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1.  Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy 
AIM: To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy.
METHODS: The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and outcome of surgery.
RESULTS: The patients were predominantly women (10/13) with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multiloculation. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy: two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with peritonitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism.
CONCLUSION: Surgical treatment of pyogenic liver abscess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.
PMCID: PMC2684003  PMID: 18205266
Pyogenic liver abscess; Surgical drainage; Liver resection; Percutaneous drainage; Outcome
2.  Laparoscopic Drainage of Pyogenic Liver Abscess 
This study suggests that minimally invasive, laparoscopic techniques be considered for drainage of liver abscess before open exploration is performed.
Background and Objectives:
Pyogenic liver abscesses are mainly treated by percutaneous aspiration or drainage under antibiotic cover. If interventional radiology fails, surgical drainage becomes necessary. Recently, we performed laparoscopic liver abscess drainage successfully, and we aimed to focus on the topic in light of a systematic review of the literature.
A 22-year-old man was admitted with a 4.5-cm multiloculated abscess in the left lobe of the liver. The abscess did not resolve with antibiotic-alone therapy. Percutaneous aspiration was unsuccessful due to viscous and multiloculated contents. Percutaneous catheter placement was not amenable. Laparoscopic abscess drainage was preferred over open abscess drainage. We used 3 trocars, operation time was 40 minutes, and blood loss was minimal. In the mean time, we searched PubMed using the key words [(liver OR hepatic) abscess*] AND [laparoscop* OR (minimal* AND invasiv*)].
Postoperative recovery of the patient was uneventful, and the patient was asymptomatic after 3 months of follow-up. In the literature search, we found 53 liver abscesses (51 pyogenic and 2 amebic) that were treated by laparoscopy. Mean success rate was 90.5% (range, 85% to 100%) and conversion rate was zero.
Treatment of liver abscess is mainly percutaneous drainage. Laparoscopic drainage should be selected as an alternative before open drainage when other modalities have failed.
PMCID: PMC3041043  PMID: 21333200
Liver; Abscess; Laparoscopy; Interventional radiology
3.  Endoscopic Nasobiliary Drainage in the Management of Acute Cholangitis: An Experience in 143 Patients 
Acute cholangitis is associated with a high mortality and morbidity and often requires drainage of the obstructed biliary system. The purpose of this study was to evaluate the usefulness and safety of endoscopic nasobiliary drainage in the treatment and prevention of acute cholangitis due to diverse etiology. During a 32-month period, 143 patients (67 males, 76 females) with age range of 15 to 84 years underwent urgent fluoroscopy guided endoscopic nasobiliary drainage using a 7 Fr catheter either to treat acute cholangitis not responding to antibiotics (group A, n = 116) or to prevent its development following endoscopic retrograde cholangiography performed in an obstructed biliary system (group B, n = 27). Underlying etiology included bile duct stones (92), malignant biliary obstruction (34), choledochal cyst (4), chronic pancreatitis (4), ruptured hydatid cyst (3), portal hypertensive cholangiopathy (3) and liver abscess (3). Endoscopic nasobiliary drainage was performed successfully in 129 patients (90.2%). Cholangitis improved within 1 to 3 days (in group A) or did not develop (in Group B) in 125 patients (96.7%) with successful endoscopic nasobiliary drainage. Two patients however required additional drainage by percutaneous transhepatic route, while two died inspite of effective endoscopic drainage. Of the 14 patients (9.8%) with failed endoscopic drainage, 9 were managed by surgical decompression or percutaneous transhepatic drainage, 3 died of septicemia. Endoscopic nasobiliary drainage is a safe and effective method to treat patients with acute cholangitis as well as to prevent its development following cholangiography performed in an obstructed biliary system.
PMCID: PMC2362563  PMID: 18493431
4.  The Long-Term Results of Percutaneous Drainage of Diverticular Abscess 
Diverticulitis is a common condition occasionally complicated by abscess formation. Small abscesses may be managed by antibiotic therapy alone but larger collections require drainage, ideally by the percutaneous route. This minimally invasive approach is appealing but there is little information regarding the long-term follow-up of patients managed in this way. To address this question, we looked at a consecutive series of patients who underwent percutaneous drainage in our institution.
A retrospective study was performed of patients undergoing percutaneous drainage of a diverticular abscess from 1999–2007.
A total of 26 abscesses were identified in 16 patients. In 69% of cases, the abscess was located in the pelvis. The mean size of the abscesses was 8.5 ± 0.9 cm. Drainage was performed under CT (83%) or ultrasound guidance. The mean duration of drainage was 8 days. Fistula formation following drainage occurred in 38% of cases. Eight patients (mean age, 71 years) underwent subsequent surgical resection 9 days to 22 months (mean, 7 months) following initial presentation. Eight patients with significant co-morbid conditions were managed by percutaneous drainage only. The 1-year mortality was 20% and resulted from unrelated causes. The long-term stoma rate was 13%.
Percutaneous drainage can safely be performed in patients with a diverticular abscess. It can be used as a bridge before definitive surgery but also as a treatment option in its own right in high-risk surgical patients. We believe percutaneous drainage reduces the need for major surgery and reduces the risk of a permanent stoma.
PMCID: PMC2647190  PMID: 18492392
Percutaneous; Drainage; Diverticular abscess; Stoma
5.  Preoperative biliary drainage for biliary tract and ampullary carcinomas 
We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.
PMCID: PMC2794354  PMID: 18274841
Biliary; Drainage; Endoscopy; Percutaneous; Bile replacement; Guidelines
6.  Endoscopic ultrasound-guided hepatic and perihepatic abscess drainage: an evolving technique 
Interventional radiology-guided percutaneous drainage of liver abscesses with concomitant use of antibiotics has been the conventional approach for the treatment of liver abscesses. Hepatic abscesses refractory or not amenable to percutaneous drainage have been treated with surgical drainage, either via laparoscopic or open laparotomy techniques. The aim of this review was to evaluate the technical feasibility and efficacy of endoscopic ultrasound (EUS)-guided drainage of liver abscesses. A literature review was performed to identify the studies describing the technique. In this review article we have summarized case series or reports describing EUS-guided liver abscess drainage. The indications, techniques, endoprostheses, limitations and complications reported are discussed. A total of seven cases have been described so far in the literature which included patients with failed conventional treatment modalities. The EUS-guided drainage technique involves puncturing the abscess using endosonography to gain access, passing a guidewire followed by tract dilation and placement of an endoprosthesis for drainage. Studies have reported 100% technical and clinical success rates in selected cases. No complications were reported. EUS-guided drainage of liver abscesses can be a safe and effective alternative approach in the management of liver abscesses in selected patients.
PMCID: PMC3903087  PMID: 24587822
drainage; endoscopic ultrasound; liver abscess; management
7.  Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines 
Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment, and their condition has not improved. Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous transhepatic, and open methods. The clinical value of both endoscopic and percutaneous transhepatic drainage is well known. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization; therefore, this approach is advocated whenever it is applicable. In endoscopic drainage, either endoscopic nasobiliary drainage (ENBD) or tube stent placement can be used. There is no significant difference in the success rate, effectiveness, and morbidity between the two procedures. The decision to perform endoscopic sphincterotomy (EST) is made based on the patient’s condition and the number and diameter of common bile duct stones. Open drainage, on the other hand, should be applied only in patients for whom endoscopic or percutaneous transhepatic drainage is contraindicated or has not been successfully performed. Cholecystectomy is recommended in patients with gallbladder stones, following the resolution of acute cholangitis with medical treatment, unless the patient has poor operative risk factors or declines surgery.
PMCID: PMC2799047  PMID: 17252299
Cholangitis; Biliary; Drainage; Endoscopy; Percutaneous; Sphincterotomy; Guidelines
8.  Are Pyogenic Liver Abscesses Still a Surgical Concern? A Western Experience 
HPB Surgery  2012;2012:316013.
Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We conducted a retrospective study of pyogenic abscess cases admitted to our university hospital between 1999 and 2010 and assessed the factors potentially associated with surgical treatment versus medical treatment alone. Results. In total, 103 liver abscess patients were treated at our center. The mortality was 9%. The main symptoms were fever and abdominal pain. All of the patients had CRP > 6 g/dL. Sixty-nine patients had a unique abscess. Seventeen patients were treated with antibiotics alone and 57 with percutaneous drainage and antibiotics. Twenty-seven patients who were treated with percutaneous techniques required surgery, and 29 patients initially received it. Eventually, 43 patients underwent abscess surgery. The factors associated with failed medical treatment were gas-forming abscess (P = 0.006) and septic shock at the initial presentation (P = 0.008). Conclusion. Medical and percutaneous treatment constitute the standard management of liver abscess cases. Surgery remains necessary after failure of the initial treatment but should also be considered as an early intervention for cases presenting with gas-forming abscesses and septic shock and when treatment of the underlying cause is immediately required.
PMCID: PMC3296144  PMID: 22536008
9.  Modern management of pyogenic hepatic abscess: a case series and review of the literature 
BMC Research Notes  2011;4:80.
Pyogenic hepatic abscesses are relatively rare, though untreated are uniformly fatal. A recent paradigm shift in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The aim of this study was to review our experience in managing pyogenic liver abscess, review the literature in this field, and propose guidelines to aid in the current management of this complex disease.
Demographic and clinical details of all patients admitted to a single institution with liver abscess over a 5 year period were reviewed. Clinical presentation, aetiology, diagnostic work-up, treatment, morbidity and mortality data were collated.
Over a 5 year period 11 patients presented to a single institution with pyogenic hepatic abscess (55% males, mean age 60.3 years). Common clinical features at presentation were non-specific constitutional symptoms and signs. Aetiology was predominantly gallstones (45%) or diverticular disease (27%). In addition to empiric antimicrobial therapy, all patients underwent radiologically guided percutaneous drainage of the liver abscess at diagnosis and only 2 patients required surgical intervention, including one 16-year old female who underwent hemi-hepatectomy for a complex and rare Actinomycotic abscess. There were no mortalities after minimum follow-up of one year.
Pyogenic liver abscesses are uncommon, and mortality has decreased over the last two decades. Antimicrobial therapy and radiological intervention form the mainstay of modern treatment. Surgical intervention should be considered for patients with large, complex, septated or multiple abscesses, underlying disease or in whom percutaneous drainage has failed.
PMCID: PMC3073909  PMID: 21435221
10.  Preoperative endoscopic versus percutaneous transhepatic biliary drainage in potentially resectable perihilar cholangiocarcinoma (DRAINAGE trial): design and rationale of a randomized controlled trial 
BMC Gastroenterology  2015;15:20.
Liver surgery in perihilar cholangiocarcinoma (PHC) is associated with high postoperative morbidity because the tumor typically causes biliary obstruction. Preoperative biliary drainage is used to create a safer environment prior to liver surgery, but biliary drainage may be harmful when severe drainage-related complications deteriorate the patients’ condition or increase the risk of postoperative morbidity. Biliary drainage can cause cholangitis/cholecystitis, pancreatitis, hemorrhage, portal vein thrombosis, bowel wall perforation, or dehydration. Two methods of preoperative biliary drainage are mostly applied: endoscopic biliary drainage, which is currently used in most regional centers before referring patients for surgical treatment, and percutaneous transhepatic biliary drainage. Both methods are associated with severe drainage-related complications, but two small retrospective series found a lower incidence in the number of preoperative complications after percutaneous drainage compared to endoscopic drainage (18-25% versus 38-60%, respectively). The present study randomizes patients with potentially resectable PHC and biliary obstruction between preoperative endoscopic or percutaneous transhepatic biliary drainage.
The study is a multi-center trial with an “all-comers” design, randomizing patients between endoscopic or percutaneous transhepatic biliary drainage. All patients selected to potentially undergo a major liver resection for presumed PHC are eligible for inclusion in the study provided that the biliary system in the future liver remnant is obstructed (even if they underwent previous inadequate endoscopic drainage). Primary outcome measure is the total number of severe preoperative complications between randomization and exploratory laparotomy. The study is designed to detect superiority of percutaneous drainage: a provisional sample size of 106 patients is required to detect a relative decrease of 50% in the number of severe preoperative complications (alpha = 0.95; beta = 0.8). Interim analysis after inclusion of 53 patients (50%) will provide the definitive sample size. Secondary outcome measures encompass the success of biliary drainage, quality of life, and postoperative morbidity and mortality.
The DRAINAGE trial is designed to identify a difference in the number of severe drainage-related complications after endoscopic and percutaneous transhepatic biliary drainage in patients selected to undergo a major liver resection for perihilar cholangiocarcinoma.
Trial registration
Netherlands Trial Register [NTR4243, 11 October 2013].
Electronic supplementary material
The online version of this article (doi:10.1186/s12876-015-0251-0) contains supplementary material, which is available to authorized users.
PMCID: PMC4332425
Perihilar cholangiocarcinoma; Resection; Preoperative biliary drainage; Complications
11.  Successful treatment of liver abscess secondary to foreign body penetration of the alimentary tract: A case report and literature review 
Hepatic abscess caused by foreign body penetration of the alimentary tract is rare. We report a case of gastric antrum penetration due to a toothpick complicated by liver abscess formation. A 41-year-old man was admitted to our hospital with the chief complaint of upper abdominal pain for 2 mo. Esophagogastroduodenoscopy performed at a local clinic revealed a toothpick penetrating the gastric antrum. Computed tomography (CT) of the abdomen at our hospital revealed a gastric foreign body embedded in the posterior wall of gastric antrum with regional phlegmon over the lesser sac and adhesion to the pancreatic body without notable vascular injury, and a hepatic abscess seven cm in diameter over the left liver lobe. Endoscopic removal of the foreign body was successfully performed without complication. The liver abscess was treated with parenteral antibiotics without drainage. The patient’s recovery was uneventful. Abdominal ultrasonography demonstrated complete resolution of the hepatic abscess six months after discharge. Relevant literature from the PubMed database was reviewed and the clinical presentations, diagnostic modalities, treatment strategies and outcomes of 88 reported cases were analyzed. The results showed that only 6 patients received conservative treatment with parenteral antibiotics, while the majority underwent either image-guided abscess drainage or laparotomy. Patients receiving abscess drainage via laparotomy had a significantly shorter length of hospitalization compared with those undergoing image-guided drainage. There was no significant difference in age between those who survived and those who died, however, the latter presented to hospitals in a more critical condition than the former. The overall mortality rate was 7.95%.
PMCID: PMC3974541  PMID: 24707157
Hepatic abscess; Foreign body; Endoscopy; Laparotomy; Drainage
12.  Management of Pleural Effusion, Empyema, and Lung Abscess 
Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.
PMCID: PMC3140254  PMID: 22379278
Pleural effusion; empyema; lung abscess; malignant pleural effusion; interventional radiology
13.  A Prospective Series Case Study of Pyogenic Liver Abscess: Recent Trands in Etiology and Management 
The Indian Journal of Surgery  2012;74(5):385-390.
Our study aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. A case series of our experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary, or intra-abdominal pathology. Percutaneous drainage may help to optimize clinical condition prior to surgery. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualized according to patient’s clinical status and abscess factors. They are complementary in the management of liver abscesses.
PMCID: PMC3477416  PMID: 24082591
Pyogenic liver abscess; Ultrasound-guided percutaneous drainage
14.  Non-surgical and non-chemical attempts to treat echinococcosis: do they work?  
Parasite  2014;21:75.
Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.
PMCID: PMC4273701  PMID: 25531730
Cystic echinococcosis; Alveolar echinococcosis; Non-surgical interventions; Non-chemical treatment
15.  Endoscopic ultrasound-guided drainage of pancreatic fluid collections 
Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in “one step”, EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.
PMCID: PMC3506965  PMID: 23189219
Endoscopic ultrasound-guided drainage; Pancreatic fluid collections; Pseudocysts; Pancreatic abscesses; Infected necrosis
16.  Walled-off pancreatic necrosis 
Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.
PMCID: PMC2852817  PMID: 20380001
Walled-off pancreatic necrosis; Infected pseudocyst; Severe pancreatitis; Acute necrotizing pancreatitis; Pancreas; Inflammation; Alcoholism
17.  Conservative treatment as an option in the management of pancreatic pseudocyst. 
BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.
PMCID: PMC1964324  PMID: 14594534
18.  Endoscopic ultrasound-guided drainage of pelvic abscess: A case series of 8 patients 
AIM: To show the safety and effectiveness of endoscopic ultrasound (EUS)-guided drainage of pelvic abscess that were inaccessible for percutaneous drainage.
METHODS: Eight consecutive patients with pelvic abscess that were not amenable to drainage under computed tomography (CT) guidance were referred for EUS-guided drainage. The underlying cause of the abscesses included diverticulitis in 4, postsurgical surgical complications in 2, iatrogenic after enema in 1, and Crohn’s disease in 1 patient. Abscesses were all drained under EUS guidance via a transrectal or transsigmoidal approach.
RESULTS: EUS-guided placement of one or two 7 Fr pigtail stents was technically successful and uneventful in all 8 patients (100%). The abscess was perisigmoidal in 2 and was multilocular in 4 patients. All procedures were performed under conscious sedation and without fluoroscopic monitoring. Fluid samples were successfully retrieved for microbiological studies in all cases and antibiotic policy was adjusted according to culture results in 5 patients. Follow-up CT showed complete recovery and disappearance of abscess. The stents were retrieved by sigmoidoscopy in only two patients and had spontaneously migrated to outside in six patients. All drainage procedures resulted in a favourable clinical outcome. All patients became afebrile within 24 h after drainage and the mean duration of the postprocedure hospital stay was 8 d (range 4-14). Within a median follow up period of 38 mo (range 12-52) no recurrence was reported.
CONCLUSION: We conclude that EUS-guided drainage of pelvic abscesses without fluoroscopic monitoring is a minimally invasive, safe and effective approach that should be considered in selected patients.
PMCID: PMC4133417  PMID: 25132921
Pelvic abscess; Endoscopic ultrasound -guided drainage
19.  Laparoscopic drainage of liver abscess: case report and literature review 
Il Giornale di Chirurgia  2013;34(5-6):180-182.
To evaluate the safety and efficacy of the minimally invasive surgical approach (laparoscopic drainage) of liver abscesses in selected cases.
Case report.
Male, 58 years old, from a rural area, presented with epigastric abdominal pain, fever, weight loss, loss of appetite, a palpable mass in the epigastrium and neutrophilic leukocytosis. CT revealed a complex multiloculated liver abscess in segments 2–3. Systemic antibiotic therapy alone was ineffective; percutaneous drainage was excluded due to the characteristics of the lesion.
Given the complexity of the lesion, a laparoscopic approach was chosen involving complete drainage of the abscess, debridement and irrigation; the cavity was unroofed using electrocautery and samples were obtained for bacterial culture and drug testing. Two drains were left in the cavity for seven days. No complications were observed.
In accordance with the scientific literature, after thorough imaging we performed laparoscopic drainage of a large, complex liver abscess as a safe, effective alternative to open surgery when antibiotic therapy alone failed and percutaneous drainage was uncertain.
Not all liver abscesses can be treated with antibiotic therapy or percutaneous drainage. Laparoscopic drainage in association with systemic antibiotic therapy is a safe and effective minimally invasive approach that should be considered in selected patients.
PMCID: PMC3915587  PMID: 23837960
Liver abscesses; Percutaneous drainage; Laparoscopic drainage; Antibiotic therapy
20.  Pre-operative biliary drainage for obstructive jaundice 
Patients with obstructive jaundice have various pathophysiological changes that affect the liver, kidney, heart, and the immune system. There is considerable controversy as to whether temporary relief of biliary obstruction prior to major definitive surgery (pre-operative biliary drainage) is of any benefit to the patient.
To assess the benefits and harms of pre-operative biliary drainage versus no pre-operative biliary drainage (direct surgery) in patients with obstructive jaundice (irrespective of a benign or malignant cause).
Search methods
We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Clinical Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2012.
Selection criteria
We included all randomised clinical trials comparing biliary drainage followed by surgery versus direct surgery, performed for obstructive jaundice, irrespective of the sample size, language, and publication status.
Data collection and analysis
Two authors independently assessed trials for inclusion and extracted data. We calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on the available patient analyses. We assessed the risk of bias (systematic overestimation of benefit or systematic underestimation of harm) with components of the Cochrane risk of bias tool. We assessed the risk of play of chance (random errors) with trial sequential analysis.
Main results
We included six trials with 520 patients comparing pre-operative biliary drainage (265 patients) versus no pre-operative biliary drainage (255 patients). Four trials used percutaneous transhepatic biliary drainage and two trials used endoscopic sphincterotomy and stenting as the method of pre-operative biliary drainage. The risk of bias was high in all trials. The proportion of patients with malignant obstruction varied between 60% and 100%. There was no significant difference in mortality (40/265, weighted proportion 14.9%) in the pre-operative biliary drainage group versus the direct surgery group (34/255, 13.3%) (RR 1.12; 95% CI 0.73 to 1.71; P = 0.60). The overall serious morbidity was higher in the pre-operative biliary drainage group (60 per 100 patients in the pre-operative biliary drainage group versus 26 per 100 patients in the direct surgery group) (RaR 1.66; 95% CI 1.28 to 2.16; P = 0.0002). The proportion of patients who developed serious morbidity was significantly higher in the pre-operative biliary drainage group (75/102, 73.5%) in the pre-operative biliary drainage group versus the direct surgery group (37/94, 37.4%) (P < 0.001). Quality of life was not reported in any of the trials. There was no significant difference in the length of hospital stay (2 trials, 271 patients; MD 4.87 days; 95% CI −1.28 to 11.02; P = 0.12) between the two groups. Trial sequential analysis showed that for mortality only a small proportion of the required information size had been obtained. There seemed to be no significant differences in the subgroup of trials assessing percutaneous compared to endoscopic drainage.
Authors’ conclusions
There is currently not sufficient evidence to support or refute routine pre-operative biliary drainage for patients with obstructive jaundice. Pre-operative biliary drainage may increase the rate of serious adverse events. So, the safety of routine pre-operative biliary drainage has not been established. Pre-operative biliary drainage should not be used in patients undergoing surgery for obstructive jaundice outside randomised clinical trials.
PMCID: PMC4164472  PMID: 22972086
Drainage [adverse effects; *methods]; Jaundice, Obstructive [mortality; surgery; *therapy]; Postoperative Complications; Randomized Controlled Trials as Topic; Stents; Humans
21.  Liver Abscess in Children: A 10-year Single Centre Experience 
Although liver abscess is more prevalent in developing countries than in developed countries, there is scant data about the characteristics of pediatric liver abscess in our region. We aimed to analyze the characteristics of pediatric liver abscess in our region and compare these with those of developed countries.
Materials and Methods:
The clinical features, laboratory, imaging, microbiologic findings, management strategy, and final outcome were extracted from the patients’ records retrospectively.
There were 18 cases of liver abscess including 16 pyogenic liver abscess, one amebic liver abscess and one candida liver abscess. Fever and abdominal pain were the most common clinical findings and leukocytosis was the most common laboratory finding. The most predisposing factors of liver abscesswere immune deficiency, minor thalassemia. Origin of liver abscess was appendicitis in two patients, the rest were considered as cryptogenic. While one patient was treated with antibiotics alone, five cases were taken for open drainage, and 12 cases were treated with percutaneous aspiration. Percutaneous aspiration failed in two patients who were later ttaken for open drainage, with an overall mortality rate of 5.5%. Conclusion: The overall characteristics of liver abscess in children in our society are not so different from developed countries. However, in contradiction to cases reported in developed countries, most cases of liver abscess were seen in healthy patients in our centre. Moreover, liver abscess was reported in our patients at a younger age and was more commonly seen in male children. Mortality rate was similar to that of developed countries.
PMCID: PMC3122091  PMID: 21546724
Children; clinical findings; complications; liver abscess; treatment
22.  JPN Guidelines for the management of acute pancreatitis:surgical management 
Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.
PMCID: PMC2779397  PMID: 16463211
Necrotizing pancreatitis; Infected pancreatic necrosis; Sterile pancreatic necrosis; Pancreatic abscess; Pancreatic pseudocyst
23.  Primary psoas abscess extending to thigh adductors: case report 
Psoas abscess is a rare condition consisting of pyomyositis of the psoas. The worldwide incidence was 12 cases per 100,000 per year in 1992, but the current incidence is unknown. Psoas abscess can descend along the psoas sheath and reach the inner upper third of the thigh, but only infrequently does it penetrate the sheath and involve the thigh adductors. Because of insidious clinical presentation, the diagnosis of psoas abscess is a challenge. Delayed diagnosis can result in poor prognosis.
Case presentation
A 45-year-old male with no significant past medical history presented with pain in the left thigh, and limitation of movement at the left hip and knee joint for one month. Ultrasound, CT, and MRI revealed a liquid mass in the left psoas. Percutaneous drainage of this mass yielded 300 ml pus from the psoas. After surgery, the patient reported relief of pain; however, ten days after removal of the drainage tube, the patient complained of persistent pain in his left thigh. CT revealed that the psoas abscess had extended inferiorly, and involved the entire set of adductors of the left thigh. Open surgical drainage was performed at the flank and at the thigh, yielding 350 ml of pus from the thigh. After open drainage and adequate antibiotic therapy, the patient made a good recovery. Follow-up CT confirmed complete resolution of the abscess.
Large psoas abscess can penetrate the psoas sheath, and descend to thigh adductors even after percutaneous drainage. Appropriate treatment includes open surgical drainage along with antibiotic therapy.
PMCID: PMC2921354  PMID: 20691069
24.  Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed? 
World Journal of Gastroenterology : WJG  2014;20(45):16925-16934.
In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.
PMCID: PMC4258561  PMID: 25493005
Delay until liquefaction; Infected necrotizing pancreatitis; Minimally invasive treatment; Transluminal endoscopic drainage/necrosectomy; Walled-off pancreatic necrosis
25.  Hepatic abscesses 
Hepatic abscesses are potentially lethal diseases if early diagnosis and treatment are not instituted. They are prevalent all over the globe and pyogenic abscesses are predominant over amoebic. With better control of intra abdominal and systemic infections by a spectrum of antibiotics, aetiology of pyogenic abscesses are secondary to interventions and diseases in the biliary tree to a large extent today. The common organisms isolated are the Gram negative group. Amoebic abscesses continue to plague some regions of the world where hygiene and sanitation are questionable.
Over the years, diagnosis, treatment and prognosis have evolved remarkably. Imaging modalities like ultrasonography and CT scan have become the cornerstone of diagnosis. The absence of ionizing radiation makes MRI an attractive alternative in patients who require multiple follow up scans. Serological testing in amoebic abscesses has become more reliable. Though antibiotics have remained the principal modality of management, percutaneous drainage of abscesses have vastly improved the chances of cure and bring down the morbidity drastically in pyogenic abscesses. Amoebic abscesses respond well to medical treatment with nitroimidazoles, and minimally invasive surgical drainage is an option in cases where open surgery is indicated.
PMCID: PMC3862548  PMID: 24532886
Pyogenic abscess; Amoebic abscess; Percutaneous drainage

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