What are the guideline sources, guidelines and references for Hepatic adenoma ?
Guideline sources The following summarized guidelines for the evaluation and management of hepatic adenoma are prepared by our editorial team based on guidelines from the Enhanced Recovery After Surgery Society (ERASS 2023), the American College of Radiology (ACR 2020), the European Federation of Societies for Ultrasound (EFSU 2020), the European Association for the Study of the Liver (EASL 2019; 2016), and the American College of Gastroenterology (ACG 2016; 2014). 1 2 3 4 5 6 7 Guidelines 1. Classification and risk stratification Risk factors: recognize that oral contraceptives may be considered risk factors for the development of hepatic adenoma. B https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 1/6 6/24/23, 12:40 PM Hepatic adenoma Pathway Show 2 more 2. Diagnostic investigations Contrast-enhanced ultrasound: As per ACR 2020 guidelines: Obtain contrast-enhanced abdominal ultrasound of an indeterminate > 1 cm liver lesion on initial ultrasound in patients with a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease. B Obtain contrast-enhanced abdominal ultrasound of an incidental liver lesion > 1 cm on initial ultrasound, non-contrast or single-phase CT, or non-contrast MRI in patients with known chronic liver disease. B As per EFSU 2020 guidelines, obtain liver ultrasound using B-mode and Doppler mode before obtaining contrast-enhanced ultrasound to characterize focal liver lesions. B Show 14 more Cross-sectional imaging: As per ACR 2020 guidelines, obtain contrast-enhanced multiphase CT, contrast-enhanced MRI, or contrast-enhanced ultrasound of an indeterminate > 1 cm liver lesion on initial ultrasound in patients with a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease. B Show 7 more As per EASL 2016 guidelines: Prefer MRI as it is superior to all other imaging modalities and due to its intrinsic properties to detect fat and vascular spaces it offers an opportunity to subtype hepatocellular adenoma up to 80%. B Recognize that MRI can identify hepatocyte nuclear factor-1 alpha hepatocellular adenoma and inflammatory hepatocellular adenoma with > 90% specificity, whereas identification of - catenin-activated hepatocellular adenoma and its distinction with unclassified hepatocellular adenoma and HCC is not possible by any imaging technique. B 3. Diagnostic procedures Liver biopsy: perform a liver biopsy in patients with inconclusive imaging findings and if a biopsy is deemed necessary to make treatment decisions. B 4. Medical management Indications for treatment: As per EASL 2016 guidelines: Decide on the treatment based on gender, size, and pattern of progression. B https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 2/6 6/24/23, 12:40 PM Hepatic adenoma Pathway Decide on the management of patients with multiple hepatocellular adenomas based on the size of the largest tumor. B As per ACG 2014 guidelines, offer operative or nonoperative management in patients with hepatocellular adenoma 5 cm because of the risk of rupture and malignancy. B 5. Therapeutic procedures Embolization: perform embolization of a bleeding hepatocellular adenoma with hemodynamic instability. B 6. Perioperative care Preoperative care (counseling): Provide preoperative information and counseling regarding the upcoming liver surgery. Consider using brochures and multimedia support to improve verbal counseling. B Advise preoperative smoking cessation at least 4 weeks before hepatectomy. Advise alcohol cessation in heavy drinkers (> 24 g/day for females or > 36 g/day for males) 4-8 weeks before surgery. A Preoperative care (nutrition): obtain a nutritional assessment before liver surgery. Administer enteral supplementation at least 7-14 days before surgery to optimize nutritional status in malnourished patients (weight loss > 10% or > 5% over 3 months and reduced BMI or a low fat- free mass index). A Show 2 more Preoperative care (rehabilitation): offer prehabilitation in high-risk patients (elderly, malnourished or overweight patients, smokers, or patients with psychological disorders) before liver surgery. Initiate prehabilitation 4-6 weeks before the operation depending upon the urgency of surgery. Insufficient evidence to recommend the content (physical exercises, dietary interventions, or anxiety reduction exercises) and duration of the prehabilitation program for liver surgery. B Preoperative care (biliary drainage): perform biliary drainage in the cholestatic liver (> 50 mmol/L). Avoid performing surgery until the bilirubin level drops < 50 mmol/L. B Preoperative care (antibiotic prophylaxis): administer antibiotic prophylaxis (such as cefazolin) within 60 minutes before surgical incision with no extension into the postoperative period. Consider administering a targeted antibiotic preemptive regimen based on preoperative bile culture in case of complex liver surgery with biliary reconstruction. B Preoperative care (corticosteroids): administer a preoperative dose of corticosteroids (methylprednisolone 500 mg). Insufficient evidence for its use in diabetic patients undergoing liver surgery. B Preoperative care (preanesthetic medication): avoid administering long-acting anxiolytic drugs, particularly in the elderly. D https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 3/6 6/24/23, 12:40 PM Hepatic adenoma Pathway Show 3 more Intraoperative care (anesthesia and analgesia): Administer multimodal analgesia, including the potential use of intrathecal opioids, both for open A and laparoscopic surgery. B Recognize that thoracic epidural analgesia can provide excellent analgesia for open liver surgery but has significant disadvantages. Do not use regional anesthesia techniques in laparoscopic surgery as multimodal analgesia combined with judicious IV opioids provide functional analgesia. Perform continuous local anesthetic wound infiltration to provide lower complication rates and overall equivalent analgesia to thoracic epidural analgesia. Perform local anesthetic transversus abdominis plane blockade as a supplement to standard analgesia to improve pain control and reduce opioid usage. A Intraoperative care (temperature management): maintain perioperative normothermia with multimodal temperature management (including circulating water garments or forced warm air) during open and minimally invasive liver surgery. B Intraoperative care (fluid management): Maintain low central venous pressure (< 5 cmH O) with close monitoring during hepatic transection. A Prefer balanced crystalloids over 0.9% saline or colloids for fluid maintenance. Provide goal- directed fluid therapy to optimize cardiac output and end-organ perfusion, recognizing that this may be particularly beneficial after the intraoperative liver resection during a low central venous pressure state to restore tissue perfusion, with patients having comorbidities and reduced cardiac function benefiting the most. A Postoperative care (thromboprophylaxis): administer routine postoperative LMWH or UFH to reduce the risk of thromboembolic events unless exceptional circumstances make this unsafe. Use intermittent pneumatic compression devices to reduce this risk further. B Postoperative care (early mobilization): initiate early mobilization (out of bed) after liver surgery from the operative day until hospital discharge. Insufficient evidence regarding the optimal duration of mobilization. B Postoperative care (nutrition): implement early oral intake with a normal diet after hepatectomy. Assess the individualized needs for artificial nutrition in malnourished patients, patients with complications causing several days of fasting, and patients with liver cirrhosis. Prefer enteral administration for artificial nutrition. A Show 2 more Postoperative care (antiemetics): use a multimodal approach to postoperative nausea and vomiting. Administer postoperative nausea and vomiting prophylaxis with at least 2 antiemetic drugs, such as dexamethasone and ondansetron. A Postoperative care (laxatives): insufficient evidence to support the routine use of postoperative laxatives, gum chewing, herbal medicine, or decoction to stimulate bowel movement after liver surgery. I https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 4/6 6/24/23, 12:40 PM Hepatic adenoma Pathway 7. Surgical interventions Surgical resection (indications): perform resection in patients with hepatocellular adenoma irrespective of size in males and in any instance of proven -catenin mutation. B Show 3 more Liver transplantation: do not offer liver transplantation in patients with multiple hepatocellular adenomas. Consider offering liver transplantation in patients with underlying liver disease. D Surgical resection (technical considerations): perform liver resection laparoscopically, in trained teams and when clinically appropriate, to reduce the postoperative length of stay and complication rates. B Show 3 more 8. Specific circumstances Pregnant patients: monitor hepatic adenomas with ultrasound during pregnancy for growth. Refer patients with large adenomas (> 5 cm) for resection before pregnancy. B 9. Patient education General counseling: As per EASL 2016 guidelines, advise lifestyle changes such as discontinuation of oral contraceptives as well as weight loss upon hepatocellular adenoma diagnosis. B As per ACG 2014 guidelines: Advise avoiding oral contraceptives, hormone-containing intrauterine devices, and anabolic steroids in patients with hepatocellular adenoma. B Counsel patients that pregnancy is not generally contraindicated in hepatocellular adenoma < 5 cm and offer an individualized approach in these patients. B 10. Follow-up and surveillance Serial imaging assessment: As per EASL 2016 guidelines, reassess female patients with lesions < 5 cm at 1 year, and annually thereafter. B As per ACG 2014 guidelines, obtain follow-up CT or MRI at 6-12-month intervals in patients with lesions suspected of being hepatocellular adenoma, if no therapeutic intervention is pursued. Decide on the duration of monitoring based on the growth patterns and stability of the lesion over time. B References https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 5/6 6/24/23, 12:40 PM Hepatic adenoma Pathway 1. Marrero JA, Ahn J, Rajender Reddy K et al. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014 Sep;109 9 1328 47. Open 2. Ga tan-Romain Joliat, Kosuke Kobayashi, Kiyoshi Hasegawa et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery ERAS Society Recommendations 2022. World J Surg. 2023 Jan;47 1 11 34. Open 3. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 4. Expert Panel on Gastrointestinal Imaging, Victoria Chernyak, Jeanne M Horowitz et al. ACR Appropriateness Criteria Liver Lesion-Initial Characterization. J Am Coll Radiol. 2020 Nov;17 11S S429 S446. Open 5. European Association for the Study of the Liver EASL . EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016 Aug;65 2 386 98. Open 6. European Association for the Study of the Liver, Clinical Practice Guideline Panel: Chair, Panel members et al. EASL Clinical Practice Guidelines: Drug-induced liver injury. J Hepatol. 2019 Jun;70 6 1222 1261. Open 7. Christoph F Dietrich, Christian P llson Nols e, Richard G Barr et al. Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound CEUS in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultrasound Med Biol. 2020 Oct;46 10 2579 2604. Open 8. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open https://web.pathway.md/diseases/recJem7gvtVJ5xwBl 6/6