Liver abscess after transcatheter oily chemoembolization for hepatic tumors: incidence, predisposing factors, and clinical outcome

Splenic Abscess: An Easily Overlooked Disease?

Splenic abscess is an uncommon but potentially life-threatening disease. Recent advances in radiology have affected the diagnosis and management of this disease entity. The purpose of this study was to review our experience in managing these patients. We retrospectively reviewed the medical records of 51 patients with splenic abscess as seen in a tertiary medical center between 1998 and 2003. We analyzed the demographics, clinical manifestations, etiology, predisposing factors, diagnostic modalities, bacteriologic profile, treatment, and outcome of these patients. The mean age was 59.9 ± 14.2 years (ranging from 21–89 years). The male:female ratio was 29:22. Common symptoms included fever (82%), abdominal pain (71%), and nausea and vomiting (46%). The majority of these patients (83%) had leukocytosis. Thirty-six patients had associated parenchymal liver diseases and 26 patients had diabetes mellitus. Abdominal sonogram or computed tomography was performed to establish the diagnosis. Most cultures from the abscess cavities grew gram-negative enteric bacilli. Patients were treated with antimicrobial therapy only (n = 33), additional percutaneous drainage with a pigtail catheter (n = 11), or splenectomy (n = 7), and the survival rates were 48 per cent, 45 per cent, and 100 per cent, respectively. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy appears to have better treatment outcome than percutaneous drainage or intravenous antibiotics alone.

Chemoembolization in Patients at High Risk: Results and Complications

PURPOSE

Transarterial chemoembolization (TACE) has become a standard treatment option for unresectable hepatocellular carcinoma (HCC) and is often used to palliate hepatic metastases. Many patients who are candidates for TACE present with poor hepatic reserve, advanced tumor stage with major portal vein (PV) invasion or thrombosis, and/or biliary dilation. These factors have been associated with a poor prognosis and increased complications after chemoembolization. Accordingly, these patients are classified as being at high risk and may not be considered for therapy. The aim of this study is to evaluate the results of TACE in these patients.

MATERIALS AND METHODS

Over a period of 5 years, 141 patients underwent 355 TACE procedures. Thirty-six patients (26%) were in the high-risk group as a result of major PV thrombosis, increased serum bilirubin level (>2 mg/dL), and/or intrahepatic biliary dilation. HCC was the underlying tumor in 60% of patients. Thirty-seven percent of patients had Child-Pugh class B/C disease. Patients in the high-risk group received more selective embolization with fewer particles and fewer procedures (2.0 vs 2.7; P < .04).

RESULTS

Patients in the high-risk group were more likely to have HCC (83% vs 51%; P < .01) and were also more likely to have advanced disease according to Child-Pugh classification versus patients in the low-risk group (49% vs 20%; P < .01). The overall complication rate was 4.3%, with no significant difference in complication rate between groups (3.2% vs 8.2%; P = .12). The overall 30-day mortality rate was 2.3%, and no significant difference in 30-day mortality rate was observed between the high- and low-risk groups (5.5% vs 1.4%; P = .11). A trend toward increased survival in the low-risk group did not reach statistical significance.

CONCLUSIONS

These data suggest that patients with advanced disease and decreased hepatic reserve who are treated with TACE exhibit no significant increase in morbidity or mortality and no significant decrease in survival. With variations in technique, TACE can be performed safely in patients with the relative risk factors that may classify them in high-risk groups.

Complications of radiofrequency ablation in hepatocellular carcinoma

Radiofrequency thermal ablation has been accepted as a promising technique to treat unresectable liver tumors. However, any interventional procedure should be performed only if the procedure is safe, with minimal morbidity and mortality rates. Recently, three separate multicenter surveys have reported acceptable morbidity and mortality rates for a minimally invasive technique. The mortality rate ranged from 0.1% to 0.5%, the major complication rate ranged from 2.2% to 3.1%, and the minor complication rate ranged from 5% to 8.9%. The most common causes of death were sepsis and hepatic failure, and the most common complications were intraperitoneal bleeding, hepatic abscess, bile duct injury, hepatic decompensation, and grounding pad burns. Minor complications and side effects are more common than major complications, but most of them are transient and self-limiting. Several strategies for avoiding or limiting the impact of complications after radiofrequency ablation are recommended: (a) careful patient selection, (b) combined treatment with other techniques when appropriate, (c) selection of the most appropriate guiding modality and approach, and (d) early detection and appropriate management of any major complications. Knowledge of the broad spectrum of complications and relevant management enables the operator to minimize the incidence and effect of any complications that occur after radiofrequency ablation.

[Non-surgical treatment of hepatocellular carcinoma. An overview]

Surgery is often not a treatment option in patients with hepatocellular carcinoma with the numerous limitations of liver transplantation or surgical resection due to coexisting cirrhosis in the later case. Non-surgical treatments deal with 3 types of methods: local ablation with curative purpose, transarterial treatments with many technical variants and systemic treatment. Local treatments rely on chemical or thermic agents to achieve ablation of liver lesions, which not exceed initially 3 cm in diameter. The use of radiofrequency ablation allows now larger limits. Intra-arterial treatment usually combines intra-arterial chemotherapy with embolisation of hepatic artery in a procedure called chemoembolisation. Its antitumoral effect mainly due to ischemia is well documented but the influence on survival remains controversial. Finally systemic treatments have yet to be demonstrated useful: new agents and new randomised trials are still needed.

Angiographic considerations in patients undergoing liver-directed therapy

The rapid evolution and increasing complexity of liver-directed therapies has forced the medical community to further advance its understanding of hepatic arterial anatomy. The anatomy of the mesenteric system, and particularly the hepatic arterial bed, has been demonstrated to have a high degree of variation. This is important when considering presurgical planning, catheterization, and transarterial hepatic therapies. Although anatomic variants have been well described, the characterization and understanding of regional hepatic perfusion is also required to optimize endovascular therapy and intervention. Although this is true for patients undergoing bland embolization or chemoembolization, drug delivery, and hepatic infusional pump therapy, it is particularly true for intraarterial brachytherapy. The purpose of this review is to provide historical perspective in angiographic aspects of liver-directed therapy, as well as a discussion of normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors. Methods of optimizing the safety and efficacy of liver-directed therapies with use of percutaneous techniques will be discussed. This review is based on the experience gained in treating more than 500 patients with transarterial liver-directed therapies. Although the principles described in this article apply to all liver-directed therapies such as chemoembolization and administration of drug-coated microspheres, they apply particularly to intraarterial brachytherapy.

Liver abscess after percutaneous radiofrequency ablation for hepatocellular carcinomas: frequency and risk factors

OBJECTIVE

The purpose of this study was to clarify the frequency and risk factors of liver abscess formation after percutaneous radiofrequency ablation in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Over a 4-year period, 603 patients with 831 hepatocellular carcinomas measuring 5 cm or less in maximum diameter who underwent a total of 751 percutaneous radiofrequency ablation procedures were enrolled in this study. We retrospectively reviewed the medical records and analyzed the overall frequency of liver abscess, risk factors for abscess, and clinical features of the patients. The relationships between liver abscess and potential risk factors were analyzed using either generalized estimating equations or multiple logistic regression analysis.

RESULTS

Liver abscess developed in 14 tumors of 13 patients after 13 (13/751 [1.7%]) ablation procedures. Generalized estimating equations and multiple logistic regression analysis of various potential risk factors revealed that preexisting biliary abnormality prone to ascending biliary infection (p = 0.0088), tumor with retention of iodized oil from previous transcatheter arterial chemoembolization (p = 0.040), and treatment with an internally cooled electrode system (p = 0.016) were associated with a significant risk of liver abscess formation. No patient died of liver abscess, and all successfully recovered from liver abscess with parenteral antibiotics and percutaneous clearance of pus.

CONCLUSION

Although liver abscess formation was infrequent in patients who underwent percutaneous radiofrequency ablation for hepatocellular carcinoma, the patients with significant risk factors-preexisting biliary abnormality prone to ascending biliary infection, tumor with retention of iodized oil, and treatment with an internally cooled electrode system-for liver abscess formation should be closely monitored after treatment.

Antibiotic prophylaxis in interventional radiology

Despite several decades of advances in both minimally invasive techniques and antibiotic therapy, infection remains one of the more common complications of invasive procedures. Interventional radiology (IR) has traditionally been believed to be associated with lower infection rates than surgery. However, new interventional techniques, as well as more aggressive therapeutic interventions, have presented new challenges in relation to pharmacological management of postprocedural infection and pain. The risk of infection associated with IR procedures can never be completely eliminated, and the reasons for this are manifold, including more virulent organisms, ongoing and newly emerging antibiotic resistance, increased numbers of immunocompromised patients, and the adoption into everyday interventional practice of more aggressive interventional techniques such as chemoembolization, uterine fibroid embolization, and complex biliary intervention. Despite the widespread use of prophylactic antibiotics in IR, and the widely held belief that they are beneficial and are the standard of care, randomized controlled clinical trials have never validated the use of antibiotics in this setting. As such, an argument could be made not to use antibiotics at all for prophylaxis in IR. The purpose of this article is to discuss some of the issues relating to the use of prophylactic antibiotics, and what choice of antibiotics physicians make when they decide to use prophylaxis for IR procedures.

Liver abscess complicating transcatheter arterial embolization: a rare but serious complication. A retrospective study after 3878 procedures

OBJECTIVES

Liver abscess is one of the complications of transcatheter arterial embolization (TAE) for hepatocellular carcinoma. We studied the clinical features and analysed the incidence, risk factors, helpful clinical clues, culture profiles and predictive factors of post-TAE liver abscess. The influence of abscess development on the evolution of the tumour process was also studied.

METHODS

We retrospectively reviewed records of 3878 TAE procedures performed over a 6 year period.

RESULTS

Ten cases of liver abscess developed in nine patients (eight males and one female). The incidence was 0.26% (10 episodes/3878 procedures). The main clinical presentations included fever (91.7%), chills (50%) and abdominal pain (33.3%). All but one febrile patient presented fever in a recurrent form. The positive culture rates were 41.7% for blood and 83.3% for pus. Gram negative bacteria were found in 80% of blood cultures and 68% of pus cultures. Polymicrobial infections were encountered in 60% of the blood cultures and 70% of pus cultures. Management included antibiotics, drainage and operation. Four patients died due to the direct complications of liver abscess. One patient experienced total tumour resolution after successful treatment for liver abscess. Patients with larger liver abscesses and patients with greater age carried higher mortality rates.

CONCLUSIONS

Liver abscess is a rare complication after TAE for hepatocellular carcinoma. Recurrent fevers after an initial symptom free interval should arouse suspicion of an abscess. The mortality is high and a large abscess and higher age predict an unfavourable outcome. Abscess formation can lead to complete tumour resolution.

Cholangitis and Liver Abscess after Percutaneous Ablation Therapy for Liver Tumors: Incidence and Risk Factors

PURPOSE

To determine the risk factors of cholangitis and liver abscess occurring after percutaneous ablation therapy for liver tumors.

MATERIALS AND METHODS

Between October 1995 and September 2002, 358 patients with 455 liver tumors underwent a total of 683 ablation procedures, such as percutaneous ethanol injection (PEI), percutaneous microwave coagulation (PMC), and radiofrequency (RF) ablation therapy. With a retrospective review of medical records, the rates and outcomes of cholangitis and/or liver abscess occurring after ablation therapy were evaluated. The relationship between cholangitis and/or liver abscess and multiple variables (age, disease, Child-Pugh class, size of nodules, multiplicity of nodules, history of transcatheter arterial embolization, presence of bilioenteric anastomosis, and lack of prophylactic antibiotics administration) were statistically analyzed.

RESULTS

Cholangitis and/or liver abscess occurred in 10 sessions (1.5%) in 10 patients: six sessions after PEI, three sessions after PMC, and one session after RF ablation. Both cholangitis and liver abscess were noted in seven sessions, cholangitis was noted in two, and liver abscess was noted in one. Six patients recovered, but two developed recurrent cholangitis and liver abscess, one developed lung abscess complicated with liver abscess, and one died of septic shock associated with cholangitis. On stepwise regression analysis, bilioenteric anastomosis was the sole significant predictor of cholangitis and/or liver abscess formation (P <.001; odds ratio = 36.4; 95% CI = 9.67-136.9).

CONCLUSION

Bilioenteric anastomosis strongly correlated with the development of cholangitis and/or liver abscess after percutaneous ablation therapy. Close posttreatment attention should be paid to this subgroup of patients.

Liver metastases: neoadjuvant downsizing with transarterial chemoembolization before laser-induced thermotherapy

PURPOSE

To evaluate a treatment protocol with repeated transarterial chemoembolization (TACE) before laser-induced thermotherapy (LITT) in patients with unresectable liver metastases that are too large for LITT alone.

MATERIALS AND METHODS

One hundred sixty-two patients who had unresectable liver metastases, with the largest lesion as large as 80 mm in diameter, and no more than four lesions were treated with repeated TACE between March 1999 and December 2001. TACE was performed with a maximum of 10 mg/m2 mitomycin for chemotherapy and a maximum of 15 mL/m2 of iodized oil and microspheres for vessel occlusion. Tumor volume before and during treatment was measured at magnetic resonance (MR) imaging. If the diameter of the tumor decreased to less than 50 mm, the patients were treated with MR imaging-guided LITT 4-6 weeks following embolization.

RESULTS

Eighty-two patients (62 with metastases from colorectal cancer, 14 with metastases from breast cancer, and six with metastases from other primary tumors) responded to TACE, with a mean reduction in tumor size of 35% +/- 14 (SD), and were treated with LITT. Each patient underwent two to seven TACE treatments (mean, 4.3) prior to LITT. In 47 patients, no reduction in tumor size was achieved, which led to further follow-up. In 33 patients, disease progression was found, with either an increasing size of the lesions (n = 18) or newly developing metastases (n = 15), and these results led to further TACE treatments or change to systemic chemotherapy. Median survival of patients who responded to this combined treatment was 26.2 months; in patients treated with only TACE, median survival was 12.8 months (range, 0.3-29.4 months).

CONCLUSION

With repeated TACE, reduction in size of primary unresectable hepatic metastases is achieved in 50.6% of cases and allows local ablative treatments such as MR imaging-guided LITT.

Adverse events during radiofrequency treatment of 582 hepatic tumors

OBJECTIVE

We describe the rates and potential risk factors of complications of radiofrequency ablation of hepatic tumors. SUBJECTS AND METHODS. Over a 5-year period, 312 patients underwent 350 sessions of radiofrequency ablation (124 intraoperative and 226 percutaneous) for treatment of 582 liver tumors including 115 hepatocellular carcinomas and 467 metastatic tumors. The chi-square test was used for a group-to-group comparison of the occurrence of adverse events.

RESULTS

Thirty-seven (10.6%) adverse events and five (1.4%) deaths were related to radiofrequency treatment. The deaths were caused by liver insufficiency (n = 1), colon perforation (n = 1), and portal vein thrombosis (n = 3). Portal vein thrombosis was significantly (p < 0.00001) more frequent in cirrhotic livers (2/5) than in noncirrhotic livers (0/54) after intraoperative radiofrequency ablation performed during a Pringle maneuver. Liver abscess (n = 7) was the most common complication. Abscess occurred significantly (p < 0.00001) more frequently in patients bearing a bilioenteric anastomosis (3/3) than in other patients (4/223). We encountered five pleural effusions, five skin burns, four hypoxemias, three pneumothoraces, two small subcapsular hematomas, one acute renal insufficiency, one hemoperitoneum, and one needle-tract seeding. The 6.3% of minor complications did not require specific treatment or a prolonged hospital stay. Among the 5.7% major complications, 3.7% required less than 5 days of hospitalization for treatment or surveillance and 2% required more than 5 days for treatment.

CONCLUSION

Radiofrequency ablation of liver tumors is a well-tolerated technique, but caution should be exercised when treating patients with a bilioenteric anastomosis, and radiofrequency ablation during vascular occlusion in cirrhotic livers should be avoided.

Major complications after radio-frequency thermal ablation of hepatic tumors: spectrum of imaging findings

Although radio-frequency (RF) ablation has been accepted as a promising and safe technique for treatment of unresectable hepatic tumors, investigation of its complications has been limited. According to the multicenter (1,139 patients in 11 institutions) survey data of the Korean Study Group of Radiofrequency Ablation, a spectrum of complications occurred after RF ablation of hepatic tumors. The prevalence of major complications was 2.43%. The most common complications were hepatic abscess (0.66%), peritoneal hemorrhage (0.46%), biloma (0.20%), ground pad burn (0.20%), pneumothorax (0.20%), and vasovagal reflex (0.13%). Other complications were biliary stricture, diaphragmatic injury, gastric ulcer, hemothorax, hepatic failure, hepatic infarction, renal infarction, sepsis, and transient ischemic attack. One procedure-related death (0.09%) occurred (due to peritoneal hemorrhage). Three important strategies for decreasing the rate of complications are prevention, early detection, and proper management. A physician who performs RF ablation of hepatic malignancies should be aware of the broad spectrum of major complications so that these strategies can be used.

Influence of a new prophylactic antibiotic therapy on the incidence of liver abscesses after chemoembolization treatment of liver tumors

Intrahepatic abscess is a complication of transcatheter arterial chemoembolization (TACE) treatment in patients who have a history of biliary reconstructive surgery. This study followed eight patients who underwent chemoembolization after biliary surgery. These patients were divided into two groups. Patients in group one (n = 4) were administered intravenous cephalexin for prophylaxis. Patients in group two (n = 4) were administered bowel preparation and tazobactam/piperacillin. All patients in group one developed hepatic abscesses, which were treated with percutaneous catheter drainage and antibiotics. None of the patients in group two developed abscesses. Aggressive antibiotic prophylaxis with bowel preparation may provide protection against intrahepatic abscesses after chemoembolization in patients who have a history of biliary reconstructive surgery.

Minimally invasive image-guided therapies for hepatocellular carcinoma

Minimally invasive therapies are gaining increasing attention as an alternative to standard surgical therapies in the treatment of primary hepatocellular carcinoma. These include therapies administered transcatheterally (arterial embolization, intraarterial chemoinfusion, and combination chemoembolization) and percutaneously (chemical ablation with ethanol or acetic acid, and thermal ablation with radiofrequency, microwave, or laser energies). Benefits over surgical resection include the anticipated reduction in morbidity and mortality, low cost, suitability for real time image guidance, the ability to perform ablative procedures on outpatients, and the potential application in a wider spectrum of patients, including nonsurgical candidates. This review examines reported clinical success, potential complications, current limitations, and future directions of development of chemoembolization, ethanol and acetic acid instillation, and radiofrequency, microwave, and laser thermal ablation.

Chemoembolization of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for patients with unresectable hepatocellular carcinoma (HCC). Chemoembolization involves delivery of some type of chemotherapy combined with some type of arterial embolization to destroy tumor cells. Whereas diffuse tumors may require lobar embolization, smaller tumors may be treated selectively. The goal of TACE is to cause tumor necrosis and control tumor growth while preserving as much functional liver tissue as possible. The ultimate purpose, however, is to prolong life. Several different TACE protocols have been developed, with no consensus as to the most effective techniques. The effect of TACE on patient survival remains unclear. Several nonrandomized studies have demonstrated a beneficial effect of TACE on survival. This result has not been confirmed with randomized trials. It is clear, however, that TACE is a palliative procedure that has been unable to provide a cure for HCC. When combined with other procedures such as percutaneous ethanol injection, TACE has been more successful at achieving survival rates matching those obtained after surgical resection in similar patient populations. Finally, TACE may also be useful as a neoadjuvant therapy by improving the outcomes of potentially curative therapies and as a bridge to liver transplantation.

Hepatic artery chemoembolization

Chemoembolization is a technique that can deliver high concentrations of therapeutic agents directly to the liver for prolonged periods. Considerable experience has been gained in the treatment of hepatocellular carcinoma, where it appears to be a safe procedure that provides survival advantage over conservative therapy. There is much less experience in the treatment of hepatic metastases. Patients with carcinoid, pancreatic islet cell tumor, and sarcoma metastatic to the liver do appear to benefit from chemoembolization. Efficacy in other groups, such as patients with colorectal cancer metastatic to the liver, is less well established, but a recently initiated multicenter trial may resolve this issue.