Optimal Treatment of Hepatic Abscess

Abstract

Many treatment strategies have been proposed for pyogenic liver abscesses; however, the indications for liver resection for treatment have not been studied in a systematic manner. The purpose of our study was to evaluate the role of surgical treatment in pyogenic abscesses and to determine an optimal treatment algorithm. We retrospectively reviewed the medical records of all patients who had a pyogenic liver abscess at Rhode Island Hospital between 1995 and 2002. Abscesses and treatment strategies were classified into three groups each. The abscess groups included Abscess Type I (small <3 cm), Abscess Type II (large >3 cm, unilocular), and Abscess Type III (large >3 cm, complex multilocular). The treatment strategy groups included Treatment Group A (antibiotics alone), Treatment Group B (percutaneous drainage plus antibiotics), and Treatment Group C (primary surgical therapy). Descriptive statistics were calculated and χ2 used for comparison with a P < 0.05 considered significant. Our study consisted of 107 patients with pyogenic liver abscess. The success rate for small abscesses treated with antibiotics was 100 per cent. The success rate with antibiotics and percutaneous drainage for large, unilocular abscesses was 83 per cent and for large, multiloculated abscesses was 33 per cent. None of the 27 patients who had surgical therapy for large, multiloculated abscesses had recurrences. Surgical treatment for large (>3 cm), multiloculated abscesses had a significantly higher success rate than percutaneous drainage plus antibiotic therapy (33% versus 100%, P ≤ 0.01). The mortality rate for the percutaneous drainage plus antibiotic group was not significantly different from the primary surgical group (4.2% versus 7.4%, P = 0.40). We propose a treatment algorithm with small abscesses being treated with antibiotics alone; large, uniloculated abscess with percutaneous drainage plus antibiotics; and large, multiloculated abscessed treated with surgical therapy.

Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses

“…For patients who required endoscopic intervention and have raised serum total bilirubin, their obstructed biliary system and with resultant increased likelihood of a septic state and coagulopathy would also mean increased likelihood of conservative management failure. Although it had been proposed that percutaneous drainage be instituted for PLA larger than 5 cm or for unilocated PLA larger than 3 cm , our data showed that the average abscess size and average intravenous antibiotics duration were not predictive for failure of antibiotics‐only therapy. Hence, percutaneous therapy, together with antibiotics, should be instituted early for elderly patients (≥55‐years‐old) with presence of multiple abscesses, malignancy as the etiology or who required endoscopic intervention.…”

“…While percutaneous drainage has been shown to be superior to percutaneous aspiration , there is no consensus on an algorithm regarding the surgical management of PLA. Various recommendations include surgical intervention for multi‐loculated PLA larger than 3 cm , patients with APACHE II score ≥15 , or for patients who were not responding clinically to percutaneous therapy . Our study demonstrated that patients with ECOG performance status ≥2, co‐morbidity of hypertension and raised serum total bilirubin were more likely to fail percutaneous therapy and thus require surgical intervention.…”

Pyogenic liver abscess trends in South Australia

“…Despite this, systemic antibiotic therapy has previously been shown to be an effective treatment for small PLA. Hope et al . retrospectively reviewed 107 PLA cases and found that when the PLA was <3 cm in size, antibiotic treatment alone had a 100% success rate.…”

“…Percutaneous treatment methods have generally overtaken open surgery as the treatment of choice; however, studies have showed varied results. Hope et al . retrospectively reviewed patients with PLA, dividing them into three groups depending on abscess size and number of loculi.…”

“…Other studies have also shown decreased mortality rates, shorter hospital stays and lower treatment costs associated with percutaneous rather than open treatment methods . Some still advocate surgical drainage claiming it is more effective, especially for large multi‐loculated abscesses or when percutaneous methods have failed; however, study results and conclusions have been varied …”