What is the treatment for liver fibrils (liver flaps) or more accurately, what is the treatment for Focal Nodular Hyperplasia (FNH) or Liver Hemangioma?

From the Guidelines

The primary treatment for liver flaps, in the context of hereditary hemorrhagic telangiectasia (HHT), focuses on addressing the underlying liver vascular malformations (VMs) and their complications, with no treatment recommended for asymptomatic liver VMs, as indicated by the most recent and highest quality study 1.

Treatment Approach

The management of liver flaps in HHT patients depends on the presence of symptoms and the type of complication.

• For patients with symptomatic liver involvement, management depends on the type of complication, with high-output heart failure, complications of portal hypertension, and cholangitis being treated as recommended in cirrhotic patients, or with antibiotics, respectively.
• Intensive medical therapy, including correction of anemia, salt restriction, diuretics, antihypertensive agents, antiarrhythmic agents, digoxin, and cardioversion, is the primary approach for high-output cardiac failure.
• For patients failing to respond to intensive medical therapy, invasive treatments, including transarterial embolization of liver VMs or orthotopic liver transplantation (OLT), may be considered.

Invasive Treatments

• Transarterial embolization of liver VMs is a palliative, temporizing, and risky procedure, to be discussed in patients with high-output cardiac failure or mesenteric angina who are not candidates for OLT.
• OLT represents the only definitive curative option for hepatic VMs in HHT, and is indicated for ischemic biliary necrosis, intractable high-output cardiac failure, and complicated portal hypertension.

Key Considerations

• Right heart catheterization should always be performed in patients with HHT being evaluated for OLT, to exclude severe pulmonary hypertension.
• Bevacizumab, an angiogenesis inhibitor, has shown the ability to reduce the cardiac index in patients with severe liver VMs and high cardiac output, but its use is limited by unpredictable efficacy and non-negligible toxicity.
• The subset of patients with severe grade 4 liver VMs, at high risk of poor outcome, could be the target for prophylactic treatments, such as angiotensin-converting enzyme inhibitors or carvedilol to prevent cardiac remodeling.

Diagnosis and Staging

• Doppler ultrasound is the ideal first-line imaging for the diagnosis and staging of liver VMs, with multiphase CT being a suitable alternative to investigate symptomatic liver VMs.
• Echocardiographic evaluation is recommended to patients with liver VMs, particularly if severe, at baseline and during follow-up, to monitor hemodynamic impact of liver VMs.

Patient Management

• Patients with HHT should be managed by a medical team with expertise in HHT, and treatment decisions should be made on a case-by-case basis, guided by symptoms and risk to maternal and fetal outcomes.
• Liver biopsy is not necessary in the diagnosis of hepatic VMs related to HHT, but may be considered in patients with known or suspected HHT, with caution due to the risk of increased bleeding.

From the Research

Treatment for Liver Flaps

• The use of a falciform ligament flap to cover the resection surface after liver surgery has been shown to be a simple and cost-effective technique that does not prolong surgical time or negatively affect other perioperative parameters 2.
• This technique may reduce postoperative morbidity, with a lower overall morbidity rate of 3.3% compared to 18.8% without the use of a falciform ligament flap 2.
• The falciform ligament flap technique has been used in both laparoscopic and robotic-assisted liver surgery, with no cases of bile leakage reported in the group that received the flap 2.
• Other studies have focused on the management of liver injuries, including the use of nonoperative management, definitive repair, and damage control surgery 3, 4.
• The management of acute liver failure has also been studied, with a focus on initial management, supportive treatment, and liver transplantation 5.
• However, the specific treatment for liver flaps is not extensively discussed in the provided studies, with the exception of the use of a falciform ligament flap in minimally invasive liver surgery 2.

Key Findings

• The falciform ligament flap technique is a safe and effective add-on step during minimally invasive liver surgery 2.
• The use of this technique may reduce postoperative morbidity, including bile leakage 2.
• Further studies are needed to substantiate the results and prove the concept of using a falciform ligament flap in liver surgery 2.

Limitations

• The provided studies do not extensively discuss the treatment for liver flaps, with the exception of the use of a falciform ligament flap in minimally invasive liver surgery 2.
• More research is needed to fully understand the effectiveness and safety of this technique in different types of liver surgery 2.