'PERCUTANEOUS CATHETER 'PERCUTANEOUS CATHETER

DRAINAGE' DRAINAGE'
Vs Vs
'PERCUTANEOUS NEEDLE 'PERCUTANEOUS NEEDLE
ASPIRATION' ASPIRATION'
IN IN LARGE HEPATIC LARGE HEPATIC
ABSCESSES ABSCESSES (10 cm / >) (10 cm / >)
MGM MedicaI CoIIege & MGM MedicaI CoIIege &
MY HospitaI, Indore MY HospitaI, Indore
Authors:
Dr. Onkar Singh (Resident of Surgery)
Dr. Sonia Moses (Assist. Prof. Surgery)
Dr. D. K. Jain (Professor of Surgery)
INTRODUCTION INTRODUCTION- -
Liver Abscess (LA)- commonIy
encountered during cIinicaI
practice in India.
Both Amoebic LA & Pyogenic LA-
important cause of morbidity &
mortaIity in tropicaI countries.
INTRODUCTION INTRODUCTION- -
AIthough, amoebic LA- primary mode of t/t
is medicaI;
-15% of these refractory to medicaI t/t.
-20% compIicated by secondary
bacteriaI infection.
Such amoebic abscesses need drainage.
AIso, pyogenic LA- has to be drained.
INTRODUCTION INTRODUCTION- -
SurgicaI drainage of LA-
associated with increased rates of
morbidity & mortaIity.
In today's era of minimaI
invasiveness- surgicaI drainage of
LA- rareIy indicated.
INTRODUCTION INTRODUCTION- -
THUS, now
Percutaneous drainage
(Aspiration/Catheter)
+
Antibiotics
Standard m/m of LA.
BUT !!! BUT !!!
to be asked to be asked- -
1. Why LA > 10 cm 1. Why LA > 10 cm
2. Percutaneous NeedIe 2. Percutaneous NeedIe
Aspiration Aspiration (PNA) (PNA)
Or Or
Percutaneous Catheter Percutaneous Catheter
Drainage Drainage (PCD) (PCD)
Why Liver Abscess > 10 cm Why Liver Abscess > 10 cm
LA- imp. cause of morbidity and mortaIity
in INDIA, & amoebic variety is endemic.
Pts. from ruraI and semi-urban areas of
centraI India, because of Iow educationaI
and SE-status, take symptomatic t/t &
present Iate when LA attains Iarge size.
Why Liver Abscess > 10 cm Why Liver Abscess > 10 cm
THUS; diagnosis is usuaIIy deIayed.
Our institution receives many cases
of LARGE- Liver abscesses every
year.
PNA or PCD PNA or PCD
What shouId be the percutaneous
intervention
PNA PNA
or or
PCD PCD
Both PNA & PCD- been shown to be
effective and safe.
CIear guideIines for type of percutaneous
t/t do not exist.
TiII now! TiII now!
There have been 3-previous studies,
comparing the two t/t options:
-2 most recent studies took onIy
pyogenic LA into account, &
-In aII 3, LA of aII sizes were
incIuded.
Study Study- - 1 1
Rajak et aI.- 1997
-Type of abscess incIuded= Both ALA &
PLA
-Size of abscesses incIuded= AII sizes
-ConcIusion/ Recommendations=
'PCD more effective than PNA'
(Rajak et al. Percutaneous treatment of liver abscesses: needle aspiration
versus catheter drainage. Am J Roentgenol 1998; 170(4): 1035-9)
Study Study- - 2 2
Yu et aI.- 2004
-Type of abscess incIuded= PLA onIy
-Size of abscesses incIuded= AII sizes
-ConcIusion/ Recommendations=
'PCD & PNA equaIIy effective but
PNA ShouId be considered first'
(: et al. Treatment of Pyogenic Liver Abscess: Prospective Randomized
Comparison of Catheter Drainage and Needle Aspiration. Hepatology
2004; 39(4); 932-8)
Study Study- - 3 3
Zerem & Hadzic- 2007
-Type of abscess incIuded= PLA onIy
-Size of abscesses incIuded= AII sizes
-ConcIusion/ Recommendations=
'PCD better than PNA for Iarge
abscesses, shouId be given preference over
PNA'
(erem E, Hadzic A. USG guided percutaneous catheter drainage versus
needle aspiration in the management of pyogenic liver abscess. Am J
Roentgenol. 2007; 189(3):W138-42)
Present study Present study- -
Conducted to compare the
effectiveness of PCD and PNA in
the management of Iarge Iiver
abscesses of size 10 cm or more.
Patients and methods Patients and methods- -
72 pts.
(amoebic + pyogenic)
LA- AII 10cm/>
randomIy
aIIocated into 2
groups; PCD
and PNA group
(36 in each)
Patients and methods Patients and methods- -
IncIusion: AII pts. With LA sized 10cm
or more.
ExcIusion: Pts. With coexisting
maIignant disease of biIiary origin
were excIuded.
Interventions done- under USG
guidedance & within 24 h of
admission.
Patients and methods Patients and methods- -
NeedIe aspiration group:
16 G trocar needIe and syringe.
R/V USG done every 3rd day. Asp.
repeated if reduction in size of abscess
cavity is Iess than 50% of previous size.
PNA- attempted for max. of 3 times.
Lack of response to 3rd asp. was
considered faiIure of t/t.
Patients and methods Patients and methods- -
Catheter drainage group:
14 F pigtaiI catheter used.
1st R/V USG done when drainage over
Iast 24 h was minimaI (<10 mI).
-If abscess resoIved- catheter removed.
-If residuaI cavity +nt- catheter fIushed.
Further R/V USG's done every 3rd day.
USG was repeated untiI- cavity resoIved
or decreased in size / static with cIinicaI
recovery.
Patients and methods Patients and methods- -
At first sitting- pus sampIe taken & sent
for
-microscopy,
-cuIture, &
-antibiotic sensitivity.
Methods Methods- -
Duration to attain cIinicaI reIief,
duration of hospitaI stay,
compIications,
treatment faiIure
&deaths
were recorded
& anaIyzed.
ResuIts ResuIts- -
Amoebic LA= 48 (67%), Pyogenic LA= 24
(33%) pts.
Rt. HypochondriaI / Epigastric pain- most
common symptom +nt in 67 (93%) patients
fever in 56 (78%).
Most common organisms in PLA- E. coIi
and KIebsieIIa.
Pus cuIture -ve in 11/24 cases of PLA.
RESULTS RESULTS- -
GB+CBD caIcuIi- mc co-existing
pathoIogy being present in 23 (32%)
choIangitis (11) and diabetes maIIitis (8).
-66% of totaI pts. had Ieucocytosis.
-TotaI biIirubin > 2.0 in over 35%, aIthough
cIinicaI jaundice +nt onIy in 15%.
-PT-INR was >2 in 30%,
RESULTS RESULTS- - Abscess characteristics Abscess characteristics
PNA PCD
No. of
abscess
SoIitary 28 31
MuItipIe 8 5
Lobe
InvoIved
Right 29 32
Left 1 0
Both 6 4
Type of
Abscess
Amoebic 22 26
Pyogenic 14 10
RESULTS RESULTS- -
Success rates:
NeedIe aspiration:
-SuccessfuI- 31/36 (86%),
After, 1 aspiration-10 pts.,
2 aspirations in 18, &
3 aspirations in 3 pts.
RESULTS RESULTS- -
Success rates:
Catheter drainage:
-SuccessfuI in 35 (97%) pts.
-TotaI duration of catheter
insertion ranged from 6-34 days
(Average 12.8 days).
FaiIures FaiIures- -
NeedIe Aspiration: 5/36
2- Both amebic, singIe abscess in
both.
3- muItipIe pyogenic abscesses.
-4 of them had gaII bIadder caIcuIi; whiIe
1 had H/O choIangitis.
Catheter drainage: 1/36
Because of rupture of abscess,
Ieading to faiIure of t/t.
CompIications CompIications- -
NeedIe Aspiration: 1/36
-hemorrhage formation of subcapsuIar
hematoma, without hemodynemic
compromise.
Catheter drainage: 2/36
(i) rupture of abscess and uItimateIy death
of one patient.
(ii) continuous biIe Ieakage, which stopped
spontaneousIy.
RESULTS RESULTS- -Treatment Response Treatment Response
Criteria PNA PCD p-vaIue
Duration of I/V
antibiotics
15.5+1.09 10.9+2.69 0.041
CIinicaI reIief
attained (Days)
10.225+
2. 09
8.085+2.69 0.028
HospitaI Stay
(Days)
18.2+2.0 16.3+2.4 0.086
Success Rate 31/36
(86%)
35/36
(97%)
0.02
ConcIusion ConcIusion- -
PCD and PNA- equaIIy effective in
the m/m of Iarge LA (>10cm), PCD is
a better option.
Present study + previous studies wiII
contribute to formuIate definite
standard guideIines for m/m of Iiver
abscesses.