Evaluation of infectious complications following percutaneous liver ablation in patients with bilioenteric anastomoses.

PURPOSE: Prior bilioenteric anastomosis (BEA) has been associated with elevated risk of abscess formation after thermal ablation of hepatic tumors. We assessed the incidence of hepatic abscess after thermal ablation in a BEA cohort treated with extended antibiotic regimens following ablation. MATERIALS AND METHODS: Retrospective review was performed to identify patients with BEA who underwent percutaneous hepatic thermal ablation between January 1, 2003-September 1, 2016. Fifteen patients with BEA underwent 18 percutaneous thermal ablation procedures. Patient and procedural characteristics were reviewed, as well as the antibiotic regiment utilized post ablation. Complications were characterized via standardized nomenclature [Common Terminology for Clinically Adverse Events (CTCAE) v4.03]. RESULTS: Fifteen patients with BEA underwent treatment of 49 liver lesions during 18 ablation sessions. Mean follow-up in these patients was 39 months (range 3-138 months). Two patients (11%) developed hepatic abscesses, both of which occurred within 45 days of the ablation procedure while the patients were still on extended prophylactic antibiotic therapy. No additional CTCAE clinically significant complications were observed. CONCLUSION: Thermal ablation of hepatic tumors can be accomplished safely in patients with BEA. Long-term post-procedural antibiotics may mitigate the risk of hepatic abscess formation. Due to the high number of patients who are deemed surgically unresectable, patients with BEA may have limited alternate treatment modalities and percutaneous hepatic thermal ablative treatments warrant consideration.

Use of Prophylactic Antibiotics to Prevent Abscess Formation Following Hepatic Ablation in Patients with Prior Enterobiliary Manipulation.

INTRODUCTION: Prior enterobiliary manipulation confers a high risk for liver abscess formation after hepatic ablation. We aimed to determine if prophylactic antibiotics could prevent post-ablation abscess in patients with a history of hepaticojejunostomy. MATERIALS AND METHODS: This single-institution retrospective study identified 262 patients who underwent 307 percutaneous liver ablation sessions between January 2010 and August 2014. Twelve (4.6 %) patients with prior hepaticojejunostomy were included in this analysis. Ten (83> %) had received an aggressive prophylactic antibiotic regimen consisting of levofloxacin, metronidazole, neomycin, and erythromycin base. Two (16.6 %) had received other antibiotic regimens. Clinical, laboratory, and imaging findings were used to identify abscess formation and antibiotic-related side effects. RESULTS: Twelve ablation sessions were performed during the period studied. During a mean follow-up period of 440 days (range, 77-1784 days), post-ablation abscesses had developed in 2 (16.6 %) patients, who both received the alternative antibiotic regimens. None of the 10 patients who received the aggressive prophylactic antibiotic regimen developed liver abscess. One of the 10 patients who received the aggressive prophylactic antibiotic regimen developed grade 2 antibiotic-related diarrhea and arthralgia. CONCLUSION: An aggressive regimen of prophylactic antibiotics may be effective in preventing liver abscess formation after liver ablation in patients with prior hepaticojejunostomy.

Prolonged antibiotic prophylaxis in patients with bilioenteric anastomosis undergoing percutaneous radiofrequency ablation.

PURPOSE: To reduce risk of development of a hepatic abscess in patients with preexisting bilioenteric anastomosis (BEA) undergoing radiofrequency (RF) ablation of hepatic tumors by use of prolonged antibiotic prophylaxis over at least 10 days. MATERIALS AND METHODS: Between April 2003 and June 2011, 184 patients underwent 206 percutaneous RF ablation procedures for hepatic malignancies. Eight patients presented with BEA and were treated in 10 sessions at 14 tumor locations. These 8 patients were male and ranged in age from 55-73 years. Median follow-up was 34 months. Antibiotic prophylaxis was given before the intervention (n = 9, piperacillin/tazobactam; n = 1, ciprofloxacin). Oral antibiotic prophylaxis after the intervention was continued with ciprofloxacin for at least 10 days. In four cases, prophylaxis after the intervention was extended with additional antibiotics. RESULTS: A liver abscess occurred 22 days after 1 of 10 RF ablation sessions in patients with preexisting BEA. The patient who developed an abscess presented with a large hepatocellular carcinoma (59 mm × 54 mm) and underwent transarterial chemoembolization 8 days before RF ablation. No hepatic abscess occurred after 196 RF ablation sessions in 176 patients without BEA. CONCLUSIONS: Preexisting BEA is a risk factor for formation of hepatic abscesses after RF ablation. An antibiotic prophylaxis regimen before the intervention and for a prolonged period after the intervention that covers anaerobic bacteria for at least 10 days is presented. Combined therapy of transarterial chemoembolization and RF ablation increases the risk for complications in patients with known BEA.

Moxifloxacin prophylaxis for chemoembolization or embolization in patients with previous biliary interventions: a pilot study.

OBJECTIVE: Abscess formation is a common serious adverse event after intraarterial therapy for hepatic malignancy in patients with colonized bile ducts. The combination of antibiotic prophylaxis and bowel preparation has been used to prevent hepatic abscess. We describe our outcomes with moxifloxacin prophylaxis alone without bowel preparation. CONCLUSION: Ten patients underwent 25 procedures and were followed for a median of 250 days. No abscesses developed. Our results suggest moxifloxacin alone may suffice for prophylaxis.

Empiric antibiotics for transarterial embolization in hepatocellular carcinoma: indicated?

BACKGROUND: Transarterial embolization (TAE) remains a common treatment option in unresectable patients with hepatocellular cancer (HCC); however there are no standard protocols for post procedure care in these patients who often have extensive disease, marginal liver function, and multiple comorbidities. The aim of this study was to examine antibiotics use in HCC undergoing TAE. METHODS: A prospective review of our center's 1109 hepato-pancreatico-biliary patients, from 1/99 to 7/07, was performed to identify all HCC patients. RESULTS: Two hundred one patients with HCC, of whom 59 (29.4%) underwent bland, TAE, or Yttrium-90 therapy. All embolizations were performed by experienced interventional radiologists and were admitted to the surgical oncology service for post-procedure care. There were 46 men and 13 women, with a median age of 61 y. The mean MELD score was 10.9 (8.5-17) with 25 of 59 having <25% liver involvement. The lesion size ranged from 2 to 12 cm with a mean of 4.88 cm; 24 patients (41%) received a single pre-procedural dose of an antibiotic, 7 (12%) a dose of an antibiotic pre- and post-procedurally, and 28 (47%) did not receive any form of antibiotic. The mean length of stay was 1 (0-5) d depending on adjuvant procedures performed during the same hospital admission. No immediate or long term infectious complications were noted, including liver abscess, cholangitis, pneumonia, or sepsis with a median follow up of 28 mo. CONCLUSION: The current practice of pre- or post-procedure antibiotics is variable and no evidence can support giving or not giving antibiotics for hepatic arterial therapy. The uses are not indicated as prophylaxis against hepatic infectious complications in patients undergoing transarterial embolization for the treatment of hepatocellular cancer.

[Percutaneous, laparoscopic and open surgical radiofrequency ablation of malignant liver lesions]. / Interventionelle, laparoskopische und offen operative Radiofrequenztherapie maligner Leberläsionen.

The growing clinical impact of radiofrequency ablation of liver lesions is reflected by a rapidly increasing number of published papers. Experimental work focuses on factors that reduce the variability of the ablation zone. The Pringle-maneuver plays a key role in this question from a surgeon's perspective. Large single center studies and a meta-analysis show a sharp rise in the rate of local recurrences for tumors larger 3 cm. An open surgical approach is significantly correlated to a low local recurrence rate. Bile duct lesions and intrahepatic abscesses are the most frequent complications. Intraductal bile duct cooling can prevent these complications. Three prospective randomized trials support the use of RFA for small hepatocellular carcinoma. The use of RFA in patients with multiple colorectal metastases is supported by single center studies showing a 3 year survival of > 35%. The favourable cost / benefit ratio will make RFA a part of future multimodal cancer therapy concepts.

Effectiveness of an aggressive antibiotic regimen for chemoembolization in patients with previous biliary intervention.

PURPOSE: Liver abscess occurs in most patients with biliary stents or bypass undergoing chemoembolization despite the use of standard prophylactic antibiotics. The present study was conducted to investigate the efficacy of an aggressive prophylactic regimen to prevent abscess in such patients. MATERIALS AND METHODS: Between November 2002 and July 2005, 16 chemoembolization procedures were performed in seven patients who had undergone biliary intervention. Prophylaxis was initiated with levofloxacin 500 mg daily and metronidazole 500 mg twice daily 2 days before chemoembolization and continued for 2 weeks after discharge. A bowel preparation regimen was given with neomycin 1 g plus erythromycin base 1 g orally at 1 p.m., 2 p.m., and 11 p. m. the day before chemoembolization. With the Fisher exact test, the incidence of infectious complications was compared with previously reported data for patients with and without earlier biliary intervention who had received standard prophylaxis. RESULTS: Liver abscess occurred in two of seven patients after two of 16 procedures. Previously reported incidences were six of seven patients (P=.103) and six of 14 procedures (P=.101) among patients with previous biliary intervention receiving standard prophylaxis and one of 150 patients (P=.005) and one of 383 procedures (P=.004) among patients with no previous biliary intervention. CONCLUSIONS: There was a trend toward a lower rate of abscess formation among patients at high risk who received more aggressive antibiotic prophylaxis, but the difference did not reach statistical significance. The rate of infection remained significantly higher than among patients without previous biliary intervention.

Liver abscess after radiofrequency ablation of tumors in patients with a biliary tract procedure.

AIM: The rate of liver abscesses after radiofrequency ablation (RFA) of liver tumors is probably high in patients with a biliary tract drainage procedure connecting the biliary duct system to the upper gastrointestinal tract. And yet, to date this rate, the time of onset of these abscesses, and the prior status of the bile ducts have never been reported in the literature. METHODS: Among 574 patients treated with RFA over 8 years, only 11 patients (with 13 sessions of RFA, 2 patients undergoing two different RFA sessions) presented with an enterobiliary anastomosis or biliary stenting at the time of RFA. This is a retrospective study of patients who were verified prospectively. RESULTS: Among the 9 patients in whom a biliary tract procedure preceded RFA, 4 developed a liver abscess at the site of RFA, which emerged between 13 and 62 days after RFA. It occurred in spite of different types of short-term antibiotic prophylaxis. Pathogenic bacteria were typical of the digestive flora. Abscesses were cured after percutaneous drainage. No abscess occurred among the 4 patients in whom a biliary tract diversion was performed synchronously with RFA. CONCLUSION: When RFA is performed in a patient with a preexisting biliary diversion, the risk of developing a liver abscess is high. Currently, we are unable to recommend any kind of preventive antibiotherapy. A preexisting biliary diversion is not an absolute contraindication for RFA, but the risk of developing a liver abscess is close to 40-50%. When RFA is performed synchronously with a biliary diversion, the risk of a liver abscess seems to disappear.

La epiploplastia no previene la formación de abscesos hepáticos postraumáticos / Epiploplasty does not prevent the formation of posttraumatic hepatic abscesses

La utilización del epiplón mayor (EM) para rellenar cavidadas hepáticas de origen traumático, es una técnica difundida. La rica vascularización y el aumento del flujo de macrófagos al foco, se postulan como factores que evitan la formación de abscesos secundarios. Esta comunicación presenta dos casos de abscesos hepáticos subyacentes al EM que ocupaba una cavidad traumática; de los cuales se infiere que en presencia de factores favorecedores de infeccidn, la epiploplastia de las cavidades, no evita la formación de abscesos. Asimismo, surge de la literatura que no hay pruebas experimentales que avalen las propiedades inmunológicas del EM y por consecuencia que la utilización del mismo disminuya la incidencia de abscesos. Parece existir evidencia clínica del papel bioestimulante del EM, pero su real capacidad y alcance en relación al proceso de cicatrización y efectos antiinfecciosos, deberían ser el objetivo de futuras investigaciones

Liver abscess formation after local treatment of liver tumors.

Our goal was to determine a subset of patients at high risk of developing liver abscesses after local treatment of liver tumors (LTLT) and establish guidelines for the conduct of LTLT in the safest conditions in such patients. Five hundred sixty-one LTLT, 489 transhepatic arterial chemoembolizations (TAC, 10 hepatic embolizations, and 62 percutaneous intratumor injections (PIT), were retrospectively reviewed for liver parenchyma necrosis and abscess formation. Four patients developed abscesses, three after TAC and one after PIT. Despite broad-spectrum antibiotherapy, percutaneous drainage, and surgery, two patients died. A left hepatectomy was required in the other two patients for cure. All four patients had a carcinoid or a neuroendocrine pancreatic tumor. Three out of four patients had bilioenteric anastomoses, and the fourth had recently undergone cholecystectomy and papillotomy. A Lipiodol/doxorubicin mixture without any particulate embolization was injected in the three patients who developed abscesses after TAC. LTLT in patients with bilio enteric anastomosis or papillotomy and/or neuroendocrine or carcinoid tumor should be performed with strict precautions during the procedure and for peri-procedural care.

Prevalence of infection following hepatic chemoembolization with cross-linked collagen with administration of prophylactic antibiotics.

PURPOSE: The authors present their experience with 494 hepatic chemoembolization (HCE) procedures in 236 patients with administration of a mixture of cross-linked collagen and chemotherapeutic agents. The prevalence of infectious complications was compared in patients who did and did not receive prophylactic administration of antibiotics as part of the HCE procedure. PATIENTS AND METHODS: Fourteen HCE procedures in nine patients were performed without prophylactic antibiotics (PA). These patients underwent embolization with cross-linked collagen alone or with low-dose cisplatinum. All of the remaining 480 procedures in 227 patients were performed with PA. RESULTS: One of the nine patients (11%) who did not receive PA experienced fatal sepsis within 24 hours of HCE. Of the 227 patients who did receive antibiotics, six (2.6%) developed hepatic abscess and no fatal sepsis was encountered. CONCLUSION: Use of PA decreases the prevalence of infectious complications following HCE.

[Liver abscess as a complication of TAE--risk factors and prevention].

Transcatheter hepatic arterial embolization for not only hepatocellular carcinoma but metastatic liver cancers is nowadays prevalent. Gall bladder infarction, cholangitis, peptic ulcers, pancreatitis, and aneurysm are reported as complications of it. But the liver abscess following it is rare. We reviewed three cases of liver abscesses after transcatheter hepatic arterial embolization. Biliary tract congestion and inflammation, and iatrogenic contaminations are supposed to major factors that caused liver abscesses. We think we should refrain from the embolization until biliary tract disorders are resolved and take care not to contaminate the proceeding materials in addition to mixing antibiotics with embolus.

Hepatic hematoma after blunt trauma--a case of nonoperative management to prevent liver abscess formation.

In an eighteen-year-old boy with a high fever, an intra-hepatic infectious hematoma following blunt hepatic trauma was treated twice with intrahepatic arterial injection chemotherapy in an attempt to prevent conversion of the hematoma to an abscess. A decrease in body temperature occurred after the arterial injections, and the hematoma was gradually diminished in size. In selected patients with blunt hepatic trauma, intrahepatic arterial injection chemotherapy seems to be an effective treatment for prevention of liver abscess formation.