[Recurrent bacterial abscess of the left liver lobe caused by a foreign body (fish bone)]. / Retsidivnyi bakterial'nyi abstsess levoi poloviny pecheni, obuslovlennyi inorodnym telom (ryb'ya kost') ­ taktika rentgenokhirurgicheskogo lecheniya.

The authors present minimally invasive surgical treatment of recurrent liver abscess caused by migration of fish bone from the upper gastrointestinal tract. Two-stage treatment implied small-caliber transparietal drainage of abscess with evacuation of purulent detritus at the first stage. At the second stage, primary percutaneous approach was transformed into access of sufficient diameter for flexible or rigid optics for visually controlled bone extraction. Foreign body removal through the drainage tube with endoscopic capture under visual control is preferable regarding safety compared to removal under ultrasound and/or X-ray control. Indeed, endoscopic approach is valuable for optimal positioning of the object and prevention of damage to liver parenchyma during extraction.

Endoscopic Ultrasound (EUS)-guided Drainage of Caudate Lobe Abscess: A Single Center Experience.

BACKGROUND: Liver abscess is usually treated with medical therapy. Few patients require drainage of the collection due to large size, certain high-risk location or rupture of the collection. Percutaneous drainage is most commonly used modality for the drainage of such collection. However, caudate lobe poses a unique difficulty in percutaneous drainage due to its deep location. METHODS: We did a retrospective analysis of all patients with caudate lobe abscess who underwent endoscopic ultrasound (EUS)-guided drainage at our center. We reviewed their indications, technical and clinical success rates of the procedure from 2020 to 2023. We also performed systemic review of published literature till June 12, 2023 showing use of EUS-guided drainage of caudate lobe abscess. RESULTS: Total of 8 patients (age: 37.33 ± 12.8 y; Males 62.5%) underwent EUS-guided drainage of caudate lobe collection at our center. Six patients underwent drainage using plastic stents, 1 patient underwent using metal stent, and 1 patient had aspiration of the abscess. Technical success was achieved in all patients. One patient succumbed to background illness and clinical success could be achieved in rest of the patients. In systemic review of literature on EUS-guided drainage of caudate lobe, a total of 10 studies (17 patients) were included. All patients achieved technical success. Majority studies reported use of plastic stents or naso-cystic drains whereas only 1 case reported use of metal stents. One procedure related complication (localized para-esophageal abscess) was reported requiring endoscopic intervention for management. CONCLUSION: EUS-guided drainage of caudate lobe abscess is safe and effective. It should be used as a first-line intervention after a failed medical management.

Rare Hypermucoviscous Klebsiella pneumoniae Liver Abscess in an Active Duty Male Requiring Partial Liver Resection for Definitive Treatment.

Antibiotics and drainage have largely replaced hepatic resection for the treatment of liver abscesses in the modern era; however, in cases caused by a rare strain of Klebsiella pneumoniae with a hypermucoviscous phenotype, more aggressive hepatic resection may be required. The patient is a 34-year-old male who presented to Landstuhl Regional Medical Center with a week of epigastric pain. His workup revealed a 6 cm liver abscess with growth to 10 cm in 48 hours. He underwent multiple drainage procedures at Landstuhl and then was transferred to Walter Reed where further surgical drainage was performed. Initial cultures demonstrated K. pneumoniae. He clinically improved and was able to discharge after a 2 week hospitalization. His final remaining surgical drain was removed as an outpatient, but 48 hours after removal, he was admitted to the intensive care unit in septic shock. Imaging revealed a 12 cm liver abscess, and cultures verified hypermucoviscous Klebsiella. After multidisciplinary discussion and counseling, he underwent an open right partial hepatectomy. Postoperatively he gradually recovered from his sepsis and major operation and then returned to his home in Landstuhl. This is a case of a rare hypermucoviscous variant of K. pneumoniae causing a liver abscess resistant to multiple drainage procedures, ultimately requiring open hepatic surgical resection for source control. This remains a last-resort option in the treatment of liver abscesses and should be considered early when caused by this rare strain of Klebsiella.

Endobronchial Watanabe Spigot Placement for Hepatic Abscess and Bronchobiliary Fistula Following Radiofrequency Ablation for Hepatocellular Carcinoma.

A bronchobiliary fistula (BBF) is an uncommon but severe complication after radiofrequency ablation (RFA). However, the definitive salvage methods are controversial. We herein report a patient with hepatocellular carcinoma with hepatic abscess and BBF following RFA. We also review previous reports of BBF after RFA. The patient was a man in his 70s who underwent RFA for recurrent hepatocellular carcinoma in the subphrenic area. Despite percutaneous transhepatic abscess drainage, bilioptysis persisted. Finally, the BBF was occluded with an endobronchial Watanabe spigot under fiber-optic bronchoscopy. Placing an endobronchial Watanabe spigot should be considered as a salvage therapy for refractory BBF following RFA.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: an updated systematic review and meta-analysis.

BACKGROUND: Liver abscesses differ in their aetiology, location, and number. Image-guided percutaneous drainage techniques are the currently used management for liver abscesses. We conducted our study to compare the clinical safety and efficacy of percutaneous needle aspiration (PNA) to percutaneous catheter drainage (PCD). METHODS: A systematic review of major reference databases was undertaken in February 2022 for randomized controlled trials (RCTs) that compare PNA to PCD in treating liver abscess patients. The quality of the included trials was assessed using the Cochrane tool. Statistical meta-analysis was conducted using RevMan and open meta-analyst software. RESULTS: Fifteen RCTs were included in this review, with 1676 patients enrolled. The overall quality of the included trials was moderate, with most domains of unclear risk. PCD was superior to PNA in the success rate (RR = 1.23; 95% CI [1.12, 1.36], P < 0.00001), time for achieving 50% reduction of cavity size (MD = -2.32; 95% CI [-3.07, -1.57], P < 0.00001), and time for clinical improvement (MD = -1.92; 95% CI [-2.55, -1.28], P < 0.00001). The two modalities did not differ in the days of hospital stay, duration of IV antibiotics, and time needed for total or subtotal reduction of cavity size (P = 0.36, P = 0.06 and P = 0.40, respectively). High heterogeneity levels were detected. Regarding major complications, the two modalities were equally safe (P = 0.39). CONCLUSION: PCD has a higher success rate and results in a faster 50% reduction in the abscess cavity size and clinical improvement. The two modalities are equally safe.

Resection for Chronic Hepatic Abscess due to Infected Embolization Coils After Liver Injury.

Liver injuries after blunt abdominal trauma are very common. Non-operative approaches to management are now the standard of care for many patients with up to and including grade V liver injuries. However, the long-term complications associated with coil embolization can be challenging to manage. We present the case of a 29-year-old male who presented with a chronic liver abscess which contained the coils following embolization of a grade IV liver injury and the subsequent transhepatic embolization of the pseudoaneurysm. In addition, the patient developed a fistula draining the abscess through the previously placed drain site that traversed the diaphragm. A multidisciplinary discussion was held between trauma surgery, hepatobiliary surgery, thoracic surgery, and interventional radiology to discuss the best treatment plan. The patient subsequently underwent liver resection, fistula tract resection, and diaphragm repair. This case presents a definitive management strategy for these complex patients.

Non-Resolving Perihepatic Abscess Following Spilled Gallstones Requiring Surgical Management.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis and is among the most frequently done procedures in United States. Spillage of gallstones occurs in up to 30 percent of these procedures and is associated with rare but important complications including abscess formation. CASE DESCRIPTION: We present a case of 44-year-old man with a peri-hepatic abscess developed three years after a laparoscopic cholecystectomy. Multiple percutaneous drainages and antibiotic courses had failed to provide a definitive resolution. CT scan showed signs of a developing abscess but no stones. A diagnostic laparoscopy was performed, and multiple retained stones were visualized. It was converted to open laparotomy and the abscess was drained along with resection of portions of liver and diaphragm. The patient remained vitally stable with no fever spikes following the procedure. DISCUSSION: Spillage of gallstones should be seriously considered in all patients presenting with peri-hepatic abscess with a history of previous LC, even if the imaging studies do not provide evidence of stones. Percutaneous drainage and antibiotics may provide temporary relief, but a surgical intervention is often the definitive management.

Klebsiella invasive liver abscess syndrome presenting with a central nervous system manifestation secondary to latent cholecystitis: a case report.

BACKGROUND: Brain abscess is a life-threatening event. Moreover, when Klebsiella pneumoniae is the cause, rapid diagnosis and appropriate treatment are required. Klebsiella invasive liver abscess syndrome, a bloodstream metastatic infection of potentially aggressive nature, has been recognized to cause infection in the central nervous system, and concern for Klebsiella liver abscess syndrome is increasing globally. CASE PRESENTATION: A 73-year-old Japanese woman was admitted to the institution complaining of aggravated dysarthria and weakness in the right upper extremities with onset 5 days earlier. Magnetic resonance imaging revealed a brain abscess in the left basal ganglia, and abdominal computed tomography revealed a liver abscess in liver segment 7. The patient's dysarthria symptoms became increasingly worse over the next few days, so surgical drainage via frontotemporal craniotomy was performed on admission day 3, and subsequent culture from the brain abscess showed growth of Klebsiella pneumoniae. On admission day 9, percutaneous transhepatic drainage of the liver segment 7 abscess was undertaken. The pus culture also showed growth of Klebsiella pneumoniae, thus associating the liver abscess with the brain abscess. Following long-term conservative treatment with antibiotics and abscess drainage, the liver abscess disappeared. However, the patient continuously presented with right upper quadrant pain, and abdominal computed tomography showed swelling of the gallbladder. Consequently, percutaneous transhepatic gallbladder drainage was initially administered, and the bile culture was also positive for Klebsiella pneumoniae. For radical treatment, a laparoscopic cholecystectomy was performed on admission day 99. The postoperative period was complicated by an intraabdominal abscess; however, conservative therapy was successful. She was subsequently discharged, and 12-month follow-up revealed no further sequelae. CONCLUSIONS: We describe a rare case of Klebsiella liver abscess syndrome, which first presented with a central nervous system manifestation. Our patient was successfully treated via an early surgical intervention and subsequent antibiotic therapy. Although surgical drainage remains the cornerstone treatment for brain abscess, when a brain abscess is found, and there is a high index of suspicion for the existence of a liver abscess, Klebsiella liver abscess syndrome should be considered as a possible diagnosis.

Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

AIMS: To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy. METHODS: The study protocol was prospectively registered in PROSPERO (registration number: CRD42021286294). A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted (last search: 14th March 2022). All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias was assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters. RESULTS: Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS: 789, CS: 397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS: 168, CS: 263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD: 14.15 min, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR: 1.34, p=0.11), bile leak (OR: 1.64, p=0.14), biliary stricture (OR: 0.84, p=0.65), cholangitis (OR: 1.54, p=0.35), or liver abscess (OR: 0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR: 0.92, p=0.90), bile leak (OR: 1.70, p=0.28), or biliary stricture (OR: 1.07, p=0.92) compared to CS. CONCLUSIONS: Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material.

Safety and efficacy of USG-guided catheter drainage in liver abscesses.

Background: This study aimed to evaluate the safety and efficacy of USG-guided percutaneous drainage in liver abscesses of >5 cm. A lot of literature is available on the minimally invasive treatment of liver abscesses since its introduction in the early 1980s. This study focuses on the eastern Indian population and the outcome of treatment of liver abscess of >5 cm by means of catheter drainage and the use of antibiotics. Patients and Methods: This is a retrospective study conducted on a total of fifty patients over a period of 1 year, 1 month (from June 2017 to June 2018). Only patients with liver abscess with size >5 cm were included in the study. The demographic characteristics; comorbidities; and clinical, radiological, and bacteriological characteristics of liver abscesses in the eastern Indian population and the safety and efficacy of catheter drainage were evaluated. Results: It was found that because of preprocedural empirical antibiotic intake, 70% of the patients had no growth in the pus, whereas 12% had Entamoeba histolytica, 8% had Escherichia coli, and 6% had Klebsiella pneumoniae as the causative agent. The total duration of hospital stay ranged from 3 to 22 days, and the duration of intravenous antibiotics ranged from 1 to 9 days with a clinical success rate of 96% without any drainage-related complications. Conclusion: In contradiction to the earlier belief, percutaneous drainage is a safe and effective means of treatment in liver abscesses of >5 cm with high clinical success rate and reduced duration of intravenous antibiotic requirement as well as hospital stay.

Résumé Résumé Contexte: Cette étude visait à évaluer l'innocuité et l'efficacité du drainage percutané guidé par USG dans les abcès du foie de > 5 cm. De nombreuses publications sont disponibles sur le traitement mini-invasif des abcès du foie depuis son introduction au début des années 1980. Cette étude se concentre sur la population de l'est de l'Inde et sur les résultats du traitement des abcès du foie > 5 cm au moyen d'un drainage par cathéter et de l'utilisation d'antibiotiques. Patients et Méthodes: Il s'agit d'une étude rétrospective menée sur un total de cinquante patients sur une période de 1 an, 1 mois (de juin 2017 à juin 2018). Seuls les patients présentant un abcès hépatique de taille > 5 cm ont été inclus dans l'étude. Les caractéristiques démographiques ; comorbidités ; et les caractéristiques cliniques, radiologiques et bactériologiques des abcès du foie dans la population de l'est de l'Inde et la sécurité et l'efficacité du drainage par cathéter ont été évaluées. Résultats: Il a été constaté qu'en raison de la prise d'antibiotiques empiriques préopératoires, 70 % des patients n'avaient pas de croissance dans le pus, alors que 12 % avaient Entamoeba histolytica, 8 % avaient Escherichia coli et 6 % avaient Klebsiella pneumoniae comme agent causal. La durée totale d'hospitalisation variait de 3 à 22 jours, et la durée d'antibiothérapie intraveineuse variait de 1 à 9 jours avec un taux de réussite clinique de 96 % sans aucune complication liée au drainage. Conclusion: Contrairement à la croyance antérieure, le percutané Le drainage est un moyen sûr et efficace de traitement des abcès hépatiques > 5 cm avec un taux de réussite clinique élevé et une durée réduite des besoins en antibiotiques intraveineux ainsi que du séjour à l'hôpital. Mots clés : abcès du foie, cathéter Malecot, drainage percutané, cathéter en queue de cochon, guidé par USG. Mots-clés: Safety and Efficacy of USG-Guided Catheter Drainage in Liver Abscesses?

Left eye enucleation caused by multi-systemic Klebsiella pneumoniae invasive syndrome.

Klebsiella pneumoniae is generally considered the most common pathogenic bacterium causing community-acquired pneumonia. In recent years, cases of liver abscess caused by the bacterium and its spread have been reported in Asia and other parts of the world. This clinical symptom of liver abscess caused by hypervirulent K. pneumoniae and its migrating infection is also called invasive K. pneumoniae liver abscess syndrome (IKPLAS). This study explored the clinical characteristics, diagnosis, and treatment of an elderly patient with IKPLAS who experienced multi-organ failure caused by the infection. The treatment of the patient was difficult, and despite our efforts, the invasive infection led to eye enucleation. This paper is expected to improve our understanding and awareness of this disease in the clinic.

Liver abscess in the caudate lobe caused by a fishbone and treated by laparoscopy: a case report.

BACKGROUND: Ingestion of fish bones leading to gastric perforation and inducing abscess formation in the caudate lobe of the liver is very rare. CASE PRESENTATION: A 67-year-old man presented to our hospital with a 2-day history of subxiphoid pain. There were no specific symptoms other than pain. Laboratory tests showed only an increase in the number and percentage of neutrophils. Contrast-enhanced Computerized tomography (CT) of the abdomen showed two linear dense opacities in the gastric cardia, one of which penetrated the stomach and was adjacent to the caudate lobe of the liver, with inflammatory changes in the caudate lobe. We finally diagnosed his condition as a caudate lobe abscess secondary to intestinal perforation caused by a fishbone based on the history and imaging findings. The patient underwent 3D laparoscopic partial caudate lobectomy, incision and drainage of the liver abscess, and fishbone removal. The procedure was successful and we removed the fishbone from the liver. The patient was discharged on the 9th postoperative day without other complications. CONCLUSIONS: Liver abscess caused by foreign bodies requires multidisciplinary treatment. Especially when located in the caudate lobe, we must detect and remove the cause of the abscess as early as possible. Foreign bodies that perforate the gastrointestinal tract can penetrate to the liver and cause abscess formation, as in this case. When exploring the etiology of liver abscesses, we should investigate the general condition, including the whole gastrointestinal tract.

[A Case of Successful Collective Treatment of Rectal Cancer Diagnosed by Liver Abscess].

A 67-year-old woman was found to have multiple liver abscess and pneumonia. Liver abscess was improved after percutaneous transhepatic abscess drainage(PTAD). A diagnosis of rectal cancer was made by colonoscopy and the patient underwent colostomy for rectal cancer on February 2018. Laparoscopic low anterior resection was performed on July 2019 after mFOLFOX plus bevacizumab(BEV)14 courses. Lower leaf partial lung resection was performed on September 2019 and upper leaf partial resection was performed on September 2020 for lung metastasis. The patient is currently alive without relapse after 21 months. Liver abscess was caused by portal vein infection of rectal cancer. Effective chemotherapy with surgery was successful.

Successful Cord Blood Transplantation for Idiopathic CD4+ Lymphocytopenia.

Idiopathic CD4+ lymphocytopenia (ICL) is the depletion of CD4+ lymphocytes to <300 cells/mm3 without human immunodeficiency virus infection or other causes of lymphocytopenia. ICL causes fatal infections; its etiology remains unclear and it lacks consensus regarding therapeutic options. We report the first patient with ICL who had a successful clinical course following a cord blood transplant (CBT). A 45-year-old woman was diagnosed with ICL and underwent partial hepatectomy for an abscess caused by the Mycobacterium avium complex. No specific gene alterations were detected through next generation sequencing-based evaluation. Following a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, busulfan, and 4 Gy total body irradiation, a single-unit CBT was performed. Neutrophils were engrafted on day +14. CD4+ lymphocyte counts increased to over 300 cells/mm3 on day +436. After 75 months, she was alive without any sequelae. CBT with an RIC regimen could be a curable treatment option for ICL.

Partial hepatectomy for treatment of multiple liver abscess in a calf: a case report.

BACKGROUND: Umbilical vein bacterial infections may cause liver abscesses during bacterial ascent. A single liver abscess can be surgically treated by marsupialization, but a risk of recurrence or non-healing remains. Moreover, there is no effective treatment for multiple abscesses. CASE PRESENTATION: A 17-day-old Holstein female calf exhibited reduced general condition, swelling and drainage of the umbilicus, and pressure sores in the area of the carpus, resulting in reluctance to stand up. The umbilicus showed pain at palpation; deep abdominal palpation indicated a swollen umbilical vein coursing from the umbilicus toward the liver. Ultrasonography confirmed a swollen umbilical vein with pus accumulation and multiple abscesses in the liver. Contrast-enhanced computed tomography (CT) examination confirmed that the swollen umbilical vein with fluid continued to the liver, and multiple unenhanced lesions, most likely abscesses, were confirmed in the liver. Partial hepatectomy was performed to remove as many abscesses as possible. For the resection, a vessel sealing device (LigaSureTM) was used to excise a part of the left liver lobe. As we could not remove all the abscesses in the liver during the operation, cefazolin sodium (5 mg/kg) was administered for 14 days after surgery. Post-operatively, blood accumulation was observed in the abdominal cavity, but no signs of peritonitis were found. The calf returned to the farm on day 38 after surgery. Follow-up information was obtained after 1 year, and complications were not reported. CONCLUSIONS: To our knowledge, this is the first report of partial hepatectomy using a vessel sealing device for a calf with multiple liver abscesses. This case report suggests that the combination of partial hepatectomy and long-term administration of antibacterial drugs may restore the health of calves with multiple liver abscesses.

Tuberculous perihepatic abscess and neurosarcoidosis: report of 2 uncommon manifestations of 2 common granulomatous diseases in 1 patient.

Infections caused by pathogens of the Mycobacterium tuberculosis complex, i. e., tuberculosis (TB), and the non-infectious, autoimmune disease sarcoidosis are among the most common granulomatous diseases worldwide. Typically, the lung is the primary site of infection and manifestation, respectively which makes the two diseases important differential diagnoses. Both diseases can affect virtually all organ systems, albeit with significantly lower incidence. CASE PRESENTATION: We report the case of a 50-year-old Indian man presenting with a tuberculous perihepatic abscess and a systemic inflammatory response after being diagnosed with neurosarcoidosis presenting as a single granuloma in the frontal lobe with lymphadenopathy in 2014. On day of admission the patient presented with right upper abdominal pain and fever for two weeks. With increased inflammatory parameters in serum and after finding of external CT images, a perihepatic abscess was suspected. This encapsulated cave was drained percutaneously under CT control. A high concentration of acid-fast rods was detected using ZN, PCR was positive for M. tuberculosis. Several samples of sputum and urine were microscopically negative but yielded growth of Mycobacteria after four weeks. DISCUSSION: This is a case presenting with two different granulomatous diseases, each of which manifested itself in an atypical form. The tuberculous liver abscess might either be explained as a flare-up of latent tuberculosis under azathioprine therapy or as a reinfection acquired during one of several visits in the high-prevalence country India. In addition, it must be discussed whether the cerebral granuloma in 2014 could have been an early stage of tuberculous granuloma. Sensitivity of ZN staining is significantly reduced in cerebral samples, and negative PCR-results might be due to low germ load or methodical issues, e. g., decreased sensitivity in formalin fixated samples.