Joint Hospital Surgical Grand Round

Carmen C.W. Chu Department of Surgery, Pamela Youde Nethersole Eastern Hospital

F/53 Philipino Newly diagnosed Ca sigmoid PET-CT : solitary liver

metastasis at segment IV/V For laparoscopic anterior

resection + RFA Intraop:

Multiple liver abscess Anchovy sauce like pus

Severe disease with 80-100% mortality if untreated

Infection of liver parenchyma

Infiltration by inflammation and pus formation

Bacterial -80%

Amoebic – 10% Fungal

Tuberculosis

Biliary Portal Traumatic Arterial Cryptogenic

↑incidence 13 to 20/100,000 hospital admissions Improved imaging techniques

Aetiology: Portal pyaemia due to appendicitis used to be the

commonest cause ↑Biliary causes

↓ Overall mortality 6-14% ↑ Resistant strains and fungal infection

↑antibiotics use

Barakate et al. Ann Surg. 1996

Gram- Negative Aerobes Gram Positive Aerobes

KlebsiellaKlebsiella Streptococcus Milleri

Escherichia ColiEscherichia Coli Staphylococcus Aureus

Pseudomonas Aeruginosa Enterococcus spp.

Proteus

Gram-Negative Anaerobes Gram-Positive Anaerobes

Bacteroides Clostridium

Fusobacterium Peptostreptococcus

Braiteh. International Journal of Infectious Diseases 2005

Polymicrobial

Cryptogenic non

invasive Mono-

microbial

Cryptogenic invasive

Mono-microbial

Metastatic infection

Rare Rare Frequent

DM 10-25% 15% 70%

Biliary/ GI Pathology

95% 0.6% nil

Mortality 31-41% <0.5% 11%

Drainage of pus

Treatment of underlying pathology

Antibiotics >6weeks

Surgical drainage is the mainstay of treatment in pre-imaging and pre-antibiotics era

McFadzean reported success with percutaneous drainage in 1953

Percutaneous drainage by interventional radiology is effective in 75-90%

McFadzean et al Br J Surg 1953Giorgio et al. Radiology 1995

Percutaneous Catheter

Drainage (PCD)

Percutaneous Needle

aspiration (PNA)Adv Continuous drainage

Especially when re-accumulation is

rapid

Can treat multiple abscesses in same

settingAvoids catheter

related complications

Disadv

Catheter related complications

Repeated aspiration required

Rajak (1998)

Yu (2004)Zerem (2007)

Sample Size

25 vs 25 32 vs 32 30 vs 30

Size of liver

abscess

336 vs 222 ml

6.15 vs 5.55 cm

7.4 vs 7.4cm

Overall efficacy

100% vs 60%

84% vs 97%

100% vs 67%

Rajak et al. AJR 1998Yu et al. Hepatology 2004

Zerem et al AJR 2007

F/73 Poorly controlled DM Admitted for fever,

deranged LFT USG:

Gas containing liver abscess

14.8 x 10.3 x 16.7cm air containing multi-loculated abscess displacing hepatic veins over right lobe of liver

CT on D7 after drainage

Right lobe liver abscess remained static in size

3 days after second catheter drainage

Present with rupture/peritonitis Failure of non-operative treatment Anatomatically not accessible Complications of percutaneous drainage Treatment of primary pathology

Tan et al. Annals of Surgery 2005

Pyogenic liver abscess remained a significant pathology and is potentially life threatening

Majority caused by bacterial infection Amoeba, fungal and tuberculosis Percutaneous drainage with antibiotics

remained first line of treatment and is effective in up to 90% of selected cases

Surgery is indicated in selected cases