Comparison of laparoscopic and open surgery for pyogenic liver abscess with biliary pathology

Clinical characteristics of pyogenic liver abscess with and without biliary surgery history: a retrospective single-center experience

BACKGROUND & AIMS

Pyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS).

METHODS

The study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed.

RESULTS

The percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%).

CONCLUSIONS

Patients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.

Klebsiella pneumoniae liver abscess with purulent meningitis and endogenous endophthalmitis: A case report

This is a rare but typical case of a Klebsiella pneumoniae liver abscess with migratory infections including purulent meningitis and endogenous endophthalmitis. The patient had a chief complaint of 7 days of fever, 4 days of blurry vision, and 4 h of glossolalia. Ultrasound scan and computed tomography (CT) suggested a liver abscess. Both blood and drainage fluid cultures grew K. pneumoniae with a high mucosal phenotype. The patient was finally diagnosed with a K. pneumoniae liver abscess, purulent meningitis, and endogenous K. pneumoniae endophthalmitis in the right eye. Ultrasound-guided percutaneous catheter drainage (PCD) of the liver abscess was performed, and meropenem was used to control infection. The patient was given 0.1 ml of vancomycin (10 g/L) and 0.1 ml of ceftazidime (20 g/L) were by intravitreal injection for the treatment of endophthalmitis. The infection was gradually controlled after such treatments. The patient was discharged from our hospital with an improved condition. However, during the time of follow-up, she developed complications due to severe pneumonia and eventually died in a local hospital. This case revealed that a rapid diagnosis followed by appropriate treatment would improve prognosis and prevent severe metastatic complications.

Indirect ballistic injury to the liver resulting in retained bullet complicated with hepatic abscess: a case report

Indirect and extraperitoneal penetrating liver injury is an extremely uncommon phenomenon. In this report, we highlight the case of an 18-year-old male patient that sustained a gunshot wound with an entry site through the right buttock and landed in the liver. He presented to us in sepsis due to developing a hepatic abscess at the site of the dislodged bullet that was confirmed with computed tomography. Interestingly, the ballistic missile did not cause any visceral injury due to its indirect and extraperitoneal trajectory. The patient underwent diagnostic laparoscopy, where the hepatic abscess was unroofed and evacuated. A free-floating bullet was found and extracted, and a small bile duct leak was repaired. The patient had an uneventful post-operative course and was duly discharged on an empiric course of antibiotics.

Efficacy of laparoscopic surgery in the treatment of hepatic abscess: A systematic review and meta-analysis

Background

Liver abscess is a common cause of intra-abdominal infection and its treatment depends on the presentation. Laparoscopy, in addition to its classic benefits, has particular advantages in the management of liver abscess but its role is not well defined and studies done in that field are heterogenous. The objective of this systematic review is to evaluate the efficacy of laparoscopic surgery in the management of liver abscess.

Methods

We realized a systematic review and meta-analysis including studies published in the 20 last years. The primary outcome was the pooled prevalence of recurrent or residual liver abscess after laparoscopic treatment.

Results

We retrieved 190 studies regarding laparoscopic surgery in liver abscess and 17 studies were included in the quantitative and qualitative synthesis. A total of 608 patients was included and 299 of them (49.1%) were treated by laparoscopic surgery. The indications were mainly failure of first line treatment (antibiotic treatment and/or percutaneous drainage and/or needle aspiration) and ruptured multiloculated, or caudate lobe liver abscess. The surgical gesture performed was laparoscopic drainage in all studies. The post-operative rate of recurrent or residual liver abscess after treatment by laparoscopy was 4.22% (95% CI: 2.29–7.07).

Conclusions

This systematic review showed that laparoscopic drainage had a considerable place in the management. The post-operative rate of recurrence was low with no mortality suggesting that laparoscopy is safe and feasible for liver abscess management.

•

Surgery in the treatment for liver abscess has its indications limited to ruptured liver abscess, particularly in the peritoneal cavity.

•

Laparoscopy can be used both for unruptured and ruptured liver abscess when there are failure or contraindications of percutaneous drainage.

•

This review suggest the safety and feasibility of laparoscopy with a low rate of post-operative recurrent or residual liver abscess.

Increased incidence of and microbiologic changes in pyogenic liver abscesses in the Mexican population

BACKGROUND

Pyogenic liver abscess (PLA) is a rare disease with an estimated incidence that varies widely across the globe, being as high as 115.4/100000 habitants in Taiwan and as low as 1.1-1.2/100000 habitants in Europe and Canada. Even though there are multiple microorganisms capable of producing an abscess in the liver, including Entamoeba histolytica, fungi, and viruses, most abscesses are derived from bacterial infections. The epidemiology of PLA in Mexico is currently unknown.

AIM

To describe the clinical, demographic and microbiologic characteristics of PLA in Mexico.

METHODS

This is a retrospective study carried out in two centers, and included patients seen between 2006 and 2018 with the diagnosis of pyogenic abscess. We collected demographic, clinical, and microbiological information, treatment, complications, and outcomes. A logistic regression analysis was used to determine the association between different variables and mortality rates.

RESULTS

A total of 345 patients were included in this study. 233 (67.5%) had confirmed PLA, 133 (30%) patients had no positive culture and negative serology and 9 (2.5%) had mixed abscesses. The mean age was 50 years (ranging from 16-97 years) and 63% were female. 65% of the patients had positive cultures for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia coli and Klebsiella pneumoniae. Cefotaxime was administered in 60% of cases. The most common sources of infection were ascending cholangitis and cholecystitis in 34 (10%) and 31 (9%), respectively. The median length of hospital stay was 14 d. 165 patients underwent percutaneous catheter drainage. The inpatient mortality rate was 63%. Immunocompromised state [OR 3.9, 95%CI: 1.42-10.46], ESBL- Escherichia coli [OR 6.7, 95%CI: 2.7-16.2] and Klebsiella pneumoniae [OR 4-8, 95%CI: 1.6-14.4] predicted inpatient mortality by multivariate analysis.

CONCLUSION

The prevalence of PLA is increasing in Mexico and has a very high mortality rate. ESBL-Escherichia coli and Klebsiella pneumoniae are the most common microorganisms causing PLA and are independent predictors of inpatient mortality.

HEPATECTOMY FOR PYOGENIC LIVER ABSCESS TREATMENT: EXCEPTION APPROACH?

BACKGROUND

Percutaneous drainage for pyogenic liver abscess has been considered the gold-standard approach for the treatment on almost of the cases. However, when percutaneous drainage fails or even in some especial situations, as multiloculate abscess, lobe or segment surgical resection can solve infectious clinical condition.

AIM

To report a series of patients who underwent hepatectomy for pyogenic liver abscess performed by a single surgical team.

METHODS

Eleven patients were operated with ages ranging from 45-73 years (mean and median 66 years). There were eight men and three women. The etiologies were: idiopathic (n=4), biliary (n=2), radiofrequency (n=2), direct extension (n=1), portal (n=1), and arterial (n=1). The mean lesion diameter was 9.27 cm (6-20 cm).

RESULTS

The mean operation length was 180 min (120-300). The mean intra-operative blood loss was 448 ml (50-1500). Surgical approaches were: right hepatectomy (n=4), left hepatectomy (n=3), left lateral sectioniectomy (n=1), right posterior sectioniectomy (n=2), resection of S8 (n=1), and S1 (n=1). Postoperative morbidity rate was 30%, while mortality was null. Median hospital stay was 18 days (5-45). The median follow-up period was 49 months (13-78). There was single lesion recurrence.

CONCLUSION

Hepatectomy can be done as exception approach for pyogenic hepatic abscess treatment; it is a good therapeutic option in special situations.

Application of ultrasound-guided percutaneous intrahepatic portal vein catheterization with antibiotic injection for treating unliquefied bacterial liver abscess

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.

Liver Abscess Formation Following Transarterial Chemoembolization: Clinical Features, Risk Factors, Bacteria Spectrum, and Percutaneous Catheter Drainage

To investigate the clinical features, risk factors, and bacterial spectrum of liver abscess following transarterial chemoembolization (TACE) and evaluate the therapeutic effect of percutaneous catheter drainage (PCD) on the abscesses.A retrospective review of patient charts was performed in 3613 patients who suffered from liver malignancies (2832 patients with hepatocellular carcinoma and 781 with metastatic hepatic tumor) and had undergone 11,054 TACE procedures from January 2005 to October 2013. Liver abscesses were found in 21 patients. PCD was performed in all abscess patients. The clinical features, risk factors, and bacterial spectrum of liver abscess following TACE were investigated and the therapeutic effect of PCD was evaluated.The incidence of liver abscess was 0.58% per patient and 0.19% per procedure. Approximately 57.1% of the patients had a medical history of bilioenteric anastomosis or biliary stent implantation. On computed tomography scans, the abscesses appeared as low-attenuation lesions and high-density iodinate oil scattered in the abscesses. The ultrasound showed the well defined, heterogeneously hypoechoic lesions. Positive microbiological isolates were obtained in all pus cultures and in 47.6% of blood cultures. The most common bacterium was Escherichia coli (52.4%). Twenty patients (95.2%) were cured from abscesses by using PCD, and 1 died of sepsis.Patients with predisposing factors are prone to an increased risk of liver abscess following TACE. Bacterial culture and antibiotic sensitivity tests on pus and blood help on the antibiotics selection. PCD combined with aggressive antibiotics can be recommended as the first-line therapeutic regimen.

The safety and efficacy of approaches to liver resection: a meta-analysis

Background:

The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.

Database:

Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).

Conclusion:

Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.

A Rare SOL of the Liver: Diagnostic and Management Dilemma

Aetiology and clinical presentation of space occupying lesions (SOL) of liver are varied. It can be solid, cystic or heterogenous. Usually liver abscess presents as a symptomatic cystic SOL in a sick patient. Here, we are reporting a case of giant liver abscess presenting as simple benign cyst with corroborative image findings of simple cyst. He had significant co-morbid illness and jaundice on clinical evaluation. Liver abscess was not a differential diagnosis from clinical history. None of the haematological and biochemical parameters were suggestive of liver abscess. It was an intra-operative surprise to find such a huge liver abscess with 2 liters of pus, which was drained. We report this case because of its unusual presentation and associated findings.

Laparoscopy may have a role in the drainage of liver abscess: Early experience at Owerri, Nigeria

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.

Laparoscopic drainage of liver abscess: case report and literature review

AIM

To evaluate the safety and efficacy of the minimally invasive surgical approach (laparoscopic drainage) of liver abscesses in selected cases.

CASE REPORT

Male, 58 years old, from a rural area, presented with epigastric abdominal pain, fever, weight loss, loss of appetite, a palpable mass in the epigastrium and neutrophilic leukocytosis. CT revealed a complex multiloculated liver abscess in segments 2-3. Systemic antibiotic therapy alone was ineffective; percutaneous drainage was excluded due to the characteristics of the lesion.

RESULT

Given the complexity of the lesion, a laparoscopic approach was chosen involving complete drainage of the abscess, debridement and irrigation; the cavity was unroofed using electrocautery and samples were obtained for bacterial culture and drug testing. Two drains were left in the cavity for seven days. No complications were observed.

DISCUSSION

In accordance with the scientific literature, after thorough imaging we performed laparoscopic drainage of a large, complex liver abscess as a safe, effective alternative to open surgery when antibiotic therapy alone failed and percutaneous drainage was uncertain.

CONCLUSION

Not all liver abscesses can be treated with antibiotic therapy or percutaneous drainage. Laparoscopic drainage in association with systemic antibiotic therapy is a safe and effective minimally invasive approach that should be considered in selected patients.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A PubMed and Medline literature review was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy, followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can be effectively treated by aspiration or drainage.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

Pyogenic liver abscess: An analysis of 58 cases

AIM: To analyze the clinical features of pyogenic liver abscess (PLA) to provide the basis for early diagnosis and treatment of this disease.

METHODS: The clinical data for 58 patients with PLA who were treated in the Second Affiliated Hospital of Nanjing Medical University from June 2000 to December 2011 were retrospectively analyzed to determine the clinical features, and laboratory, imaging, and microbiologic findings as well as the treatment outcome.

RESULTS: Fever and chills (94.8%) were the most common clinical manifestations, followed by right upper quadrant pain (58.6%). Twenty-seven cases (46.5%) had diabetes mellitus. The most common laboratory abnormality was increased alkaline phosphatase (ALP) (77.6%), followed by increased white blood cell (WBC) count (70.7%) and fibrinogen (FIB) (60%). The most commonly identified organism was Klebsiella pneumoniae (17.2%). The majority of patients had solitary liver abscess (86.2%), and most of liver abscesses were found in the right hepatic lobe with an average diameter of 7.1 cm ± 4.0 cm (1-24 cm). All patients underwent combined antibiotic treatment. Ultrasound or CT-guided needle aspiration or continuous drainage after needle aspiration of pyogenic liver abscess was performed in 26 patients (44.8%). Surgery was required in 3 patients (5.2%). One patient (1.7%) died due to septic shock after admission.

CONCLUSION: Patients who have fever, chills, and right upper quadrant pain should be considered of pyogenic liver abscess, especially in patients with diabetes, biliary tract disease, or cancer. Elevated ALP, WBC and FIB were more commonly seen than positive bacterial culture in PLA patients, which may have suggestive significance in clinical diagnosis. Antibiotics combined with needle aspiration or continuous drainage after needle aspiration are safe and effective treatments.

Hepatic abscesses

Hepatic abscesses are potentially lethal diseases if early diagnosis and treatment are not instituted. They are prevalent all over the globe and pyogenic abscesses are predominant over amoebic. With better control of intra abdominal and systemic infections by a spectrum of antibiotics, aetiology of pyogenic abscesses are secondary to interventions and diseases in the biliary tree to a large extent today. The common organisms isolated are the Gram negative group. Amoebic abscesses continue to plague some regions of the world where hygiene and sanitation are questionable. Over the years, diagnosis, treatment and prognosis have evolved remarkably. Imaging modalities like ultrasonography and CT scan have become the cornerstone of diagnosis. The absence of ionizing radiation makes MRI an attractive alternative in patients who require multiple follow up scans. Serological testing in amoebic abscesses has become more reliable. Though antibiotics have remained the principal modality of management, percutaneous drainage of abscesses have vastly improved the chances of cure and bring down the morbidity drastically in pyogenic abscesses. Amoebic abscesses respond well to medical treatment with nitroimidazoles, and minimally invasive surgical drainage is an option in cases where open surgery is indicated.