Pyogenic Liver Abscess Following Biliary Stent Placement in Pancreatic Cancer Patients: A Retrospective Case Series

Pyogenic Liver Abscess Following Biliary Stent Placement in Pancreatic Cancer Patients: A Retrospective Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pyogenic Liver Abscess Following Biliary Stent Placement in Pancreatic Cancer Patients: A Retrospective Case Series Dongxue Geng, Nan Lv, Yi Miao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6023795/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 May, 2025 Read the published version in BMC Cancer → Version 1 posted 10 You are reading this latest preprint version Abstract Biliary stent placement is widely used in clinical, especially in patients with pancreatic cancer complicated with obstructive jaundice. Pyogenic liver abscess (PLA) is a severe complication following biliary stent placement which predominantly occurs in the right lobe of the liver, with an incidence rate ranging from 4.3–13.5% and a mortality rate up to 30%. It is related to the following mechanisms: retrograde bacterial infection; bile stasis and increased bile duct pH; stent-related bile duct injury; biofilm formation; immune system suppression. The main causative pathogens are gram-negative bacilli, particularly Escherichia coli and Klebsiella pneumoniae . The combination of antibiotic therapy and percutaneous transhepatic abscess drainage is the main treatment option. Pyogenic liver abscess Biliary stent Pancreatic cancer Figures Figure 1 Introduction Biliary stent placement is a common surgical procedure used to treat biliary strictures and obstructions[1], and it is widely applied in both malignant and nonmalignant biliary strictures[2]. Although this procedure offers significant advantages in reducing biliary pressure, alleviating jaundice, and improving patients' quality of life, it also presents potentially serious complications, one of which is pyogenic liver abscess (PLA)[3]. The incidence of PLA following biliary stent placement has been reported to range from 4.3% to 13.5%[4,5,6], with a mortality rate as high as 30%[4]. However, most studies have little samples and include a variety of disease categories, and no systematic studies have specifically focused on the occurrence of PLA in pancreatic cancer patients with obstructive jaundice following biliary stent placement. This article analyses 9 cases of pancreatic cancer patients who were diagnosed with PLA after biliary stent placement at our center, describes their clinical characteristics and treatment outcomes, and aims to provide a reference for future clinical research. Materials and methods 1. Patient selection A retrospective analysis was conducted on 98 patients who were diagnosed with pancreatic cancer and who underwent biliary stent placement at the Pancreas Center of Affiliated BenQ Hospital of Nanjing Medical University, between October 20, 2020, and May 31, 2024. The retrospective study was conducted in accordance with the principles of the Declaration of Helsinki, which was approved by the hospital's Medical Ethics Committee(ethics approval number: 2024-KL020, date of approval: July 31, 2024). As this study is a retrospective clinical study, patients were exempted from informed consent. 2. Inclusion and exclusion criteria Inclusion criteria: Patients admitted between October 20, 2020, and May 31, 2024; Pathological diagnosis of pancreatic ductal adenocarcinoma; Underwent biliary stent placement; Postoperative diagnosis of pyogenic liver abscess (PLA) confirmed by medical records and imaging data. Exclusion criteria: Patients with incomplete medical data. 3. Data collection (1) Preoperative data: Body mass index (BMI), CA19-9, glycated hemoglobin, albumin, alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin, and alkaline phosphatase. (2) Endoscopic surgical data: Duration of endoscopic procedures, blood loss, and volume of blood transfusion. (3) Postoperative complications: Postoperative pancreatitis, biliary leakage (BL), surgical site infection (SSI), and hemorrhage. (4) Postoperative adjuvant therapies include chemotherapy, radiotherapy, and other adjuvant therapies. (5) PLA-related data: PLA size, number, location, treatment methods, bacterial culture results, recurrence, length of hospital stay, hospital expenses, chemotherapy status, and overall survival (OS) after surgery. 4. Definitions (1) Diagnosis of pyogenic liver abscess (PLA): PLA is diagnosed on the basis of the presence of hypoechoic areas in the liver with peripheral enhancement on CT imaging, accompanied by related symptoms such as fever, leukocytosis, and positive bacterial culture (either pus culture or blood culture). In cases where bacterial cultures are negative, PLA can still be diagnosed if imaging and other laboratory findings strongly suggest the presence of a liver abscess. (2) Postoperative pancreatitis is defined by the presence of pancreatitis-related clinical symptoms lasting more than 24 hours, with a serum amylase level exceeding three times the upper limit of normal, or by meeting at least two of the following three criteria: abdominal pain characteristic of acute pancreatitis (sudden onset of severe, persistent upper abdominal pain, typically radiating to the back); serum lipase or amylase levels elevated at least three times the upper limit of normal; and imaging features of acute pancreatitis on enhanced CT, MRI, or abdominal ultrasound[7]. (3) Surgical site infection (SSI): SSIs include infections of the incision or infections involving organs or spaces related to the surgical procedure, typically occurring within 30 days postoperatively or within 90 days if the implants are involved. The focus of this study was organ or space infections[8]. (4) Definition of biliary leakage (BL): BL is defined as the leakage of bile into the abdominal cavity or through drainage tubes postoperatively, with the bilirubin level in the drainage fluid exceeding normal serum bilirubin levels[9]. 5. Statistical methods Statistical analysis was performed via SPSS version 29.0. Continuous variables with a normal distribution are expressed as the means ± standard deviations, whereas skewed data are presented as the medians (M) with ranges. Categorical variables are described as frequencies and percentages (%). Results A total of 98 patients underwent biliary stent placement, of whom 9 patients (9.2%, 9/98) developed PLA postoperatively. Among these patients, 6 were male and 3 were female, with a mean age of 63.3 ± 5.5 years (range: 56–71 years). All 9 patients were diagnosed with pancreatic ductal adenocarcinoma of the pancreatic head. The preoperative laboratory results for these patients were as follows: CA19-9: 757.4 ± 167.5 U/mL; glycated hemoglobin (%): 6.3 ± 0.2; alanine transaminase (ALT): 291.2 ± 66.2 U/L; aspartate transaminase (AST): 258.1 ± 59.3 U/L; plasma albumin: 37.4 ± 1.8 g/L; total bilirubin: 87.2 ± 16.5 µmol/L; and alkaline phosphatase: 367.8 ± 44.7 U/L (Table 1 ). The mean duration of endoscopic surgery was 38.9 ± 2.7 minutes, with no recorded intraoperative blood loss and transfusions. Postoperatively, none of the 9 patients experienced pancreatitis, biliary leakage, and surgical site infections. Table 1 Preoperative laboratory results of 9 patients with PLA following biliary stent placement Case CA19-9(U/mL) Glycated Hemoglobin(%) ALT(U/L) AST(U/L) Albumin(g/L) Total Bilirubin(umol/L) Alkaline Phosphatase(U/L) 1 542.9 6.0 224.0 138.0 37.0 174.1 219.0 2 736 6.1 401.0 188.4 37.3 93.2 380.0 3 1587.3 5.9 82.9 171.3 28.2 72.5 338.0 4 980.4 6.1 42.8 237.3 43.0 42.8 356.0 5 40.5 7.4 408.0 180.0 44.1 81.3 453.0 6 68.7 5.9 62.1 44.0 30.9 23.1 105.0 7 823.5 5.7 333.9 260.0 42.8 42.0 477.0 8 788.3 6.3 467.9 521.9 35.6 113.9 459.0 9 1248.8 7.5 598.2 581.7 38.1 141.9 523.0 Seven pancreatic cancer patients (77.8%, 7/9) received chemotherapy after biliary stent placement, and 1 patient (11.1%, 1/9) underwent radiofrequency ablation (RFA). The average time to the occurrence of PLA was 4.3 ± 1.3 months post stent placement (range: 2.0-14.5 months). According to the imaging results, the average size of the PLA poststent placement was 4.2 ± 0.8 cm (range: 1.5–10.9 cm). Single abscess patients accounted for 66.7% (6/9), whereas multiple abscess patients accounted for 33.3% (3/9). Among the single abscesses, 1 was located in the left lobe of the liver (1/6), and the remaining were located in the right lobe (5/6) (Fig. 1 ). All 9 patients had fever. Blood cultures were performed for 8 PLA patients, with a positivity rate of 75.0% (6/8). 8 patients underwent percutaneous liver abscess puncture and drainage, 7 of whom had pus cultures; the positivity rate was 85.7% (6/7). The blood culture results revealed that Klebsiella pneumoniae (37.5%, 3/8) was the most common pathogen. Other 3 results included Enterobacter cloacae + Enterococcus faecium , Enterococcus faecalis , and Escherichia coli . In pus cultures, Klebsiella pneumoniae (42.9%, 3/7) and Enterococcus faecalis (28.6%, 2/7) were the most common pathogens. Among the 7 patients with positive pus cultures, 2 had mixed infections with two types of bacteria (28.6%, 2/7). Additionally, atypical infections such as Pseudomonas aeruginosa were also observed (Table 2 ). Table 2 Clinical characteristics of the PLA patients Case Number Location Treatment Method Pus Culture Blood Culture Total Cost Antibiotic Cost 1 Single VI Antibiotics + Drainage Klebsiella pneumoniae, Enterococcus faecalis Klebsiella pneumoniae 79,356.1 12,316.1 2 Single IV Antibiotics + Drainage Klebsiella pneumoniae Klebsiella pneumoniae 61,600.1 9,278.71 3 Single VII Antibiotics + Drainage Klebsiella pneumoniae Negative 70,453.4 5,776.8 4 Multiple Right Lobe Antibiotics + Drainage Enterococcus faecalis Enterococcus faecalis 71,890.4 9,906.2 5 Multiple Left Lobe Antibiotics + Drainage Enterobacter cloacae, Enterococcus faecium Enterobacter cloacae,Enterococcus faecium 290,933.7 21,666.4 6 Single VI Antibiotics Not Punctured Not tested 60,132.7 4,990.6 7 Single V Antibiotics + Drainage Pseudomonas aeruginosa Escherichia coli 76,141.8 9,234.9 8 Single VII Antibiotics + Drainage Negative Negative 18,927.6 3,795.4 9 Multiple Left Lobe Antibiotics Not tested Klebsiella pneumoniae 49,866.6 8,397.9 For patients with PLA following biliary stent placement, considering the immunosuppression caused by tumors and chemotherapy, the preferred treatment approach is the combination of antibiotics and percutaneous drainage (77.8%, 7/9). All patients received intravenous antibiotics upon hospitalization. Initially, third-generation cephalosporins, carbapenems, and other effective antibiotics were chosen before microbiological sensitivity data were available, with antibiotics adjusted on the basis of culture results. The average hospitalization cost was 86,589.2 ± 26,258.8 CNY, with antibiotic costs amounting to 9,484.8 ± 1,764.6 CNY, accounting for 10.9% of the total costs. The average length of hospital stay for the 9 PLA patients was 32.7 ± 9.2 days (range: 17–104 days). 2 patients experienced recurrent PLA requiring further treatment, and no surgical drainage was performed. Follow-up until May 31, 2024, revealed 6 deaths among the 9 PLA patients, with an average overall survival of 14.6 ± 5.7 months for the deceased PLA patients. Discussion PLA is a serious infection that can lead to sepsis, liver failure, and death[ 10 ]. The incidence of PLA in the general population is reported to be 2.3 to 15.5 per 100,000 people[ 11 , 12 ], whereas the incidence following biliary stent placement ranges from 4.3–13.5%[ 4 , 5 , 6 ], which is significantly higher than that in the general population. However, there are no published studies specifically addressing the incidence of PLA in pancreatic cancer patients undergoing biliary stenting. Cameron et al. reported that in patients with malignant biliary obstruction and stent placement, PLAs are often solitary and located in the right liver lobe[ 13 ]. In our retrospective study, 55.6% of patients had solitary abscesses in the right liver lobe, which is consistent with the findings of previous studies. Following biliary stent placement, bacteria can ascend retrogradely through the bile duct into the intrahepatic bile duct system[ 14 ]. Once within the liver, bacteria can localize and proliferate, ultimately forming liver abscesses[ 15 ]. In cases of PLA, gram-negative bacteria are the most frequently isolated pathogens, accounting for 40–60% of cases[ 16 ], with Escherichia coli , Klebsiella pneumoniae , and Pseudomonas aeruginosa being the most common[ 17 ]. Anaerobes account for 35–45% of liver abscess pathogens, whereas Streptococcus , Staphylococcus , and Enterococcus infections are relatively less common[ 17 , 18 ]. In recent years, infections caused by highly pathogenic Klebsiella pneumoniae have increased, particularly in Southeast Asia, where some reports indicate an infection rate as high as 80%[ 19 , 20 ]. Similar cases have also been increasingly reported in the US and Europe[ 21 ]. Zheng et al. reported that E. coli infections account for 21–36% of cases in patients with PLA after biliary surgery, followed by Klebsiella pneumoniae infections (9–31%), with polymicrobial infections occurring in 40–68% of cases[ 22 ]. When studying the microbiome of the PLA in pancreatic cancer patients post biliary stenting, it is important to consider not only the displacement of the gut flora but also the changes in the gut microbiota induced by pancreatic cancer. Sammallahti et al. reported increased abundances of Firmicutes , Bacteroides , and Proteobacteria in the gut microbiota of patients with pancreatic cancer compared with normal individuals[ 23 ]. Similar results were reported by Thomas et al.[ 24 ]. Our study also identified Klebsiella pneumoniae and Escherichia coli as the primary pathogens, which aligns with previous reports by Zheng et al., but further research with larger sample sizes is needed to validate these findings. Biliary stent placement can lead to obstructed bile flow and bile reflux, resulting in increased pressure within the bile ducts, bile stasis, and elevated bile duct pH. These conditions create a favourable environment for intestinal bacteria to proliferate within the bile ducts[ 25 , 26 ]. Mechanical damage to the bile duct mucosa caused by stent placement can disrupt the integrity of the bile duct and serve as a portal for bacterial invasion[ 27 ], making it easier for bacteria to penetrate the bile duct wall and enter the surrounding liver tissue. Additionally, the long-term presence of the stent may trigger a chronic inflammatory response, further increasing the risk of infection. Previous studies have also identified biofilm formation as a significant factor in bacterial infections and the development of PLA following stent placement. Biofilms formed on the stent surface can resist antibiotic penetration and host immune clearance[ 28 ], leading to the development of difficult-to-treat infections. Moreover, in pancreatic cancer patients, the immune system may be compromised by various factors, including the tumor itself, diabetes, and the use of immunosuppressive drugs[ 29 , 30 ]. Reduced immune function diminishes the body’s ability to defend against bacterial infections, facilitating bacterial growth and proliferation in the liver and ultimately leading to the formation of PLA. Early empirical antibiotic therapy is crucial for controlling infection following the development of PLA after biliary stent placement. The choice of antibiotics should initially cover common gram-negative and anaerobic bacteria. Antibiotic therapy should be adjusted on the basis of the results of pus and blood cultures. However, many experts believe that percutaneous transhepatic abscess drainage (PTAD) remains the most effective treatment for these infections[ 31 , 32 ]. Currently, the primary approach for treating PLA includes antibiotic therapy combined with PTAD. As early as 1953, McFADZEAN et al. reported the successful treatment of 14 cases of single liver abscesses via intravenous antibiotics, percutaneous aspiration, and abscess cavity antibiotic lavage[ 33 ]. Recent studies increasingly support the use of image-guided percutaneous drainage (such as ultrasound or CT-guided drainage) as the preferred method for larger or multiple liver abscesses, with surgery as a secondary option if necessary[ 34 , 35 , 36 ]. In our retrospective study, 8 of 9 patients received PTAD combined with antibiotic therapy, whereas 1 patient refused PTAD and received only antibiotics. All patients experienced symptom relief and had their drainage tubes removed before discharge. 2 patients experienced recurrence of PLA after discharge; however, the abscesses resolved after additional PTAD. Furthermore, for PLA resulting from stent obstruction, it is advisable to consider stent replacement or cleaning to restore bile drainage and reduce the risk of reinfection. Conclusion Postoperative PLA in patients with pancreatic cancer, although a rare complication, significantly impacts patient prognosis. The occurrence of PLA may be related to the following mechanisms: bacterial retrograde infection; biliary stasis and increased pH; stent-associated biliary injury; biofilm formation; immune system suppression. Understanding these mechanisms, the evolving patterns of pathogenic bacteria, and effective treatment strategies is essential for advancing the understanding of this condition and developing new approaches for treating PLA. Declarations Acknowledgements N/A. Author contributions DXG and YM designed the research. DXG and NL collected the data and performed the analysis. DXG and NL prepared the manuscript draft. YM provided research support and revised the manuscript. All the authors read and approved the final manuscript. Funding No. Availability of data and materials All the data and materials are presented in this manuscript. Ethics approval and consent to participate Our research complies with the Declaration of Helsinki. Ethics approval was obtained from the Ethics Committees of the Affiliated BenQ Hospital of Nanjing Medical University (Clinical Research Ethics Committee of Nanjing BenQ Hospital). As this study is a retrospective clinical study, patients were exempted from informed consent. Competing interests The authors declare that they have no competing interests. References Dinescu B, Voiosu T, Benguş A, Mateescu RB, Voiosu MR, Voiosu A. The perfect biliary plastic stent: the search goes on. Ann Gastroenterol. 2023 Sep-Oct;36(5):490–6. 10.20524/aog.2023.0826 . Epub 2023 Jul 25. PMID: 37664231; PMCID: PMC10433249. Chen YI, Sahai A, Donatelli G, Lam E, Forbes N, Mosko J, et al. 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Cite Share Download PDF Status: Published Journal Publication published 29 May, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Revision requested 22 Apr, 2025 Reviews received at journal 22 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviews received at journal 05 Apr, 2025 Reviewers agreed at journal 30 Mar, 2025 Reviews received at journal 25 Mar, 2025 Reviewers agreed at journal 25 Mar, 2025 Reviewers invited by journal 25 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 14 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6023795","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":450190338,"identity":"c8aab7a8-c4b8-4b3f-8546-2292153a5f26","order_by":0,"name":"Dongxue Geng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACfvb2AwcSfvy342dmPkCcFsmeM4kPPvYwJ0u2syUQp8XgRoKx4Qw2ZsYN53kMiHTZjYQ0aR4eNmbJZp6PN94w2MnpNhDQwdjz8Jg0jwUPHz8z72bLOQzJxmYHCGhhZgfbIgG0hXebNA/DgcRthLSwMSSYSfOwGTBuOMzzjDgtPBxg7yeAtLARp0WCBxzIB5Ilm9mMLecYEOEX++PgqDxgx89/+OGNNxV2cgS1oFlJbNQgaSFVxygYBaNgFIwIAABrMkBAGFd+sAAAAABJRU5ErkJggg==","orcid":"","institution":"The Affiliated BenQ Hospital of Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Dongxue","middleName":"","lastName":"Geng","suffix":""},{"id":450190339,"identity":"029c3426-b5a1-4797-a170-ae3f3b290d29","order_by":1,"name":"Nan Lv","email":"","orcid":"","institution":"The First Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Lv","suffix":""},{"id":450190340,"identity":"a5139e19-c29b-484a-9698-bff707866d87","order_by":2,"name":"Yi Miao","email":"","orcid":"","institution":"The Affiliated BenQ Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Miao","suffix":""}],"badges":[],"createdAt":"2025-02-13 14:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6023795/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6023795/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-14377-5","type":"published","date":"2025-05-29T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82075418,"identity":"f42569af-aa75-491f-9cc3-695538c1081c","added_by":"auto","created_at":"2025-05-06 13:42:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":204349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImaging data of PLA patients \u003c/strong\u003e(CT images of 9 PLA patients). The black arrows indicate the biliary stent. The white arrows indicate the PLA lesions, which typically presentas hypoechoic areas in the liver with possible peripheral enhancement. Images a and i show gas within the abscess. Image c corresponds to a patient with a small PLA lesion who did not undergo puncture treatment. Image f corresponds to a patient who received RFA treatment postoperatively, with the PLA developing in the original RFA treatment area one month later.)\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6023795/v1/637cadb6e6af806504d7ae1e.jpg"},{"id":83782769,"identity":"a39c6078-0d92-405b-87a3-ee73403f86d3","added_by":"auto","created_at":"2025-06-02 16:04:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":772639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6023795/v1/b60fcf30-70e5-453f-80b3-d6a14d140a94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pyogenic Liver Abscess Following Biliary Stent Placement in Pancreatic Cancer Patients: A Retrospective Case Series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBiliary stent placement is a common surgical procedure used to treat biliary strictures and obstructions[1], and it is widely applied in both malignant and nonmalignant biliary strictures[2]. Although this procedure offers significant advantages in reducing biliary pressure, alleviating jaundice, and improving patients\u0026apos; quality of life, it also presents potentially serious complications, one of which is pyogenic liver abscess (PLA)[3]. The incidence of PLA following biliary stent placement has been reported to range from 4.3% to 13.5%[4,5,6], with a mortality rate as high as 30%[4]. However, most studies have little samples and include a variety of disease categories, and no systematic studies have specifically focused on the occurrence of PLA in pancreatic cancer patients with obstructive jaundice following biliary stent placement. This article analyses 9 cases of pancreatic cancer patients who were diagnosed with PLA after biliary stent placement at our center, describes their clinical characteristics and treatment outcomes, and aims to provide a reference for future clinical research.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e1. Patient selection\u003c/p\u003e\n\u003cp\u003eA retrospective analysis was conducted on 98 patients who were diagnosed with pancreatic cancer and who underwent biliary stent placement at the Pancreas Center of Affiliated BenQ Hospital of Nanjing Medical University, between October 20, 2020, and May 31, 2024. The retrospective study was conducted in accordance with the principles of the Declaration of Helsinki, which was approved by the hospital's Medical Ethics Committee(ethics approval number: 2024-KL020, date of approval: July 31, 2024).\u0026nbsp;As this study is a retrospective clinical study, patients were exempted from informed consent.\u003c/p\u003e\n\u003cp\u003e2. Inclusion and exclusion criteria\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePatients admitted between October 20, 2020, and May 31, 2024;\u003c/li\u003e\n \u003cli\u003ePathological diagnosis of pancreatic ductal adenocarcinoma;\u003c/li\u003e\n \u003cli\u003eUnderwent biliary stent placement;\u003c/li\u003e\n \u003cli\u003ePostoperative diagnosis of pyogenic liver abscess (PLA) confirmed by medical records and imaging data.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eExclusion criteria:\u003c/p\u003e\n\u003cp\u003ePatients with incomplete medical data.\u003c/p\u003e\n\u003cp\u003e3. Data collection\u003c/p\u003e\n\u003cp\u003e(1) Preoperative data: Body mass index (BMI), CA19-9, glycated hemoglobin, albumin, alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin, and alkaline phosphatase.\u003c/p\u003e\n\u003cp\u003e(2) Endoscopic surgical data: Duration of endoscopic procedures, blood loss, and volume of blood transfusion.\u003c/p\u003e\n\u003cp\u003e(3) Postoperative complications: Postoperative pancreatitis, biliary leakage (BL), surgical site infection (SSI), and hemorrhage.\u003c/p\u003e\n\u003cp\u003e(4) Postoperative adjuvant therapies include chemotherapy, radiotherapy, and other adjuvant therapies.\u003c/p\u003e\n\u003cp\u003e(5) PLA-related data: PLA size, number, location, treatment methods, bacterial culture results, recurrence, length of hospital stay, hospital expenses, chemotherapy status, and overall survival (OS) after surgery.\u003c/p\u003e\n\u003cp\u003e4. Definitions\u003c/p\u003e\n\u003cp\u003e(1) Diagnosis of pyogenic liver abscess (PLA): PLA is diagnosed on the basis of the presence of hypoechoic areas in the liver with peripheral enhancement on CT imaging, accompanied by related symptoms such as fever, leukocytosis, and positive bacterial culture (either pus culture or blood culture). In cases where bacterial cultures are negative, PLA can still be diagnosed if imaging and other laboratory findings strongly suggest the presence of a liver abscess.\u003c/p\u003e\n\u003cp\u003e(2) Postoperative pancreatitis is defined by the presence of pancreatitis-related clinical symptoms lasting more than 24 hours, with a serum amylase level exceeding three times the upper limit of normal, or by meeting at least two of the following three criteria: abdominal pain characteristic of acute pancreatitis (sudden onset of severe, persistent upper abdominal pain, typically radiating to the back); serum lipase or amylase levels elevated at least three times the upper limit of normal; and imaging features of acute pancreatitis on enhanced CT, MRI, or abdominal ultrasound[7].\u003c/p\u003e\n\u003cp\u003e(3) Surgical site infection (SSI): SSIs include infections of the incision or infections involving organs or spaces related to the surgical procedure, typically occurring within 30 days postoperatively or within 90 days if the implants are involved. The focus of this study was organ or space infections[8].\u003c/p\u003e\n\u003cp\u003e(4) Definition of biliary leakage (BL): BL is defined as the leakage of bile into the abdominal cavity or through drainage tubes postoperatively, with the bilirubin level in the drainage fluid exceeding normal serum bilirubin levels[9].\u003c/p\u003e\n\u003cp\u003e5. Statistical methods\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed via SPSS version 29.0. Continuous variables with a normal distribution are expressed as the means ± standard deviations, whereas skewed data are presented as the medians (M) with ranges. Categorical variables are described as frequencies and percentages (%).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 98 patients underwent biliary stent placement, of whom 9 patients (9.2%, 9/98) developed PLA postoperatively. Among these patients, 6 were male and 3 were female, with a mean age of 63.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5 years (range: 56\u0026ndash;71 years). All 9 patients were diagnosed with pancreatic ductal adenocarcinoma of the pancreatic head. The preoperative laboratory results for these patients were as follows: CA19-9: 757.4\u0026thinsp;\u0026plusmn;\u0026thinsp;167.5 U/mL; glycated hemoglobin (%): 6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2; alanine transaminase (ALT): 291.2\u0026thinsp;\u0026plusmn;\u0026thinsp;66.2 U/L; aspartate transaminase (AST): 258.1\u0026thinsp;\u0026plusmn;\u0026thinsp;59.3 U/L; plasma albumin: 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 g/L; total bilirubin: 87.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5 \u0026micro;mol/L; and alkaline phosphatase: 367.8\u0026thinsp;\u0026plusmn;\u0026thinsp;44.7 U/L (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean duration of endoscopic surgery was 38.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 minutes, with no recorded intraoperative blood loss and transfusions. Postoperatively, none of the 9 patients experienced pancreatitis, biliary leakage, and surgical site infections.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative laboratory results of 9 patients with PLA following biliary stent placement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA19-9(U/mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGlycated Hemoglobin(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eALT(U/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAST(U/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAlbumin(g/L)\u003c/p\u003e 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\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e105.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e823.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e333.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e260.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e477.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e788.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e467.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e521.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e113.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e459.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1248.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e598.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e581.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e141.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e523.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSeven pancreatic cancer patients (77.8%, 7/9) received chemotherapy after biliary stent placement, and 1 patient (11.1%, 1/9) underwent radiofrequency ablation (RFA). The average time to the occurrence of PLA was 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 months post stent placement (range: 2.0-14.5 months). According to the imaging results, the average size of the PLA poststent placement was 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 cm (range: 1.5\u0026ndash;10.9 cm). Single abscess patients accounted for 66.7% (6/9), whereas multiple abscess patients accounted for 33.3% (3/9). Among the single abscesses, 1 was located in the left lobe of the liver (1/6), and the remaining were located in the right lobe (5/6) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All 9 patients had fever. Blood cultures were performed for 8 PLA patients, with a positivity rate of 75.0% (6/8). 8 patients underwent percutaneous liver abscess puncture and drainage, 7 of whom had pus cultures; the positivity rate was 85.7% (6/7).\u003c/p\u003e \u003cp\u003eThe blood culture results revealed that \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (37.5%, 3/8) was the most common pathogen. Other 3 results included \u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u0026thinsp;+\u0026thinsp;\u003cem\u003eEnterococcus faecium\u003c/em\u003e, \u003cem\u003eEnterococcus faecalis\u003c/em\u003e, and \u003cem\u003eEscherichia coli\u003c/em\u003e. In pus cultures, \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (42.9%, 3/7) and \u003cem\u003eEnterococcus faecalis\u003c/em\u003e (28.6%, 2/7) were the most common pathogens. Among the 7 patients with positive pus cultures, 2 had mixed infections with two types of bacteria (28.6%, 2/7). Additionally, atypical infections such as \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e were also observed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of the PLA patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTreatment Method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePus Culture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlood Culture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal Cost\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAntibiotic Cost\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae, Enterococcus faecalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e79,356.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12,316.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e61,600.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9,278.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e70,453.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5,776.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight Lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus faecalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus faecalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e71,890.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9,906.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft Lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eEnterobacter cloacae, Enterococcus faecium\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eEnterobacter cloacae,Enterococcus faecium\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e290,933.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e21,666.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot Punctured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot tested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e60,132.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4,990.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e76,141.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9,234.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u0026thinsp;+\u0026thinsp;Drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18,927.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3,795.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft Lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot tested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49,866.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8,397.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor patients with PLA following biliary stent placement, considering the immunosuppression caused by tumors and chemotherapy, the preferred treatment approach is the combination of antibiotics and percutaneous drainage (77.8%, 7/9). All patients received intravenous antibiotics upon hospitalization. Initially, third-generation cephalosporins, carbapenems, and other effective antibiotics were chosen before microbiological sensitivity data were available, with antibiotics adjusted on the basis of culture results. The average hospitalization cost was 86,589.2\u0026thinsp;\u0026plusmn;\u0026thinsp;26,258.8 CNY, with antibiotic costs amounting to 9,484.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1,764.6 CNY, accounting for 10.9% of the total costs. The average length of hospital stay for the 9 PLA patients was 32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2 days (range: 17\u0026ndash;104 days). 2 patients experienced recurrent PLA requiring further treatment, and no surgical drainage was performed. Follow-up until May 31, 2024, revealed 6 deaths among the 9 PLA patients, with an average overall survival of 14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 months for the deceased PLA patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePLA is a serious infection that can lead to sepsis, liver failure, and death[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The incidence of PLA in the general population is reported to be 2.3 to 15.5 per 100,000 people[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], whereas the incidence following biliary stent placement ranges from 4.3\u0026ndash;13.5%[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which is significantly higher than that in the general population. However, there are no published studies specifically addressing the incidence of PLA in pancreatic cancer patients undergoing biliary stenting.\u003c/p\u003e \u003cp\u003eCameron et al. reported that in patients with malignant biliary obstruction and stent placement, PLAs are often solitary and located in the right liver lobe[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our retrospective study, 55.6% of patients had solitary abscesses in the right liver lobe, which is consistent with the findings of previous studies. Following biliary stent placement, bacteria can ascend retrogradely through the bile duct into the intrahepatic bile duct system[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Once within the liver, bacteria can localize and proliferate, ultimately forming liver abscesses[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In cases of PLA, gram-negative bacteria are the most frequently isolated pathogens, accounting for 40\u0026ndash;60% of cases[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], with \u003cem\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e being the most common[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. \u003cem\u003eAnaerobes\u003c/em\u003e account for 35\u0026ndash;45% of liver abscess pathogens, whereas \u003cem\u003eStreptococcus\u003c/em\u003e, \u003cem\u003eStaphylococcus\u003c/em\u003e, and \u003cem\u003eEnterococcus\u003c/em\u003e infections are relatively less common[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In recent years, infections caused by highly pathogenic \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e have increased, particularly in Southeast Asia, where some reports indicate an infection rate as high as 80%[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similar cases have also been increasingly reported in the US and Europe[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Zheng et al. reported that \u003cem\u003eE. coli\u003c/em\u003e infections account for 21\u0026ndash;36% of cases in patients with PLA after biliary surgery, followed by \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e infections (9\u0026ndash;31%), with \u003cem\u003epolymicrobial\u003c/em\u003e infections occurring in 40\u0026ndash;68% of cases[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. When studying the microbiome of the PLA in pancreatic cancer patients post biliary stenting, it is important to consider not only the displacement of the gut flora but also the changes in the gut microbiota induced by pancreatic cancer. Sammallahti et al. reported increased abundances of \u003cem\u003eFirmicutes\u003c/em\u003e, \u003cem\u003eBacteroides\u003c/em\u003e, and \u003cem\u003eProteobacteria\u003c/em\u003e in the gut microbiota of patients with pancreatic cancer compared with normal individuals[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similar results were reported by Thomas et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our study also identified \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e and \u003cem\u003eEscherichia coli\u003c/em\u003e as the primary pathogens, which aligns with previous reports by Zheng et al., but further research with larger sample sizes is needed to validate these findings.\u003c/p\u003e \u003cp\u003eBiliary stent placement can lead to obstructed bile flow and bile reflux, resulting in increased pressure within the bile ducts, bile stasis, and elevated bile duct pH. These conditions create a favourable environment for intestinal bacteria to proliferate within the bile ducts[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Mechanical damage to the bile duct mucosa caused by stent placement can disrupt the integrity of the bile duct and serve as a portal for bacterial invasion[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], making it easier for bacteria to penetrate the bile duct wall and enter the surrounding liver tissue. Additionally, the long-term presence of the stent may trigger a chronic inflammatory response, further increasing the risk of infection. Previous studies have also identified biofilm formation as a significant factor in bacterial infections and the development of PLA following stent placement. Biofilms formed on the stent surface can resist antibiotic penetration and host immune clearance[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], leading to the development of difficult-to-treat infections. Moreover, in pancreatic cancer patients, the immune system may be compromised by various factors, including the tumor itself, diabetes, and the use of immunosuppressive drugs[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Reduced immune function diminishes the body\u0026rsquo;s ability to defend against bacterial infections, facilitating bacterial growth and proliferation in the liver and ultimately leading to the formation of PLA.\u003c/p\u003e \u003cp\u003eEarly empirical antibiotic therapy is crucial for controlling infection following the development of PLA after biliary stent placement. The choice of antibiotics should initially cover common gram-negative and anaerobic bacteria. Antibiotic therapy should be adjusted on the basis of the results of pus and blood cultures. However, many experts believe that percutaneous transhepatic abscess drainage (PTAD) remains the most effective treatment for these infections[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Currently, the primary approach for treating PLA includes antibiotic therapy combined with PTAD. As early as 1953, McFADZEAN et al. reported the successful treatment of 14 cases of single liver abscesses via intravenous antibiotics, percutaneous aspiration, and abscess cavity antibiotic lavage[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Recent studies increasingly support the use of image-guided percutaneous drainage (such as ultrasound or CT-guided drainage) as the preferred method for larger or multiple liver abscesses, with surgery as a secondary option if necessary[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In our retrospective study, 8 of 9 patients received PTAD combined with antibiotic therapy, whereas 1 patient refused PTAD and received only antibiotics. All patients experienced symptom relief and had their drainage tubes removed before discharge. 2 patients experienced recurrence of PLA after discharge; however, the abscesses resolved after additional PTAD. Furthermore, for PLA resulting from stent obstruction, it is advisable to consider stent replacement or cleaning to restore bile drainage and reduce the risk of reinfection.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePostoperative PLA in patients with pancreatic cancer, although a rare complication, significantly impacts patient prognosis. The occurrence of PLA may be related to the following mechanisms: bacterial retrograde infection; biliary stasis and increased pH; stent-associated biliary injury; biofilm formation; immune system suppression. Understanding these mechanisms, the evolving patterns of pathogenic bacteria, and effective treatment strategies is essential for advancing the understanding of this condition and developing new approaches for treating PLA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDXG and YM designed the research. DXG and NL collected the data and performed the analysis. DXG and NL prepared the manuscript draft. YM provided research support and revised the manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data and materials are presented in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur research complies with the Declaration of Helsinki.\u0026nbsp;Ethics approval was obtained from the Ethics Committees of the Affiliated BenQ Hospital of Nanjing Medical University (Clinical Research Ethics Committee of Nanjing BenQ Hospital).\u0026nbsp;As this study is a retrospective clinical study, patients were exempted from informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDinescu B, Voiosu T, Benguş A, Mateescu RB, Voiosu MR, Voiosu A. 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Indian J Surg. 2012;74(5):385\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12262-011-0397-0\u003c/span\u003e\u003cspan address=\"10.1007/s12262-011-0397-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Jan 7. PMID: 24082591; PMCID: PMC3477416.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pyogenic liver abscess, Biliary stent, Pancreatic cancer","lastPublishedDoi":"10.21203/rs.3.rs-6023795/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6023795/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBiliary stent placement is widely used in clinical, especially in patients with pancreatic cancer complicated with obstructive jaundice. Pyogenic liver abscess (PLA) is a severe complication following biliary stent placement which predominantly occurs in the right lobe of the liver, with an incidence rate ranging from 4.3\u0026ndash;13.5% and a mortality rate up to 30%. It is related to the following mechanisms: retrograde bacterial infection; bile stasis and increased bile duct pH; stent-related bile duct injury; biofilm formation; immune system suppression. The main causative pathogens are gram-negative bacilli, particularly \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e. The combination of antibiotic therapy and percutaneous transhepatic abscess drainage is the main treatment option.\u003c/p\u003e","manuscriptTitle":"Pyogenic Liver Abscess Following Biliary Stent Placement in Pancreatic Cancer Patients: A Retrospective Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 13:33:58","doi":"10.21203/rs.3.rs-6023795/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-23T02:10:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-22T18:39:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105694924351425811520162016729273290079","date":"2025-04-16T17:47:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T05:11:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77399753498067941479019589666512451095","date":"2025-03-30T09:49:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-25T14:00:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273242299933156083270317782448874948853","date":"2025-03-25T13:46:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-25T08:42:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T08:30:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-03-14T11:28:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f758d0ea-4c53-4dd8-9335-4a66afcdfeb7","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T15:58:34+00:00","versionOfRecord":{"articleIdentity":"rs-6023795","link":"https://doi.org/10.1186/s12885-025-14377-5","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-05-29 15:56:57","publishedOnDateReadable":"May 29th, 2025"},"versionCreatedAt":"2025-05-06 13:33:58","video":"","vorDoi":"10.1186/s12885-025-14377-5","vorDoiUrl":"https://doi.org/10.1186/s12885-025-14377-5","workflowStages":[]},"version":"v1","identity":"rs-6023795","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6023795","identity":"rs-6023795","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}