1
|
Liu J, Liu Y, Li C, Peng W, Jiang C, Peng S, Fu L. Characteristics of Klebsiella pneumoniae pyogenic liver abscess from 2010-2021 in a tertiary teaching hospital of South China. J Glob Antimicrob Resist 2024; 36:210-216. [PMID: 38154752 DOI: 10.1016/j.jgar.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVES Pyogenic liver abscess (PLA) is a severe and potentially fatal infectious disease. Klebsiella pneumoniae (K. pneumoniae) is the predominant pathogen responsible for PLA. This study aims to investigate the clinical characteristics and prognostic factors of K. pneumoniae-induced pyogenic liver abscess (KP-PLA), particularly those caused by carbapenem-resistant K. pneumoniae (CRKP). METHODS Analyses were performed on PLA patients from January 2010 to December 2021, to investigate the differences of K. pneumoniae from other etiologically infected PLA patients. Univariate and multivariate logistic regression analyses were used to compare prognostic factors between patients with carbapenem-resistant K. pneumoniae PLA (CRKP-PLA) and patients with carbapenem-sensitive K. pneumoniae PLA. RESULTS Univariate analysis demonstrated a significant association between KP-PLA and factors including diabetes mellitus (P < 0.001), cholecystitis and cholelithiasis (P = 0.032), single abscess (P = 0.016), and abscesses with a diameter over 50 mm (P = 0.004). The CRKP group exhibited a higher prevalence of therapeutic interventions before K. pneumoniae infection, including abdominal surgery, mechanical ventilation, sputum suction, tracheal cannula, routine drainage of the abdominal cavity, and peripherally inserted central venous catheters (P < 0.05). Multivariate logistic regression analysis revealed that admission to the intensive care unit was an independent risk factor associated with CRKP-PLA (odds ratio 36; 95% confidence interval 1.77-731.56; P = 0.020). CONCLUSION The KP-PLA patients were significantly associated with diabetes and were more likely to have single abscesses larger than 50 mm. PLA patients with a history of admission to intensive care unit or invasive therapeutic procedures should be given special consideration if combined with CRKP infection.
Collapse
Affiliation(s)
- Jinqing Liu
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yao Liu
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunhui Li
- Centre for Healthcare-Associated Infection Control, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenting Peng
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chuan Jiang
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shifang Peng
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lei Fu
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| |
Collapse
|
2
|
Justo I, Vega V, Marcacuzco A, Caso Ó, García-Conde M, Manrique A, Calvo J, García-Sesma Á, San Juan R, Fernández-Ruiz M, Rivas C, Calero MR, Jiménez-Romero C. Risk factors indicating the need for surgical therapy in patients with pyogenic liver abscesses. Langenbecks Arch Surg 2023; 408:97. [PMID: 36808482 PMCID: PMC9942623 DOI: 10.1007/s00423-023-02837-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST. METHODS We reviewed the medical charts of all of our institution's adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed. RESULTS The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST. CONCLUSIONS There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD.
Collapse
Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Viviana Vega
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Rivas
- Department of Thoracic Surgery and Lung Transplantation, Madrid, Spain
| | - María Rosa Calero
- Department of Radiology, "Doce de Octubre" Hospital, Research Institute (imas12), Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, 4ª Floor Ctra Andalucía Km 5,4, 28041, Madrid, Spain.
| |
Collapse
|
3
|
Nojima H, Shimizu H, Murakami T, Yamazaki M, Yamazaki K, Suzuki S, Shuto K, Kosugi C, Usui A, Koda K. Successful hepatic resection for invasive Klebsiella pneumoniae large multiloculated liver abscesses with percutaneous drainage failure: A case report. Front Med (Lausanne) 2023; 9:1092879. [PMID: 36687430 PMCID: PMC9852881 DOI: 10.3389/fmed.2022.1092879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023] Open
Abstract
Background Invasive Klebsiella-associated liver abscesses can progress rapidly and cause severe metastatic infections such as meningitis and hydrocephalus, which are associated with high morbidity and mortality. In patients with large multiloculated liver abscesses after failure of percutaneous drainage, rapid diagnosis of the abscess followed by hepatic resection is necessary for early recovery and to prevent severe secondary metastatic complications. Case presentation An 84-year-old woman with a large liver abscess and in septic shock was transferred to our hospital. Abdominal CT showed multiloculated liver abscesses 15 cm in diameter in the right lobe of the liver. We first performed percutaneous liver abscess drainage. The patient was managed in the intensive care unit, as well as treated with intravenous administration of meropenem followed by cefozopran according to the antibiogram. Klebsiella pneumoniae with invasive infection was confirmed by a string test in an isolated colony of K. pneumoniae; the K1 serotype with the rmpA and magA genes was determined by polymerase chain reaction and Sanger sequencing. Additional percutaneous liver abscess drainage was performed due to initial inadequate drainage. Although the abscess had shrunk to a diameter of 8 cm after drainage in 4 weeks, the patient recovered from sepsis, but still had low-grade fever (occasionally 38°C) and continued to have symptoms of chronic inflammation with persistent hyper mucus discharge from the liver abscess. Surgical resection was chosen to prevent prolonged hospitalization and ensure early recovery. A right posterior sectionectomy of the liver, including liver abscess, was performed. The post-operative course was uneventful, with no complications, and she was discharged after 18 days. There were no signs of abscess recurrence 1 year after surgery. Conclusion We present a case of successful hepatic resection after percutaneous drainage failure in a patient with invasive K. pneumoniae multiloculated liver abscess.
Collapse
Affiliation(s)
- Hiroyuki Nojima
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan,*Correspondence: Hiroaki Shimizu,
| | - Takashi Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Masato Yamazaki
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Kazuto Yamazaki
- Department of Pathology, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Seiya Suzuki
- Department of Pathology, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Akihiro Usui
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| |
Collapse
|
4
|
Liu Y, Li Z, Liu A, Xu J, Li Y, Liu J, Liu Y, Zhu H. Early percutaneous catheter drainage in protecting against prolonged fever among patients with pyogenic liver abscess: a retrospective cohort study. Ann Med 2022; 54:2269-2277. [PMID: 35975970 PMCID: PMC9387318 DOI: 10.1080/07853890.2022.2110612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Percutaneous catheter drainage (PCD) has been viewed as first-line treatment for pyogenic liver abscess (PLA), yet detailed guidance is lacking for best practice of PCD. This study investigated characteristics of patients with PLA who had received PCD, identified factors associated with prolonged fever, and aimed to evaluate the relationship between timing of PCD and clinical improvement. METHODS This was a retrospective study of patients with PLA who had undergone PCD over a 7-year period. PCD performed when the liquefaction degree of abscesses was less than 30% and/or within 1 week after fever onset was defined as early PCD. Patients were grouped and analysed based on the timing of PCD (early vs. delayed). Factors associated with prolonged fever were also analysed using univariate and multivariate logistic regression. RESULTS Among 231 patients with PLA, 81 treated with PCD were included in the study after exclusion. The size of abscesses ranged from 3.4 to 16 cm in diameter. Interestingly, the abscesses were predominantly multiloculated in this cohort (82.7%). The most common pathogen isolated from pus was Klebsiella pneumoniae (60.5%), followed by Escherichia coli (8.6%). The duration of fever was significantly shortened with early PCD as compared to delayed PCD intervention (p = .042). No statistical differences were found between the two groups with regard to catheter adjustment and salvage drainage. Maximum body temperature and diameter of abscess > 7.5 cm were found to be associated with prolonged fever while early PCD was inversely related to prolonged fever. Multivariate analysis suggested that early PCD treatment was an independent protective factor of prolonged fever (p = .030). CONCLUSIONS Large abscesses with loculation could be successfully treated with PCD, and early PCD protected patients with PLA from prolonged fever. Our findings suggest that early intervention should be provided if PCD is indicated in clinical practice.KEY MESSAGESLarge abscesses and multiloculated abscesses can be treated with percutaneous catheter drainage.Early percutaneous catheter drainage is identified as a protective factor of prolonged fever among patients with pyogenic liver abscesses.Early intervention should be provided if percutaneous catheter drainage is indicated for pyogenic liver abscesses.
Collapse
Affiliation(s)
- Yang Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zexi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Anlei Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Xu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jihai Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yecheng Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
5
|
Yasin NA, Ali AM, Ahmed MA, Keleşoğlu Sİ. Epidemiological Characteristics, Antimicrobial Susceptibility Profile, and Surgical Outcome of Complicated Intra-Abdominal Infection at a Tertiary Hospital in Somalia. Int J Gen Med 2022; 15:7427-7434. [PMID: 36172084 PMCID: PMC9512019 DOI: 10.2147/ijgm.s379711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background Intra-abdominal infections (IAIs) are common surgical emergencies and one of the leading causes of non-trauma deaths in hospitals worldwide. Because of limited resources, most patients in low-income countries experience delayed diagnosis and treatment. To the best of our knowledge, this is the first study to evaluate the epidemiological characteristics, antimicrobial susceptibility profile, and outcome of patients with complicated IAI at a tertiary hospital in Somalia. Methods This study included all patients with confirmed IAIs who underwent laparotomy or percutaneous drainage, either emergency or elective, and whose cultures showed growth. Sociodemographic and clinical characteristics, culture results, antimicrobial susceptibility profile, and the type of source control were reviewed. Results The prevalence of CIAI was 5.3%, 144 (70%) were male, and 61 (30%) were female. The mean age was 38.6±8.5 years. Appendicitis was the most common source of infection, accounting for 32%, followed by bowel perforation in 37 (18%). Out of 15 patients with liver abscesses, ten patients had diabetes (67%). E. coli 82 (40%) was the most common isolated organism, followed by Klebsiella pneumonia (n = 44, 21.5%). The prevalence of extended-spectrum beta-lactamase-producing and multidrug-resistant pathogens was 6.8% and 5.9%, respectively. The pathogens revealed a higher antimicrobial resistance against penicillins in 62%, cephalosporins in 54%, and fluoroquinolones in 44%. E. coli showed 2.5–13% antimicrobial resistance against carbapenems, lower than Klebsiella pneumonia in about 4.5%. Tigecycline, teicoplanin, and linezolid revealed the highest sensitivity against pathogens, about 100%. Source control was achieved by laparotomy in 81%, while the 19% were managed in a percutaneous approach. The mortality rate in our study was 9.3%. Conclusion The prevalence of CIAI in our study was 5.3%, with an increasing number of MDR microorganisms isolated from cultures. CIAI and intra-abdominal abscess are significant sources of high morbidity and mortality with sepsis and poor clinical outcome; thus, early detection and intervention are crucial.
Collapse
Affiliation(s)
- Nor Abdi Yasin
- Department of General Surgery, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
- Correspondence: Nor Abdi Yasin, Tel +252 615732173, Email
| | - Abdihamid Mohamed Ali
- Department of General Surgery, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
| | - Mohamed Abdi Ahmed
- Department of General Surgery, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
| | - Salim İdris Keleşoğlu
- Department of General Surgery, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
| |
Collapse
|
6
|
Meister P, Irmer H, Paul A, Hoyer DP. Therapy of pyogenic liver abscess with a primarily unknown cause. Langenbecks Arch Surg 2022; 407:2415-2422. [PMID: 35635587 PMCID: PMC9467942 DOI: 10.1007/s00423-022-02535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
Purpose Pyogenic liver abscess (PLA) is a collection of pus in the liver, often without a known direct cause. There is discord on the best diagnostic and therapeutic strategy. We aimed to examine these questions in our patient cohort. Methods A total of 66 out of 309 patients with PLA at our tertiary referral center between 2012 and 2020 had a primarily unknown cause. We analyzed PLA configuration, comorbidities, and whether an underlying cause could be found later. Therapy was sorted by antibiotics alone, percutaneous drainage, and primary surgery. Success was assessed by a change of initial therapy, in-hospital mortality, and mean hospital stay. Results Overall mortality was 18%; in 55%, a causative condition could be found. CRP, GGT, size, and multiple localization go along with higher mortality. Antibiotics alone had a failure rate of 82%. Percutaneous drainage was successful in 70% of cases. Surgery was mainly reserved for failed previous non-surgical treatment and had in-hospital mortality of 12%. Conclusions PLA goes along with high mortality. In the majority of all patients, a causative condition can be identified by detailed diagnostics. Percutaneous drainage together with antibiotics is the therapy of choice and is successful in 70% of cases. If drainage is insufficient or impossible, surgery is an effective alternative.
Collapse
|
7
|
Prasad D, Ahmad M, Katyal S, Thakral AK, Husain M, Mohsin M. Large Solitary Pyogenic Liver Abscesses: A Review of Their Management at a Tertiary Care Hospital. Cureus 2022; 14:e23170. [PMID: 35433141 PMCID: PMC9008598 DOI: 10.7759/cureus.23170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Liver abscesses are one of the common surgical diseases to be treated as an emergency in any tertiary care hospital in India. The formation of abscesses in the liver is still a major problem and associated with significant morbidity in developing countries. We come across all types of liver abscesses, such as amoebic (most common), pyogenic, mixed, and occasionally fungal. There have been several studies on the percutaneous modality of treatment for pyogenic liver abscesses. Most of the studies suggest that percutaneous catheter drainage (PCD) offers a better approach than aspirations for treating pyogenic liver abscesses. However, a few recent studies suggest that percutaneous aspiration leads to equally good results when compared to percutaneous drainage. In this study, we aimed to review the management of solitary large pyogenic liver abscesses and to assess the effectiveness of ultrasonography (USG)-guided aspiration in the procedure. Methods A retrospective study was carried out at the Department of General Surgery of our institute. In this study, a total of 27 patients treated for solitary pyogenic liver abscess were included. All patients with a large liver abscess greater than 5 cm without the features of frank peritonitis were included. These patients were followed up regularly for six months. Results The single-attempt USG-guided aspiration was successful in 70.3% of patients. Repeat USG-guided aspiration was performed in 18.5% of patients. In 7.4% of patients, a USG-guided percutaneous pigtail catheter was placed. And only 3.7% of cases required exploratory laparotomy. Conclusion Based on our findings, USG-guided aspiration is a fairly efficient method for treating a large solitary pyogenic abscess with acceptable results, shorter hospital stays, and minimal complications.
Collapse
|
8
|
Yu J, Ma J, Wang H, Shi Y, He S, Chen Y, Tang C. Clinical comparison of febrile and afebrile patients with pyogenic liver abscess: A two-centre retrospective study. Saudi J Gastroenterol 2021; 27:370-375. [PMID: 34657029 PMCID: PMC8656327 DOI: 10.4103/sjg.sjg_17_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND : Limited research has been conducted on afebrile pyogenic liver abscess (PLA). This poses a challenge in rapid diagnosis and early tailored care to physicians. In his study, we aimed to compare the clinical characteristics of afebrile and febrile patients with PLA. METHODS : We retrospectively analyzed the data of patients with PLA who were admitted to the emergency departments of two university hospitals between January 2014 and March 2020. Patients were classified into afebrile and febrile groups by using body temperature higher than 38°C as the reference standard. The demographic, clinical, and laboratory characteristics of both groups were compared. The primary outcome was all-cause in-hospital mortality and length of hospital stay. Multivariate analysis was performed to define factors associated with afebrile PLA. RESULTS : Of the 239 patients included in this study, 51 patients (21.3%) were afebrile and 188 patients (78.7%) were febrile. There were no differences between the abscess characteristics, laboratory manifestations, and disease severity of both groups; however, age and Charlson score differed between the groups (P = 0.009 and P = 0.011). The all-cause in-hospital mortality rate was much higher in the afebrile PLA group than in the febrile PLA group (9.8% vs. 2.1%, P = 0.011). Regarding the length of stay, no significant differences were noted in the febrile PLA group compared with the afebrile PLA group (18.5% vs 17.3%, P = 0.514). In multivariate analyses, only age greater than 65 years was significantly associated with afebrile PLA. CONCLUSIONS : Afebrile patients with PLA tend to be older, have higher Charlson scores, and in-hospital mortality rate than those with febrile patients. PLA patients older than 65 years are more likely to present without fever (<38°C) at the time of the emergency visit.
Collapse
Affiliation(s)
- Jie Yu
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China
| | - Jun Ma
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China
| | - Hairong Wang
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Xinhua Hospital, Kongjiang Road, Yangpu District, Shanghai, China
| | - Yujun Shi
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China
| | - Shuangjun He
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China
| | - Yi Chen
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China
| | - Chao Tang
- Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, Jiangyue Road, Minhang District, Shanghai, China,Address for correspondence: Dr. Chao Tang, Department of Emergency, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai - 200025, China. E-mail:
| |
Collapse
|
9
|
Liver Abscesses in Tropics. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
10
|
Tebbe JJ, Kulamadayil-Heidenreich NSA, Heidenreich H, Bongartz HG, Tebbe S. Multidisciplinary out-patient treatment with monitoring by telemedicine for a large-volume multifocal pyogenic liver abscess in times of the pandemic. Clin Case Rep 2021; 9:e04970. [PMID: 34721853 PMCID: PMC8543053 DOI: 10.1002/ccr3.4970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/15/2021] [Accepted: 09/24/2021] [Indexed: 12/03/2022] Open
Abstract
Pyogenic liver abscesses represent one of the rarer, but potentially life-threatening diseases of the liver. The treatment for large-volume liver abscesses is usually multimodal with percutaneous drainage combined with several days of treatment in hospital. We are presenting a report on a male patient with type-2 diabetes mellitus who suffered from a multifocal liver abscess (>10 cm). Due to the exceptional situation caused by the corona pandemic, the patient was treated conservatively with non-standard treatment which involved a multidisciplinary team and out-patient visits. Follow-up to ensure the treatment would be successful was carried through dialogue with the GP responsible for the patient's care, as well as daily telemedicine visits. The daily telemedicine visits were supplemented by episodic follow-up testing of laboratory values and contrast-enhanced ultrasound scans (CEUS) of the liver. We show that purely conservative therapy can be successful in a case with a high risk of mortality by using a combination of close telemedical monitoring and proactive interdisciplinary collaboration with the GP.
Collapse
Affiliation(s)
- Johannes J Tebbe
- Department of Gastroenterology and Infectious Disease University Hospital OWL Campus Lippe University of Bielefeld Bielefeld Germany
| | | | - Holger Heidenreich
- Department of Gastroenterology and Infectious Disease University Hospital OWL Campus Lippe University of Bielefeld Bielefeld Germany
| | | | | |
Collapse
|
11
|
Jorch SK, Surewaard BG, Hossain M, Peiseler M, Deppermann C, Deng J, Bogoslowski A, van der Wal F, Omri A, Hickey MJ, Kubes P. Peritoneal GATA6+ macrophages function as a portal for Staphylococcus aureus dissemination. J Clin Invest 2020; 129:4643-4656. [PMID: 31545300 DOI: 10.1172/jci127286] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/01/2019] [Indexed: 12/20/2022] Open
Abstract
Essentially all Staphylococcus aureus (S. aureus) bacteria that gain access to the circulation are plucked out of the bloodstream by the intravascular macrophages of the liver - the Kupffer cells. It is also thought that these bacteria are disseminated via the bloodstream to other organs. Our data show that S. aureus inside Kupffer cells grew and escaped across the mesothelium into the peritoneal cavity and immediately infected GATA-binding factor 6-positive (GATA6+) peritoneal cavity macrophages. These macrophages provided a haven for S. aureus, thereby delaying the neutrophilic response in the peritoneum by 48 hours and allowing dissemination to various peritoneal and retroperitoneal organs including the kidneys. In mice deficient in GATA6+ peritoneal macrophages, neutrophils infiltrated more robustly and reduced S. aureus dissemination. Antibiotics administered i.v. did not prevent dissemination into the peritoneum or to the kidneys, whereas peritoneal administration of vancomycin (particularly liposomal vancomycin with optimized intracellular penetrance capacity) reduced kidney infection and mortality, even when administered 24 hours after infection. These data indicate that GATA6+ macrophages within the peritoneal cavity are a conduit of dissemination for i.v. S. aureus, and changing the route of antibiotic delivery could provide a more effective treatment for patients with peritonitis-associated bacterial sepsis.
Collapse
Affiliation(s)
- Selina K Jorch
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bas Gj Surewaard
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mokarram Hossain
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Moritz Peiseler
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carsten Deppermann
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Deng
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ania Bogoslowski
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fardau van der Wal
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abdelwahab Omri
- Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Ontario, Canada
| | - Michael J Hickey
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Paul Kubes
- Department of Physiology and Pharmacology, Immunology Research Group, and Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
12
|
Sharma A, Mukewar S, Mara KC, Dierkhising RA, Kamath PS, Cummins N. Epidemiologic Factors, Clinical Presentation, Causes, and Outcomes of Liver Abscess: A 35-Year Olmsted County Study. Mayo Clin Proc Innov Qual Outcomes 2018; 2:16-25. [PMID: 30225428 PMCID: PMC6124335 DOI: 10.1016/j.mayocpiqo.2018.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective To report the changing incidence, clinical presentation, microbiologic spectrum, and outcomes of pyogenic liver abscess (PLA) in Olmsted County, Minnesota, over the past 35 years. Patients and Methods The Rochester Epidemiology Project was used to identify residents with PLA from January 1, 1980, through December 31, 2014. The study included all patients older than 18 years, with the diagnosis of PLA confirmed through radiographic review and microbiologic cultures. Results In total, 72 patients received a diagnosis of PLA from 1980 through 2014. The age-adjusted incidence for men was 3.92 cases per 100,000 person-years (95% CI, 2.76-5.09 cases per 100,000 person-years) compared with 1.87 cases per 100,000 person-years (95% CI, 1.15-2.59 cases per 100,000 person-years) for women. Incidence was higher in the period from January 1, 2001, through December 31, 2014, than in the period from January 1, 1980, through December 31, 2000, for women (incidence rate ratio [IRR], 3.8; 95% CI, 1.43-10.09; P=.007) but not for men (IRR, 0.99; 95% CI, 0.55-1.76; P=.96). Fifteen additional patients had postintervention PLA (1980-2000: n=3 of 29 [10.3%] vs 2001-2015: n=12 of 58 [20.6%]). A significant association was seen between age- and sex-adjusted incidence rates of PLA and year of diagnosis (per year since 1980: IRR, 1.04; 95% CI, 1.02-1.07; P<.001) after including postintervention PLA. Streptococcus milleri was the most common organism identified (52.5%). Organisms with multidrug resistance were more common in the period from 2001 through 2014 than in the period from 1980 through 2000 (51% vs 14%; P=.005). The overall mortality rate of PLA was 16.8% (95% CI, 7.6%-25.0%) at 6 months. Conclusion The incidence of PLA is increasing, probably because of increase in frequency of hepatobiliary interventions and organisms with multidrug resistance.
Collapse
Key Words
- CT, computed tomography
- ERCP, endoscopic retrograde cholangiopancreatography
- HR, hazard ratio
- IRR, incidence rate ratio
- MDR, multidrug resistance
- PLA, pyogenic liver abscess
- PY, person-year
- REP, Rochester Epidemiology Project
- RFA, radiofrequency ablation
- TACE, transarterial chemotherapy embolization
Collapse
Affiliation(s)
- Ayush Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Nathan Cummins
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| |
Collapse
|
13
|
Zhang RG, Zhang XL, Yang YS. Alcoholization of pyogenichepatic abscess with absolute alcohol in Bama minipigs. Exp Ther Med 2017; 14:4483-4488. [PMID: 29067123 DOI: 10.3892/etm.2017.5022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/26/2017] [Indexed: 11/05/2022] Open
Abstract
Pyogenic hepatic abscess (PHA) is a rare, but potentially serious disease. At present, ultrasound-guided or computed tomography-guided percutaneous needle aspiration or catheter drainage is appropriate as a first-line treatment. However, it is difficult to aspirate or drain pus and to select the appropriate antibiotic therapy if the abscess consists of thick pus and polymicrobial confections, or its pathogenic bacterium is multidrug resistant and cryptogenic. Case studies of alcoholization provide a novel method to manage PHA. However, the efficacy and safety of this treatment should be further evaluated. In the present study, the therapeutic efficacy and complications of alcoholization for PHAs in Bama minipigs were investigated. PHAs were prospectively treated by ultrasound-guided percutaneous instillation of absolute alcohol in the abscess cavity. The criteria for considering a successful intervention were met in all minipigs subsequent to alcoholization twice within 14 days. The procedures were well tolerated in all animals, and there were no alcoholic adverse effects or procedure-associated complications. In conclusion, ultrasound-guided percutaneous alcoholization is a safe and effective procedure to manage PHA. The problems of thick pus aspiration and selection of an appropriate antibiotic observed in other treatments were resolved effectively using alcoholization. This technique may reduce the treatment period and possibly become a novel strategy for the management of PHA.
Collapse
Affiliation(s)
- Ru-Gang Zhang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Xiu-Li Zhang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Yun-Sheng Yang
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing 100853, P.R. China
| |
Collapse
|
14
|
Rismiller K, Haaga J, Siegel C, Ammori JB. Pyogenic liver abscesses: a contemporary analysis of management strategies at a tertiary institution. HPB (Oxford) 2017; 19:889-893. [PMID: 28693978 DOI: 10.1016/j.hpb.2017.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/06/2017] [Accepted: 06/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite equivocal evidence, non-surgical management for pyogenic liver abscess (PLA) has become the standard of care at most institutions with surgery relegated to salvage therapy for those who fail less invasive means. The aim of this study was to describe the outcomes of a step-up approach to PLA management. METHODS A retrospective chart review was conducted at a single institution for patients diagnosed with PLA over a 10-year period. Demographic, radiologic, microbiological, treatment, and outcomes data were collected and analyzed. RESULTS 64 patients with PLA were identified. Initial treatment included antibiotics alone (n = 9), percutaneous drainage (PD) (n = 54), and surgery (n = 1). Surgery was ultimately required in 8 patients while 50 were cured with PD and 4 with antibiotics alone. Two (3%) patients died. Overall, PD carried an 85% success rate. CONCLUSION PLA patients should be initially treated non-operatively, barring indications for emergent surgery or inaccessibility for PD. Surgery can be reserved for failure of PD.
Collapse
Affiliation(s)
- Kyle Rismiller
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John Haaga
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher Siegel
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| |
Collapse
|
15
|
Gallagher MC, Andrews MM. Postdischarge Outcomes of Pyogenic Liver Abscesses: Single-Center Experience 2007-2012. Open Forum Infect Dis 2017; 4:ofx159. [PMID: 28948182 PMCID: PMC5604130 DOI: 10.1093/ofid/ofx159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/25/2017] [Indexed: 11/14/2022] Open
Abstract
Background Pyogenic liver abscesses (PLA) are increasingly managed by percutaneous treatment instead of surgery, but there are limited data about postdischarge outcomes. Postdischarge services and factors predicting poor outcomes have not been described. Methods We performed a retrospective, descriptive case series at a single center assessing treatment and outpatient follow-up for patients treated for PLA from 2007 to 2012. We reviewed the electronic medical record for patient characteristics and outcomes. Data for care received at other facilities were not available. In our analysis, we compared patients with malignancy with those without and attempted to determine predictors of emergency department (ED) visits and hospital readmissions. Results Of 125 patients identified with PLA, 12 had surgical drainage, 23 had percutaneous aspiration, 78 had percutaneous drainage (PD), 11 had no drainage, and 1 was made comfort measures only. Seventy (60%) were discharged with a drain, and 31 (25%) were discharged on intravenous (IV) antibiotics. After discharge, 46 (38%) had ED visits and 36 (30%) were readmitted within 30 days of discharge. Fourteen (12%) had complications from antibiotics, and 4 (13%) had complications from peripherally inserted center catheter lines. A total of 8 patients, 5 in-hospital and 3 postdischarge, died. In our analysis of risk factors for 90-day postdischarge ED visit/readmission, only malignancy was a predictor. Conclusions Pyogenic liver abscess patients have intense postdischarge needs (drain management, IV antibiotics) and a high rate of ED visits and readmissions. Although PD provides source control without surgery, ambulatory needs are now more complex, requiring multidisciplinary collaboration.
Collapse
Affiliation(s)
- Megan C Gallagher
- Infectious Diseases and International Health Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mary-Margaret Andrews
- Infectious Diseases and International Health Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| |
Collapse
|
16
|
Abstract
OBJECTIVE The purpose of this study was to identify the details of percutaneous catheter drainage (PCD) of pyogenic liver abscesses, the etiologic factors, and the management techniques that contribute to successful treatment. MATERIALS AND METHODS The records of 75 consecutively registered patients who underwent PCD of 96 abscesses at a single institution between May 2009 and May 2014 were retrospectively reviewed. Thirty-nine patients (52%) were oncology patients, and 36 (48%) had recently undergone abdominal surgery. Primary success was defined as abscess healing with the primary PCD intervention and 30-day postdrainage survival. Salvage success was defined as abscess healing with follow-up secondary PCD placement for symptomatic hepatic satellite collections or for clinical recurrence. Catheter adjustments were performed during follow-up to optimize existing drains. Univariate, multivariate, and general linear mixed model analyses were performed. The median follow-up time after catheter removal was 6 months (range, 2-62 months). RESULTS Drains were primarily successful in 54 patients (72%), and 17 patients (23%) needed salvage PCD; thus, overall success was achieved in 71 patients (95%). The other four patients (5%) died of sepsis. The primary success rate was reduced in patients with unresectable malignancies (p = 0.01), multiple abscesses (p = 0.01), and output ≥ 15 mL/d at catheter endpoint (n = 7, p = 0.001). Only unresectable malignancies had slightly lower overall success. Large abscesses (> 150 cm3) required more catheter adjustments and longer drainage duration to reach abscess cavity closure. Successfully drained abscesses reached cavity closure a mean of 23 days (95% CI, 20-27 days) after treatment. CONCLUSION PCD was effective first-line treatment of complicated pyogenic liver abscesses, which often require catheter adjustment and salvage drainage procedures to reliably achieve success.
Collapse
|
17
|
Xu S, Wang Y, Chen J, Hu Y, Zhang Q, Chen G, Yu F. Application of ultrasound-guided percutaneous intrahepatic portal vein catheterization with antibiotic injection for treating unliquefied bacterial liver abscess. Hepatol Res 2017; 47:E187-E192. [PMID: 27271941 DOI: 10.1111/hepr.12749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/19/2016] [Accepted: 05/23/2016] [Indexed: 02/08/2023]
Abstract
AIM To investigate whether ultrasound-guided percutaneous portal vein catheterization can be successfully carried out in the intrahepatic region of patients with unliquefied bacterial liver abscess (UBLA), who are subsequently treated with an injection of antibiotics. METHODS Thirty-two UBLA patients were enrolled in this study. Among them, 13 patients were included in the experimental group; an ultrasound-guided percutaneous portal vein catheterization was undertaken in the intrahepatic region of these patients, and they also received an injection of antibiotics. The remaining 19 patients were retrospectively included in the control group; these patients only received systemic antibiotic therapy. The efficacy of intervention was compared with that of systemic treatment. RESULTS The catheterization procedures were successful in all the patients of the experimental group. However, two cases (15.4%) developed complications postoperatively. Compared to the control group, the following parameters of the experimental group were significantly shorter/lower: (i) duration for regaining normal body temperature; (ii) time period for achieving normal white blood cell count; (iii) length of hospitalization; (iv) cases of liquefied liver abscess during follow-up; and (v) cost of hospitalization (P < 0.05). CONCLUSION Ultrasound-guided percutaneous portal vein catheterization is a simple, minimally invasive, and effective treatment for UBLA. It must be carried out in the intrahepatic region and a subsequent injection of antibiotics must be given.
Collapse
Affiliation(s)
- Shihao Xu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Wenzhou Medical University, China
| | - Yiluan Wang
- Department of Anesthsiology, The Second Affiliated Hospital, Wenzhou Medical University, China
| | - Jingfeng Chen
- Department of Surgery, The Sixth Affiliated Hospital, Wenzhou Medical University, China
| | - Yuanping Hu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Wenzhou Medical University, China
| | - Qiyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Wenzhou Medical University, China
| | - Gang Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Wenzhou Medical University, China
| | - Fuxiang Yu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Wenzhou Medical University, China
| |
Collapse
|
18
|
Mavilia MG, Molina M, Wu GY. The Evolving Nature of Hepatic Abscess: A Review. J Clin Transl Hepatol 2016; 4:158-68. [PMID: 27350946 PMCID: PMC4913073 DOI: 10.14218/jcth.2016.00004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/25/2016] [Accepted: 03/09/2016] [Indexed: 12/19/2022] Open
Abstract
Hepatic abscess (HA) remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system. However, over the years, the etiologies and risks factors for HA have continued to evolve. Prompt recognition is important for instituting effective management and obtaining good outcomes.
Collapse
Affiliation(s)
- Marianna G. Mavilia
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
- *Correspondence to: Marianna G. Mavilia, University of New England College of Osteopathic Medicine, 11 Hills Beach Road, Biddeford, ME 04005, USA. Tel: +1-617-435-1185, Fax: +1-860-679-6582,
| | - Marco Molina
- Department of Radiology, UCONN Health, Farmington, CT, USA
| | - George Y. Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA
| |
Collapse
|
19
|
Alshammari D, Memeo R, Tzedakis S, Hargat J, Mutter D, Marescaux J, Pessaux P. Minimally invasive management of intrahepatic type II gallbladder perforation: a case report. Hepatobiliary Surg Nutr 2016; 5:79-82. [PMID: 26904560 DOI: 10.3978/j.issn.2304-3881.2015.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Intrahepatic gallbladder perforation (GBP) is a rare medical entity, which creates a cholecystohepatic communication. We describe the case of a 70-year-old patient who presented with abdominal pain and a Niemeier type II GBP. This case report illustrates the minimally invasive management of a rare and life-threatening pathology.
Collapse
Affiliation(s)
- Dheidan Alshammari
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Riccardo Memeo
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Stylianos Tzedakis
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Julie Hargat
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Didier Mutter
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Patrick Pessaux
- 1 Department of Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France ; 2 IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France ; 3 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| |
Collapse
|
20
|
Cho AR, Lee TH, Park MJ, Oh SH, Lee JA, Park JH, Ryu KH, Koo HS, Song KH, Kim SM, Huh KC, Choi YW, Kang YW. Septic Shock in Pyogenic Liver Abscess: Clinical Considerations. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 67:245-52. [DOI: 10.4166/kjg.2016.67.5.245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A Reum Cho
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Min Ji Park
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Sun Hee Oh
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Joo Ah Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Joo Ho Park
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Ki Hyun Ryu
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Hoon Sup Koo
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Kyung Ho Song
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Sun Moon Kim
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Kyu Chan Huh
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Young Woo Choi
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Young Woo Kang
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| |
Collapse
|
21
|
Ogura T, Masuda D, Saori O, Wataru T, Sano T, Okuda A, Miyano A, Kitano M, Abdel-Aal UM, Takeuchi T, Fukunishi S, Higuchi K. Clinical Outcome of Endoscopic Ultrasound-Guided Liver Abscess Drainage Using Self-Expandable Covered Metallic Stent (with Video). Dig Dis Sci 2016; 61:303-8. [PMID: 26254774 DOI: 10.1007/s10620-015-3841-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/01/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Percutaneous drainage (PCD) is now the first-line drainage method for liver abscess because of its minimal invasiveness and high technical success rate. However, this procedure has several disadvantages, such as extra-drainage and self-tube removal. Recently, EUS-guided liver abscess drainage (EUS-AD) has been developed. However, only a few reports of EUS-AD have been reported. In addition, the clinical benefits of PCD and EUS-AD have not been reported. AIMS In the present study, the safety and feasibility of EUS-AD using fully covered SEMS (FCSEMS) and the clinical outcomes of EUS-AD and PCD were examined retrospectively. METHODS Twenty-seven consecutive patients who underwent PCD or EUS-AD between April 2012 and April 2015 were included in this study. EUS-AD was performed using FCSEMS. In addition, to prevent stent migration, 7-Fr pig tail plastic stent was placed within FCSEMS. RESULTS Technical success was achieved in all patients of both groups. Clinical success was 100 % in the EUS-AD group although it was 89 % in PCD group (P = 034). Three adverse events were seen in the PCD group (self-tube removal n = 1, tube migration n = 2), but no adverse events were seen in the EUS-AD group. The median hospital stay was significantly shorter in the EUS-AD group than in the PCD group (21 vs 41 days, P = 0.03). CONCLUSION Because of the short hospital stay, the high clinical success rate, and the low adverse event rate compared to PCD, EUS-AD has potential as a first-line treatment for liver abscess.
Collapse
Affiliation(s)
- Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan.
| | - Daisuke Masuda
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Onda Saori
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Takagi Wataru
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Tatsushi Sano
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Atsushi Okuda
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Akira Miyano
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Usama M Abdel-Aal
- Division of Gastroenterology, Department of Internal Medicine, Sohag University, Sohag, Egypt
| | - Toshihisa Takeuchi
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Shinya Fukunishi
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, 1-1 Daigakuchou, Takatsukishi, Osaka, 464-8681, Japan
| |
Collapse
|
22
|
Abstract
Background Liver abscess (LA) is an uncommon but potentially life-threatening disease with significant morbidity and mortality. Methods This review comprehensively describes epidemiology, pathogenesis, diagnosis, and treatment of LA, with a strong focus on antimicrobial treatment choices and the impact of multidrug-resistant pathogens. Results In industrialized areas, pyogenic liver abscess (PLA) accounts for over 80% of the cases, whereas Entamoeba histolyticais responsible for up to 10% of the cases, with a higher incidence in tropical areas. Highly virulent strains of Klebsiella pneumoniaehave emerged as a predominant cause of PLA in Asian countries and tend to spread to the USA, Australia, and European countries, therefore requiring special alertness. Most common symptoms of LA are fever, chills, and right upper quadrant abdominal pain, although a broad spectrum of non-specific symptoms may also occur. Conclusion Imaging studies (ultrasound, computed tomography scan) and microbiological findings play a crucial role in the diagnosis of LA. The treatment of choice for PLA is a multimodal approach combining broad-spectrum antibiotics and aspiration or drainage of larger abscess cavities. Amebic LA can be cured by metronidazole therapy without drainage.
Collapse
Affiliation(s)
- Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Johannes Wiegand
- Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Thomas Karlas
- Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| |
Collapse
|
23
|
Lee JY, Kim KH. Endogenous endophthalmitis complicated by pyogenic liver abscess: a review of 17 years' experience at a single center. Digestion 2015; 90:116-21. [PMID: 25277733 DOI: 10.1159/000367649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/15/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endogenous endophthalmitis is a rare complication of pyogenic liver abscess. It is a devastating intraocular infection which constitutes a vision-threatening emergency. Recently, a significant increase in the incidence of endogenous endophthalmitis associated with pyogenic liver abscess has been reported in East Asia. In this study, the authors investigated the incidence, risk factors, clinical features, and treatment outcomes of endogenous endophthalmitis arising as a complication of pyogenic liver abscess. METHODS The medical records of 8 cases of endogenous endophthalmitis associated with a pyogenic liver abscess treated from 1997 to 2013 at a single tertiary hospital in Korea were retrospectively reviewed. RESULTS Median patient age was 71.1 ± 9.8 years. The most common underlying disease was diabetes mellitus (4 patients, 50%). Klebsiella pneumoniae was isolated from all patients, and all were treated with intravenous antibiotics including ceftriaxone. Seven patients received an intravitreal injection. Four patients needed additional surgical interventions. Outcomes were generally poor; only 1 patient achieved a slight improvement in visual outcome. CONCLUSION Old age, diabetes mellitus, and K. pneumoniae infection could predispose the development of endogenous endophthalmitis in patients with a pyogenic liver abscess. Physicians should pay attention to ocular symptoms as early diagnosis and intensive treatment are required to achieve improvements in visual outcome.
Collapse
Affiliation(s)
- Jae Young Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | | |
Collapse
|
24
|
Ekwunife CN, Okorie O, Nwobe O. Laparoscopy may have a role in the drainage of liver abscess: Early experience at Owerri, Nigeria. Niger J Surg 2015; 21:35-7. [PMID: 25838764 PMCID: PMC4382640 DOI: 10.4103/1117-6806.152724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Image-guided percutaneous drainage with antimicrobial agents is the standard modality of treatment of liver abscess. Open surgical drainage, and lately laparoscopic drainage becomes useful in selected patients. Nigeria is awakening late to the laparoscopic surgery revolution. Public health institutions have started making enormous investments in minimal access surgery, which can augment deficient diagnostic capacities. Objective: To describe the outcomes of the patients who underwent laparoscopic liver abscess drainage at the Federal Medical Centre, Owerri. Materials and Methods: A retrospective analysis of the laparoscopic liver abscess drainage procedures done between the period September 2007 and December 2012 was done. Results: A total of eight patients in the study period were worked up for abscess surgical drainage based on ultrasound (seven cases) and computed tomography (one case) supported localized collection in the liver. Intraoperatively, one patient was noticed to have nodules on the liver that was later confirmed as hepatocellular carcinoma. Operating time ranged from 37 to 126 min. There was no conversion to open surgery. On the follow-up, one patient had residual abscess of 45 mm diameter size, after 6 weeks, and in whose aspirate acid-fast bacilli were identified. Conclusion: Laparoscopic drainage should be considered in the management of liver abscess.
Collapse
Affiliation(s)
| | - Ogechukwu Okorie
- Department of Anaesthesia, Federal Medical Centre, Owerri, Nigeria
| | - Ogechukwu Nwobe
- Department of Surgery, Federal Medical Centre, Owerri, Nigeria
| |
Collapse
|
25
|
Dulku G, Mohan G, Samuelson S, Ferguson J, Tibballs J. Percutaneous aspiration versus catheter drainage of liver abscess: A retrospective review. Australas Med J 2015; 8:7-18. [PMID: 25848403 DOI: 10.4066/amj.2015.2240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND A review of the effectiveness and outcomes in liver abscess drainage performed by different operators using percutaneous aspiration (PA) and catheter drainage (PCD), respectively, from 2008-2013 at Sir Charles Gairdner Hospital, a tertiary hospital in Australia. METHODS Forty-two patients (29 males and 13 females; aged between 28-93 years; median age of 67 years) with liver abscesses underwent either ultrasound or CT-guided PA (n=22) and PCD (n=20) in conjunction with appropriate antimicrobial therapy. A median of 18 Gauge needle and 10 French catheters were utilised. RESULTS Nineteen (86.4 per cent) PA cases and 12 (60 per cent) PCD cases were successfully drained on a single attempt (p=0.08). More male patients (69 per cent) than females (31 per cent) were observed. Portal sepsis (42.9 per cent) was the most common cause identified. Fever (47.6 per cent) was the most frequent clinical presentation on admission. Thirty-two patients (76.2 per cent) had solitary abscesses with a right lobe (59.5 per cent) predilection. CRP was significantly raised. The PCD group observed a significantly larger abscess size (p=0.01). Klebsiella pneumoniae was the most common organism isolated in both pus (33.3 per cent) and blood cultures (11.9 per cent). Five procedure-related complications were noted, all in the PCD group. Thirty-day mortality was 2.4 per cent. No difference was observed in clinical and treatment outcomes in both groups. CONCLUSION The null hypothesis that both PA and PCD are equally effective in the drainage of liver abscess cannot be rejected. Apart from PA being simpler and safer to perform, the higher incidence of indwelling catheter-associated complications suggests that a trial of PA should always be attempted first.
Collapse
Affiliation(s)
- Gurjeet Dulku
- Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Geeta Mohan
- Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Shaun Samuelson
- Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - John Ferguson
- Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jonathan Tibballs
- Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| |
Collapse
|
26
|
Lo JZW, Leow JJJ, Ng PLF, Lee HQ, Mohd Noor NA, Low JK, Junnarkar SP, Woon WWL. Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:156-65. [PMID: 25339111 DOI: 10.1002/jhbp.174] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adult pyogenic liver abscess (PLA) is a major hepato-biliary infection. We aim to identify risk factors associated with therapy failure. METHODS Retrospective study of 741 PLA patients (2001-2011) and comparison with earlier data (1994-1997). Risk factors associated with therapy failure were identified with multivariate analysis. RESULTS Incidence of PLA is 86/100 000 admissions, with average size 5.75 cm. 68% of PLA were secondary to Klebsiella pneumoniae and there is increasing extended-spectrum beta-lactamase (ESBL) resistance. Compared with 1990s, there is an increasing annual incidence (from 18 to 67). Elderly age (≥55-years-old), presence of multiple abscesses, malignancy as etiology and patients who underwent endoscopic intervention are independent predictors for failure of antibiotics-only therapy while average intravenous antibiotics duration and average abscess size are not. ECOG performance status ≥2, pre-existing hypertension and hyperbilirubinaemia are independent predictors for failure of percutaneous therapy while the presence of multiple abscesses and average abscess size are not. CONCLUSION There is an increasing PLA incidence with increasing ESBL resistance. Percutaneous drainage should be considered early for elderly patients (≥55-years-old), with multiple abscesses, malignancy as etiology or who required endoscopic intervention. We should have a low threshold for surgical intervention for patients with ECOG performance status ≥2, co-morbidity of hypertension or hyperbilirubinaemia.
Collapse
Affiliation(s)
- Joseph Zhi Wen Lo
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Chang AC, Ha NB, Satyadas T, Maddern G. Pyogenic liver abscess trends in South Australia. ANZ J Surg 2013; 85:179-82. [DOI: 10.1111/ans.12411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Angela Christine Chang
- Discipline of Surgery; The Queen Elizabeth Hospital; The University of Adelaide; Adelaide South Australia Australia
| | - Ngoc Buu Ha
- Discipline of Surgery; The Queen Elizabeth Hospital; The University of Adelaide; Adelaide South Australia Australia
| | - Thomas Satyadas
- Discipline of Surgery; The Queen Elizabeth Hospital; The University of Adelaide; Adelaide South Australia Australia
| | - Guy Maddern
- Discipline of Surgery; The Queen Elizabeth Hospital; The University of Adelaide; Adelaide South Australia Australia
| |
Collapse
|
28
|
An Increasing Prominent Disease of Klebsiella pneumoniae Liver Abscess: Etiology, Diagnosis, and Treatment. Gastroenterol Res Pract 2013; 2013:258514. [PMID: 24194749 PMCID: PMC3806164 DOI: 10.1155/2013/258514] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/15/2013] [Indexed: 02/07/2023] Open
Abstract
Background. During the past two decades, Klebsiella pneumoniae (K. pneumoniae) had surpassed Escherichia coli (E. coli) as the predominant isolate from patients with pyogenic liver abscess (PLA) in Asian countries, the United States, and Europe, and it tended to spread globally. Since the clinical symptom is atypical, the accurate and effective diagnosis and treatment of K. pneumoniae liver abscesses (KLAs) are very necessary. Methods. Here, we have comprehensively clarified the epidemiology and pathogenesis of KLA, put emphases on the clinical presentations especially the characteristic radiographic findings of KLA, and thoroughly elucidated the most effective antibiotic strategy of KLA. Results. K1 serotype is strongly associated with KLA especially in diabetic patients. Computed tomography (CT) and ultrasound (US) were two main diagnostic methods of KLA in the past. Most of KLAs have solitary, septal lobular abscesses in the right lobe of liver, and they are mainly monomicrobial. Broad-spectrum antibiotics combined with the US-guided percutaneous drainage of liver abscesses can increase their survival rates, but surgical intervention still has its irreplaceable position. Conclusion. The imaging features contribute to the early diagnosis, and the percutaneous intervention combined with an aminoglycoside plus either an extended-spectrum betalactam or a second- or third-generation cephalosporin is a timely and effective treatment of KLA.
Collapse
|
29
|
Kuo SH, Lee YT, Li CR, Tseng CJ, Chao WN, Wang PH, Wong RH, Chen CC, Chen SC, Lee MC. Mortality in Emergency Department Sepsis score as a prognostic indicator in patients with pyogenic liver abscess. Am J Emerg Med 2013; 31:916-21. [PMID: 23623237 DOI: 10.1016/j.ajem.2013.02.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/28/2013] [Accepted: 02/28/2013] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this study was to explore the predictor index of mortality in patients with pyogenic liver abscess (PLA). METHODS We performed a retrospective review that enrolled 431 patients 18 years and older hospitalized due to PLA between January 2005 and December 2010. Clinical characteristics, laboratory results, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. RESULTS The mean age of the 431 patients identified with PLA was 56.9 ± 15.0 years. The mean Mortality in Emergency Department Sepsis (MEDS) score on admission was 4.8 ± 4.1 (range, 0-17). During hospitalization, 94 patients (22%) required intensive care. Of the 431 patients, 63 died, yielding a 15% case fatality rate. Multivariate analysis revealed that higher MEDS scores on admission (P < .0001) and the presence of underlying malignancy (P = .006), multiple abscesses (P = .001), anaerobic infections (P < .0001), hyperbilirubinemia (P < .0001), and higher serum creatinine levels (P < .0001) were significantly associated with PLA mortality. The estimated area under the receiver operating characteristic curve for MEDS in predicting PLA mortality was 0.829 (95% confidence interval, 0.791-0.864; P < .0001). The optimal cutoff MEDS value of 7 or higher had a sensitivity of 76% sensitivity and a specificity of 81%, with a 10.7-fold PLA mortality risk (P < .0001) and a 26.2-fold intensive care unit admission risk (P < .0001). CONCLUSIONS The MEDS scores on admission represent a significant prognostic indicator for patients with PLA.
Collapse
Affiliation(s)
- Sheng-Hung Kuo
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Laparoscopic drainage of cryptogenic liver abscess. Surg Endosc 2013; 27:3308-14. [PMID: 23494514 DOI: 10.1007/s00464-013-2910-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/15/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND To retrospectively compare the outcomes of percutaneously drained and laparoscopically drained liver abscesses. METHODS Eight-five consecutive patients with radiological evidence of liver abscess were treated at National University Hospital of Singapore from 2005 to 2011. Multivariable logistic regression was used to identify failures of intervention. This was defined as persistent objective signs of sepsis. Complications, length of antibiotic therapy, and hospital stay were recorded but not used as indicators for failure of intervention. A propensity score analysis was used to adjust for possible confounders. RESULTS Twenty-seven (40.3%) patients in the percutaneous group did not respond to primary intervention compared to 2 patients (11.1%) in the laparoscopic group (p = 0.020). Two patients within the percutaneous group died from progression of sepsis despite intervention. In the multivariate model with propensity score, laparoscopic drainage had a protective effect against failure compared to percutaneous drainage of liver abscess (odds ratio [OR], 0.03; 95% confidence interval [CI], [0-0.4]; p = 0.008). There were no differences in complications related to the intervention (p = 0.108). Mean duration of antibiotics (p = 0.437) and hospital stay (p = 0.175) between the groups was similar. CONCLUSIONS Laparoscopic drainage of cryptogenic liver abscesses should be considered as an option for drainage of liver abscess.
Collapse
|
31
|
|
32
|
Ekwunife CN, Amadi EC, Amaechi FN, Ukaha IC. Laparoscopy-guided Liver Abscess Drainage: An Additional Use of Veress Needle. J Surg Tech Case Rep 2012; 4:36-8. [PMID: 23066462 PMCID: PMC3461776 DOI: 10.4103/2006-8808.100352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Percutaneous image-guided drainage is the standard of care in the treatment of liver abscess. However this may not suffice in multi-loculated abscesses and those associated with concomitant biliary pathology. We report the case of a 34 year old male who presented to our hospital with a huge hepatic abscess that could not be aspirated percutaneously. Subsequently he had a laparoscopic guided aspiration of the abscess, with the aid of veress needle. Three weeks post operatively, no residual abscess cavity was noticeable. We believe that minimal access surgery techniques should always be considered in the management of liver abscess, and that the veress needle can be an additional aspiration device, in our environment.
Collapse
|
33
|
Are pyogenic liver abscesses still a surgical concern? A Western experience. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2012; 2012:316013. [PMID: 22536008 PMCID: PMC3296144 DOI: 10.1155/2012/316013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 12/25/2011] [Accepted: 12/30/2011] [Indexed: 01/03/2023]
Abstract
Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We conducted a retrospective study of pyogenic abscess cases admitted to our university hospital between 1999 and 2010 and assessed the factors potentially associated with surgical treatment versus medical treatment alone. Results. In total, 103 liver abscess patients were treated at our center. The mortality was 9%. The main symptoms were fever and abdominal pain. All of the patients had CRP > 6 g/dL. Sixty-nine patients had a unique abscess. Seventeen patients were treated with antibiotics alone and 57 with percutaneous drainage and antibiotics. Twenty-seven patients who were treated with percutaneous techniques required surgery, and 29 patients initially received it. Eventually, 43 patients underwent abscess surgery. The factors associated with failed medical treatment were gas-forming abscess (P = 0.006) and septic shock at the initial presentation (P = 0.008). Conclusion. Medical and percutaneous treatment constitute the standard management of liver abscess cases. Surgery remains necessary after failure of the initial treatment but should also be considered as an early intervention for cases presenting with gas-forming abscesses and septic shock and when treatment of the underlying cause is immediately required.
Collapse
|
34
|
Tu JF, Huang XF, Hu RY, You HY, Zheng XF, Jiang FZ. Comparison of laparoscopic and open surgery for pyogenic liver abscess with biliary pathology. World J Gastroenterol 2011; 17:4339-43. [PMID: 22090791 PMCID: PMC3214710 DOI: 10.3748/wjg.v17.i38.4339] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Revised: 05/19/2011] [Accepted: 05/26/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility and therapeutic effect of laparoscopic surgery for pyogenic liver abscess (PLA) with biliary pathology.
METHODS: From January 2004 to October 2010, 31 patients with PLA combined with biliary pathology meeting entry criteria received surgical management in our hospital. Of the 31 patients, 13 underwent laparoscopic surgery (LS group) and 18 underwent open surgery (OS group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, length of postoperative hospital stay, and abscess recurrence rate were retrospectively analyzed and compared between the two groups.
RESULTS: All patients received systemic antibiotic therapy. Four patients underwent ultrasound-guided percutaneous catheter drainage before operation. Postoperative complications occurred in 5 patients (16.1%, 5/31) including 2 in the LS group and 3 in the OS group. One patient had retained calculus in the common bile duct and another had liver abscess recurrence in the OS group. No retained calculus and liver abscess recurrence occurred in the LS group. In the two groups, there was no mortality during the perioperative period. There were no significant differences in operation time, intraoperative blood loss and transfusion, postoperative complication rate and abscess recurrence rate between the two groups. Oral intake was earlier (1.9 ± 0.4 d vs 3.1 ± 0.7 d, P < 0.05) and length of postoperative hospital stay was shorter (11.3 ± 2.9 d vs 14.5 ± 3.7 d, P < 0.05) in the LS group than in the OS group.
CONCLUSION: Laparoscopic surgery for simultaneous treatment of PLA and biliary pathology is feasible in selected patients and the therapeutic effect is similar to that of open surgery.
Collapse
|
35
|
Liao WI, Tsai SH, Yu CY, Huang GS, Lin YY, Hsu CW, Hsu HH, Chang WC. Pyogenic liver abscess treated by percutaneous catheter drainage: MDCT measurement for treatment outcome. Eur J Radiol 2011; 81:609-15. [PMID: 21330079 DOI: 10.1016/j.ejrad.2011.01.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 01/03/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze multidetector computed tomographic (MDCT) parameters in patients with pyogenic liver abscess (PLA), and to identify which parameters can be predicted percutaneous catheter drainage (PCD) treatment outcome. MATERIALS AND METHODS Clinical, laboratory and MDCT findings of 175 patients with PLA who had undergone PCD were retrospectively reviewed. All abscesses shown on MDCT were evaluated for size, margin, attenuation values, location, number of large (>3cm) abscesses, presence of a cystic component, presence of gas, and the shortest length to the liver capsule. Univariate and multivariate analyses of the MDCT parameters that affect PCD treatment outcome was performed. For continuous data of MDCT parameters (abscess size and the shortest length), we used receiver-operating-characteristic (ROC) curve to determine the optimal cut-off values. RESULTS PCD was failed in 32 patients and the overall failure rate was 18.28%. Multivariate analysis revealed that PCD failure was predicted by the presence of gas (odds ratio [OR], 42.67), a large abscess (OR 1.21), low minimal attenuation values (OR 1.02), wide range of attenuation values (OR 1.01), a shorter length to the liver capsule (OR 0.09) and lack of a cystic component (OR 0.09) of the PLA. ROC curve showed that the shortest length less than 0.25cm and an abscess size greater than 7.3cm were the optimal cut-off values predicting PCD treatment failure. CONCLUSION Among these MDCT parameters, gas formation within PLA was the most important predictor for PCD failure. Surgical intervention might be considered early in high-risk patients of PCD failure.
Collapse
Affiliation(s)
- Wen-I Liao
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Howley I, Gregg SC, Heffernan DS, Adams CA. Peritoneal free air due to evacuation of pneumobilia in blunt abdominal trauma. J Emerg Trauma Shock 2010; 3:412-5. [PMID: 21063570 PMCID: PMC2966580 DOI: 10.4103/0974-2700.70777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 07/19/2010] [Indexed: 11/12/2022] Open
Abstract
Pneumobilia is mostly observed on computed tomography (CT) following surgical biliary-enteric anastomosis and biliary manipulation through endoscopic procedures. Although pneumobilia can be seen in pathological conditions, post-surgical pneumobilia is typically not associated with morbidity. In the present article, we report a case in which blunt abdominal trauma led to the evacuation of pre-existing pneumobilia causing pneumoperitoneum. Given that the subsequent laparotomy proved to be non-therapeutic, this report adds to the few cases of intra-peritoneal free air not helped by surgical intervention.
Collapse
Affiliation(s)
- Isaac Howley
- Department of Surgery, Rhode Island Hospital and the Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | | | | | | |
Collapse
|
37
|
Su YJ, Lai YC, Lin YC, Yeh YH. Treatment and prognosis of pyogenic liver abscess. Int J Emerg Med 2010. [PMID: 21373309 DOI: 10.1007/s12245-010-0232-6.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There are many combinations of treatments for pyogenic liver abscess (PLA). Different treatments are indicated for different clinical courses of PLA. AIMS To realize the current prevalence, clinical course, trend of treatment, and prognosis of pyogenic liver abscess (PLA) in Taiwan. METHODS We retrospectively reviewed the medical records of 126 patients with PLA. We divided them into four groups: M, MD, MS, and MDS, represented as parenteral antibiotic only, parenteral antibiotic with drainage, parenteral antibiotic with surgical intervention, and parenteral antibiotic with surgical drainage. We analyzed data by commercial statistical software (SPSS for Windows, version 11.0, SPSS Ltd., Chicago, IL). We used Student's t-test and χ(2) test for statistical analyses, and significance was set at a p value less than 0.05. RESULTS PLA patients who were treated only with parenteral antibiotics had early diagnosis of PLA with a mean fever period of 3.3 days (p = 0.043). Patients who needed surgical drainage were highly associated with shock presentation in the clinical course (35.7% versus 14.3%, p = 0.007). CONCLUSION The earlier we can diagnose PLA, the shorter the patient's hospital stay (20.6 days) will be. In PLA patients with shock, a higher rate of surgical intervention is mandatory to save their lives.
Collapse
|
38
|
Su YJ, Lai YC, Lin YC, Yeh YH. Treatment and prognosis of pyogenic liver abscess. Int J Emerg Med 2010; 3:381-4. [PMID: 21373309 PMCID: PMC3047832 DOI: 10.1007/s12245-010-0232-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 08/24/2010] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There are many combinations of treatments for pyogenic liver abscess (PLA). Different treatments are indicated for different clinical courses of PLA. AIMS To realize the current prevalence, clinical course, trend of treatment, and prognosis of pyogenic liver abscess (PLA) in Taiwan. METHODS We retrospectively reviewed the medical records of 126 patients with PLA. We divided them into four groups: M, MD, MS, and MDS, represented as parenteral antibiotic only, parenteral antibiotic with drainage, parenteral antibiotic with surgical intervention, and parenteral antibiotic with surgical drainage. We analyzed data by commercial statistical software (SPSS for Windows, version 11.0, SPSS Ltd., Chicago, IL). We used Student's t-test and χ(2) test for statistical analyses, and significance was set at a p value less than 0.05. RESULTS PLA patients who were treated only with parenteral antibiotics had early diagnosis of PLA with a mean fever period of 3.3 days (p = 0.043). Patients who needed surgical drainage were highly associated with shock presentation in the clinical course (35.7% versus 14.3%, p = 0.007). CONCLUSION The earlier we can diagnose PLA, the shorter the patient's hospital stay (20.6 days) will be. In PLA patients with shock, a higher rate of surgical intervention is mandatory to save their lives.
Collapse
Affiliation(s)
- Yu-Jang Su
- Department of Emergency Medicine, Mackay Memorial Hospital, No.92, Sec 2 Chung-Shan North Rd, Taipei, 10449 Taiwan
- Mackay Medicine, Nursing and Management College, No.92, Shengjing Rd.,Beitou District, Taipei, 112 Taiwan
| | - Yen-Chun Lai
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, 116 Taiwan
| | - Yu-Chia Lin
- Department of Family Medicine, Mackay Memorial Hospital, No.92, Sec 2,Chung-Shan North Rd, Taipei, 10449 Taiwan
| | - Yu-Hang Yeh
- Department of Emergency Medicine, Mackay Memorial Hospital, No.92, Sec 2 Chung-Shan North Rd, Taipei, 10449 Taiwan
| |
Collapse
|
39
|
Mezhir JJ, Fong Y, Jacks LM, Getrajdman GI, Brody LA, Covey AM, Thornton RH, Jarnagin WR, Solomon SB, Brown KT. Current management of pyogenic liver abscess: surgery is now second-line treatment. J Am Coll Surg 2010; 210:975-83. [PMID: 20510807 DOI: 10.1016/j.jamcollsurg.2010.03.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 02/26/2010] [Accepted: 03/03/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage. STUDY DESIGN Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined. RESULTS Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02). CONCLUSIONS Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.
Collapse
Affiliation(s)
- James J Mezhir
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
McKenzie TJ, Lillegard JB, Grotz TE, Moir CR, Ishitani MB. Pyogenic liver abscess secondary to Streptococcus anginosus in an adolescent. J Pediatr Surg 2010; 45:e15-7. [PMID: 20438908 DOI: 10.1016/j.jpedsurg.2010.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 02/09/2010] [Accepted: 02/10/2010] [Indexed: 10/19/2022]
Abstract
Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort.
Collapse
Affiliation(s)
- Travis J McKenzie
- Department of Pediatric Surgery, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | | | |
Collapse
|
41
|
Meddings L, Myers RP, Hubbard J, Shaheen AA, Laupland KB, Dixon E, Coffin C, Kaplan GG. A population-based study of pyogenic liver abscesses in the United States: incidence, mortality, and temporal trends. Am J Gastroenterol 2010; 105:117-24. [PMID: 19888200 DOI: 10.1038/ajg.2009.614] [Citation(s) in RCA: 188] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Few population-based studies have evaluated pyogenic liver abscess (PLA) in North America. We assessed the incidence of PLA and evaluated predictors of mortality. METHODS We used the Nationwide Inpatient Sample to identify all patients with discharges for PLA (ICD-9 572.0) between 1994 and 2005. Multivariable logistic regression analysis was performed to determine whether mortality was associated with patient and hospital characteristics including comorbidities, interventions, and bacterial cultures. We determined the annual incidence for PLA in the US population and assessed for temporal changes using generalized linear regression models. RESULTS We identified 17,787 PLA discharges for an overall incidence of PLA of 3.6 (95% confidence interval (CI): 3.5-3.7) per 100,000 population. From 1994 to 2005, the annual average percent increase in incidence was 4.1% (95% CI: 3.4-4.8; P<0.0001). In-hospital mortality was 5.6% (95% CI: 5.3-6.0). Mortality was associated with older age (65-84 vs. 18-34: odds ratio (OR)=2.28 (1.48-3.51)); Medicaid (OR=1.74 (1.36-2.23)) and Medicare (OR=1.48 (1.18-1.85) vs. private insurance; and comorbidities such as cirrhosis (OR=2.48 (1.85-3.31)), chronic renal failure (OR=1.99 (1.28-3.09)), and cancer (OR=2.32 (1.97-2.73)). Patients who underwent percutaneous liver aspiration (OR=0.45 (0.39-0.52)) had lower mortality, whereas surgical drainage (OR=0.87 (0.68-1.10)) and endoscopic retrograde cholangiopancreatography (OR=0.73 (0.52-1.03)) were not associated with mortality. The most commonly recorded bacterial infections were Streptococcus species (29.5%) and Escherichia coli (18.1%). Patients with bacteremia or septicemia (OR=3.88 (3.36-4.48)) had an increased risk of death. CONCLUSIONS The incidence of PLA is increasing and is associated with significant mortality that is attributable to several modifiable risk factors.
Collapse
Affiliation(s)
- Liisa Meddings
- Department of Medicine, University of Calgary, Alberta, Canada
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Chiche L, Dargère S, Le Pennec V, Dufay C, Alkofer B. Abcès à pyogènes du foie. Diagnostic et prise en charge. ACTA ACUST UNITED AC 2008; 32:1077-91. [DOI: 10.1016/j.gcb.2008.09.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 09/04/2008] [Accepted: 09/25/2008] [Indexed: 01/09/2023]
|
43
|
Cerwenka H. Is surgery still needed for the treatment of pyogenic liver abscess? Dig Liver Dis 2008; 40:697-8. [PMID: 18373965 DOI: 10.1016/j.dld.2008.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 01/31/2008] [Accepted: 02/02/2008] [Indexed: 12/11/2022]
Affiliation(s)
- H Cerwenka
- Department of Surgery, Medical University of Graz, A-8036 Graz, Austria.
| |
Collapse
|