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Special Feature
April 01, 2007

Image of the Month—Diagnosis

Arch Surg. 2007;142(4):400. doi:10.1001/archsurg.142.4.400
Answer: Kasabach-Merritt Syndrome in a Giant Cavernous Liver Hemangioma

Kasabach-Merritt syndrome (KMS) is characterized by severe thrombocytopenia secondary to platelet trapping by an abnormally proliferated endothelium within congenital subcutaneous and/or visceral hemangiomas. This is usually accompanied by a secondary consumptive coagulopathy, which is reflected by hypofibrinogenemia, elevated levels of fibrin degradation products, and fragmentation of red blood cells.1Neither the site nor the size of the hemangioma appears to reliably predict the occurrence of KMS, which is associated with a high mortality (30%-40%) as a result of uncontrollable bleeding secondary to disseminated intravascular coagulation.2

This syndrome has its highest incidence in early infancy and most of the cases are secondary to single or multiple subcutaneous hemangiomas.1However, those associated with a more severe phenotype are often localized in visceral organs, especially in the retroperitoneal space.3The reported incidence of KMS in a giant hepatic hemangioma is very low and its occurrence in adults is exceptional.2A KMS secondary to occult hemangiomas should always be considered in patients with spontaneous hematomas due to unexplained thrombocytopenia and coagulopathy. A prompt, aggressive diagnostic imaging approach is paramount to identify the presence of visceral lesions and offer proper treatment.

The gold standard treatment of KMS is the removal of the underlying hemangioma, which will correct the consumptive coagulopathy. Although many nonoperative strategies have been used to control the disease,2,3the only curative treatment remains the surgical resection of the hemangioma. However, surgical resection of hepatic hemangiomas could be hazardous in the presence of uncontrolled coagulopathy secondary to disseminated intravascular coagulation. Perioperative substitution of consumed clotting factors with fresh frozen plasma or platelet concentrates may prevent perioperative bleeding. Hemangiectomy by means of enucleation of the tumor through dissection in a fibrous cleavage plane between the capsule of the hemangioma and surrounding normal liver parenchyma is often preferred rather than anatomical hepatic resections.4This technique, when feasible, avoids resection of normal liver tissue and minimizes damage to biliary and vascular structures.5Finally, a meticulous surgical hemostasis is paramount to prevent postoperative bleeding in patients with this syndrome.

In conclusion, the development of a thrombocytopenic consumptive coagulopathy in a previously healthy patient should alert physicians regarding the occurrence of a KMS. A prompt surgical removal of the underlying liver hemangioma will provide the better outcome in patients with this life-threatening syndrome.

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Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Pierre-Alain Clavien, MD, PhD, Department of Visceral and Transplantation Surgery, Zurich University Hospital, Rämistrasse 100, CH-8091, Zurich 8091, Switzerland (clavien@chir.unizh.ch).

March 28, 2006.

: McCormack. : McCormack and Petrowsky. : McCormack and Petrowsky. : McCormack and Petrowsky. : Clavien. : McCormack. : McCormack, Petrowsky, and Clavien. : Clavien.

None reported.

Dr Petrowsky is the recipient of the Novartis Fellowship in Hepato-Pancreato-Biliary Surgery and Liver Transplantation at the Swiss HPB Centre at the University of Zurich.

References
1.
Antovic  JBakic  MMilicevic  RGojkovic  GBlomback  M Activation of the coagulation system occurs within rather than outside cutaneous haemangiomas. Acta Paediatr 2001;901137- 1140
PubMedArticle
2.
Hall  GW Kasabach-Merritt syndrome: pathogenesis and management. Br J Haematol 2001;112851- 862
PubMedArticle
3.
Shin  HYRyu  KHAhn  HS Stepwise multimodal approach in the treatment of Kasabach-Merritt syndrome. Pediatr Int 2000;42620- 624
PubMedArticle
4.
Lerner  SMHiatt  JRSalamandra  J  et al.  Giant cavernous liver hemangiomas: effect of operative approach on outcome. Arch Surg 2004;139818- 821, discussion 821-823
PubMedArticle
5.
Gedaly  RPomposelli  JJPomfret  EALewis  WDJenkins  RL Cavernous hemangioma of the liver: anatomic resection vs. enucleation. Arch Surg 1999;134407- 411
PubMedArticle
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