Pyogenic Liver Abscess And Its Surgical Treatment

BACKGROUND AND PURPOSE:Commensurate with the advances in diagnostic and therapeutic radiology in the past two decades, percutaneous needle aspiration and catheter drainage have replaced open operation as the first choice of treatment for both single and multiple pyogenic liver abscesses. Our study has been done in context of laparotomy as the treatment of pyogenic liver abscess due to underlying hepatobiliary pathology or after failure of non-operative managementAIM:The main aim of this study is to discuss the causesof PLA and its diagnosis and surgical intervention.Patients and methods:49 patients who had pyogenic liver abscess from the year 2003 to 2008 were identified from a prospective data base of patients admitted under the care of the first affiliated hospital of Chongqing medical university (Hepato billiary Unit). The medical records were retrospectively reviewed, and the demographics, time from onset of symptoms to medical treatment and operation, site of abscess (es), organisms cultured, etiology, and cause operation and outcome were recorded and analyzed.In all, 49 patients (25 women, 24 men) with a median age of 46 years (range 30 60) underwent treatment for PLA. The abscesses were single (19), out of these 19 single abscesses 11 were multi-loculated. The multiple abscesses were 19. These abscesses (both single and multiple) were located in the right hemi-liver in 29 cases and left hemi-liver in 20 cases, with five extending across the principal plane.Most common concomitant disease was DM (diabetes mellitus) DM=22 Male =10 Female =12All the 49 patients underwent conservative medical treatment at first. In 40patients the treatment was not satisfactory and they had to be treated bylaparotomy.The time from onset of symptoms to commencement of medical treatmentand hospital admission ranged from 10 to 40 days (median 21) and thetime from onset of medical treatment to operation ranged from 4 to 10 days(median 6). All patients were treated with intravenous antibiotic drugs. All 49 patients were subjected to image guided percutaneous aspiration of the abscess at first an 18-gauge needle was used to aspirate the abscess cavity. Laparotomy was performed in 40 patients out of 49patients, the main indication was the failure of response of the of the conservative therapy by needle aspiration and the Increase in the size of cavity with deteriorating general condition after needle aspiration was the other indication of laparotomy the these patients.Rest of the 9 patients were managed successfully by conservative treatment and discharged.RESULTS:Biliary tract disease was the most frequently identified cause. Leukocytosis, hypoalbuminemia and hyperbilirubinemia were the common laboratory findings. The most common microorganism cultured was Klebsiella pneumonia and Escherichia coli. The most common concomitant disease was diabetes mellitus. On multivariate logistic regression analysis, the presence of sepsis (p = 0.0031) in diabetic patients was found to be an independent risk factor for complications. Antibiotics were ceased within 10-15 days of operation in all but 7 patients. All the 49 patients were treated for PLA and were discharged with a mean hospital stay of 15-21 days, the time for the removal of drain was 15-30 days with a mean time of 17 days9 patients out of 49 didn't require laparotomy for PLA and their hospital stay was more as compared to the patients that were managed with laparotomy and adjunct medical treatment.CONCLUSION:Laparotomy is advocated as primary treatment for PLA especially when the initial presentation is intraperitoneal rupture or possibly in cases of hepatobiliary pathology causing multiple abscesses above an obstructed duct system these patients had these indications. Diabetes is a strong, potentially modifiable risk factor for pyogenic liver abscess.