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A JR :1 7O , A pril 1 99 8 1035

Percu tan eou s T re a tm en t o f LiverAbscesses : Need le A sp i ra tion V ersusC a the te r D ra inage

Cha tu rbhu j La ) R a jak1S an ja y G up taSan jay Jam 2Y ogesh C haw la3M adhu G ula ti1Sudha Sun 1

OBJECTIVE .Th is s tud y w as de s ig n ed to d e te rm ine and com pare the e ffica cy o f s on og ra ph -ica lly gu ided percu taneous need le asp ira tio n and percu taneous cathe te r d ra inage in the treatm en tof li ve r a bs ce ss es .

SUB JECTS AND M ETHODS . In a ra ndom ize d s tu dy , 50 pa tie n ts (38 m a le s and 12 fe -ma le s ; age range , 2 -7 2 y ears ; av erag e age , 35 years ) w ith live r ab sce sse s (am eb ic . 20 ; p yog enic .1 1 ; in determ ina te , 19 ) u nd erw ent eith er p ercu tan eo us n eed le asp ira tio n (ii = 25 ) o r c ath et erdra inage (n = 25 ) a lo ng w ith a pp rop ria te a n tim ic rob ia l th e rap y . In p a tie n ts a ss ign ed to th e need leaspiration gro up , a n 18 -g auge need le w a s u sed to asp ira te the ab sce ss ca v ity . R epea te d asp ira tio nw a s a tt em p te d on ly once in each p a tien t no t respon d ing to the first asp iration : non respon se to th ese cond a sp ira tion was con s id e red fa ilu re o f trea tm en t, a nd the se pa tie n ts w e re g iv en ca the te rdrainage (how ever, these p atien ts w ere no t inc luded in the ca the ter d ra inage gro up). F or ca th ete rd rainag e, 8 - to 1 2-F ren ch ca the ters w e re in trod uced in to the ab sce ss cav ity us ing th e Seld in gertechn iqu e. In pa tien ts w ith m u ltip le abscesses (seven in asp iration g ro up and f ive in ca the te rg ro up ), a ll th e ab sce sses excep t th os e sm a lle r th an 3 cm w ere sub jected to percu taneous t rea t -m ent. P a tien ts w ere fo llow ed up to assess the o u tcom e of the percu taneou s trea tm en t, len g th ofho sp ita l s ta y , a nd de ve lo pm en t o f an y com p lica tio ns . S onog ra ph y w as per fo rm ed eve ry th ird da yd u ri ng h o sp it al iz a ti on . A fter d ischarge of the pa tie n t, p e r io d ic c lin ica l an d sonograph ic e xam in a -t ions were don e un til to tal reso lu tio n o f a bs ce ss es w as a ch ie ve d.

RESULTS . A ltho ugh perc u ta neou s need le a sp ira tion w as suc ces s fu l in on ly 15 (6 0% ) o f the25 pa tien ts af te r o ne (n = 1 1 ) o r tw o (n = 4 ) asp ira tio n s . ca the te r d ra in a ge w as cu ra tive in a ll 25p atien ts (1 00% ) (p < .05). Am ong th e succes s fu lly tre a te d pat ien ts, the av erage tim e fo r c lin ica lim p rov em en t a nd the m ean hosp ita l s tay w ere s im ila r in the tw o trea tm en t g roups . A lthough th eaverag e tim e needed fo r a 50% reduc tion in the size of the abscess cav ity w as sign ifican tly (p 3 7. 2# {1 7 6} C 25 pa tie n ts 23 pa tien tsP ain a nd te nde rne ss in u pper 2 5 p a ti e nt s 2 5 p a ti e nt s

abdomenJaund ice 3 pa tie n ts 3 pa tien tsLeu ko cy tos is (> 10 ,00 0 /m m 3)a 2 2 pa tie n ts 2 0 p a ti en tsN um be r o f a bs ce ss es 43 ( 37b ) 3 2 (3 1b )

So lita ry l8 pa tie n ts 2 0 p a ti en tsMult ip le 7 p a ti e nt s c 5 p a ti e nt s d

L oc atio n o f a bs ce ss esRigh t lobe 1 7 p a ti e nt s 1 7 p a ti e nt sLe ft lo be 3 pa tie n ts 4 p a ti e nt sB oth lo be s 5 pa tie n ts 4 pa tien ts

V olu me o f p ercu ta neo us ly tre ate d 1 0-8 47 m l (2 21 .8 6 205 .4 9 m l) 3 3 -1 834 m l (3 35 .74 3 76 .7 2 m l)a b s ce s se s e (m ean SO )S igns o f im pend in g ru p tu re 1 6 ab sce sse s 1 4 a b s ce s s es

C au se o f a bs ce ss esAmeb i c 1 1 p a ti e nt s 9 p a ti e nt sP yogen ic 6 pa tie n ts 5 p a ti e nt sIn de term in ate 8 pa tien ts 1 1 p a ti e nt sa lo ta l le uk oc yte c ou nt .bIn pat ients with m u ltip le a bs ce ss es , a bs ce ss es s ix in asp ira tion g roup and one in ca th e te r g rou p l m easuring

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P ercu tan eous T re a tm en t o f L ive r Abscesses

A JR :1 70 , A pril 1 99 8 1037

seven p atien ts w ith m ultip le absc esses. a l l b u t sixabsc esses (w hich w ere

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R a ja k e t a l.

1038 A JR :1 70 , A pril 1 99 8

t ion , i f l im ited to tw o a ttem p ts , ha s a s ign ifi-can tly low er su cce ss rate th an ca the terd ra in age (6 0% vers us 100% ).

The su ccess ra te o f p ercu tan eo us need le as -p ira tion in the va r ious se r ie s repo rted in the lit-e ra tu re va r ies from 79% to 100% [14-18].The re la tive ly low er suc ce ss ra te (60% ) o fpe rcu tan eou s n eed le asp ira tion in ou r s tud y isposs ib ly re la ted to the fac t tha t repea ted asp i-ration was a ttem pted on ly once in cases o fnon respo nse to th e firs t asp ira tion ; th is proce-dure is in contrast to tha t in m os t o f the o the rs tud ies , in w h ich rep ea ted asp ira tio ns w e redone up to th ree o r fou r tim es [9 , 1 4, 1 5, 1 7,18 ] . In ou r study a lso , th e s uc ce ss ra te a fte ron e asp ira tion w as on ly 44% ; it i nc r eased to60% afte r tw o asp iration s. A h ig her successra te w ould lik ely ha ve been ach ieved if m u lt i-p le repea ted asp ira tions w ere a ttem pted . H ow -e ve r, s ub je ctin g th e p atie nts to m ultip le need leasp i ra t ions (w i th the a ve rage num ber of asp i-ra tions per pa tien t rang in g from 1.4 to five [9 ,14 -18 ]) ove r a sh o rt per iod va ry in g from 5 to14 day s [1 4-1 7] is a t ra u m at ic a nd u np le as an texperience fo r the pa tien ts and m ay no t be ac -c ep tab le to m any . M o reo ve r, ev en m ult ip le at -tempts do no t gua ran tee a 100% cu re ra te [9 ,14 -18 ]. Fo r these reasons , w e pre fe rred tosub jec t the pa tien ts to pe rcu taneous ca the te rdra inage a fte r fa ilu re by se cond a sp ira tion .

T he a ve ra ge s ize o f the ab sce ss in o u r s tudyw as la rge r th an in o th e r se ries [14 , 15 , 18 ]. Incontrast to som e of th e earlie r repor ts tha t showtha t the in itia l s ize o f the abscess cav ity di d no taf fect th e u ltim ate ou tcom e [1 5 , 16 ], w e be lie vetha t large abscesses a re m ore d ifficu lt to evacu-a te c o m pl et el y in on e at tempt, neces s i t a t ing re -peated asp ira tio ns. T he av erag e vo lum e ofabscesses in the 10 pa tien ts in w hom percu ta-neous need le asp ira tio n w as un su cce ss fu l wa ss ign ific an tly la rg e r th a n the ave ra ge vo lum e o fth e absces ses in the 1 5 pa tien ts w ho respo ndedto one or t wo a sp ir at io ns .

O n e im po rtan t reason for fa ilu re of ne ed leasp ira tion is the inab ility to com ple te ly evacu -a te the th ic k v isco us pus th a t m ay be p resen tin som e of th e ab sce sse s [9 , 1 5 ]; th is pus w asseen in th ree of ou r p atie nts . R ap id re ac cu m u-la tion o f the abscess a fte r n eed le asp ira tion isanothe r p rob lem , described by D ie trick [17 ]an d seen in 1 2 o f ou r pa tie n ts a fte r firs t asp ira -tion an d e ig h t pa tie n ts a fte r s econd a sp ira tion .In som e of the pa tien ts ( tw o in our se ries), th israp id re fillin g cou ld have been du e to b ilia rycom m un ica tion ; h ow eve r, in m os t pat ien ts noob v iou s p re d isp os in g fac to r e x is te d , an d th econt inu ing in flam ma tory p rocess itse lf p roba -b ly con tr ibu ted to the reaccum ula tion o f flu id .

In con trast to percu taneous need le asp ira-tio n , pe rcu taneous p lacem en t o f a n in dw e lli ngcathe te r p ro v ides con tinuou s d rain ag e; h en ce,t he p ro b le m s o f incom plete evacua tio n and re -accum ula tio n are n o t a s so c ia te d w ith c ath ete rd ra in ag e, a cc ou ntin g fo r the h igh success ra tesof ca th e te r d ra in a ge re po rted in m os t o f th eea rlie r s tu d ies [7 , 9 -1 1 , 19 ] and a lso seen inou r se rie s . The on ly reasons fo r fa ilu re o fpe rcu taneous ca the te r d ra inage , as repo rtedin som e o f th e ea rlie r se rie s [1 0 , 1 9 ], h avebeen e ither th ick pus no t am enab le to pe rcu -tan eo us d ra ina ge (th is p rob lem can be ove r-c ome by us ing la rge r bo re ca thete rs ) o rprem atu re rem ova l o f th e d ra ina ge ca th e te r(s tr ic t a dh er en ce to the cr ite ria fo r ca the te rrem ova l can p reven t th is p rob lem [1 1 ]) . N ore cu rren ce o ccu rre d in a n y o f ou r ca se s dur-in g the fo llow -up pe riod .

Ou r s tud y sugges ts no m ean in g fu l d iffe r-ence in e ithe r the tim e taken fo r de fe rvescenceor th e dura tion of ho sp ita liza tion am ong th epa tie n ts suc ces s fu lly trea ted w ith e ith e r te ch -n ique . In keep ing w ith the find ings o f ea r lie rre po rts [7 , 9 -1 1 , 1 4-1 9], bo th tre a tm en t te ch -n iques resu lted in rap id c lin ic a l re lie f, w ithmos t pa tien ts sh ow in g re so lu tion o f fe ve r , lo -ca l sym ptom s, and leukocy tos is w ith in 3 daysof t he p r oc e du re .

The ave rage hosp ita l s ta y ( 1 1 days ) o f thepa t ien ts w ho unde rwen t pe rcu taneous ca the -te r d ra inage in ou r s tudy w as sho rte r than tha trepor ted in tw o earlier se r ies [7 , 19 ]. O ne pos -s ib le exp lana tion is tha t a ll the pa tien ts inthose se r ie s had pyogen ic live r abscesses andco n tin ue d to be hosp ita lized fo r th e def in i t ivetrea tm en t o f the p re d isp os in g cond ition s su chas d ive rticu lit is , ga ll s to ne s , g a ll b lad de r ca r-c in om a, and so fo rth even a fte r rem ova l o fca the te r and reso lu tion o f the abscess [7 , 19 ].No such pre d isp os in g cond ition s w ere recog -nized in th e sma l l numbe r (n = 1 1) o f p at ie nt sw ith p roven pyogen ic liv e r abscesses encoun -te red in ou r s tudy . The sho rte r hosp ita l s ta yco u ld a lso be re la ted to the fac t tha t, un liketh e pra c tic e in p rev iou s s tud ies , w e di d no twa i t fo r to ta l rad io log ic re so lu tio n o f a bsc esscav ity be fo re d is cha rge ; the ave rage vo lum eof abs ce ss a t th e tim e o f d isch a rge w as 70 m l.A lso , fou r o f our p atie nts w ere d is ch arg edwith ca the te rs in s itu w hen they be came c l in i-cally stable bu t had pe rs is ten t d ra inage fromt h e c a t h e te r .

The tim e requ ired fo r com p le te sono -g ra ph ic re so lu tio n o f abscess cav itie s a fte rpercu ta ne ou s tre a tm en t ra nges from 2 w ee ksto 9 m onths [9 , 18] . In fac t, to ta l reso lu tio nm ay no t o ccu r, a nd sm all re s idua l cav itie s

m ay pe rs is t fo r yea rs . S uch ca v itie s a re usu -ally ind is ting u ishab le from sim ple h epa ticc ys ts [2 0]. In a se ries o f 3 0 pa tien ts , S in g h andK ashy ap [9 ] no te d m uch fa s te r a n d m ore com -p le te res o lu tio n o f a bs ce ss ca v ity a fte r p e rcu -taneous ca the te r d ra inage than a fte rpe rcu taneous need le asp ira tion . H ow eve r, there su lts o f ou r s tu d y sugges t tha t a lth o ugh m i-t ia l co llap se o f the abscess cav ity is ach ieve dearlie r in pa tie n ts u nde rg o ing ca the te r d ra in -age than in those unde rgo ing need le asp ira -tion , the tim e needed fo r to ta l re so lu tion o f theabsces ses is s im ila r in th e tw o g ro up s .

C om p lica tio ns ha ve been repo rted w ithboth c at he te r d ra in ag e (12% in the se r ie s o fLam biase et a l. [21 ] ) an d n ee dle a sp ira tio n(4 % in the se r ie s o f B aek e t a l. [14 ]) . B aek e ta l. a nd G io rg io e t a l. [1 5 ] d esc rib e the m uchlo we r in cid en ce o f c o m pl ic a ti on s with percu -taneous need le asp ira tion than w ith ca the te rd ra in ag e as on e o f the m a jo r ad va n ta ge s o fneed le asp ira tion . H ow eve r, ou r s tudy andsom e recen t repo rts sugges t tha t bo th proce -dures , if p rop e r ly pe rfo rm ed , a re es sen tia llysafe procedure s w ith m in im al c om plica tio ns[5 , 7 -15 ]. S in gh and K ash yap [9 ] re po rted a15 % inc ide n ce o f se conda ry ba c te ria l c on -tam ina t ion a fte r m u ltip le ne ed le a sp ira t ion s ;how ever, o the r w ork e rs [14 -1 8 ] ha ve no t en -co un te red th is p rob lem . A lth ough seconda ryb ac te rial in fe ctio n rem ains a d is tin c t the o re ticp oss ib il ity w ith an indw e llin g c a th e te r, th iscomp l ica t ion ha s been ra re ly re p o rte d in liv e ra bsces ses [7 , 9 -1 1 , 1 9 ].

O ne lim ita tio n o f o u r s tu dy is th a t th e pa -tie n ts in c luded fo rm ed a he terogeneous g roupw ith ab sce sse s o f bo th am eb ic and pyogen icca uses e x is tin g in b o th g roups . A lso , m any ab -scesses (n = 19) w ere of ind ete rm ina te cause .B ecause our ins titu tio n is a re fe rra l h osp ita l,man y of th es e pa tie n ts had been pa rtia llytreated w ith an tib io tic s and an tiam eb ic drugsbe fo re be ing re fe rred to us ; th is p robab ly ac-coun ts fo r the h igh perc en tag e o f ab scessesw ith nega tiv e find ings on pus cu ltu res in ou rs tud y . S om e pre v iou s re sea rch e rs h ave a lsohad th is experience [1 0 , 1 7]. H ence , ana lys iso f these cases d oes no t a l low pred ic t ion of asuccess fu l ou tcome based on the cause o f ab -sce sse s . T h is in fo rm a tion cou ld be ob ta ine dfrom a p r os p ec t iv e s tu d y th a t inc lu ded a la rg e rnum be r o f absces ses o f a s ing le c ause.

In conc lus io n , a lth ough bo th percu taneousneed le a sp ira tio n and ca the te r d ra ina ge aresa le m ethods fo r the nonsu rg ica l trea tm en t o fliv e r ab sce sse s , c a th e te r d ra ina ge is m o re e f-fe c tiv e than need le asp ira tion , w hich , i f lim -i ted to tw o attem p ts, is a sso cia te d w ith a h igh

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Percu tan eous T re a tm en t o f L iv er A bscesses

A JR :17 0, A pr il 1 99 8 1039

fa ilu re ra te , e sp ec ia lly in la rg e ab sce sse s andin abscesses w ith th ic k v is co us pus . Howeve r ,the resu lts a lso ind ica te tha t need le asp i ra t ionw ith app ropria te an tim ic rob ia l the rap y w ill, inmany pat ien ts, resu lt in a cu re . A lso , am ongth e s uc ce ss fu lly tre ate d p atie nts , n o s ig nific an td i f fe rence ex ists in the t im e requ ired fo r c lin i-cal im provem ent, the d ura tio n o f h o sp it al iz a -tion , a nd the tim e needed fo r re so lu tion o f theabscess cav ity in the tw o tre a tm en t g rou ps .Un fo rtuna te ly , ou r da ta do no t a llow us to p re -d ic t th e typ e o f ab sce sse s like ly to re spond toneed le asp ira tion a lone . F urthe r p rospec tiv e ,ra ndom ize d s tu d ies in ve s tig a ting need le a sp i-ration a lone are th e re fo re w arran ted to spec ifi-ca lly ad d re ss th is p rob lem .

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21 . Lamb i a se RE , Deyoe L Cronan L C ro na n J J, D or f-m an G S. P ercu taneo us d rain age o f 3 35 c on se cu tiv eab sce sse s: re su l ts o f p rim ary drain age w ith I -y earfo l low-up . Radiology 1 99 2; l8 4: 1 67 -1 79