Absceso hepatico1

Absceso hepatico1

• 1.
  Clinical Surgery-International Aggressive hepaticresection for patients with pyogenic liver abscess and APACHE II score >15 Huan-Fa Hsieh, M.D.a,b , Teng-Wei Chen, M.D.a , Chih-Yung Yu, M.D.c , Ning-Chi Wang, M.D.d , Heng-Cheng Chu, M.D.e , Ming-Liang Shih, M.D.a , Jyh-Cherng Yu, M.D.a , Chung-Bao Hsieh, M.D.a,b, * a Division of General Surgery, Department of Surgery, c Department of Radiology, d Division of Infectious Disease and Tropical Medicine, and e Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei; b Division of General Surgery, Department of Surgery, Yeezen General Hospital, Taoxuan, Taiwan, ROC Abstract BACKGROUND: Most liver abscesses resolve after antimicrobial therapy or percutaneous tube drainage (PD). The aim of this study was to evaluate the results of hepatic resection (HR) for patients with pyogenic liver abscesses and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score Ն15. METHODS: We compared the clinical outcomes of 81 patients with APACHE II scores Ն15 undergoing PD and/or HR. RESULTS: The failure rate (3 of 65) and double-treatment rate (32 of 65) in the PD group were significantly higher than in the HR group (3 of 35 vs 0 of 35; P ϭ .0002). The mortality rate in the PD group was significantly higher than the other 2 groups (14 of 46 vs 2 of 19 and 1 of 16; P ϭ .038). The length of hospital stay was significantly shorter and antibiotic use less in the HR group than in the PD group (P Ͻ .05). CONCLUSIONS: Aggressive HR for patients with liver abscesses and APACHE II scores Ն15 produced better clinical outcomes. © 2008 Elsevier Inc. All rights reserved. KEYWORDS: APACHE II; Hepatic resection; Pyogenic liver abscess The mortality rate of patients with pyogenic liver abscesses has decreased in the past 2 decades from improvements in imaging modalities, ultrasound (US)-guided drainage tech- niques, availability of potent antibiotic drugs, and advanced intensive care.1 Treating patients having pyogenic liver abscess with a combination of percutaneous tube drainage (PD) and antibiotic therapy for 2 to 3 weeks is highly effective,2,3 and such medical treatment is considered adequate. Since the 1980s, surgical treatment has been reserved for patients who do not respond to such medical therapies.4 However, the mor- tality rate remains high (8% to 16%) with current treatment strategies.5,6 Occasionally, some patients fail to respond to medical treatment but show a dramatic improvement after surgical drainage of their pyogenic liver abscess. Few studies have discussed the subgroup of patients who might require vlearlier surgical intervention.7 Although some investigators have been concerned that surgical treatment for pyogenic liver abscess would cause bacterial spread and induce severe bac- teremia,8 others investigators, such as Tan et al, recommended * Corresponding author. Tel.: ϩ011-886-2-87927191; fax: ϩ1-886-2- 87927372. E-mail address: [email protected] Manuscript received June 25, 2007; revised manuscript September 13, 2007 0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.09.051 The American Journal of Surgery (2008) 196, 346–350
• 2.
  surgical drainage firstfor patients with liver abscesses Ͼ5 cm.7 There is no consensus in the literature. Patients with liver abscesses in Taiwan tend to be elderly, cryptogenic in origin, and with complex underlying diseases.2,9 We must search for specific guides for the most effective surgical treatment for these patients. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score can reflect the severity of some dis- eases, such as acute pancreatitis or intra-abdominal ab- scesses, and is well correlated with the associated mortality rate.9–11 We also found that patients with APACHE II scores Ն15 had significantly higher mortality rates.12 This study aimed to delineate whether early aggressive hepatic resection (HR) for patients with pyogenic liver abscesses and APACHE II scores Ն15 would achieve better out- comes. Patients and Methods From January 2001 to April 2006, 432 patients with pyogenic liver abscesses were admitted into 2 medical cen- ters: Tri-Service General Hospital and Yeezen General Hos- pital, Taipei, Taiwan. Of these, 92 patients had APACHE II scores Ն15. No liver transplant patients were included in this study. A retrospective comparative study of non- matched groups of patients defined by eventual intervention (HR, percutaneous drainage [PD], or PD ϩ HR) was per- formed. Medical records were reviewed retrospectively to docu- ment the results of the following: imaging studies (eg, ultrasonography or computed tomography); bacteriologic studies of aspirated pus; abscess patterns, origins, locations, and sizes; underlying diseases; APACHE II scores11 ; treat- ments; infectious and procedure-related complications13 ; procedure failure and double-treatment rates; and hospital- ization outcomes. PD was performed by the radiologists using pigtail catheters under sonoguidance and fluoroguid- ance. Most HRs were performed with the wedge resection pattern, including 3 patients who underwent bilateral resec- tion. Two patients underwent right lobectomies, and 1 pa- tient underwent left lobectomy. The therapeutic approaches of our patients are summa- rized in Figure 1. During hospitalization, we tried to control patients’ blood sugar levels within normal ranges and elim- inate other possible infectious causes. All patients were given empirical antibiotic therapy initially and were then directed according to the culture results. If the abscesses originated in the biliary tract, endoscopic retrograde cholan- giopancreatography with papillotomy and stone removal and/or endoscopic nasal biliary drainage were performed to relieve the common bile duct obstruction. If these treat- ments did not successfully cure the abscesses, PD or HR was arranged. PD was applied first except in patients with nonliquefied abscesses or abscess size Ͻ3 cm. HR was recommended for patients who failed PD, or those with suspect malignancy, biliary tract infection, abscess rupture– induced peritonitis. In-hospital mortality was defined as death caused by this disease during hospitalization. Hospitalization outcomes in- cluded durations of hospital stay, antibiotic use, and persis- tent symptoms after intervention. All clinical data and APACHE II scores were collected on days 1 and 2 before PD or HR (Table 1). Failure of treatment was defined as death or need for additional procedures related to the liver abscess. Double treatment was defined as need for repeated procedures related to progression or persistence of sepsis or recurrence of liver abscess. Length of hospital stay was defined as number of days from admission to discharge. Figure 1 The scheme of treatment for pyogenic liver abscess. The number in the parentheses expressed the number of mortality. Table 1 Characteristics of patients with pyogenic liver abscesses treated by PD, by PD ϩ HR, or by HR Characteristics PD and PD ϩ HR (n ϭ 65) HR (n ϭ 16) P APACHE II score 17.7 Ϯ 3.2 17.4 Ϯ 2.3 .7653 Age (y) 67.2 Ϯ 13.4 65.7 Ϯ 14.4 .6856 Men 38 10 .99 Women 27 6 DM history 41 10 .99 KP infection 48 11 Single bacterium 45 11 .99 Multiple bacteria 20 5 Biliary origin 13 8 .08 Cryptogenic origin 52 8 .37 Single abscess 40 6 .4653 Multiple abscesses 25 10 .3357 Size of abscess (cm) 17.2 Ϯ 2.8 6.4 Ϯ 3.6 .3719 Gas forming 14 1 .295 Single lobe 51 13 .99 Bilateral 14 3 DM history ϭ history of DM; KP infection ϭ Klebsiella pneumoniae infection. 347H.-F. Hsieh et al. Liver abscess and APACHE II score
• 3.
  Length of hospitalstay after drainage or surgery was de- fined as number of days after intervention to day of dis- charge. Duration of antibiotic use was defined as number of days of antibiotic use during hospitalization; duration of antibiotic use after drainage or surgery was defined like- wise. Duration of persistent symptoms after intervention was defined as number of days after intervention until pa- tient body temperature decreased to Յ37.5°C. Statistical analysis Continuous numeric data are expressed in the tables as means Ϯ SDs. The difference between the 3 patient groups (see Results section) was analyzed by 1-way analysis of variance (ANOVA). Student’s t and Fisher’s exact tests were used to analyze differences between pairs of patient groups or procedures. P Ͼ .05 was accepted as significant. Results Our study initially included 92 patients with APACHE II scores Ն15. Eleven patients receiving conservative treatments were excluded, and 9 of these died within 2 days. Eighty-one patients were enrolled in the study and were allocated to 2 groups: (1) 65 patients who underwent PD, including 19 pa- tients who underwent PD followed by HR (PD ϩ HR) and (2) 16 patients who underwent HR. Sixty-five patients underwent drainage procedures, and 35 underwent surgery. The characteristics of the 2 patient groups are listed in Table 1. Mean APACHE II scores of the PD and PD ϩ HR groups and the HR group were 17.7 and 17.4, respectively. Mean ages of the 2 groups were 67.2 and 65.7 years, and mean abscess sizes were 7.2 and 6.4 cm, respectively. There were no significant differences in patient characteristics between groups. Table 2 lists infection-induced septic symptoms and com- plications in the 2 groups. These symptoms included pleural effusions, metabolic acidosis or alkalosis, acute respiratory distress syndrome, acute renal failure, thrombocytopenia, dif- fuse intravascular coagulopathy, multiple organ failure, septic shock, and infections spreading to other organs. Distributions of infection-related complications were not statistically differ- ent between groups. The underlying diseases and conditions of the 2 groups are listed in Table 3. These included advanced age (Ͼ75 years), hemodialysis before hospitalization, end-stage liver disease, chronic obstructive pulmonary disease, heart fail- ure, biliary tract stones, history of intra-abdominal cancer, upper gastrointestinal tract bleeding, stroke, long-term bed- ridden state, and pancreatitis. No statistically significant differ- ences in the distributions of underlying diseases were found between the 2 groups. To evaluate the effect of salvage HR on liver abscess treatment, comparisons were made between the 3 groups (PD, PD ϩ HR, and HR) for mortality rate, length of hospital stay, antibiotic use, persistence of symptoms, and procedure-related complications, all of which are listed in Table 4. Mortality rates differed significantly between the 3 groups (14 of 46 for PD, 2 of 19 for PD ϩ HR, and 1 of 16 for HR; P ϭ .038) as well as the lengths of hospital stay (39.6, 27.2, and 24.1 days respec- tively; P ϭ .0453). Length of hospital stay after PD was significantly longer than after HR (36.8 vs 19.5 days; P ϭ .0296) but was similar to that in the PD ϩ HR group. Lengths of hospital stay in the PD ϩ HR and HR-only groups were not significantly different. Duration of antibiotic use after PD was significantly longer than after HR (29.4 vs 15.7 days; P ϭ .0082). There were no significant differences between the PD and PD ϩ HR groups or between the PD ϩ HR and HR-only Table 2 Spectrum of infection-induced septic syndrome and complications Syndromes and complications PD and PD ϩ HR (n ϭ 65) HR (n ϭ 16) P Pleural effusion 25 5 .7918 Metabolic acidosis 17 4 .99 Metabolic alkalosis 3 1 .99 ARDS 17 5 .7696 Acute renal failure 7 2 .99 Thrombocytopenia 5 4 .1064 DIC 17 5 .7696 Infection metastasis 11 2 .99 MOF 12 0 .1186 Septic shock 27 6 .99 Ventilator support 15 3 .99 No complications 1 0 .99 1 complication 7 2 .99 Ն2 complications 57 14 ARDS ϭ acute respiratory distress syndrome; DIC ϭ diffuse intra- vascular coagulopathy; MOF ϭ multiple organ failure. Table 3 Underlying diseases or conditions Disease or condition PD and PD ϩ HR (n ϭ 65) HR (n ϭ 16) P Age Ͼ75 y 10 3 .7219 HD 10 2 .99 ESLD 5 2 .6282 COPD 2 0 .99 Heart failure 13 0 .1153 Biliary stones 13 5 .5253 History of intra- abdominal cancer 4 0 .99 UGI bleeding 6 4 .2178 Stroke 11 0 .2014 Long-term bedridden 7 1 .99 Pancreatitis 1 0 .99 No underlying disease 1 0 .99 1 disease 16 5 .7632 Ն2 diseases 48 11 .99 HD ϭ hemodialysis; ESLD ϭ end-stage liver disease; COPD ϭ chronic obstructive pulmonary disease; UGI ϭ upper gastrointestinal tract. 348 The American Journal of Surgery, Vol 196, No 3, September 2008
• 4.
  groups regarding durationof antibiotic use. No significant differences in duration of persistent symptoms between the 3 groups were found. Regarding procedure-related compli- cations, there were significant differences between PD and HR procedures in failure (33 of 65 vs 3 of 35, P ϭ .004) and double-treatment rates (32 of 65 vs 0 of 35, P ϭ .0002). Comments According to the results of this retrospective study, pa- tients undergoing HR for severe liver abscesses with APACHE II scores Ն15 had better clinical outcomes than if they only underwent PD. These included lower mortality, procedure failure, and double-treatment rates, shorter hos- pital stay, and shorter duration of antibiotic use. According to the classic study by Ochsner et al in 1938,14 open surgical drainage or HR were the only recom- mended curative treatments for patients with liver ab- scesses. These were performed widely in the 1970s and early 1980s.4,14–16 The mortality rate of patients with pyo- genic liver abscesses was approximately 40% until the 1980s. Because of improvements in the availability of an- tibiotic drugs and US-guided techniques for evaluating liver abscesses, as well as the contention that surgical treatment would manipulate the liver and cause life-threatening bac- teremia,8,17 the treatment of patients with liver abscesses shifted to a nonsurgical approach in the late 1980s. Surgical treatment was only indicated in those patients who devel- oped complications, such as perforation, peritonitis, and drainage tube failure, or when their conditions worsened.18 Hepatic resection of liver abscess was deemed a salvage therapy after medical or drainage tube failures.19 Mischinger et al used the APACHE II score as a phys- iologic measure of illness severity.18 For patients with lower APACHE II scores, it was recommended that US-guided percutaneous treatment could be done initially to lower surgical risks.18 However, some investigators noted that patients with more complex abscesses developed abdominal pathologies; therefore, they recommended that patients with high APACHE II scores might be served better by surgical exploration.9,10,20 In addition, the results of our previous study12 confirmed that patients with pyogenic liver ab- scesses and high APACHE II scores (Ն15) at admission had higher risk of in-hospital mortality. With the advancement of modern surgical techniques, HR is no longer a dangerous procedure.21,22 With this in mind, the role of HR in patients with severe pyogenic liver abscesses should be reconsidered. HR could achieve total eradication of pathogens from the abscess region and in- flamed liver tissue. It could achieve a better outcome for patients with severe liver abscesses and infectious compli- cations. In fact, many patients with pyogenic liver abscesses have shown dramatic improvements after surgical interven- tion. Serious infectious complications, such as renal failure, respiratory failure, or disturbed consciousness, improved within 2 days after HR. In our series, HR for patients with liver abscesses proved an effective treatment, with a lower failure rate, as well as a decreased need for repeated pro- cedures, than PD. Durations of hospital stay and antibiotic use after HR were shorter than after PD. Mortality rate after HR was also significantly lower than after PD. Our results are similar to those of Herman et al,23 as well those of as other studies,7,23,24 confirming the improved results of sur- gical drainage for patients with liver abscesses. Because of the geographic distribution and characteris- tics of our patient population, most etiologies of our liver abscesses were cryptogenic. Our results and treatment al- gorithm are consistent with other groups in Taiwan.2,9,17 In general, the PD procedure produced fewer complica- tions in patients with single, liquefied liver abscesses and without septic syndromes. In patients with less severe liver Table 4 Comparisons between mortality rates, durations of hospital stay and antibiotic use, persistence of symptoms, and procedure-related complications Rates, symptoms, and complications PD PD ϩ HR HR P a Mortality rate 14 of 46 2 of 19 1 of 16 .038 Hospital stay (d) 39.6 Ϯ 29.2 27.2 Ϯ 15.5 24.1 Ϯ 7.3 .0453 After PD 36.8 Ϯ 29.3 26.2 Ϯ 15.4 .1713 .0296 After surgery 19.4 Ϯ 13.5 19.5 Ϯ 7.0 .9768 Antibiotic use (d) After PD 29.4 Ϯ 18.7 21.0 Ϯ 15.5 .1188 .0082 After surgery 14.2 Ϯ 12.8 15.7 Ϯ 5.6 .6774 Persistence of symptoms (d) After PD 18.6 Ϯ 19.9 14.2 Ϯ 8.9 .3926 .0631 After surgery 7.4 Ϯ 6.6 8.3 Ϯ 8.5 .7174 Procedure-related complications Failure 33 of 65 3 of 35 .004 Double treatment 32 of 65 0 of 35 .0002 Hospital stay ϭ time from admission to discharge; hospital stay after PD ϭ time from first day of drainage to day of discharge; hospital stay after surgery ϭ time from surgery to day of discharge. a Comparison between PD and surgery groups by Student t test. 349H.-F. Hsieh et al. Liver abscess and APACHE II score
• 5.
  abscesses, a combinationof PD and antibiotic treatment could achieve the therapeutic goal easily. However, in pa- tients with more severe liver abscesses, the PD procedure alone could not eradicate inflammatory hepatic cells and necrotic tissue. As a result, the infectious symptoms might progress to sepsis or death. Since the late 1980s, surgical drainage of liver abscesses has been considered a salvage therapy because of high mortality and complication rates. In this study, the complication rates of PD and HR were equivalent. Therefore, the role of surgical treatment for liver abscesses, especially in severe cases, should be re-evalu- ated. Tan et al concluded that when a liver abscess is Ͼ5 cm in diameter, surgical drainage should be a first-line strategy.7 However, high APACHE II score, rather than abscess size, is a risk factor for mortality in such patients.12 Severe liver abscess will be indicated by APACHE II scores Ն15, and such patients would have no time to complete the whole treatment course of advanced broad-spectrum antibi- otics or US-guided tube drainage. In these patients, HR is beneficial because it can completely remove necrotic tissue and inflammatory hepatic cells. In our series, patients with severe pyogenic liver abscesses and APACHE II scores Ն15 treated by HR had a significantly lower mortality rate than patients treated by PD (P ϭ .038). In patients who underwent PD followed by HR for treat- ment of severe liver abscesses had longer hospital stays, more prolonged antibiotic use, and higher complication rates. Differences between the PD ϩ HR group and those who underwent only 1 procedure were significant (Table 4). For clinical application, we recommend that patients with severely pyogenic liver abscesses (APACHE II scores Ն15) should receive HR as a first-line treatment. The treatment strategy in this study was for PD to be applied first. Patients who failed PD or those with biliary tract infection, peritonitis, or suspect malignancy were rec- ommended to undergo HR. Therefore, there may have been some patient selection bias, but the clinical characteristics showed no statistical differences between treatment modal- ities. In conclusion, patients with pyogenic liver abscesses and APACHE II scores Ն15, or those with increasing APACHE II scores after tube drainage, should be treated with surgical intervention to decrease risk of death. References 1. Jepsen P, Vilstrup H, Schonheyder HC, et al. A nationwide study of the incidence and 30-day mortality rate of pyogenic liver abscesses in Denmark, 1977–2002. Aliment Pharmacol Ther 2005;21:1185–8. 2. Wang JH, Liu YC, Lee SSJ, et al. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998;26:1434–8. 3. Cheng HP, Siu LK, Chang FY. Extended-spectrum cephalosporin compared to cefazolin for treatment of Klebsiella pneumoniae-caused liver abscess. Antimicrob Agent Chemother 2003;47:2088–92. 4. Chu KM, Fan ST, Lai ECS, et al. Pyogenic liver abscess: an audit of experience over the past decade. Arch Surg 1996;131:148–52. 5. Chou FF, Sheen-Chen SM, Chen YS, et al. Prognostic factors for pyogenic abscess of the liver. J Am Coll Surg 1994;179:727–32. 6. Kandel G, Marcon NE. Pyogenic liver abscess: new concepts of an old disease. Am J Gastroenterol 1984;79:217–26. 7. Tan YM, Chung YF, Chow KH, et al. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm. Ann Surg 2005;241:485–90. 8. Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic hepatic abscess: change trends over 42 years. Ann Surg 1996;223:600–9. 9. Chou FF, Sheen-Chen SM, Chen YS, et al. Single and multiple pyogenic liver abscesses: clinical course, etiology and results of treat- ment. World J Surg 1997;21:384–9. 10. Levison MA, Zeigler D, Michigan D. Correlation of APACHE II score, drainage technique and outcome in postoperative intra-abdom- inal abscess. Surg Gynecol Obset 1991;172:89–94. 11. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification. Crit Care Med 1985;13:818–29. 12. Hsieh CB, Tzao C, Yu CY, et al. APACHE II score predicts hospital mortality in patients with pyogenic liver abscess. Dig Liver Dis 2006; 38:498–502. 13. Dindo D, Demartines N, Clavien PA. Classification of surgical com- plications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. 14. Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver: II. An analysis of forty-seven cases with review of the literature. Am J Surg 1938;40:292–319. 15. Pitt HA, Zuidema GD. Factors influencing mortality in the treatment of pyogenic hepatic abscess. Surg Gynecol Obstet 1975;140:228–34. 16. Balasegaram M. Management of hepatic abscess. Curr Probl Surg 1981;18:282–340. 17. Chang FY, Chou MY. Comparison of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-K. pneumoniae pathogens. J For- mos Med Assoc 1995;94:232–7. 18. Mischinger HJ, Hauser H, Rabl H, et al. Pyogenic liver abscess: studies of therapy and analysis of risk factors. World J Surg 1994;18: 852–8. 19. Klatchko BA, Schwartz SI. Diagnostic and therapeutic approaches to pyogenic abscess of the liver. Surg Gynecol Obstet 1989;168:332–6. 20. van Sonnenberg E, Wittich GR, Goodacre BW, et al. Percutaneous abscess drainage: update. World J Surg 2001;25:362–72. 21. Imamura H, Seyama Y, Kokudo N, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138: 1198–1206. 22. Fan ST, Lo CM, Liu CL, et al. Hepatectomy for hepatocellular carci- noma: toward zero hospital deaths. Ann Surg 1999;229:322–30. 23. Herman P, Pugliese V, Montagnini AL, et al. Pyogenic liver abscess: the role of surgical treatment. Int Surg 1997;82:98–101. 24. Farges O, Leese T, Bismuth H. Pyogenic liver abscess: an improve- ment in prognosis. Br J Surg 1988;75:862–5. 350 The American Journal of Surgery, Vol 196, No 3, September 2008