Current Management of Pyogenic Liver Abscess: Surgery is Now Second-Line Treatment

Current Management of Pyogenic Liver Abscess:
Surgery is Now Second-Line Treatment
James J Mezhir, MD, Yuman Fong, MD, FACS, Lindsay M Jacks, MS, George I Getrajdman, MD,
Lynn A Brody, MD, Ann M Covey, MD, Raymond H Thornton, MD, William R Jarnagin, MD, FACS,
Stephen B Solomon, MD, Karen T Brown, MD
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. (J Am Coll Surg 2010;210:
975–983. © 2010 by the American College of Surgeons)
BACKGROUND:
tients with larger and multiloculated abscesses had better
clinical outcomes with surgery compared with PD.6
This study analyzes the results of treatment of liver abscess
both in the context of cryptogenic disease and in patients with
actively treated advanced malignancy. Patients with malignancy are often malnourished, are being treated with chemotherapy, or have suboptimal performance status precluding
major surgery. Furthermore, these patients may be undergoing liver-directed therapies such as hepatic artery embolization, radiofrequency ablation, and resection. The percutaneous approach in these patients, if effective, would be the
preferred method of treatment.11,12 A better understanding of
which clinicopathologic factors predict failure in this population could be beneficial in guiding therapy.
Treatment of pyogenic liver abscess (PLA) has evolved over
the last 10 years such that percutaneous drainage (PD) is
now the most common approach,1-5 although some still
advocate surgical drainage as more effective.6-10 Proponents
of early operative intervention generally reported on abscesses related to benign disease, and contended that pa-
Disclosure Information: Nothing to disclose.
Presented at the American College of Surgeons 95th Annual Clinical Congress, Chicago, IL, October 2009.
Received November 13, 2009; Revised February 26, 2010; Accepted March
3, 2010.
From the Departments of Surgery (Mezhir, Fong, Jarnagin), Interventional
Radiology (Getrajdman, Brody, Covey, Thornton, Solomon, Brown), and
Epidemiology and Biostatistics (Jacks), Memorial Sloan-Kettering Cancer
Center, New York, NY.
Correspondence address: Yuman Fong, MD, FACS, Department of Surgery,
Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, New
York 10065. email: fongy@mskcc.org
© 2010 by the American College of Surgeons
Published by Elsevier Inc.
METHODS
The Memorial Sloan-Kettering Cancer Center interventional radiology and hepatopancreaticobiliary databases
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ISSN 1072-7515/10/$36.00
doi:10.1016/j.jamcollsurg.2010.03.004
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Mezhir et al
Management of Pyogenic Liver Abscess
Abbreviations and Acronyms
OR ⫽ odds ratio
PD ⫽ percutaneous drainage
PLA ⫽ pyogenic liver abscess
were queried for patients diagnosed with PLA. Patients met
criteria for inclusion based on 2 specific factors: clinical
signs of infection such as leukocytosis, fever, bacteremia, or
sepsis; and imaging consistent with PLA. All imaging was
retrospectively reviewed to confirm PLA; any patient with
an extrahepatic abscess or perihepatic fluid collection was
excluded. There were 58 patients who met criteria for analysis, and complete data were collected retrospectively from
the medical record.
All patients were treated with broad-spectrum antibiotics during the initial drainage procedure. The most common antibiotics administered during this interval were
ticarcillin/clavulanate (36%), piperacillin/tazobactam (31%),
or a fluoroquinolone (21%) with or without metronidazole
(22%). Vancomycin was given alone or in combination
with other gram-negative and anaerobic coverage in 9 patients (16%). Antibiotic therapy was subsequently tailored
based on culture and sensitivity results. For patients with
yeast in their culture, treatment with intravenous fluconazole
was initiated. If a resistant organism was found, treatment
with a ␤-glucan synthase inhibitor such as caspofungin or
micafungin was initiated. Patients routinely remained on antibiotic therapy until their sepsis was resolved and there was no
clinical evidence of infection (afebrile, no leukocytosis, negative blood cultures).
The initial treatment in all patients was with PD and was
performed using standard Seldinger technique; 6.5- to 12F
locking, pigtail-type drains were placed under CT, ultrasound, and/or fluoroscopic guidance at the discretion of
the attending interventional radiologist performing the
procedure. All patients received preprocedure antibiotics.
Patients with platelet count ⬍50,000/␮L and/or international normalized ratio (INR) ⬎1.9 were typically transfused with appropriate products immediately before drainage. All catheters were connected to gravity drainage and
flushed twice daily with 3 to 10 mL of saline.
Success of PD was defined as having clinical or radiologic evidence of abscess resolution followed by drain removal. Drain removal was typically performed when the
patient demonstrated no signs of infection (fever, leukocytosis, bacteremia) and drainage was nonbilious and less
than 30 mL over a 24- to 48-hour period. Drain exchange
was reserved for patients who had a decrease in drainage
with clinical signs of infection or persistent abscess on imaging. Failure of PD was defined as requiring operative
J Am Coll Surg
intervention, or death with abscess drains in place (including patients who died of disease unrelated to septic complications). Patients requiring operative intervention either
demonstrated no improvement in clinical symptoms with
initial drainage or had persistent abscesses despite multiple
drainage attempts.
Radiologic characteristics
Examples of liver abscesses in this study are shown in Figure
1. Abscesses are solitary or multiple well-defined lesions,
and may be round, oval, or lobulated. On CT, liver abscesses appear isodense with normal liver parenchyma on
unenhanced scans, and with low attenuation on contrastenhanced equilibrium phase images. They may be complex
and multiloculated (Fig. 1A) or unilocular (Fig. 1B) with or
without an air-fluid level. Abscesses typically have an enhancing rim or peripheral capsule (Fig. 1B). On MRI, they
exhibit a low signal on T1-weighted images and appear
hyperintense on T2 (Fig. 1C). They are often surrounded
by a local increase in signal on T2-weighted images; this
“halo” is secondary to edema. Most have peripheral enhancement after the intravenous administration of gadolinium. Biliary fistula, when present, can be demonstrated
by fluoroscopic contrast injection study (Fig. 1D).
Statistical analysis
Characteristics of the cohort were summarized. Linear regression was used to determine predictors of prolonged
dwell time for patients treated successfully with PD alone.
Dwell time was modeled using a log transformation due to
the skewed nature of the distribution. Multivariable logistic regression was used to determine predictors of failure of
PD defined as either death or requiring operative debridement. Variables statistically significant (p ⬍ 0.05) on univariate analysis were considered in a multivariable model.
All statistical analyses were performed using SAS 9.2 (SAS
Institute).
RESULTS
From January 1998 until May 2009, there were 58 patients
with PLA treated with PD. During this time period, 2,738
hepatic resections were performed, and 5 (0.2%) were for
treatment of PLA. Clinicopathologic variables are listed in
Table 1. The vast majority (88%) of patients in the study
had a history of metastatic or primary adenocarcinoma or
neuroendocrine neoplasm of the pancreas, bile ducts, duodenum, or liver. There were 17 patients (29%) receiving
chemotherapy at the time of their abscess diagnosis; 8 patients (14%) had diabetes mellitus. Hepatic metastases
were present in 45% of patients. Nine patients (16%) had
a previous liver resection. Among the 7 patients without a
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Management of Pyogenic Liver Abscess
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Figure 1. Radiographic presentation of abscesses. (A) Multiloculated abscess seen on contrast-enhanced CT scan. Note extensive
loculation; a classic appearance for a liver abscess. (B) Patient with indwelling wall stent (short arrow) for cholangiocarcinoma presented with
fever, cholangitis; unilocular liver abscess with air fluid level (long arrow). (C) MRI in patient with acinar cell pancreatic cancer with liver
metastases who developed fever and bacteremia. Note 2 hyperintense liver abscesses in the left lateral segment and segment IV (short
arrows) on T2-weighted image adjacent to known liver metastasis (long arrow) in right liver. The abscesses were new findings since the
previous scan 2 months earlier. (D) Contrast study revealing communication of abscess cavity (short arrow) with biliary tree.
diagnosis of cancer, 3 had a previous hepaticojejunostomy
for bile duct injury, and 1 had resection of a giant cavernous
hemangioma. Three of these 7 patients had biliary obstruction that preceded the development of the hepatic abscess,
and 4 abscesses were cryptogenic.
Presenting characteristics and diagnostic and therapeutic measures are shown in Table 2. For the entire cohort,
median white blood cell count (14,200/␮L, normal range
4,000 to 11,000/␮L) and total bilirubin levels (1.3 mg/dL,
normal ⬍1.0 mg/dL) were elevated. Median creatinine and
international normalized ratio (INR) were within normal
limits. The median albumin level was low (2.6 mg/dL,
normal ⱖ 4.0 mg/dL). Most patients (72%) had only 1
liver abscess and the most common method for abscess
diagnosis was CT scan (97%). Consistent with earlier reports, the right hepatic lobe was the most common location
for abscess (91%).3,6 Communication with the biliary tract
was determined by contrast study and was noted in 15
patients (26%). Among the patients with biliary tract communication, 14 of 15 (93%) had concomitant biliary tract
obstruction. Seven of these patients underwent treatment
for biliary obstruction with either percutaneous or endoscopic
drainage. A secondary procedure was defined as requiring an
additional interventional procedure to reposition or replace
the initial drain or to study the abscess cavity; more than 1
procedure was required in 38 patients (66%).
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Management of Pyogenic Liver Abscess
Table 1. Clinicopathologic Variables of 58 Patients with
Pyogenic Hepatic Abscess
Variable
Age ⱖ 60 y
Gender (male)
History of malignancy
Pancreatic/duodenal adenocarcinoma
Cholangiocarcinoma
Colon adenocarcinoma
Pancreatic/duodenal neuroendocrine tumor
Gallbladder adenocarcinoma
Other
Current cancer therapy
Chemotherapy
Octreotide
Radiation
Diabetes mellitus
Liver disease
Hepatic metastases
Previous liver resection
Portal vein thrombosis
Bilioenteric anastomosis
Pancreaticoduodenectomy
Hepaticojejunostomy
Choledochojejunostomy or duodenostomy
Cholecystojejunostomy
Previous biliary intervention
ERCP with plastic endobiliary stent
PTC with internal/external drain
ERCP or PTC with metal stent
Previous hepatic artery embolization
Previous radiofrequency ablation
n
%
30
33
51
15
10
7
7
6
6
23*
17
5
2
8
33
26
9
7
30
14
11
4
1
17
7
6
4
12
1
52
57
88
30
20
14
14
12
20
40
74
22
9
14
57
45
16
12
52
47
37
13
3
29
41
35
24
21
2
*One patient was being treated with chemotherapy and radiation.
ERCP, endoscopic retrograde cholangiopancreatography; PTC, percutaneous
transhepatic cholangiogram.
Microbiology
Initial drainage specimens for all patients were sent for
Gram stain and culture; 3 abscesses (5%), despite aspiration of purulent material with positive Gram stains, did not
grow bacteria on final culture (Table 3). Eight patients
(14%) had negative Gram stains, but subsequent positive
cultures. Culture growth was polymicrobial in 32 patients
(55%) and the most common bacterial species cultured was
Streptococcus (34%) followed by Enterococcus (22%) and
Escherichia coli (22%). Candida was the only yeast that
grew from cultures, and included albicans (3 patients), glabrata (5 patients), albicans and glabrata (1 patient), and
krusei (1 patient). Blood cultures were positive in 27 patients (47%) and in each instance had bacterial growth of at
least 1 of the species from the corresponding abscess
culture.
J Am Coll Surg
Table 2. Presenting Characteristics, Diagnostic and Therapeutic Measures
Variable
n (%) or median
(range)
Symptoms at presentation
Fever ⫾ chills
57 (98)
Leukocytosis
36 (62)
Bacteremia
9 (16)
Sepsis/multisystem organ failure
5 (9)
White blood cell count, K/␮L
14.2 (3.9–42.8)
Creatinine, mg/dL
0.9 (0.3–2.0)
Albumin, mg/dL
2.6 (1.5–3.8)
International normalized ratio
1.3 (1.0–2.9)
Total bilirubin, mg/dL
1.3 (0.2–19.1)
Method of diagnosis
CT scan
56 (97)
Other (ultrasound, MRI)
2 (3)
Abscesses imaged per patient, n
1
41 (71)
ⱖ2
17 (29)
Abscesses drained per patient, n
1
55 (95)
2
3 (5)
Primary abscess location
Right lobe
53 (91)
Left lobe
3 (5)
Central
2 (3)
Loculations present
24 (41)
Air in abscess
27 (47)
Abscess size, maximum diameter, cm
5.7 (2.3–1.6)
⬍5
23 (40)
5–10
28 (48)
⬎10
7 (12)
Initial amount of fluid drained from abscess, mL 35 (3.0–1,300)
Communication of abscess with biliary tract
15 (26)
Method of drainage
CT-guided drain placement
49 (84)
Fluoroscopy or ultrasound
9 (16)
All purpose drainage catheter used
12F
4 (7)
10F
5 (9)
ⱕ 8.5F
49 (84)
Procedures required per patient, n
1
20 (34)
2
13 (22)
3
7 (12)
4
12 (21)
ⱖ5
6 (10)
Drain dwell time, d
32 (2–319)
Initial hospital stay, d
13 (2–115)
ICU stay during initial drainage, d
6 (10)
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Management of Pyogenic Liver Abscess
979
Outcomes
ther therapy, either percutaneous or operative. In these 6
patients, care was withdrawn and they subsequently died of
sepsis. One patient presented with liver failure and sepsis
and later died from complications of a perforated duodenal
ulcer.
As shown in Table 5, the 2 factors that predicted failure
of PD were growth of yeast in abscess culture (odds ratio
[OR] 14.76; CI 2.49 to 87.30; p ⫽ 0.003) and communication of the abscess cavity with the biliary tree (OR 5.51;
CI 1.38 to 21.96; p ⫽ 0.02). On univariate analysis, there
was a trend toward significance for current cancer therapy
(p ⫽ 0.09) and higher serum bilirubin levels (p ⫽ 0.07). To
determine factors associated with failure of PD resulting in
operation (5 events) or death (15 events), a separate multivariable analysis was performed for each of these endpoints. The results were similar in that yeast in culture and
communication with the biliary tree were the only independent predictors of failure (data not shown).
Thirty-eight patients (66%) were treated successfully with
PD alone (defined as abscess resolution with drain removal). Median drain dwell time for successfully treated
patients was 26 days (range 3 to 319 days). On univariate
analysis, younger age was the only factor associated with a
prolonged dwell time (p ⫽ 0.02); there was a trend toward
significance for previous embolization or radiofrequency
ablation (p ⫽ 0.07) (data not shown).
Five patients (9%) required operative intervention due
to either clinical deterioration or imaging that demonstrated failure of abscess resolution with PD. The median
drain dwell time among these patients was 21 days (range 4
to 215 days). Initial operative intervention in all cases involved exploratory laparotomy, debridement, and placement of drains. Three patients subsequently required repeat operations; 2 required right hepatic lobectomy and 1
patient had a repeat drainage procedure. Mortality in patients requiring surgery was 40% (2 of 5 patients). The
details of patients requiring operative intervention are
listed in Table 4.
Fifteen patients (26%) died before resolution of abscess
at a median time of 51 days (range 4 to 106 days) from the
time of initial drainage. The most common cause of death
was progression of disease in patients with advanced malignancy (9 of 15, 60%) with controlled but unresolved abscess. Among these 9 patients, all had advanced disease,
including 6 patients with multiple hepatic metastases.
There were 6 patients with pancreatic cancer, 2 with gallbladder cancer, and 1 with anal squamous cell carcinoma.
None of the patients had evidence of complete abscess resolution before death; however, their sepsis was controlled
with PD. Of the remaining 6 patients, 5 (33%) developed
signs of recurrent infection (leukocytosis, fever), but due to
advanced cancer, were extremely poor candidates for fur-
DISCUSSION
Therapy for PLA continues to evolve. Early reports demonstrated high morbidity and mortality in patients managed primarily with operative intervention (drainage with
or without liver resection).3,13,14 With improvements in antibiotic therapy, the incidence of PLA has decreased and the
most common cause has shifted from portal seeding from
appendicitis and diverticulitis to malignant biliary tract
disease. The treatment paradigm has also shifted, with increased use of PD as the preferred first line management
over surgical drainage.1,15-17
Some authors continue to favor open surgical drainage
rather than PD. Tan and colleagues6 reported on 80 patients with PLA ⬎ 5 cm in diameter: 36 patients (45%)
were managed with PD and 44 (55%) by surgical drainage.
The majority (66%) of the abscesses were cryptogenic. Failure of treatment was defined as death or deterioration of
clinical status requiring additional procedures. Patients
who underwent surgical drainage had a shorter hospital
stay and required a secondary procedure less often compared with the percutaneous group. Ten patients in the
percutaneous group (28%) versus 3 in the surgical group
(7%) met the criteria for failure of treatment (p ⫽ 0.01);
mortality was equivalent.
Hope and associates7 retrospectively stratified 107 patients with PLA into 3 types: I (small, ⬍3 cm); II (large, ⬎3
cm, unilocular), and III (large, ⬎3 cm, complex multilocular). All type I abscesses were treated successfully with
antibiotics alone; type II abscesses were treated successfully
with PD in 40 of 48 patients (83%). Type III abscesses were
successfully treated with operative drainage in 27 of 27
patients; PD only succeeded in 8 of 24 patients (33%).
Table 3. Microbiology from Final Cultures of Initial Abscess
Cavity Drainage
Growth from culture
n
%
Polymicrobial
Streptococcus
Enterococcus
Escherichia coli
Klebsiella
Candida
Vancomycin-resistant Enterococcus
Enterobacter
Citrobacter
Lactobacillus
Bacteroides
Other bacterial species
Negative
32
20
13
13
12
10
9
8
6
4
3
17
3
55
34
22
22
21
17
16
14
10
7
5
30
5
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Mezhir et al
Management of Pyogenic Liver Abscess
J Am Coll Surg
Table 4. Details of Patients Who Required Operative Intervention
Patient
Age (y)/
gender
39F
54M
46M
63F
69F
Primary diagnosis
Pancreatic NET after
Whipple with liver
metastases.
Abscess developed after
embolization.
Pancreatic NET with liver
metastases.
Abscess developed after
embolization.
Pancreatic
adenocarcinoma after
biliary bypass.
Biliary obstruction.
Liver resection for giant
cavernous hemangioma.
Postoperative abscess.
Whipple for duodenal
adenocarcinoma.
Postoperative liver
necrosis.
Operative intervention
Abscess
size, cm
Procedures
before
surgery, n
Days after
drainage, n
Operation
Outcomes
11
1
4
Persistent sepsis
Incision and drainage;
second operation
for right
hepatectomy.
Died of septic
shock
9
4
21
Persistent sepsis
Discharged
home
11
1
21
Persistent sepsis
Incision and drainage;
second operation
for right
hepatectomy.
Incision and drainage
8
1
22
Persistent sepsis
Died of septic
shock
6
3
81
Persistent abscess
Incision and drainage;
second operation
for repeat drainage
Incision and drainage
Indication
Discharged
home
Discharged
home
NET, neuroendocrine tumor.
Eight of the 16 failures (50%) were managed with repeat
PD, 5 (31%) were managed with resection, and 3 patients
(19%) died. These studies concluded that larger, loculated
abscesses should be treated with operative drainage as primary treatment.
Systemic antibiotic therapy alone has also been shown to
be effective as primary treatment of PLA in well-selected
patients with small abscesses (⬍ 3cm).7 Percutaneous aspiration is another technique that has the potential to enhance systemic antibiotic therapy by providing bacterial
speciation and antimicrobial sensitivities. Giorgio and coworkers18 treated 39 patients with multiple PLA, including
patients with abscesses larger than 4 cm, with percutaneous
aspiration. All patients were successfully treated with aspiration alone. Yu and coauthors19 randomized 64 patients
with PLA of at least 3 cm to percutaneous needle aspiration
or catheter drainage. Abscess resolution, hospital stay, and
mortality were not significantly different between groups.
Several investigators have reported their experience with
PD of pyogenic hepatic abscess.15,16 Ferraioli and colleagues15 treated 148 patients with PLA with either percutaneous (n ⫽ 104) or surgical (n ⫽ 44) drainage. The
authors compared the 2 treatment approaches and found
that patients treated with surgical drainage had a longer
hospital stay and higher cost of care when compared with
patients treated with PD; surgical drainage was also associated with higher morbidity. Notably, there were no failures
among the 104 patients treated with either percutaneous
needle aspiration or drainage. To determine the effectiveness of PD for the management of multiple and/or loculated abscesses, Liu and associates16 analyzed a series of 109
patients treated with PD alone. Primary PD was successful
regardless of the presence of loculations or the number of
abscesses treated.
Many of the previously listed studies do not include
patients with advanced malignancy. As demonstrated in
earlier reports, patients with pyogenic hepatic abscess in the
setting of malignant disease often had poor outcomes.1,11
Yeh and coworkers11 reviewed 52 patients with pyogenic
hepatic abscess and underlying malignant disease. Patients
with malignancy of the liver, bile duct, or pancreas were
compared with patients who had cancer in other sites. Patients with abscesses in the setting of biliary tract malignancy were more likely to have a fistulous connection with
the biliary tree. Furthermore, compared with patients with
cancer of other sites, those with biliary tract cancer had a
higher in-hospital mortality (28% vs 10%; p ⫽ 0.04) and
72% of these patients died of sepsis, disease progression, or
both within 6 months of abscess diagnosis. When compared with a cohort of patients without cancer, in-hospital
mortality was 21% versus 11%. The majority (88%) of the
patients in our study had a history of malignancy and represent a special cohort of patients with high risk for death
after diagnosis.
Biliary tract communication is a known factor associated
with failure of PD.20 Sugiyama and Atomi20 reported a
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Table 5. Multivariate Analysis for Failure of Percutaneous Drainage Defined as Either Death or Requiring Operative
Debridement
Variable
Age
Gender
Female
Male
Current cancer therapy
Yes
No
Bilioenteric anastomosis
Yes
No
Previous biliary instrumentation
Yes
No
Previous embolization or RFA
Yes
No
Abscesses, n
1
⬎1
Abscess size
White blood cells
Total bilirubin
Albumin
Gram-negative in culture
Yes
No
Yeast in culture
No
Yes
Anaerobic in culture
Yes
No
VRE in culture
No
Yes
Loculations present
Yes
No
Air in abscess cavity
Yes
No
Biliary tract communication
No
Yes
Univariate unadjusted
OR (95% CI)
p Value
1.01 (0.97–1.05)
0.79
1.00
0.65 (0.22–1.94)
0.44
1.00
0.38 (0.12–1.15)
0.09
1.00
1.11 (0.38–3.28)
0.85
1.00
0.66 (0.21–2.13)
0.49
1.00
0.93 (0.27–3.28)
0.91
1.00
2.15 (0.67–6.89)
0.99 (0.84–1.17)
1.04 (0.97–1.11)
1.25 (0.99–1.59)
0.36 (0.10–1.31)
0.20
0.91
0.31
0.07
0.12
1.00
0.72 (0.21–2.45)
0.60
1.00
12.00 (2.23–64.49)
0.004
1.00
0.74 (0.23–2.35)
0.60
1.00
1.65 (0.39–6.99)
0.50
1.00
3.00 (0.91–9.91)
0.07
1.00
0.60 (0.20–1.77)
0.35
1.00
4.36 (1.26–15.07)
0.02
OR, odds ratio; RFA, radiofrequency ablation; VRE, vancomycin-resistant Enterococcus.
Multivariate adjusted OR
(95% CI)
p Value
1.00
14.76 (2.49–87.30)
0.003
1.00
5.51 (1.38–21.96)
0.02
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Mezhir et al
Management of Pyogenic Liver Abscess
series of 61 patients with PLA; 20 had communication
with the biliary tree. Among these 20 patients, only 3
(15%) were treated successfully with PD alone compared
with 37 of 41 (90%) of patients treated without biliary
tract communication. When patients with biliary tract
communication had persistent discharge from their abscess
drain in the presence of biliary obstruction, endoscopic
stenting resulted in resolution. In the Liu and colleagues16
study previously mentioned, 19 of 104 (18%) patients had
radiologic evidence of communication with the biliary tree.
In patients without concomitant biliary obstruction, PD
was successful in 74% of patients. In 4 patients with biliary
tract communication with concomitant obstruction, PD
failed in all.
Two important factors relate to the finding that failure of
PD is associated with communication with the biliary tree.
First, the majority of patients (14 of 15, 93%) with biliary
tract communication in this study also had evidence of
biliary obstruction. It is possible that the presence of biliary
obstruction rather than communication with the biliary
tree alone led to failure of PD. This leads to the conclusion
that treatment of biliary tract obstruction, whether percutaneous or endoscopic, is imperative for successful treatment of abscesses that communicate with the biliary tree.
Second, an additional 15 patients (26%) in this study did not
undergo a subsequent contrast study due to abscess resolution.
It is possible that communication with the biliary tree was
present in these patients, but not demonstrated.
There are several limitations to this study. The study is
retrospective in nature and the patient cohort was selected
from the interventional radiology and hepatopancreaticobiliary databases, imposing selection bias for the analysis. It
is possible that there were patients with small abscesses
primarily treated with antibiotics alone or by percutaneous
aspiration that were not included in this study. Despite
having criteria for antibiotic therapy and abscess catheter
removal, the heterogeneous nature of this patient cohort
limits our ability to promote a specific antibiotic and drainage duration protocol. Finally, the majority of patients in
this study had advanced malignancy, which limits the generalizability of our findings to patients with cryptogenic
liver abscesses.
We conclude that PD is safe and effective as first-line
treatment for the management of PLA. Operative intervention remains second-line therapy, although surgical treatment should be considered when clinically indicated and in
those who grow yeast. In addition to percutaneous abscess
drainage, initial management of hepatic abscesses in patients who have biliary tract communication and concomitant biliary obstruction should include biliary drainage.
J Am Coll Surg
Author Contributions
Study conception and design: Mezhir, Fong, Brown
Acquisition of data: Mezhir, Brown
Analysis and interpretation of data: Mezhir, Fong, Jacks, Getrajdman, Brody, Covey, Thornton, Jarnagin, Solomon,
Brown
Drafting of manuscript: Mezhir, Fong, Brown
Critical revision: Mezhir, Fong, Jacks, Getrajdman, Brody,
Covey, Thornton, Jarnagin, Solomon, Brown
Acknowledgment: We thank Dr Ronald P DeMatteo and
Dr Michael I D’Angelica for their critical review of the
manuscript.
REFERENCES
1. Rintoul R, O’Riordain MG, Laurenson IF, et al. Changing management of pyogenic liver abscess. Br J Surg 1996;83:1215–
1218.
2. Herbert DA, Fogel DA, Rothman J, et al. Pyogenic liver abscesses: successful non-surgical therapy. Lancet 1982;1:134–
136.
3. Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic hepatic abscess.
Changing trends over 42 years. Ann Surg 1996;223:600–607;
discussion 607–609.
4. Strong R, Fawcett J, Lynch S, et al. Hepatectomy for pyogenic
liver abscess. HPB (Oxford) 2003;5:86–90.
5. Berger LA, Osborne DR. Treatment of pyogenic liver abscesses by percutaneous needle aspiration. Lancet 1982;1:
132–134.
6. Tan YM, Chung AY, Chow PK, et al. An appraisal of surgical
and percutaneous drainage for pyogenic liver abscesses larger
than 5 cm. Ann Surg 2005;241:485–490.
7. Hope WW, Vrochides DV, Newcomb WL, et al. Optimal treatment of hepatic abscess. Am Surg 2008;74:178–182.
8. Bertel CK, van Heerden JA, Sheedy PF 2nd. Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage. Arch
Surg 1986;121:554–558.
9. Chu KM, Fan ST, Lai EC, et al. Pyogenic liver abscess. An audit
of experience over the past decade. Arch Surg 1996;131:148–
152.
10. Herman P, Pugliese V, Montagnini AL, et al. Pyogenic liver
abscess: the role of surgical treatment. Int Surg 1997;82:98–
101.
11. Yeh TS, Jan YY, Jeng LB, et al. Pyogenic liver abscesses in patients with malignant disease: a report of 52 cases treated at a
single institution. Arch Surg 1998;133:242–245.
12. Branum GD, Tyson GS, Branum MA, et al. Hepatic abscess.
Changes in etiology, diagnosis, and management. Ann Surg
1990;212:655–662.
13. Northover JM, Jones BJ, Dawson JL, et al. Difficulties in the
diagnosis and management of pyogenic liver abscess. Br J Surg
1982;69:48–51.
14. Neoptolemos JP, Macpherson DS, Holm J, et al. Pyogenic liver
abscess: a study of forty-four cases in two centres. Acta Chir
Scand 1982;148:415–421.
Vol. 210, No. 6, June 2010
15. Ferraioli G, Garlaschelli A, Zanaboni D, et al. Percutaneous and
surgical treatment of pyogenic liver abscesses: observation over a
21-year period in 148 patients. Dig Liver Dis 2008;40:690–
696.
16. Liu CH, Gervais DA, Hahn PF, et al. Percutaneous hepatic
abscess drainage: do multiple abscesses or multiloculated abscesses preclude drainage or affect outcome? J Vasc Interv Radiol
2009;20:1059–1065.
17. Pearce N, Knight R, Irving H, et al. Non-operative management
of pyogenic liver abscess. HPB (Oxford) 2003;5:91–95.
Mezhir et al
Management of Pyogenic Liver Abscess
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18. Giorgio A, de Stefano G, Di Sarno A, et al. Percutaneous needle
aspiration of multiple pyogenic abscesses of the liver: 13-year
single-center experience. AJR Am J Roentgenol 2006;187:
1585–1590.
19. Yu SC, Ho SS, Lau WY, et al. Treatment of pyogenic liver
abscess: prospective randomized comparison of catheter
drainage and needle aspiration. Hepatology 2004;39:932–
938.
20. Sugiyama M, Atomi Y. Pyogenic hepatic abscess with biliary
communication. Am J Surg 2002;183:205–208.