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Digestive and Liver Disease 40 (2008) 697698

Commentary

Is surgery still needed for the treatment of pyogenic liver abscess?

H. Cerwenka
Department of Surgery, Medical University of Graz, A-8036 Graz, Austria Available online 25 March 2008

First of all, I would like to congratulate the authors on their thorough evaluation of a large number of patients over a long period of time. They conclude in their abstract that, Percutaneous and surgical treatment of pyogenic liver abscesses are both effective, nevertheless percutaneous drainage carries lower morbidity and is cheaper [1]. This implies that surgical treatment could now be completely replaced by percutaneous drainage. Although the text specically states that many patients in this study had surgery as primary treatment at a time when percutaneous drainage was not yet so popular and available, and that direct comparison of these two techniques is not feasible in this context, I would like to add a few comments from the surgical point of view. There is no doubt that at present, percutaneous drainage is the treatment of choice for most patients with pyogenic liver abscess (PLA) and that surgery usually serves as a back-up strategy for non-responders. However, we are sometimes confronted with patients referred late for surgical treatment with sepsis and beginning multiorgan failure [2]. Thus, it seems to be important to better dene patient groups for whom percutaneous and antibiotic treatment will not sufce and for whom surgery is the best or only option, invasiveness and costs notwithstanding. This certainly includes patients with gallbladder empyema who make up a rather substantial percentage of PLA patients [2], and those with malignancies, insofar as they are candidates for curative operations. The outcome of PLA largely depends on underlying diseases and concomitant pathologies [3]; thus, the treatment of these conditions is of utmost importance whenever possible. As for biliary stulas perpetuating liver abscesses [4], the situation is more complex, as only larger stulas can be well identied and are amenable to surgical treatment. In the remaining patients with biliary stulas, it may be helpful to improve bile ow by endoDOI of original article:10.1016/j.dld.2008.01.016. Tel.: +43 316 385 2755; fax: +43 316 385 4666. E-mail address: herwig.cerwenka@meduni-graz.at.

scopic papillotomy and biliary stenting, and thus to enhance stula closure in addition to percutaneous PLA drainage. Multicentricity, which was found in an almost equal percentage of patients (about one-quarter) in the study of Ferraioli et al. [1] and in our study [2], will not always require surgery but may hinder sufcient percutaneous drainage. A permanent stimulus for infection may be a foreign body, for instance a toothpick, as in one of our patients [2]; in these cases, surgical removal of the foreign body will be the only effective treatment. Moreover, we should always think of the possibility of amoebic abscesses [5] even in non-endemic areas like ours; these patients will prot from adequate antibiotic treatment. As for postoperative and postinterventional liver abscesses, for those occurring after hepatic resections or after chemoembolization and radiofrequency ablation, percutaneous drainge can often be successful; however, PLAs after liver transplantation are frequently due to hepatic artery thrombosis as a predisposing factor requiring re-intervention. As prognosis is very critical in this group of PLA patients, early diagnosis of hepatic artery thrombosis after liver transplantation is crucial [6]. Last but not least, it should be mentioned that in selected patients, laparosopic drainage with deroong of the abscess cavity and destruction of septa in septate abscesses is feasible when percutaneous drainage and antibiotic treatment do not sufce. In some patients, however, concomitant pathologies may require open surgery. Thus, PLA treatment should be individually tailored to the specic situation of every single patient. Close cooperation of all disciplines involved with regular discussions on the management of problem patients is crucial for success.

Conict of interest statement None declared.

1590-8658/$30 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2008.02.009

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H. Cerwenka / Digestive and Liver Disease 40 (2008) 697698 [4] Cerwenka H, Werkgartner G, Bacher H, el-Shabrawi A, Mischinger HJ. Intrahepatic hematoma with secondary Salmonella infection via biliary stula. Hepatogastroenterology 1997;44:52932. [5] Jimenez-Saenz M, Romero-Vazquez J, Linares-Santiago E, HerreriasGutierrez JM. A case of long latency amoebic liver abscess in a nonendemic country: the clue diagnostic value of subtle colonoscopic changes. Dig Liver Dis 2007;39:1012. [6] Piscaglia F, Vivarelli M, La Barba G, Morselli-Labate AM, Taddei S, Cucchetti A, et al. Analysis of risk factors for early hepatic artery thrombosis after liver transplantation. Possible contribution of reperfusion in the early morning. Dig Liver Dis 2007;39:529.

References
[1] Ferraioli G, Garlaschelli A, Zanaboni D, Gulizia R, Brunetti E, Tinozzi FP, et al. Percutaneous and surgical treatment of pyogenic liver abscess: observation over a 21-year period in 148 patients. Dig Liver Dis 2008; 40:6906. [2] Cerwenka H, Bacher H, Werkgartner G, El-Shabrawi A, Kornprat P, Bernhardt GA, et al. Treatment of patients with pyogenic liver abscess. Chemotherapy 2005;51:3669. [3] Hsieh CB, Tzao C, Yu CY, Chen CJ, Chang WK, Chu CH, et al. APACHE II score and primary liver cancer history had risk of hospital mortality in patients with pyogenic liver abscess. Dig Liver Dis 2006;38:498502.