Current management of pyogenic liver abscess: surgery is now second-line treatment.

BACKGROUND The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage. STUDY DESIGN Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined. RESULTS Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02). CONCLUSIONS Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.