patients with ruptured HA [61]. Moreover, some surgeons consider laparoscopic surgery the standard of care for the treatment of HA [59]. Hand-assisted or "hybrid" techniques are also optional approaches [64] and the parietal incision is later used for specimen retrieval. In pure laparoscopic surgery, the specimen is retrieved through a Pfannenstiel incision even when the tumor is

Pringle maneuver can be of great use to minimize the intraoperative blood loss and it is used by surgeons both in laparotomy and laparoscopy. Some authors consider it unnecessary for laparoscopic left lateral sectionectomy [60]. Instead, others perform the maneuver for both atypical and anatomical resections. Laparoscopy is restricted by the localization of HA involving segments VII and VIII. The half-Pringle maneuver was associated for right posterior sectionectomy and resulted in less bleeding [65]. Total vascular exclusion of the liver is routinely recommended in high dorsal

Intraoperative blood transfusion is rarely needed and generally is performed in case of ruptured bleeding adenoma. Conversion of laparoscopy to laparotomy should be considered just in case of too much bleeding and difficulties for the

The high rates of mortality and morbidity previously reported after liver resection for bleeding HA are recently denied by new evidences [30]. Emergency resection of ruptured HA has a mortality rate of 5–10%, whereas elective surgery has a mortality rate of less than 1% [67]. These results are explained nowadays by the availability of improved hemostatic techniques, excellent anesthesia support, and postoperative intensive care. In the past, in the presence of signs of hemorrhagic shock, the mortality was as high as 20% for resection [68]. At present, the mortality for such patients trends toward zero. Nonsurgical strategies such as arterial embolization or gauze packing have been recommended in order to stabilize the patient and delay resection to an elective setting. There are situations when intraperitoneal bleeding from a ruptured adenoma is self-limited and a laparotomy is done just for biopsy. A recent bleeding adenoma does not necessarily need resection. After this acute bleeding, some of these tumors regress, others are stationary, and few rebleed. Transarterial embolization (TAE) can not only stabilize the patient but also obtain complete avoidance of surgical intervention. Sometimes, repeated embolization is needed to achieve hemostasis. However, liver resection remains the

best means to achieve hemostasis and also to obtain a thorough histology.

Liver transplantation is an extraordinary choice in a few selected patients, with multiple HAs, giant HAs [69], or recurrent adenomas that are not technically resectable [70]. Those HAs considered unresectable are either in close proximity to major vascular structures or the liver hilum or less than 20% of viable hepatic parenchyma remains after resection. Liver transplantation for recurrent HA is a more technically demanding procedure if compared to the cases with chronic liver disease due to the presence of postoperative adhesions that must be divided before reaching the liver and also due to difficulties in liver implantation when at least a major hepatic vein and hepatic pedicle are absent after major hepatectomy [70]. Transplanted liver is generally harvested from a cadaveric donor but living liver transplantation has also been reported [71]. Due to an expanding armamentarium and experience in angiographically controlling bleeding from a ruptured HA, liver transplantation as an ultimate life-rescue therapy remains exceptionally rare, being reported for spontaneous intra-partum rupture of hepatocellular adenoma [72]

**136**

(**Algorithm 1**).

**Algorithm 1.** Management in hepatic adenoma.

#### **7.3 Management of liver adenomatosis**

The management of cases with liver adenomatosis is cumbersome. All women with adenomatosis must discontinue exogenous hormone therapy and should avoid pregnancies. In the massive pattern of adenomatosis, if larger lesions comprise a single lobe, a hemihepatectomy or more limited hepatic resection (**Figure 19**) could be a wise choice. Laparoscopic left lateral sectionectomy can be a good approach for those patients expecting a future liver transplantation [73] (**Algorithm 2**).

**Algorithm 2.** Management in liver adenomatosis.

Even the resection of only the complicated nodule (i.e., hemorrhagic liver nodule) seems appropriate as the first step toward enlisting for liver transplantation. Multiple resections are the preferable options in patients with liver

#### **Figure 19.**

*Upper left: massive liver adenomatosis that deforms the contour of the left lateral sector. Upper right: a left lateral sectionectomy is planned and a cotton loop around hepatic pedicle is placed for Pringle maneuver. Lower left: intraoperative aspect after left lateral sectionectomy. Lower right: sectioned surgical specimen with evidence of the largest HA.*

adenomatosis, unless technically impossible or unsafe. Radiofrequency ablation or embolization in these patients was successful in some authors' experience [74]. Liver adenomatosis becomes an indication for liver transplantation if there is evidence of malignant transformation or complications [75]. Observing these changes is possible only if patients are carefully followed on a regular basis with imaging. Liver transplantation should be considered as the last resort for patients with adenomatosis. Patients with GSD should undergo transplantation earlier than other patients with HA because the literature considers this underlying disease as a risk factor for malignant transformation of adenomas [72]. Like in transplantation for HCC, imaging diagnosis of vascular invasion should be considered an absolute contraindication to transplantation. So all the efforts are directed to early diagnose a malignant transformation of HA, and any suspicion of malignancy has to be rapidly confirmed by biopsy. Discussion with the patients with liver adenomatosis about liver transplantation must be initiated when a major criterion or at least 3 minor criteria are identified. The only major criterion is the histological proof of malignancy in at least one adenoma. The minor criteria are: (1) more than 2 serious (life-threatening) hemorrhages, (2) more than 2 previous hepatectomies, (3) β mutated or inflammatory adenomas, (4) underlying liver disease (major steatosis and vascular abnormalities), and (5) age > 30 years [72] (**Figure 20**).
