Pyogenic Liver Abscess After Pancreaticoduodenectomy: A Single-Center Experience

A Case of Primary Sclerosing Cholangitis Complicated With Liver Abscess Caused by Hyperviscous Klebsiella pneumoniae

Liver abscesses caused by Klebsiella pneumoniae with a positive string test for hyperviscosity are more likely to develop invasive conditions than those with a negative string test. Here, we report the case of primary sclerosing cholangitis (PSC) who developed a treatment-resistant liver abscess caused by hyperviscous Klebsiella pneumoniae. A 67-year-old woman with PSC and a history of pancreaticoduodenectomy developed a fever. She had recurrent bacterial cholangitis after pancreaticoduodenectomy. This time, she was diagnosed with a liver abscess and bacterial cholangitis and then admitted to a local hospital. As her condition did not improve with intravenous administration of meropenem, she was transferred from another hospital to our hospital on the 7th day of admission. The percutaneous transhepatic abscess drainage was performed, and intravenous administration of cefepime and metronidazole was started. Klebsiella pneumoniae with a positive string test was detected in the blood culture test and the pus culture of the liver abscess. Although the liver abscess was reduced in size, the infection did not subside completely. Her general condition gradually deteriorated. She passed away on the 45th day of illness. In PSC patients, the formation of a liver abscess caused by hyperviscous Klebsiella pneumoniae can be life-threatening. In such cases, pus should be collected as soon as possible to identify the causative bacteria.

The New Changes of Epidemiology, Etiology, and Clinical Characteristics of Pyogenic Liver Abscesses: A Retrospective Study in a Hospital in Northern China

Purpose

To investigate the epidemiology, etiology, and clinical characteristics of patients with pyogenic liver abscesses (PLA) and provide guidance for clinical treatments.

Patients and Methods

A retrospective study was performed on a cohort of 402 hospitalized patients diagnosed with PLAs at the Affiliated Hospital of Chengde Medical College between January 2016 and December 2021. Patient demographics, drug sensitivity profiles, and microbiological culture results of drainage and blood samples were thoroughly analyzed to identify significant patterns or trends. Furthermore, clinical characteristics and treatments for patients with PLA were comprehensively assessed.

Results

Patients aged 50-69 years had the highest incidence of PLA, accounting for 59.9% of all cases, and 91.5% of them had a fever. Bacterial culture analysis of the 200 patients revealed that Klebsiella pneumoniae (K. pneumoniae) was the most predominant pathogen, detected in 70.5% of cases, exhibiting an upward trend. Escherichia coli (E. coli) was the second most frequently detected pathogen, identified in 14.5% of cases, showing a downward trend. Coexisting diabetes mellitus (DM) was found to be the most common comorbidity for PLA, occurring in most patients with the condition. Patients with a history of abdominal surgery and malignancy had an increased risk for PLA, while those with gallstones had a decreased risk. Drainage combined with antibiotic therapy was identified as the primary treatment of PLA. In addition, multivariate analysis demonstrated that coexisting DM and the presence of gas in the abscess cavity were independent risk factors for septic shock in patients with PLA.

Conclusion

This study reveals a shift in the proportions of pathogens and risk factors in patients with PLA, underscoring the necessity for improved diagnostic and therapeutic strategies.

Clostridium perfringens sepsis after pancreatoduodenectomy: a case report

Background

Clostridium perfringens sepsis associated with massive intravascular hemolysis has an extremely poor prognosis. We here report a case of C. perfringens sepsis associated with massive intravascular hemolysis that developed secondary to a post-pancreaticoduodenectomy (PD) hepatic abscess.

Case presentation

A 70-year-old man with Type 2 diabetes underwent PD for an ampulla of Vater carcinoma. His postoperative course was uneventful. He was discharged on the 16th post-operative day (POD 16) after confirming no major abnormalities on abdominal contrast computed tomography (CT) on POD 14 or laboratory results on POD 16. Two days after discharge, he was readmitted because of fever and chills. Laboratory tests showed only a mild inflammatory reaction (white blood cell count, 11,980/mm³; C-reactive protein, 2.07 mg/dL). Abdominal CT showed an irregular, approximately 20-mm diameter, low-density area in the liver S6 region that had not been seen on a recent previous scan. We initially suspected postoperative cholangitis associated with biliary reconstruction and started empirical treatment with sulbactam/ampicillin after drawing blood for culture. Eight hours after admission, he developed septic shock with body temperature 40.0 ℃ and blood pressure 70/40 mm Hg. Laboratory findings showed a severe inflammatory reaction, severe anemia, and massive hemolysis (white blood cell count, 37,400/mm³; hemoglobin, 7.7 g/dL; total bilirubin, 8.05 mg/dL; direct bilirubin, 2.66 mg/dL; and lactate dehydrogenase, 1686 U/L). Hemoglobinuria was noted in the urinary catheter output. Repeat CT 9 h after admission showed the low-density area in S6 had become a gas-forming abscess. C. perfringens sepsis was strongly suspected on the basis of these findings and the abscess was drained percutaneously immediately after its diagnosis. His vital signs improved dramatically and he recovered within 24 h. Blood and abscess cultures grew C. perfringens 4 days after admission, leading to a definitive diagnosis of C. perfringens sepsis associated with massive intravascular hemolysis. He was discharged 18 days after admission. His sepsis has not recurred.

Conclusions

Clostridium perfringens infection should be considered in patients who have undergone PD and present with gas-forming hepatic abscesses and/or sepsis associated with intravascular hemolysis. Prompt aggressive treatment is crucial, because C. perfringens infections can cause death within hours.

Does pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma affect postoperative morbidity and R0 resection? A bi-centric French cohort study

BACKGROUND

Sacrificing a replaced right hepatic artery (rRHA) from the superior mesenteric artery is occasionally necessary to obtain an R0 resection after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Preoperative embolization (PEA) of the rRHA has been proposed to avoid the onset of postoperative biliary and ischemic liver complications.

METHODS

Eighteen patients with cephalic PA with an rRHA underwent PEA of the rRHA from 2013 to 2019. The monitoring after embolization and PD was systematic and included a clinical-biological evaluation and a computed tomography scan. This study aimed to determine the feasibility of PEA of the rRHA, postoperative morbidity at 90 days, and quality of oncologic resection after PD.

RESULTS

Feasibility of PEA was 100% without complications. A PD was performed in 16/18 patients. Mortality was 2/16 with one death after septic shock with hepatic ischemia without an arterial obstruction. Overall morbidity was 44% including one hepatic abscess after hepatic ischemia (6%). Two resections were R1 (<1 mm) in contact with the origin of the rRHA (2/4 R1).

CONCLUSION

PEA of the rRHA before PD was safe and reproducible. PEA of the rRHA followed by en bloc PD resection seems to limit the risk of bilio-hepatic ischemia and could facilitate oncologic resection.

Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders. However, the operation may result in significant postoperative complications. Here, we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.

CASE SUMMARY

A 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess. One year and five months ago, he underwent PD at a local hospital to treat chronic pancreatitis. After the operation, the patient had recurrent intrahepatic abscesses for 4 times, and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital. Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy. The patient underwent percutaneous drainage but continued to have recurrent episodes. His condition was eventually cured by right hepatectomy. In this case, preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.

CONCLUSION

A careful computed tomography analysis should be considered mandatory not only to define the operability (with radical intent) of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.

Small Klebsiella pneumoniae Plasmids: Neglected Contributors to Antibiotic Resistance

Klebsiella pneumoniae is the causative agent of community- and, more commonly, hospital-acquired infections. Infections caused by this bacterium have recently become more dangerous due to the acquisition of multiresistance to antibiotics and the rise of hypervirulent variants. Plasmids usually carry genes coding for resistance to antibiotics or virulence factors, and the recent sequence of complete K. pneumoniae genomes showed that most strains harbor many of them. Unlike large plasmids, small, usually high copy number plasmids, did not attract much attention. However, these plasmids may include genes coding for specialized functions, such as antibiotic resistance, that can be expressed at high levels due to gene dosage effect. These genes may be part of mobile elements that not only facilitate their dissemination but also participate in plasmid evolution. Furthermore, high copy number plasmids may also play a role in evolution by allowing coexistence of mutated and non-mutated versions of a gene, which helps to circumvent the constraints imposed by trade-offs after certain genes mutate. Most K. pneumoniae plasmids 25-kb or smaller replicate by the ColE1-type mechanism and many of them are mobilizable. The transposon Tn1331 and derivatives were found in a high percentage of these plasmids. Another transposon that was found in representatives of this group is the bla KPC-containing Tn4401. Common resistance determinants found in these plasmids were aac(6')-Ib and genes coding for β-lactamases including carbapenemases.

Ruptured Pyogenic Liver Abscess with Pneumoperitoneum 19 Years After Pancreatoduodenectomy

BACKGROUND Rupture of a pyogenic liver abscess is rare but serious complication. In patients after pancreatoduodenectomy, there are some conditions causing the development of liver abscesses (e.g., chronic reflux-cholangitis, efferent jejunal loop stasis, stenosis of the biliary anastomosis, and pancreatogenic diabetes). However, the number of published cases of liver abscess after pancreatoduodenectomy is small. CASE REPORT A 42-year-old male was admitted with severe abdominal pain, fever, and jaundice. Nineteen years previously, he had undergone pancreatoduodenectomy and cholecystectomy for chronic pancreatitis with obstructive jaundice. Two years later, diabetes mellitus was diagnosed, with subsequent insulin treatment. At admission, symptoms of peritonitis were present. Plain abdominal radiography showed free gas under the right hemidiaphragm and heterogeneous liver shade with small gas-fluid levels. The rupture of a liver abscess was suspected. Laparotomy with adhesiolysis, debridement of the liver abscess cavity, and abdominal drainage were performed. The postoperative period was complicated by sepsis, right lower lobe pneumonia, and two-sided pleural effusions, on the background of insulin-dependent diabetes and malnutrition. The patient was discharged on the 40th day and the subdiaphragmatic drains were removed on the 114th day. Sixteen months after surgery, the patient's condition was satisfactory. Magnetic resonance imaging and echography showed the absence of biliary hypertension. The liver tissue had healed completely. CONCLUSIONS A unique case of ruptured liver abscess after pancreatoduodenectomy is presented. To the best of our knowledge, this is the first published case with such a long time interval (19 years) between pancreatoduodenectomy and the formation of a pyogenic liver abscess.