Pyogenic liver abscess following Roux-en-Y choledochojejunostomy in advanced pancreatic cancer: a retrospective case series

Pyogenic liver abscess following Roux-en-Y choledochojejunostomy in advanced pancreatic cancer: 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 Roux-en-Y choledochojejunostomy in advanced pancreatic cancer: a retrospective case series Dongxue Geng, Yi Miao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8726704/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Roux-en-Y choledochojejunostomy increases the incidence of pyogenic liver abscess, but no cohort study has been reported to date on pyogenic liver abscess occurring in pancreatic cancer patients after Roux-en-Y choledochojejunostomy. Methods This article (Oct 2020–Sep 2024) analyzed 81 advanced pancreatic cancer patients undergoing Roux-en-Y choledochojejunostomy, of whom 11 (13.6%) developed postoperative PLA. Data included preoperative labs, imaging, microbiology, and outcomes. Results The study (6 males, 5 females; mean age 65.3 ± 12.2 years) exhibited elevated preoperative biomarkers: CA19-9 (395.3 ± 513.8 U/mL), ALT (131.7 ± 149.7 U/L), total bilirubin (109.8 ± 121.9 µmol/L). Median PLA onset was 6.0 months postoperatively (range:1.0–30.0). Abscesses were solitary (45.5%, 5/11) and multiple (54.5%, 6/11), averaging 12.4 ± 8.3 cm. CT revealed gas-containing cavities in 36.4% (4/11). Pus cultures were positive in 81.8% (9/11), dominated by Klebsiella pneumoniae (55.6%) and Escherichia coli (44.4%), with 33.3% polymicrobial infections. All patients received antibiotics plus percutaneous drainage (median hospitalization:19 days; 1 recurrence). No major surgical complications occurred. Mortality reached 54.5% (6/11) by Dec 2024, with median survival of 9.0 months. Literature review identified 10.5% PLA incidence post-choledochojejunostomy (vs. 0.0023–0.0155% in general population), driven by bacterial translocation, immunosuppression, and hepatic ischemia. Conclusions PLA incidence after Roux-en-Y choledochojejunostomy in pancreatic cancer patients is 13.6%, predominantly caused by Gram-negative bacilli. Early antibiotic-minimally invasive drainage remains critical. Clinicians should monitor high-risk patients for delayed PLA onset (median 6 months). Pyogenic liver abscess Roux-en-Y choledochojejunostomy Pancreatic cancer Figures Figure 1 Introduction Roux-en-Y choledochojejunostomy is widely used for the treatment of biliary diseases such as biliary obstruction, common bile duct injury, cholangiocarcinoma and other biliary tract diseases[ 1 ]. Although it can effectively improve biliary drainage and reduce the incidence of jaundice and cholangitis [ 2 ], it may also lead to a series of complications, among which pyogenic liver abscess(PLA) is a rare but serious complication. The reported incidence of PLA is approximately 10% [ 3 ]. Major causes include the entry of intestinal bacteria into the bile ducts and liver after surgery [ 4 , 5 ]; biliary obstruction and stricture following Roux-en-Y choledochojejunostomy[ 6 ]; immunosuppression [ 7 ]; and hepatic artery ischemia [ 8 , 9 ]. There have been no specific population studies on PLA occurrence after undergoing Roux-en-Y choledochojejunostomy for advanced pancreatic cancer. This study analyses 11 PLA patients after Roux-en-Y choledochojejunostomy with pancreatic cancer and discusses the mechanisms of PLA, clinical manifestations, diagnostic methods, and treatment strategies, in order to provide a reference for clinician. Materials and methods We retrospectively identified 11 patients diagnosed with PLA following surgery among 81 pancreatic cancer patients undergoing Roux-en-Y choledochojejunostomy at our center between October 2020 and September 2024. Cases were confirmed via imaging, clinical symptoms, and microbiological records. Postoperative complications (e.g., surgical site infection, pancreatitis, biliary leakage) were monitored using standardized criteria [ 10 – 11 ]. The study protocol adhered to the Declaration of Helsinki and was approved by the Institutional Review Board of the Affiliated BenQ Hospital of Nanjing Medical University (Approval No. 2024-KL029). Informed consent was waived due to the retrospective nature of the study. Data were analyzed using SPSS 29.0. Normally distributed continuous variables are presented as mean ± SD; non-normal variables as median (IQR). Categorical variables are reported as counts (%). Group comparisons utilized Student’s t-test or Mann-Whitney U test. Results Among 81 patients undergoing Roux-en-Y choledochojejunostomy, 11 (13.6%) developed postoperative pyogenic liver abscess (PLA). One patient with recurrent PLA remained hospitalized at data cutoff; their CT imaging is presented separately, and clinical data were excluded from statistical analysis. The PLA cohort included 6 males (54.5%) and 5 females (45.5%), with a mean age of 65.3 ± 12.2 years (range: 49–79). All had histologically confirmed pancreatic ductal adenocarcinoma of the head (stage III–IV). The preoperative laboratory results were as follows: CA19-9 (U/mL): 395.3 ± 513.8; glycated hemoglobin (%): 6.2 ± 0.7; alanine transaminase (ALT) (U/L): 131.7 ± 149.7; aspartate transaminase (AST) (U/L): 99.1 ± 100.0; plasma albumin (g/L): 37.8 ± 4.6; total bilirubin (µmol/L): 109.8 ± 121.9; and alkaline phosphatase (U/L): 224.8 ± 158.0 (Table 1 ). Table 1 Preoperative laboratory results of 11 patients with PLA following Roux-en-Y choledochojejunostomy Case CA19-9(U/mL) Glycated Hemoglobin(%) ALT(U/L) AST(U/L) Albumin(g/L) Total Bilirubin(umol/L) Alkaline Phosphatase(U/L) 1 413.0 5.3 322.0 162.3 40.0 203.8 365.0 2 61.2 7.2 9.5 11.8 41.6 26.4 66.0 3 235.4 6.9 70.9 63.2 34.8 240.0 303.0 4 358.0 5.9 33.0 36.0 35.4 395.5 143.0 5 1456.6 5.7 146.9 90.9 36.3 53.2 515.0 6 1315.1 7.2 11.6 18.5 47.9 14.3 82.0 7 1.1 5.7 89.6 97.9 34.3 62.1 123.0 8 24.1 6.2 3.3 7.2 36.6 9.2 58.0 9 36.8 5.5 464.8 290.5 41.2 116.7 363.0 10 68.7 5.9 62.1 44.0 30.9 23.1 105.0 11 378.9 6.7 235.1 268.0 37.2 63.2 350.2 Procedures required a mean operative time of 192.2 ± 72.5 minutes with estimated blood loss of 85.3 ± 45.4 mL. All surgeries were completed without transfusion. No cases of postoperative hemorrhage, biliary leakage, or SSI occurred. The median time to PLA onset post-choledochojejunostomy was 6.0 months (range: 1.0–30.0). Imaging analysis revealed a mean abscess diameter of 12.4 ± 8.3 cm (range: 2.5–22.3), with solitary abscesses in 45.5% (5/11) and multiple abscesses in 54.5% (6/11). Among solitary cases, 60.0% (3/5) localized to the left hepatic lobe and 40.0% (2/5) to the right lobe, 36.4% (4/11) of cases presented with gas-containing cavities on CT (Fig. 1 ). All patients exhibited fever (median temperature: 38.9°C). Blood cultures obtained from 9 patients showed a 66.7% positivity rate (6/9), with Klebsiella pneumoniae (50.0%, 3/6) predominating. Polymicrobial bacteremia (≥ 2 pathogens) occurred in one case ( Klebsiella pneumoniae , Escherichia coli , Achromobacter xylosoxidans , and Candida tropicalis ). Other isolates included Enterobacter cloacae , Enterococcus faecalis , and Streptococcus bovis . Abscess fluid cultures demonstrated an 81.8% positivity rate (9/11), dominated by Klebsiella pneumoniae (55.6%, 5/9) and Escherichia coli (44.4%, 4/9). Polymicrobial infections (two species) occurred in 33.3% (3/9), with additional isolates of Pseudomonas aeruginosa , Achromobacter xylosoxidans , and Candida tropicalis (Table 2 ). Table 2 Clinical characteristics of the PLA patients Case Number of Abscesses Location Treatment Method Pus Culture Blood Culture Hospital Stay (Days) Total Cost (CNY) Antibiotic Cost (CNY) 1 Unifocal Segment IV Antibiotics + Drainage Klebsiella pneumoniae Klebsiella pneumoniae 13 38,700.4 6,562.4 2 Unifocal Segment VIII Antibiotics + Drainage Klebsiella pneumoniae Negative 6 12,210.6 555.5 3 Multifocal Left Lobe Antibiotics + Drainage Escherichia coli , Enterococcus faecalis Enterococcus faecalis 13 25,283.6 2,429.8 4 Multifocal Right Lobe Antibiotics + Drainage Escherichia coli , Achromobacter xylosoxidans, Candida tropicalis Klebsiella pneumoniae , Escherichia coli , Achromobacter xylosoxidans, Candida tropicalis 104 464,335.7 33,177.9 5 Multifocal Right Lobe Antibiotics + Drainage Klebsiella pneumoniae Negative 19 52,366.5 8,392.1 6 Unifocal Segment III Antibiotics + Drainage Negative Negative 13 23,710.6 4,996.2 7 Unifocal Segment IV Antibiotics + Drainage Escherichia coli , Pseudomonas aeruginosa Negative 89 134,514.3 35,128.7 8 Unifocal Segment VI Antibiotics + Drainage Negative Enterobacter cloacae 41 129,044.1 13,741.9 9 Multifocal Right Lobe Antibiotics + Drainage Klebsiella pneumoniae Klebsiella pneumoniae 25 24,564.8 12,098.1 10 Multifocal Right Lobe Antibiotics + Drainage Klebsiella pneumoniae Negative 10 20,586.0 4,253.6 11 Multifocal Right Lobe Antibiotics + Drainage Escherichia coli Streptococcus bovis 39 15,632.8 8,320.1 The standard treatment protocol comprised combined antibiotic therapy and percutaneous drainage (11/11, 100%). Empirical intravenous antibiotics were initiated per IDSA guidelines (e.g., piperacillin-tazobactam or third-generation cephalosporins) and later tailored to culture susceptibility.The mean total hospitalization cost reached 85,540.8 ± 132,938.6 RMB, with antibiotic expenditures accounting for 13.8% (11,786.9 ± 11,720.6 RMB). The median hospital stay was 19 days (IQR: 6-104 days). One case required reintervention for recurrent PLA. No surgical drainage (open or laparoscopic) was performed. By December 2024, mortality reached 54.5% (6/11), with a median OS of 9.0 months (range: 6.0–32.0) among deceased patients. Discussion PLA is a rare but serious infection that can lead to liver failure and death in patients [ 12 ]. Reports in the literature indicate that the incidence of PLA in the general population is approximately 2.3–15.5 per 100,000 [ 13 , 14 ]. Following Roux-en-Y choledochojejunostomy, PLA incidence rises dramatically: our cohort demonstrated a 13.6% rate (11/81), consistent with Kubos et al.'s report of 10.5% (4/38) [ 3 ]. This population exhibits distinct PLA features: delayed onset (median: 6.0 months; range: 1.0–30.0), frequent polymicrobial infections (33.3%, 3/9), and a pathogen profile dominated by gut-derived Klebsiella pneumoniae (55.6%, 5/9) and Escherichia coli (44.4%, 4/9). Notably, 36.4% (4/11) of cases presented with gas-containing cavities on CT, indicative of aggressive infection. For patients with advanced pancreatic cancer complicated with obstructive jaundice, Roux-en-Y choledochojejunostomy was preferred over biliary stenting for palliative biliary decompression in our institution due to: (1)Roux-en-Y choledochojejunostomy provides longer-term patency compared to stents, which are prone to occlusion (median patency: 4–6 months in advanced pancreatic cancer). (2)All patients had obstructive jaundice due to locally advanced/unresectable tumors involving the biliary confluence, where endoscopic stenting was technically challenging. (3)For patients with anticipated survival > 6 months (based on preoperative CA19-9 trends and metastatic burden), Roux-en-Y choledochojejunostomy was favored to avoid repeated interventions. The comparison of stent and Roux-en-Y cholangiojejunostomy in the treatment of patients with advanced pancreatic cancer needs more follow-up control studies to confirm. The creation of a biliary-enteric anastomosis establishes a direct anatomical pathway for bacterial migration, significantly altering the physiological barrier between the biliary and intestinal systems. Experimental evidence from animal models robustly supports this mechanism. Porcine studies have demonstrated rapid bacterial colonization at the anastomotic site, reaching concentrations of 8.3×10⁶ CFU/g within one week postoperatively [ 15 ]. Furthermore, hepatic bacterial loads in these models exhibited a significant decline from (5.02 ± 1.59) to (2.19 ± 1.09) ×10⁶ CFU/g over a two-month period (p = 0.006) [ 16 ], with 50% of experimental pigs (7/14) showing concordant bacterial isolates ( Escherichia coli and Staphylococcus aureus ) at both anastomotic and hepatic sites. In addition to the above mechanism, additional risk factors include: (1) Biliary stasis: Anastomotic strictures or bile duct stones promote bacterial overgrowth [ 17 , 18 ]. In our cohort, elevated preoperative bilirubin (109.8 ± 121.9 µmol/L) and alkaline phosphatase (224.8 ± 158.0 U/L) suggest subclinical biliary obstruction may contribute.(2) Immunosuppression: Chemotherapy and surgical stress impair hepatic defenses [ 19 ]. The median survival of 9.0 months in our cohort highlights the advanced disease state and compromised immunity in these patients.(3) Tumor microenvironment: Pancreatic cancer-associated inflammation may facilitate bacterial adhesion and invasion. Elevated CA19-9 (395.3 ± 513.8 U/mL) in our cohort reflects tumor burden, potentially exacerbating infection risk. Our data validate antibiotic therapy combined with percutaneous drainage as effective first-line management (100% success in this series). However, the surgical vs. percutaneous drainage debate persists. Scholars who support prioritizing surgery believe that: (1) Higher success rates for multiloculated/non-liquefied abscesses (100% vs. 33% with percutaneous) [ 20 ]; (2) Reduced reoperation needs and shorter hospital stays [ 21 ]; (3) Preferred for abscesses > 5 cm (mean diameter in our cohort: 12.4 ± 8.3 cm) or with biliary-enteric anastomosis history [ 22 ]. Scholars advocating for prioritizing puncture believe that puncture drainage has advantages under the following conditions:(1) Minimally invasive with lower ICU utilization rates (11.1% vs. 27.3%) [ 23 ]; (2)Effective for single, well-liquefied abscesses, even > 5 cm [ 24 ]. Emerging approaches, such as laparoscopic drainage, combine the advantages of both modalities, demonstrating 100% efficacy in preliminary studies [ 25 ]. Given the prolonged hospitalization (median: 19 days) and substantial economic burden (mean cost: 85,540.8 ± 132,938.6 RMB) associated with current strategies, future research should prioritize randomized trials to define the role of laparoscopic techniques in high-risk cohorts. Conclusion PLA following Roux-en-Y choledochojejunostomy is a serious complication. Our analysis of case studies revealed that its pathogenesis is complex, and early diagnosis and timely treatment are crucial. This article summarizes the characteristics, the common causes, and effective treatment strategies for PLA following Roux-en-Y choledochojejunostomy through an analysis of 11 typical cases, aiming to increase clinical awareness and management skills regarding this complication. Declarations Ethics approval and consent to participate The study protocol adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated BenQ Hospital of Nanjing Medical University(Approval No. 2024-KL029). Consent for publication Not Applicable. Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No. Authors' contributions DXG and YM designed the research. DXG collected the data and performed the analysis. DXG prepared the manuscript draft. All the authors read and approved the final manuscript. Acknowledgements Not Applicable. References Kim D, Bolus C, Iqbal SI, et al. Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses. J Vasc Interv Radiol. 2019;30(1):76–81. Kim EY, Lee SH, Hong TH. Palliative laparoscopic Roux-en-Y choledochojejunostomy as a feasible treatment option for malignant distal biliary obstruction. Surg Today. 2022;52(11):1568–75. Kubo S, Kinoshita H, Hirohashi K, Tanaka H, Tsukamoto T, Kanazawa A. Risk factors for and clinical findings of liver abscess after biliary-intestinal anastomosis. Hepatogastroenterology 1999 Jan-Feb;46(25):116–20. Rayman S, Ross SB, Pattilachan TM, Christodoulou M, Rosemurgy A, Sucandy I. The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience. World J Surg. 2024;48(1):203–10. Jia CK, Lu XF, Yang QZ, Weng J, Chen YK, Fu Y. 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Chuang JH, Chen WJ, Lee SY, Chang NK. Prompt colonization of the choledochojejunostomy and translocation of bacteria to liver after bile duct reconstruction. J Pediatr Surg. 1998;33(8):1215–8. Chuang JH, Lee SY, Chen WJ, Hsieh CS, Chang NK, Lo SK. Changes in bacterial concentration of the liver correlate with that in the hepati_x0002_cojejunostomy after bile duct reconstruction: implication in the patho_x0002_genesis of postoperative cholangitis. World J Surg. 2001;25:1512–18. Satish KR, Sathyanarayana BA, Madhu SL, Nataraj NR, Amit GM, Hemanth V. A study of predictors for identification of risk of complications in patients with liver abscess. Trop Gastroenterol. 2015 Apr-Jun;36(2):96–100. Sharma S, Ahuja V. Liver Abscess: Complications and Treatment. Clin Liver Dis (Hoboken). 2021;18(3):122–6. Vega-Pérez A, Villarrubia LH, Godio C, et al. Resident macrophage-dependent immune cell scaffolds drive antibacterial defense in the peritoneal cavity. Immunity. 2021;54(11):2578–94. Hope WW, Vrochides DV, Newcomb WL, Mayo-Smith WW, Iannitti DA. Optimal treatment of hepatic abscess. Am Surg. 2008;74(2):178–82. Tan Y, Chung A, Chow P, et al. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm. Ann Surg. 2005;241:485–90. Liaoning Province Interventional Diagnosis and Treatment Technology Quality Control Center for Peripheral Vascular. Diseases and Tumors Consensus of Liaoning experts on interventional treatment of liver abscess (2022) [J]. J Interventional Radiol. 2022;31(7):642–50. Chong VH. Large pyogenic liver abscess: open surgical drainage for all? Ann Surg. 2006;244(1):163. Cioffi L, Belli A, Limongelli P, et al. Laparoscopic Drainage as First Line Treatment for Complex Pyogenic Liver Abscesses. Hepatogastroenterology. 2014;61(131):771–5. Wang Siqi S, Yuan C, Zhenxing, Li Y. Observation of the therapeutic effect of laparoscopic puncture tube drainage and laparoscopic incision tube drainage on patients with liver abscess [J]. J Practical Hepatol. 2022;25(2):283–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 20 Feb, 2026 Editor assigned by journal 20 Feb, 2026 Editor invited by journal 04 Feb, 2026 Submission checks completed at journal 02 Feb, 2026 First submitted to journal 02 Feb, 2026 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. We do this by developing innovative software and high quality services for the global research community. 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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-8726704","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594245064,"identity":"1b5ddde3-a762-42da-9f39-33eb49f2f940","order_by":0,"name":"Dongxue Geng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACfvb2AwcSfvy342dmPkCcFsmeM4kPPvYwJ0u2syUQp8XgRoKx4Qw2ZsYN53kMiHTZjYQ0aR4eNmbJZp6PN94w2MnpNhDQwdjz8Jg0jwUPHz8z72bLOQzJxmYHCGhhZgfbIgG0hXebNA/DgcRthLSwMSSYSfOwGTBuOMzzjDgtPBxg7yeAtLARp0WCBxzIB5Ilm9mMLecYEOEX++PgqDxgx89/+OGNNxV2cgS1oFlJbNQgaSFVxygYBaNgFIwIAABrMkBAGFd+sAAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Jiangsu University","correspondingAuthor":true,"prefix":"","firstName":"Dongxue","middleName":"","lastName":"Geng","suffix":""},{"id":594245065,"identity":"c00d66ab-092d-493f-a273-8841c82cb1ad","order_by":1,"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":"2026-01-29 03:53:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8726704/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8726704/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103400490,"identity":"88642d82-8392-4ba3-b903-facfcac43a12","added_by":"auto","created_at":"2026-02-25 09:22:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141630,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImaging data of PLA patients.\u003c/strong\u003e The white arrows indicate the PLA lesions, which typically present as hypoechoic areas in the liver with unclear borders, showing liquefactive necrosis internally, and some may exhibit gas shadows. Enhancement scans may show peripheral enhancement. In Panels B, C, D and K, gas can be seen within the abscess cavities. Panel K corresponds to a patient whose PLA lesion occupied most of the right lobe of the liver, measuring 23.6 cm in the long axis, accompanied by severe septicemia. The patient recovered after treatment with antibiotics combined with puncture therapy. Panel L shows imaging 2 months after recovery of the patient in PanelK, indicating multiple abscesses in the left lobe of the liver, accompanied by significant ascites.)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8726704/v1/41464dfb16246ba44c32a9eb.jpeg"},{"id":103400494,"identity":"68ac15c0-7a2c-4258-a7b6-d81309bf0ab0","added_by":"auto","created_at":"2026-02-25 09:22:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":750161,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8726704/v1/21d4f1ff-096c-4e51-85b4-7b2ffa90b50c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pyogenic liver abscess following Roux-en-Y choledochojejunostomy in advanced pancreatic cancer: a retrospective case series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRoux-en-Y choledochojejunostomy is widely used for the treatment of biliary diseases such as biliary obstruction, common bile duct injury, cholangiocarcinoma and other biliary tract diseases[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although it can effectively improve biliary drainage and reduce the incidence of jaundice and cholangitis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], it may also lead to a series of complications, among which pyogenic liver abscess(PLA) is a rare but serious complication. The reported incidence of PLA is approximately 10% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Major causes include the entry of intestinal bacteria into the bile ducts and liver after surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; biliary obstruction and stricture following Roux-en-Y choledochojejunostomy[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; immunosuppression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; and hepatic artery ischemia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. There have been no specific population studies on PLA occurrence after undergoing Roux-en-Y choledochojejunostomy for advanced pancreatic cancer. This study analyses 11 PLA patients after Roux-en-Y choledochojejunostomy with pancreatic cancer and discusses the mechanisms of PLA, clinical manifestations, diagnostic methods, and treatment strategies, in order to provide a reference for clinician.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eWe retrospectively identified 11 patients diagnosed with PLA following surgery among 81 pancreatic cancer patients undergoing Roux-en-Y choledochojejunostomy at our center between October 2020 and September 2024. Cases were confirmed via imaging, clinical symptoms, and microbiological records. Postoperative complications (e.g., surgical site infection, pancreatitis, biliary leakage) were monitored using standardized criteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The study protocol adhered to the Declaration of Helsinki and was approved by the Institutional Review Board of the Affiliated BenQ Hospital of Nanjing Medical University (Approval No. 2024-KL029). Informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\u003cp\u003eData were analyzed using SPSS 29.0. Normally distributed continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD; non-normal variables as median (IQR). Categorical variables are reported as counts (%). Group comparisons utilized Student\u0026rsquo;s t-test or Mann-Whitney U test.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong 81 patients undergoing Roux-en-Y choledochojejunostomy, 11 (13.6%) developed postoperative pyogenic liver abscess (PLA). One patient with recurrent PLA remained hospitalized at data cutoff; their CT imaging is presented separately, and clinical data were excluded from statistical analysis.\u003c/p\u003e \u003cp\u003eThe PLA cohort included 6 males (54.5%) and 5 females (45.5%), with a mean age of 65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2 years (range: 49\u0026ndash;79). All had histologically confirmed pancreatic ductal adenocarcinoma of the head (stage III\u0026ndash;IV).\u003c/p\u003e \u003cp\u003eThe preoperative laboratory results were as follows: CA19-9 (U/mL): 395.3\u0026thinsp;\u0026plusmn;\u0026thinsp;513.8; glycated hemoglobin (%): 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7; alanine transaminase (ALT) (U/L): 131.7\u0026thinsp;\u0026plusmn;\u0026thinsp;149.7; aspartate transaminase (AST) (U/L): 99.1\u0026thinsp;\u0026plusmn;\u0026thinsp;100.0; plasma albumin (g/L): 37.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6; total bilirubin (\u0026micro;mol/L): 109.8\u0026thinsp;\u0026plusmn;\u0026thinsp;121.9; and alkaline phosphatase (U/L): 224.8\u0026thinsp;\u0026plusmn;\u0026thinsp;158.0 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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 11 patients with PLA following Roux-en-Y choledochojejunostomy\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=\"char\" char=\".\" 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 \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal Bilirubin(umol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlkaline Phosphatase(U/L)\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e413.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e322.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e162.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e203.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e365.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e66.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e235.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e240.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e303.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e358.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e395.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e143.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1456.6\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\u003e146.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e53.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e515.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1315.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e82.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.1\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\u003e89.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e123.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e58.0\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e464.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e290.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e116.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e363.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44.0\u003c/p\u003e \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\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e378.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e235.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e268.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e350.2\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\u003eProcedures required a mean operative time of 192.2\u0026thinsp;\u0026plusmn;\u0026thinsp;72.5 minutes with estimated blood loss of 85.3\u0026thinsp;\u0026plusmn;\u0026thinsp;45.4 mL. All surgeries were completed without transfusion. No cases of postoperative hemorrhage, biliary leakage, or SSI occurred.\u003c/p\u003e \u003cp\u003eThe median time to PLA onset post-choledochojejunostomy was 6.0 months (range: 1.0\u0026ndash;30.0). Imaging analysis revealed a mean abscess diameter of 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 cm (range: 2.5\u0026ndash;22.3), with solitary abscesses in 45.5% (5/11) and multiple abscesses in 54.5% (6/11). Among solitary cases, 60.0% (3/5) localized to the left hepatic lobe and 40.0% (2/5) to the right lobe, 36.4% (4/11) of cases presented with gas-containing cavities on CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll patients exhibited fever (median temperature: 38.9\u0026deg;C). Blood cultures obtained from 9 patients showed a 66.7% positivity rate (6/9), with \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (50.0%, 3/6) predominating. Polymicrobial bacteremia (\u0026ge;\u0026thinsp;2 pathogens) occurred in one case (\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, \u003cem\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003eAchromobacter xylosoxidans\u003c/em\u003e, and \u003cem\u003eCandida tropicalis\u003c/em\u003e). Other isolates included \u003cem\u003eEnterobacter cloacae\u003c/em\u003e, \u003cem\u003eEnterococcus faecalis\u003c/em\u003e, and \u003cem\u003eStreptococcus bovis\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAbscess fluid cultures demonstrated an 81.8% positivity rate (9/11), dominated by \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (55.6%, 5/9) and \u003cem\u003eEscherichia coli\u003c/em\u003e (44.4%, 4/9). Polymicrobial infections (two species) occurred in 33.3% (3/9), with additional isolates of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e, \u003cem\u003eAchromobacter xylosoxidans\u003c/em\u003e, and \u003cem\u003eCandida tropicalis\u003c/em\u003e (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=\"9\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\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 of Abscesses\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\u003eHospital Stay (Days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTotal Cost (CNY)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAntibiotic Cost (CNY)\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\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSegment IV\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\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e38,700.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6,562.4\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\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSegment VIII\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\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12,210.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e555.5\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\u003eMultifocal\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\u003eEscherichia coli\u003c/em\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\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e25,283.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2,429.8\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\u003eMultifocal\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\u003eEscherichia coli\u003c/em\u003e, Achromobacter xylosoxidans,\u003c/p\u003e \u003cp\u003e\u003cem\u003eCandida tropicalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, \u003cem\u003eEscherichia coli\u003c/em\u003e, Achromobacter xylosoxidans,\u003c/p\u003e \u003cp\u003e\u003cem\u003eCandida tropicalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e464,335.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e33,177.9\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\u003eMultifocal\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\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\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e52,366.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8,392.1\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\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSegment III\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\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e23,710.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4,996.2\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\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSegment IV\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\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003ePseudomonas aeruginosa\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\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e134,514.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e35,128.7\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\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSegment VI\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\u003e\u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e129,044.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e13,741.9\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\u003eMultifocal\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\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\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e24,564.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12,098.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultifocal\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\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\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20,586.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4,253.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultifocal\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\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eStreptococcus bovis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15,632.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8,320.1\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\u003eThe standard treatment protocol comprised combined antibiotic therapy and percutaneous drainage (11/11, 100%). Empirical intravenous antibiotics were initiated per IDSA guidelines (e.g., piperacillin-tazobactam or third-generation cephalosporins) and later tailored to culture susceptibility.The mean total hospitalization cost reached 85,540.8\u0026thinsp;\u0026plusmn;\u0026thinsp;132,938.6 RMB, with antibiotic expenditures accounting for 13.8% (11,786.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11,720.6 RMB). The median hospital stay was 19 days (IQR: 6-104 days). One case required reintervention for recurrent PLA. No surgical drainage (open or laparoscopic) was performed. By December 2024, mortality reached 54.5% (6/11), with a median OS of 9.0 months (range: 6.0\u0026ndash;32.0) among deceased patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePLA is a rare but serious infection that can lead to liver failure and death in patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Reports in the literature indicate that the incidence of PLA in the general population is approximately 2.3\u0026ndash;15.5 per 100,000 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Following Roux-en-Y choledochojejunostomy, PLA incidence rises dramatically: our cohort demonstrated a 13.6% rate (11/81), consistent with Kubos et al.'s report of 10.5% (4/38) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This population exhibits distinct PLA features: delayed onset (median: 6.0 months; range: 1.0\u0026ndash;30.0), frequent polymicrobial infections (33.3%, 3/9), and a pathogen profile dominated by gut-derived \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (55.6%, 5/9) and \u003cem\u003eEscherichia coli\u003c/em\u003e (44.4%, 4/9). Notably, 36.4% (4/11) of cases presented with gas-containing cavities on CT, indicative of aggressive infection.\u003c/p\u003e \u003cp\u003eFor patients with advanced pancreatic cancer complicated with obstructive jaundice, Roux-en-Y choledochojejunostomy was preferred over biliary stenting for palliative biliary decompression in our institution due to: (1)Roux-en-Y choledochojejunostomy provides longer-term patency compared to stents, which are prone to occlusion (median patency: 4\u0026ndash;6 months in advanced pancreatic cancer). (2)All patients had obstructive jaundice due to locally advanced/unresectable tumors involving the biliary confluence, where endoscopic stenting was technically challenging. (3)For patients with anticipated survival\u0026thinsp;\u0026gt;\u0026thinsp;6 months (based on preoperative CA19-9 trends and metastatic burden), Roux-en-Y choledochojejunostomy was favored to avoid repeated interventions. The comparison of stent and Roux-en-Y cholangiojejunostomy in the treatment of patients with advanced pancreatic cancer needs more follow-up control studies to confirm.\u003c/p\u003e \u003cp\u003eThe creation of a biliary-enteric anastomosis establishes a direct anatomical pathway for bacterial migration, significantly altering the physiological barrier between the biliary and intestinal systems. Experimental evidence from animal models robustly supports this mechanism. Porcine studies have demonstrated rapid bacterial colonization at the anastomotic site, reaching concentrations of 8.3\u0026times;10⁶ CFU/g within one week postoperatively [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, hepatic bacterial loads in these models exhibited a significant decline from (5.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59) to (2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09) \u0026times;10⁶ CFU/g over a two-month period (p\u0026thinsp;=\u0026thinsp;0.006) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], with 50% of experimental pigs (7/14) showing concordant bacterial isolates (\u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e) at both anastomotic and hepatic sites.\u003c/p\u003e \u003cp\u003eIn addition to the above mechanism, additional risk factors include: (1) Biliary stasis: Anastomotic strictures or bile duct stones promote bacterial overgrowth [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our cohort, elevated preoperative bilirubin (109.8\u0026thinsp;\u0026plusmn;\u0026thinsp;121.9 \u0026micro;mol/L) and alkaline phosphatase (224.8\u0026thinsp;\u0026plusmn;\u0026thinsp;158.0 U/L) suggest subclinical biliary obstruction may contribute.(2) Immunosuppression: Chemotherapy and surgical stress impair hepatic defenses [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The median survival of 9.0 months in our cohort highlights the advanced disease state and compromised immunity in these patients.(3) Tumor microenvironment: Pancreatic cancer-associated inflammation may facilitate bacterial adhesion and invasion. Elevated CA19-9 (395.3\u0026thinsp;\u0026plusmn;\u0026thinsp;513.8 U/mL) in our cohort reflects tumor burden, potentially exacerbating infection risk.\u003c/p\u003e \u003cp\u003eOur data validate antibiotic therapy combined with percutaneous drainage as effective first-line management (100% success in this series). However, the surgical vs. percutaneous drainage debate persists. Scholars who support prioritizing surgery believe that: (1) Higher success rates for multiloculated/non-liquefied abscesses (100% vs. 33% with percutaneous) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; (2) Reduced reoperation needs and shorter hospital stays [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; (3) Preferred for abscesses\u0026thinsp;\u0026gt;\u0026thinsp;5 cm (mean diameter in our cohort: 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 cm) or with biliary-enteric anastomosis history [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Scholars advocating for prioritizing puncture believe that puncture drainage has advantages under the following conditions:(1) Minimally invasive with lower ICU utilization rates (11.1% vs. 27.3%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]; (2)Effective for single, well-liquefied abscesses, even \u0026gt;\u0026thinsp;5 cm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmerging approaches, such as laparoscopic drainage, combine the advantages of both modalities, demonstrating 100% efficacy in preliminary studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given the prolonged hospitalization (median: 19 days) and substantial economic burden (mean cost: 85,540.8\u0026thinsp;\u0026plusmn;\u0026thinsp;132,938.6 RMB) associated with current strategies, future research should prioritize randomized trials to define the role of laparoscopic techniques in high-risk cohorts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePLA following Roux-en-Y choledochojejunostomy is a serious complication. Our analysis of case studies revealed that its pathogenesis is complex, and early diagnosis and timely treatment are crucial. This article summarizes the characteristics, the common causes, and effective treatment strategies for PLA following Roux-en-Y choledochojejunostomy through an analysis of 11 typical cases, aiming to increase clinical awareness and management skills regarding this complication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated BenQ Hospital of Nanjing Medical University(Approval No. 2024-KL029).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\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\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDXG and YM designed the research. DXG collected the data and performed the analysis. DXG prepared the manuscript draft. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKim D, Bolus C, Iqbal SI, et al. Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses. J Vasc Interv Radiol. 2019;30(1):76\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim EY, Lee SH, Hong TH. Palliative laparoscopic Roux-en-Y choledochojejunostomy as a feasible treatment option for malignant distal biliary obstruction. Surg Today. 2022;52(11):1568\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubo S, Kinoshita H, Hirohashi K, Tanaka H, Tsukamoto T, Kanazawa A. Risk factors for and clinical findings of liver abscess after biliary-intestinal anastomosis. Hepatogastroenterology 1999 Jan-Feb;46(25):116\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayman S, Ross SB, Pattilachan TM, Christodoulou M, Rosemurgy A, Sucandy I. The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience. World J Surg. 2024;48(1):203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia CK, Lu XF, Yang QZ, Weng J, Chen YK, Fu Y. Pancreaticojejunostomy, choledochojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases. World J Gastroenterol. 2014;20(36):13200\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutson DG, Russell E, Levi JU, et al. Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis. World J Surg. 2001;25(10):1251\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWanford JJ, Hames RG, Carreno D, et al. Interaction of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e with tissue macrophages in a mouse infection model and ex-vivo pig organ perfusions: an exploratory investigation. Lancet Microbe. 2021;2(12):e695\u0026ndash;703.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanden S, Ursaru D, Delugeau V, Landen C. How to deal with hepatic artery injury during pancreaticoduodenectomy. A systematic review. J Visc Surg. 2017;154(4):261\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Qiang D, Menghua Z. Research on the causes and diagnosis and treatment of liver infarction and liver abscess after pancreaticoduodenectomy [J]. Chin J Practical Surg. 2019;39(6):599\u0026ndash;605.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawaguchi Y, Wente MN, Bassi C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142(5):761\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAghalarov I, Beyer E, Niescery J, Belyaev O, Uhl W, Herzog T. Outcome of combined pancreatic and biliary fistulas after pancreatoduodenectomy. HPB (Oxford). 2023;25(6):667\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan GG, Gregson DB, Laupland KB. Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clin Gastroenterol Hepatol. 2004;2:1032\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo JJ, Lee TK, Kyoung DS, Park MA, Kim SG, Kim YS. A population-based study of pyogenic liver abscess in Korea: Incidence, mortality and temporal trends during 2007\u0026ndash;2017. Liver Int. 2021;41(11):2747\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen YC, Lin CH, Chang SN, Shi ZY. Epidemiology and clinical outcome of pyogenic liver abscess: an analysis from the National Health Insurance Research Database of Taiwan, 2000\u0026ndash;2011. J Microbiol Immunol Infect. 2016;49(5):646\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuang JH, Chen WJ, Lee SY, Chang NK. Prompt colonization of the choledochojejunostomy and translocation of bacteria to liver after bile duct reconstruction. J Pediatr Surg. 1998;33(8):1215\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuang JH, Lee SY, Chen WJ, Hsieh CS, Chang NK, Lo SK. Changes in bacterial concentration of the liver correlate with that in the hepati_x0002_cojejunostomy after bile duct reconstruction: implication in the patho_x0002_genesis of postoperative cholangitis. World J Surg. 2001;25:1512\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSatish KR, Sathyanarayana BA, Madhu SL, Nataraj NR, Amit GM, Hemanth V. A study of predictors for identification of risk of complications in patients with liver abscess. Trop Gastroenterol. 2015 Apr-Jun;36(2):96\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma S, Ahuja V. Liver Abscess: Complications and Treatment. Clin Liver Dis (Hoboken). 2021;18(3):122\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVega-P\u0026eacute;rez A, Villarrubia LH, Godio C, et al. Resident macrophage-dependent immune cell scaffolds drive antibacterial defense in the peritoneal cavity. Immunity. 2021;54(11):2578\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHope WW, Vrochides DV, Newcomb WL, Mayo-Smith WW, Iannitti DA. Optimal treatment of hepatic abscess. Am Surg. 2008;74(2):178\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan Y, Chung A, Chow P, et al. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm. Ann Surg. 2005;241:485\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiaoning Province Interventional Diagnosis and Treatment Technology Quality Control Center for Peripheral Vascular. Diseases and Tumors Consensus of Liaoning experts on interventional treatment of liver abscess (2022) [J]. J Interventional Radiol. 2022;31(7):642\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong VH. Large pyogenic liver abscess: open surgical drainage for all? Ann Surg. 2006;244(1):163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCioffi L, Belli A, Limongelli P, et al. Laparoscopic Drainage as First Line Treatment for Complex Pyogenic Liver Abscesses. Hepatogastroenterology. 2014;61(131):771\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Siqi S, Yuan C, Zhenxing, Li Y. Observation of the therapeutic effect of laparoscopic puncture tube drainage and laparoscopic incision tube drainage on patients with liver abscess [J]. J Practical Hepatol. 2022;25(2):283\u0026ndash;6.\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":false,"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, Roux-en-Y choledochojejunostomy, Pancreatic cancer","lastPublishedDoi":"10.21203/rs.3.rs-8726704/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8726704/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRoux-en-Y choledochojejunostomy increases the incidence of pyogenic liver abscess, but no cohort study has been reported to date on pyogenic liver abscess occurring in pancreatic cancer patients after Roux-en-Y choledochojejunostomy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis article (Oct 2020\u0026ndash;Sep 2024) analyzed 81 advanced pancreatic cancer patients undergoing Roux-en-Y choledochojejunostomy, of whom 11 (13.6%) developed postoperative PLA. Data included preoperative labs, imaging, microbiology, and outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study (6 males, 5 females; mean age 65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2 years) exhibited elevated preoperative biomarkers: CA19-9 (395.3\u0026thinsp;\u0026plusmn;\u0026thinsp;513.8 U/mL), ALT (131.7\u0026thinsp;\u0026plusmn;\u0026thinsp;149.7 U/L), total bilirubin (109.8\u0026thinsp;\u0026plusmn;\u0026thinsp;121.9 \u0026micro;mol/L). Median PLA onset was 6.0 months postoperatively (range:1.0\u0026ndash;30.0). Abscesses were solitary (45.5%, 5/11) and multiple (54.5%, 6/11), averaging 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 cm. CT revealed gas-containing cavities in 36.4% (4/11). Pus cultures were positive in 81.8% (9/11), dominated by \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (55.6%) and \u003cem\u003eEscherichia coli\u003c/em\u003e (44.4%), with 33.3% polymicrobial infections. All patients received antibiotics plus percutaneous drainage (median hospitalization:19 days; 1 recurrence). No major surgical complications occurred. Mortality reached 54.5% (6/11) by Dec 2024, with median survival of 9.0 months. Literature review identified 10.5% PLA incidence post-choledochojejunostomy (vs. 0.0023\u0026ndash;0.0155% in general population), driven by bacterial translocation, immunosuppression, and hepatic ischemia.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePLA incidence after Roux-en-Y choledochojejunostomy in pancreatic cancer patients is 13.6%, predominantly caused by Gram-negative bacilli. Early antibiotic-minimally invasive drainage remains critical. Clinicians should monitor high-risk patients for delayed PLA onset (median 6 months).\u003c/p\u003e","manuscriptTitle":"Pyogenic liver abscess following Roux-en-Y choledochojejunostomy in advanced pancreatic cancer: a retrospective case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 09:22:40","doi":"10.21203/rs.3.rs-8726704/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-20T05:34:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T05:24:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-04T20:00:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T00:00:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-02-02T23:53:00+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":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-25T09:22:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 09:22:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8726704","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8726704","identity":"rs-8726704","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}