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COMPARATIVE STUDY OF CATHETER DRAINAGE AND NEEDLE ASPIRATION IN THE MANAGEMENT OF LIVER ABSCESS.

BACKGROUND

Liver abscess both amoebic and pyogenic continues to be an important cause of morbidity and mortality globally. The mainstay of treatment of liver abscess in the recent past has been either a percutaneous catheter drainage or percutaneous needle aspiration. Various studies done in the recent past have not given a concrete conclusion as to which of the two is better in the treatment of liver abscess. Hence the purpose of this study is to compare the above-mentioned treatment modalities and to identify the better option for treating patients suffering from liver abscess in our setup [1].

Although needle aspiration of liver abscess is easier, less costly the important reason for failure of needle aspiration is its inability to completely evacuate the pus.

In contrast to needle aspiration percutaneous placement of an indwelling catheter provides continuous drainage, Hence the problem of incomplete evacuation and reaccumulation are not associated with catheter drainage, accounting for higher success rates. The role of surgical therapy in liver abscess is reduced. But surgical associated other abdominal pathology and multiloculated, thick-walled abscess cavity with viscous pus [2].

Aims and Objectives

1. To compare and correlate the therapeutic effectiveness of percutaneous needle aspiration and percutaneous catheter drainage in the treatment of liver abscess.

2. To identify and compare the morbidity and side effects associated with both procedures.

MATERIALS AND METHODS

A Non-Randomized controlled trial was conducted between January 2017 to June 2018 over 60 cases, admitted in Basaveshwara Teaching and General Hospital Gulbarga. Source of data is from a pretested proforma from the inpatient registry. Out of 60 patients studied 30(50%) patients were treated with percutaneous needle aspiration with 18G spinal needle. 30(50%) patients were treated with percutaneous catheter drainage using 12F pigtail catheter. Sample size was taken for convenience.

Inclusion Criteria

All patients clinically and radiologically diagnosed to have liver abscess.

Exclusion Criteria

1. Patients with already ruptured liver abscess.

2. Very small volume (<100 ml) and multiple abscesses.

3. Patients below 12 year of age.

Statistical Analysis

The data was analyzed using mean [+ or -] SD and frequency, unpaired t test and Chi-square test

P value of <0.01 will be considered as significant. The data collected was entered into Microsoft excel spread sheet and analyzed using IBM SPSS Statistics, Version 22

RESULTS

After admission, the patients were resuscitated with fluids. All the patients empirically received injection Amoxycillinc-lavulanate 1.2 g IV b.i.d, injection Metronidazole 750 mg IV every t.i.d, injection Gentamicin 80 mg IV b.i.d, which covers both aerobic and anaerobic organisms. Later antibiotics changed according to culture & sensitivity report. LFT was done for all cases. BT, CT, PT-INR, done for cases which needed aspiration or surgical intervention. Anaemia was treated with blood transfusion. In doubtful cases CT scan was done. Amoebic abscess identified by clinical features, USG, presence of anchovy sauce pus, E.histolytica ELISA and presence of E.histolytica in pus. Identification of bacteria in a liver abscess was considered synonymous with diagnosis of pyogenic liver abscess. Spontaneous bacterial contamination of an amoebic liver abscess is an event of such extraordinary rarity as to challenge its existence. So presence of bacteria in pus was considered as pyogenic liver abscess.

After the diagnosis, where the patients were treated with two different modalities of treatment which include therapeutic percutaneous needle aspiration and percutaneous catheter drainage. In all cases USG guided marking was done before doing diagnostic or therapeutic aspiration and when there are multiple abscess, larger and more accessible cavity likely to be drained

The data obtained was tabulated and analysed. the final results and observations were tabulated as below

DISCUSSION

Age wise distribution: In this study, maximum number of cases was in 41-50 years age group (26.67%). The youngest patient we recorded was 16 years old and oldest was 75 years. The mean age was 46 years.

Success Rate

In this study, PCD has higher success rates (63.33%) compared to PNA (36.67%). The first non-randomized trial conducted by Rajak and colleagues in 19983 showed 100% resolution of PLAs in the PCD group with a 60% success rate in the PNA group. according to (Zerem & Hadzic. 2007)4 PCD is successful in all 30 patients undergoing one or two PCD's. In the PNA group, a 33% failure rate was reported after three aspiration procedures. According to S Sing et al [5] pcd is successful in 100%, while PNA in 77% of cases. Yu and colleagues in 2004 found no significant differences found PCD and PNA, suggesting that PNA may be as effective as catheter drainage.

Clinical Improvement in Days

In this study, the mean time for clinical improvement is 3.63 PCD group while it is 4.07 in PNA group. There is no statistically significant difference between the two groups. Our findings are consistent with S Sing et al.

Time for 50% Decrease in The Size of Abscess Cavity in Days

In this study, the mean time for 50% decrease in size of abscess cavity is 3.93 in PCD group while it is 5.50 in PNA group. There is a statistically significant difference between the two groups. Our findings are consistent with S Sing et al.

Hospital stay in days: In this study, the mean time of hospital stay is 11.33 in PCD group while it is 10.70 in PNA group. There is no statistically significant difference between the two groups. Our findings are consistent with S Sing et al, O'Farrell et al. [6] According to Yu and colleagues in 2004 a tendency toward a shorter hospitalization and lower mortality rate was found in the PNA group.

Duration of IV antibiotics in days in this study, the mean duration of iv antibiotics is 9.67 in PCD group while it is 8.80 in PNA group. There is no statistically significant difference between the two groups. Our findings are consistent with S Sing et al,

Time for total/near total resolution of cavity in weeks. In this study, the mean time for total/near total resolution of cavity is 11.13 in PCD group while it is 10.37 in PNA group. There is no statistically significant difference between the two groups. Our findings are consistent with S Sing et al.

Complications

In this study, no complications were met with PNA group while 2 patients in the PCD group has complications related to catheter placement. There is no statistically significant difference between the two groups. Baek et al [7] and Giorgio et al [8] described the much lower incidence of complications with PNA than with PCD. However, in our study and some recent studies (Rajaket al 1998,3 Yu et al 2004, [9]) both the procedures were found to be safe if performed properly with minimal complications. There was no mortality in either of the study groups.

CONCLUSION

Percutaneous catheter drainage is a better modality as compared to percutaneous needle aspiration in terms of overall success rate, especially in larger abscesses. Percutaneous needle aspiration is a cheaper method with its use limited to smaller abscesses. There is no statistically significant difference in terms of complications associated with PCD and PNA of liver abscess. We the authors conclude PCD as first-line treatment option but consider PNA as an alternative in small abscesses.

REFERENCES

[1] Singer AJ, Talan DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. The New England Journal of Medicine 2014;370(11):1039-47.

[2] Ochsner A, De Bakey M, Murray S. Pyogenic abscess of the Liver. II. An analysis of forty-seven cases with review of the literature. Am J Surg 1938;40(1):292319.

[3] Rajak CL, Gupta S, Jain S, et al. Percutaneous treatment of liver abscesses: needle aspiration versus catheter drainage. Am J Roentgenol 1998;170(4):1035-9.

[4] Zerem E, Hadzic A. Sonographically guided percutaneous catheter drainage versus needle aspiration in the management of pyogenic liver abscess. Am J Roentgenol 2007;189(3):W138-W42.

[5] Singh S, Chaudhury P, Saxena N, et al. Treatment of liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology 2013;26(4):3329.

[6] O'Farrell N, Collins CG, McEntee GP. Pyogenic liver abscesses: diminished role for operative treatment. Surgeon 2010;8(4):192-6.

[7] Baek SY, Lee MG, Cho KS, et al. Therapeutic percutaneous aspiration of hepatic abscesses: effectiveness in 25 patients. Am J Roentgenol 1993;160(4):799-802.

[8] Giorgio A, De Stefano G, Di Sarno A, et al. Percutaneous needle aspiration of multiple pyogenic abscesses of the liver: 13-year single-center experience. Am J Roentgenol 2006;187(6):1585-90.

[9] Yu SC, Ho SS, Lau WY, et al. Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 2004;39(4):932-8.

Umeshchandra D. G (1), Kiran Chayagol (2)

(1) MBBS, MS, Department of General Surgery, M. R. Medical College, Kalaburagi, Karnataka, India.

(2) 3rd Year Postgraduate Student, Department of General Surgery, Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India.

'Financial or Other Competing Interest': None.

Submission 02-01-2019, Peer Review 16-02-2019,

Acceptance 22-02-2019, Published 04-03-2019.

Corresponding Author:

Kiran Chayagol, 1-1495/38-2, Basava Nilaya, Godutai Nagar, Kalaburagi-585102, Karnataka, India.

E-mail: kiranchayagol4@gmail.com

DOI: 10.14260/jemds/2019/125
Table 1. Age Wise Distribution of Cases
P = 0.548

Age        PNA                 PCD                Total

           No.         %       No.        %       No.         %

<30        05          16.66   02         6.67    07          11.67
31-40      06          20      08         26.67   14          23.33
41-50      08          26.67   08         26.67   16          26.67
51-60      08          26.67   07         23.33   15          25
>60        03          10      05         16.66   08          13.33
Total      30          100     30         100     60          100
Mean       45.03               48.97              47
[+ or -]   [+ or -]            [+ or -]           [+ or -]
SD         13.99               12.08              13.11

Inference- There is no statistically significant difference
between the groups for age distribution.

Table 2. Lab Parameters

Lab              PNA        PCD      p Value
Parameters

TLC            13033.33   13383.33    0.209
               [+ or -]   [+ or -]
               4571.90    7454.463

S. Bilirubin     1.48       1.9       0.129
               [+ or -]   [+ or -]
                 0.97       1.38

ALP             184.93     178.93     0.684
               [+ or -]   [+ or -]
                140.46     99.08

Inference- There is no statistically significant difference
between the groups for lab parameters.

Table 3. Comparison of PNA and PCD

                PNA                   PCD                   p
              Positive   Negative   Positive   Negative   value

Amoebic          10         20         09         21
Serology      (33.33)    (66.67)      (30)       (70)     0.133

Anchovy Pus      08         22         09         21
              (26.67)    (73.33)      (30)       (70)

Pus Culture      13         17         13         17
              (43.33)    (56.67)    (43.33)    (56.67)

Inference- There is no statistically significant difference
between the groups for the parameters.

Table 4. Microbiologic Distribution of Cases

Organism Isolated   PNA N (%)   PCD N (%)

E coli               06(20)       5(17)
Streptococcus         01(3)        --
Klebsiella           05(17)       2(7)
S. aureus             01(3)       4(13)
Pseudomonas            --         2(7)
Cysts                  --         2(7)
No Growth            17(57)      15(50)

Table 5. Clinical Variables of PNA and PCD Groups

Type of Abscess            PNA Mean          PCD Mean          P
                          [+ or -] SD       [+ or -] SD      value

Volume of Abscess       426.00 [+ or -]   428.17 [+ or -]    0.446
Cavity                      373.65            210.44

Hospital Stay           10.70 [+ or -]    11.33 [+ or -]     0.212
in Days                      4.43              3.67

Clinical                 4.07 [+ or -]     3.63 [+ or -]     0.092
Improvement in Days          1.76              2.01

Time For 50%             5.50 [+ or -]     3.93 [+ or -]
Decrease in                  1.74
Size Of Abscess                                             0.001 *
Cavity In                                      1.57
Days

Time for Total/         10.37 [+ or -]    11.13 [+ or -]
Near Total
Resolution of                3.29
Cavity in                                                    0.219
Weeks                                          2.95

Duration of IV           8.80 [+ or -]     9.67 [+ or -]     0.104
Antibiotics in Days          2.59              2.59

* Significant

Inference- Statistically significant difference between the
groups only for time for 50% decrease in size of abscess
cavity in days.

Table 6. Comparison of Success Among PNA and PCD
Groups
P=0.001

Success      PNA          PCD         Total

Yes       19 (63.33)   26 (86.67)   38 (63.33)
No        11 (36.67)   04 (13.33)   22 (36.67)
Total      30 (100)     30 (100)     60 (100)

Inference--There is statistically significant difference
between the groups for success of treatment with more
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Title Annotation:Original Research Article
Author:Umeshchandra, D.G.; Chayagol, Kiran
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Mar 4, 2019
Words:2028
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