Pyogenic liver abscess (LA) is a rare disease associated with high morbidity and mortality rates, and prolonged hospital stay. Certain microbiological agents have assumed a predominant role in Asian series, however, few studies have been published in Europe regarding the microbiological agents involved in liver abscesses and their relationship with prognosis and length of hospital stay. The aim of this study was to characterize the main microbiological agents involved in LA in a European hospital, to assess resistance patterns and to relate them to patient prognosis and length of hospital stay. A retrospective analysis was conducted on all LA-diagnosed adult patients, admitted to a northern Portuguese hospital between 2013 and 2018. Clinical, laboratory, imaging, and microbiological data were collected for descriptive and statistical analysis. A total of 63 LA diagnosed patients were admitted to the General Surgery Unit between January 2013 and December 2018. Patients´ mean age at diagnosis was 71.4 years. Abdominal pain and fever were the most common symptoms on admission (73.0 and 61.9%, respectively). Fifty-eight percent of patients were female. Leukocytosis and increased C-reactive protein were the most observed analytical changes. The most frequently isolated microbiological agents were Escherichia coli (36.5%), Streptococcus species (27.8%), Klebsiella pneumoniae (11.4%), and anaerobic agents (10.1%). Of the isolated species, 12.5% proved multi-resistant. A higher LA frequency caused by Klebsiella pneumoniae was identified in relation to other Western series. Klebsiella pneumoniae was associated with a longer hospital stay (25.67 vs 16.50 days, p=0.07) when compared to other agents. There were 4 mortality cases in our series (6.3%). Microbiological agents, namely Klebsiella pneumoniae and multidrug-resistant agents have a predominant role in LA management, negatively affecting prognosis and length of hospital stay. Despite advances in LA treatment, more studies are required to determine the appropriate therapy owing to the absence of internationally defined guidelines. Our results provide important information for the proper management of these patients.

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failed. A choledochoduodenal fistula (infundibulotomy) was performed. A plastic endoprosthesis was inserted. Immediate after this procedure, patient developed diffuse peritonitis, leading to emergency laparotomy. Duodenal perforation was suspected but perforation site was not identified. Drain was placed. Drainage ceased after 3 weeks, drain was removed, and patient was transferred to our care. Multidisciplinary team decided for upfront pancreaticoduodenectomy. Robotic approach was proposed, and consent was obtained. Da Vinci Xi robotic system was used. Operation begins with division of adhesions from previous operation. The Kocher maneuver is performed and the ligament of Treitz is mobilized. The proximal jejunum is passed behind the mesenteric vessels and divided with stapler. The duodenum is divided with stapler 2 centimeters below the pylorus. The gastroduodenal artery is dissected, ligated and divided between hemolocks. The common bile duct is divided with robotic scissors; however, the biliary stent is not found in the common bile duct. We suspected that it has migrated distally. Pancreas is divided with harmonic shears until identification of the pancreatic duct which is divided with scissors. Pancreatic head and uncinate process are carefully dissected from the portal vein and from the superior mesenteric artery. When the surgical specimen was only attached by a large branch from portal vein, this branch was dissected for hemolock insertion. However, hemolock insertion failed due to tissue resistance. We then realize that the missing biliary stent was, in fact, inside this portal branch and extended into the main portal vein. This branch is encircled and opened with identification of the biliary stent. Portal vein branch was clamped for safe removal of the biliary stent with minimum loss of blood. Reconstruction of the alimentary tract was then performed as usual. Surgical specimen is removed through extension of auxiliary port incision. Abdominal cavity is drained, and procedure is completed. Results: Total operative time was 6 hours and 38 minutes. Estimated blood loss was 320 mL, with no need of transfusion. Recovery was uneventful and patient was discharged on the 7th postoperative day. Pathology confirmed ampulla of Vater adenocarcinoma T2N0M0. Patient is well with no signs of disease, 4 months after operation. Conclusion: Robotic pancreaticoduodenectomy is safe and feasible even after ERCP complications that required laparotomy. Absence of endoprosthesis in the common bile duct may arise suspicion of wrongful insertion towards adjacent organs and must be dealt with caution.

months (HR 0.26, p< 0.05) and > 9 months (HR 0.28, p< 0.05) were associated with decreased risk of death. Conclusions: Our results suggest that in patients with LAPC who proceed to resection, duration of chemotherapy between 6-8 months prior to resection or radiation conferred the most survival benefit. Figure 1. Kaplan-Meier curves for NAC or NAC-CRT by duration of neoadjuvant chemotherapy

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