European Journal of Pediatrics

, Volume 178, Issue 1, pp 1–6 | Cite as

Clinical and economic impact of surgery for treating infantile hemangiomas in the era of propranolol: overview of single-center experience from La Paz Hospital, Madrid

  • Juan-Carlos López-GutiérrezEmail author


Propranolol has changed the management of infantile hemangiomas (IHs). We summarize the evolution of surgical treatment for IH at La Paz Children’s Hospital (Madrid) in the era of propranolol, with a focus on hepatic IHs.

Retrospectively, we compared surgical treatment of IHs in children referred during the periods 2004–2009 and 2009–2014. Hepatic IH mortality rates before and after the introduction of propranolol therapy were evaluated specifically.

The majority of hemangiomas needing surgical excision were located on the head/face/scalp of female patients. Since the introduction of propranolol therapy, surgery for IH has decreased from about 60 to 6 procedures/year at our institution and no transplants for hepatic IH have been registered.

Conclusions: Surgical procedures for IH have decreased by about 90% at our institution since the introduction of propranolol treatment and hepatic IH have not needed liver transplantation. Referrals for surgery for IH are generally the consequence of absent or delayed propranolol treatment. Given the significant reduction in the number of surgical procedures, propranolol can be considered as having a strong economic and social impact.

What is Known:

The use of oral propranolol solution is currently considered as the treatment of choice in the management of infantile hemangiomas.

Propranolol treatment achieves better outcomes and less side effects than systemic corticosteroids.

What is New:

Social and financial impact of the significant reduction in the number of reconstructive surgical procedures and liver transplants due to the use of propranolol in tertiary health institutions remains to be analyzed.


Beta-blockers Facial hemangioma Hepatic hemangioma Infantile hemangioma Propranolol Surgery 



Writing assistance was provided by Content Ed Net (France), funded by Pierre Fabre Dermatologie.

Authors’ Contributions

Juan Carlos Lopez-Gutierrez: literature search, study design, data collection, analysis, interpretation, and writing.

Compliance with ethical standards

Conflict of interest

The author declares that he has no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Baselga Torres E, Bernabéu Wittel J, van Esso Arbolave DL, Febrer Bosch MI, Carrasco Sanz Á, de Lucas Laguna R, del Pozo Losada J, Hernández Martín Á, Jiménez Montañés L, López Gutiérrez JC, Martín-Santiago A, Redondo Bellón P, Ruíz-Canela Cáceres J, Torrelo Fernández A, Vera Casaño Á, Vicente Villa MA (2016) Spanish consensus on infantile haemangioma. An Pediatr (Barc) 85:256–265CrossRefGoogle Scholar
  2. 2.
    Bauland CG, Lüning TH, Smit JM, Zeebregts CJ, Spauwen PHM (2011) Untreated hemangiomas: growth pattern and residual lesions. Plast Reconstr Surg 127:1643–1648CrossRefGoogle Scholar
  3. 3.
    Bentley TS. 2014 U.S. organ and tissue transplant cost estimates and discussion; December 2014. Available from [last accessed 30 November 2017]
  4. 4.
    Boon LM, Burrows PE, Paltiel HJ, Lund DP, Ezekowitz RAB, Folkman J, Mulliken JB (1996) Hepatic vascular anomalies in infancy: a twenty-seven-year experience. J Pediatr 129:346–354CrossRefGoogle Scholar
  5. 5.
    Caussé S, Aubert H, Saint-Jean M, Puzenat E, Bursztejn AC, Eschard C, Mahé E, Maruani A, Mazereeuw-Hautier J, Dreyfus I, Miquel J, Chiaverini C, Boccara O, Hadj-Rabia S, Stalder JF, Barbarot S, the Groupe de Recherche Clinique en Dermatologie Pédiatrique (2013) Propranolol-resistant infantile haemangiomas. Br J Dermatol 169:125–129CrossRefGoogle Scholar
  6. 6.
    Cheng CE, Friedlander SF (2016) Infantile hemangiomas complications and treatments. Semin Cutan Med Surg 35:108–116CrossRefGoogle Scholar
  7. 7.
    Cost Helper Health. Birthmark removal cost. Available from [last accessed 30 November 2017]
  8. 8.
    Darrow DH, Greene AK, Mancini AJ et al (2015) The section on dermatology, section on otolaryngology-head & neck surgery, and section on plastic surgery. diagnosis and management of infantile hemangioma: executive summary. Pediatrics 136:786–791CrossRefGoogle Scholar
  9. 9.
    Dickie B, Dasgupta R, Nair R, Alonso MH, Ryckman FC, Tiao GM, Adams DM, Azizkhan RG (2009) Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg 44:125–133CrossRefGoogle Scholar
  10. 10.
    Drolet BA, Frommelt PC, Chamlin SL, Haggstrom A, Bauman NM, Chiu YE, Chun RH, Garzon MC, Holland KE, Liberman L, MacLellan-Tobert S, Mancini AJ, Metry D, Puttgen KB, Seefeldt M, Sidbury R, Ward KM, Blei F, Baselga E, Cassidy L, Darrow DH, Joachim S, Kwon EKM, Martin K, Perkins J, Siegel DH, Boucek RJ, Frieden IJ (2013) Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics 131:128–140CrossRefGoogle Scholar
  11. 11.
    Gnarra M, Behr G, Kitajewski A, Wu JK, Anupindi SA, Shawber CJ, Zavras N, Schizas D, Salakos C, Economopoulos KP (2016) History of the infantile hepatic hemangioma: from imaging to generating a differential diagnosis. World J Clin Pediatr 5:273–280CrossRefGoogle Scholar
  12. 12.
    Harries L, Schrem H, Stahmeyer JT, Krauth C, Amelung VE (2017) High resource utilization in liver transplantation-how strongly differ costs between the care sectors and what are the main cost drivers? A retrospective study. Transpl Int 30:621–637CrossRefGoogle Scholar
  13. 13.
    Hoeger PH, Harper JI, Baselga E, Bonnet D, Boon LM, Atti MCD, el Hachem M, Oranje AP, Rubin AT, Weibel L, Léauté-Labrèze C (2015) Treatment of infantile haemangiomas: recommendations of a European expert group. Eur J Pediatr 174:855–865CrossRefGoogle Scholar
  14. 14.
    Hogeling M, Adams S, Wargon O (2011) A randomized controlled trial of propranolol for infantile hemangiomas. Pediatrics 128:e259–e266CrossRefGoogle Scholar
  15. 15.
    Iyer CP, Stanley P, Mahour GH (1996) Hepatic hemangiomas in infants and children: a review of 30 cases. Am Surg 62:356–360Google Scholar
  16. 16.
    Ji Y, Chen S, Xiang B, Xu Z, Jiang X, Liu X, Wang Q, Lu G, Yang L (2016) Clinical features and management of multifocal hepatic hemangiomas in children: a retrospective study. Sci Rep 6:31744CrossRefGoogle Scholar
  17. 17.
    Keller RG, Stevens S, Hochman M (2017) Modern management of nasal hemangiomas. JAMA Facial Plast Surg 19:327–332CrossRefGoogle Scholar
  18. 18.
    Kitazawa T, Matsumoto K, Fujita S, Seto K, Hasegawa T (2017) Cost analysis of transplantation in Japan, performed with the use of the national database. Transplant Proc 49:4–9CrossRefGoogle Scholar
  19. 19.
    Kulungowski AM, Alomari AI, Chawla A, Christison-Lagay ER, Fishman SJ (2012) Lessons from a liver hemangioma registry: subtype classification. J Pediatr Surg 47:165–170CrossRefGoogle Scholar
  20. 20.
    Léauté-Labrèze C, Dumas de la Roque E, Hubiche T et al (2008) Propranolol for severe hemangiomas of infancy. N Engl J Med 358:2649–2651CrossRefGoogle Scholar
  21. 21.
    Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier L et al (2015) A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med 372:735–746CrossRefGoogle Scholar
  22. 22.
    Léauté-Labrèze C, Harper JI, Hoeger PH (2017) Infantile haemangioma. Lancet 390:85–94CrossRefGoogle Scholar
  23. 23.
    Lee TC, Barshes NR, Agee EE, O'Mahony CA, Karpen SJ, Carter BA, Bristow JD, Goss JA (2006) Resolution of medically resistant hypothyroidism after liver transplantation for hepatic hemangioendothelioma. J Pediatr Surg 41:1783–1785CrossRefGoogle Scholar
  24. 24.
    Liang MG, Frieden IJ (2014) Infantile and congenital hemangiomas. Semin Pediatr Surg 23:162–167CrossRefGoogle Scholar
  25. 25.
    Lou Y, Peng WJ, Cao Y, Cao DS, Xie J, Li HH (2014) The effectiveness of propranolol in treating infantile haemangiomas: a meta-analysis including 35 studies. Br J Clin Pharmacol 78:44–57CrossRefGoogle Scholar
  26. 26.
    Markiewicz-Kijewska M, Kasprzyk W, Broniszczak D, Bacewicz L, Ostoja-Chyzynska A, Ismail H, Kosciesza A, Dembowska-Baginska B, Teisseyre J, Kluge P, Brzezinska-Rajszys G, Jankowska I, Kalicinski P (2009) Hemodynamic failure as an indication to urgent liver transplantation in infants with giant hepatic hemangiomas or vascular malformations--report of four cases. Pediatr Transplant 13:906–912CrossRefGoogle Scholar
  27. 27.
    Marqueling AL, Oza V, Frieden IJ, Puttgen KB (2013) Propranolol and infantile hemangiomas four years later: a systematic review. Pediatr Dermatol 30:182–191CrossRefGoogle Scholar
  28. 28.
    Mazereeuw-Hautier J, Hoeger PH, Benlahrech S, Ammour A, Broue P, Vial J, Ohanessian G, Léauté-Labrèze C, Labenne M, Vabres P, Rössler J, Bodemer C (2010) Efficacy of propranolol in hepatic infantile hemangiomas with diffuse neonatal hemangiomatosis. J Pediatr 157:340–342CrossRefGoogle Scholar
  29. 29.
    Munden A, Butschek R, Tom WL, Marshall JS, Poeltler DM, Krohne SE, Alió AB, Ritter M, Friedlander DF, Catanzarite V, Mendoza A, Smith L, Friedlander M, Friedlander SF (2014) Prospective study of infantile haemangiomas: incidence, clinical characteristics and association with placental anomalies. Br J Dermatol 170:907–913CrossRefGoogle Scholar
  30. 30.
    Ng M, Knuth C, Weisbrod C, Murthy A (2016) Propranolol therapy for problematic infantile hemangioma. Ann Plast Surg 76:306–310CrossRefGoogle Scholar
  31. 31.
    Organización Nacional de Transplantes. Memoria Trasplante Hepático 2015. Available from [last accessed 29 November 2017]
  32. 32.
    Paragò V, El HM, Bonamonte D et al (2014) Cost-utility analysis comparing propranolol with corticosteroids in the treatment of proliferating infantile hemangioma in Italy. Value Health 17:A511CrossRefGoogle Scholar
  33. 33.
    Pediatric Liver Unresectable Tumor Observatory (PLUTO) Registry. Available from [last accessed 29 November 2017]
  34. 34.
    Price CJ, Lattouf C, Baum B et al (2011) Propranolol vs corticosteroids for infantile hemangiomas: a multicenter retrospective analysis. Arch Dermatol 147:1371–1376CrossRefGoogle Scholar
  35. 35.
    Rialon KL, Murillo R, Fevurly RD, Kulungowski AM, Christison-Lagay ER, Zurakowski D, Kozakewich HPW, Alomari AI, Fishman SJ (2015) Risk factors for mortality in patients with multifocal and diffuse hepatic hemangiomas. J Pediatr Surg 50:837–841CrossRefGoogle Scholar
  36. 36.
    Rodriguez JA, Becker NS, O’Mahony CA, Goss JA, Aloia TA (2008) Long-term outcomes following liver transplantation for hepatic hemangioendothelioma: the UNOS experience from 1987-2005. J Gastrointest Surg 12:110–116CrossRefGoogle Scholar
  37. 37.
    Sarıalioğlu F, Yazıcı N, Erbay A et al (2017) A new perspective for infantile hepatic hemangioma in the age of propranolol: experience at Baskent University. Exp Clin Transplant 15(Suppl 2):74–78Google Scholar
  38. 38.
    Seiffert A, Schneider M, Roessler J, Larisch K, Pfeiffer D (2017) Incidence, treatment patterns, and health care costs of infantile hemangioma: results of a retrospective German database analysis. Pediatr Dermatol 34:450–457CrossRefGoogle Scholar
  39. 39.
    Solman L, Murabit A, Gnarra M, Harper JI, Syed SB, Glover M (2014) Propranolol for infantile haemangiomas: single centre experience of 250 cases and proposed therapeutic protocol. Arch Dis Child 99:1132–1136CrossRefGoogle Scholar
  40. 40.
    United Network for Organ Sharing. Organ Procurement and Transplantation Network database. Available from [last accessed 29 November 2017]
  41. 41.
    Vega Mata N, López Gutiérrez JC, Vázquez Estévez J et al (2016) Surgical treatment of infantile hemangiomas in the era of propranolol. Ann Pediatr Child Health 4:1098Google Scholar
  42. 42.
    Waner M, O TM (2013) The role of surgery in the management of congenital vascular anomalies. Tech Vasc Interv Radiol 16:45–50CrossRefGoogle Scholar
  43. 43.
    Wedgeworth E, Glover M, Irvine AD, Neri I, Baselga E, Clayton TH, Beattie PE, Bjerre JV, Burrows NP, Foelster-Holst R, Hedelund L, Hernandez-Martin A, Audrain H, Bhate K, Brown SJ, Baryschpolec S, Darne S, Durack A, Dvorakova V, Gach J, Goldstraw N, Goodyear H, Grabczynska S, Greenblatt D, Halpern J, Hearn RMR, Hoey S, Hughes B, Jayaraj R, Johansson EK, Lam M, Leech S, O'Regan GM, Morrison D, Porter W, Ramesh R, Schill T, Shaw L, Taylor AEM, Taylor R, Thomson J, Tiffin P, Tsakok M, Janmohamed SR, Laguda B, McPherson T, Oranje AP, Patrizi A, Ravenscroft JC, Shahidullah H, Solman L, Svensson A, Wahlgren CF, Hoeger PH, Flohr C (2016) Propranolol in the treatment of infantile haemangiomas: lessons from the European Propranolol In the Treatment of Complicated Haemangiomas (PITCH) Taskforce survey. Br J Dermatol 174:594–601CrossRefGoogle Scholar
  44. 44.
    Zhang L, Wu HW, Yuan W et al (2017) Propranolol therapy for infantile hemangioma: our experience. Drug Des Devel Ther 8(11):1401–1408CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Pediatric Surgery, Vascular Anomalies CenterAutonoma University of MadridMadridSpain

Personalised recommendations