DOI:10.2214/AJR.07.2173
AJR 2007; 189:W138-W142
© American Roentgen Ray Society
Sonographically Guided Percutaneous Catheter Drainage Versus Needle Aspiration in the Management of Pyogenic Liver Abscess
Enver Zerem1 and
Amir Hadzic
1 Both authors: Interventional Ultrasonography Department, University Clinical
Center, Trnovac bb, Tuzla, Bosnia and Herzegovina.
Received December 17, 2006;
accepted after revision March 28, 2007.
Address correspondence to E. Zerem
(zerem{at}inet.ba).
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. The purpose of this study was to determine the
effectiveness of percutaneous catheter drainage (PCD) and to compare PCD with
percutaneous needle aspiration in the management of liver abscess.
SUBJECTS AND METHODS. Sixty patients with pyogenic liver abscess
were randomly assigned to two groups in a prospective study. Antibiotics were
administered for 10 days, starting the day of the beginning of percutaneous
treatment. One group was treated with sonographically guided PCD and the other
group with repeated percutaneous needle aspiration. Percutaneous needle
aspiration was attempted a maximum of three times. Lack of response to the
third aspiration was considered failure of treatment; these patients were
treated with PCD but were not included in the PCD group for analysis. Patient
demographics, duration of hospital stay, treatment outcome, and complications
were analyzed.
RESULTS. Percutaneous needle aspiration was successful in 20 (67%)
of the 30 patients after one (n = 12), two (n = 7), or three
(n = 1) aspirations. PCD was curative in all 30 patients after one
(n = 24) or two (n = 6) procedures. All abscesses 50 mm or
less in longest diameter were successfully managed, 10 by percutaneous needle
aspiration and 12 by PCD. None of patients in the percutaneous needle
aspiration group with multiloculated abscesses (n =5) was
successfully treated. Hospital stay did not differ significantly between the
groups. There were no complications related to the procedure.
CONCLUSION. PCD is more effective than percutaneous needle
aspiration in the management of liver abscess. Percutaneous needle aspiration
can be used as a valid alternative for simple abscesses 50 mm in diameter or
smaller.
Keywords: antibiotic therapy • interventional sonography • liver abscess
Introduction
Liver abscess is a relatively uncommon lesion with a high mortality
rate because of delayed detection and treatment. The classic presentation of
fever, right upper quadrant pain, and tender hepatomegaly is unusual. The
frequency of any particular symptom varies widely among reports. Management of
liver abscess was exclusively surgical in the past. Modern treatment has
shifted toward IV broad-spectrum antibiotics and imaging-guided percutaneous
needle aspiration or percutaneous catheter drainage (PCD). Surgical
intervention is still indicated for inaccessible abscesses, multiple lesions
that cannot be effectively managed percutaneously, and abscesses that do not
respond to less invasive methods
[1-3].
Continuous catheter drainage is widely accepted and in combination with
antibiotics is considered a safe and effective method of management of liver
abscess [4,
5]. Some authors prefer
repeated needle aspiration, considering it as effective and safe as PCD but
easier to perform, less complicated, less aggressive, less risky for
postprocedure septicemia, and less expensive. This approach requires careful
follow-up and often-repeated imaging procedures to monitor response to therapy
[6-9].
The objective of our randomized study was to compare the efficacy and safety
of PCD with those of percutaneous needle aspiration and to determine the
first-line management of pyogenic liver abscess.
Subjects and Methods
Patients
All patients with pyogenic liver abscess who were admitted to our hospital
between February 2002 and March 2006 were considered candidates for the study.
A patient was enrolled if he or she had symptoms and signs of pyogenic liver
abscess and if liver abscess was confirmed at sonographic or CT examination.
We excluded patients with coexisting malignant disease of biliary origin,
which is the leading cause of death from liver abscess, regardless of the type
of percutaneous treatment. We also excluded patients who were initially
treated with antibiotics other than cefazolin and gentamicin. All patients
gave written informed consent, and the study was approved by the local ethics
committee. Sealed envelopes containing the names of the treatments were used
to randomly assign 60 eligible patients to undergo percutaneous needle
aspiration or PCD (30 patients in each group). The allocation schedule was
created with a computerized random number generation system.
At presentation, all patients included for randomization were treated with
IV cefazolin 1 g three times a day and gentamicin 1 mg/kg three times a day
for 10 days. Percutaneous treatment was performed within 24 hours after
admission. Immediately after catheter or needle placement into the abscess
cavity, pus was obtained from all 60 patients. The antibiotics were adjusted
according to the results of culture and sensitivity testing of the pus
aspirated during the procedure. Patients with negative culture results were
continuously treated with a combination of cefazolin and gentamicin. If
antibiotic therapy was changed according to the results of sensitivity
testing, new antibiotics were administered for 10 days. Patients were
discharged earlier with an IV catheter inserted for completion of therapy if
fever had subsided for at least 48 hours. IV antibiotic therapy was followed
by a 4-week course of appropriate oral antibiotics.
Percutaneous Catheter Drainage
The drainage technique was a trocar method with an 8-French
multiple-sidehole pigtail catheter (Boston Scientific) introduced into the
abscess cavity. The procedure was performed with local anesthesia, the patient
supine. Conscious sedation was not used. Careful localization of the abscess
and proper selection of the entry site were required. The optimal route of
access traversed the least possible amount of liver tissue and avoided bowel
and pleura. Aspiration was performed with the catheter until no more pus was
removed. The catheter then was secured to the skin for continuous external
drainage and was left in place until production of content stopped. Residual
cavities of abscesses were managed by catheter repositioning and aspiration or
by introduction of a new catheter.
Needle Aspiration
Evacuation of pus from an abscess was performed with an 18-gauge disposable
trocar needle. Sonography was performed every 3 days, and the size of the
abscess cavity was recorded. If there was no significant reduction in the
abscess cavity on control examination, aspiration was repeated. Repeated
aspiration was attempted a maximum of twice for each patient not responding;
lack of response to a third aspiration attempt was considered failure of
treatment, and a catheter for continuous drainage was introduced. Patients who
needed this treatment were not included in the PCD group.
Follow-Up and Outcome
All patients underwent clinical follow-up and monitoring during daily
rounds until they were discharged from the hospital. Follow-up sonography was
performed 24 hours after intervention and repeated every 3 days, and the size
of the abscess was recorded. Criteria for successful treatment were clinical
subsidence of infection and sonographic evidence of abscess resolution, such
as disappearance or marked decrease in the abscess cavity (more than 50%
reduction of longest diameter before treatment) (Fig.
1A,
1B,
1C,
1D).
After discharge from the hospital, patients underwent follow-up evaluations
in the outpatient clinic at least once a week during treatment and biweekly
until 6 months from the beginning of the treatment. Patients discharged with a
catheter underwent follow-up sonography every 3 days until there was no
catheter output for 24 hours, and then the catheter was removed. Patient
outcome, including length of hospital stay, complications related to the
procedure, and treatment failure, were recorded.
Statistical Analysis
Statistical analysis was done with statistical software (SPSS 12.0, SPSS).
Descriptive and analytic statistics were used. Quantitative variables were
compared by two-sample Student's t test for independent samples with
adjustment for unequal variances when needed or by Mann-Whitney U
test for variables not normally distributed. Categoric variables were analyzed
by chi-square test. All statistical tests were performed with a 95% level of
statistical significance.
Results
Seventy-one patients were initially enrolled in the study. Eleven of them
were excluded, nine because of malignant disease of biliary origin and two
because they were initially treated with antibiotic combinations other than
cefazolin and gentamicin. Of the remaining 60 patients, 36 were women and 24
men. The mean age was 51.2 ± 14.4 (SD; range, 22-75) years. Before
admission, patients had symptoms for a mean of 5.9 ± 2.9 days (range,
2-14 days). The patient groups did not differ significantly with respect to
baseline characteristics, clinical features, or biochemical values
(Table 1). There was no
statistically significant difference between the two groups with regard to
underlying pathologic condition and abscess characteristics. A potential
underlying condition for liver abscess was found in 46 (77%) of the 60
patients (Table 2). The most
common coexisting disease was diabetes in 17 (28%) of the patients.
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TABLE 1: Characteristics of Patients with Pyogenic Liver Abscesses Managed with
Percutaneous Catheter Drainage and Needle Aspiration
|
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A microbial pathogen was isolated in 23 (77%) of the patients in the PCD
group and 22 (73%) of the patients in the percutaneous needle aspiration
group. All patients who had positive results of both blood and abscess
cultures had identical pathogens. Bacteria in the positive cultures were
predominantly gram-negative, Klebsiella pneumoniae being the leading
species. In seven patients in the drainage group and five patients in the
needle group, antibiotics were changed after the results of pus culture and
sensitivity tests were obtained (Table
3).
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TABLE 3 : Microbiologic Data on Liver Abscesses Managed with Percutaneous
Catheter Drainage and Needle Aspiration
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Details on the outcome of the procedure are shown in
Table 4. Repeated aspiration
was attempted for 18 of 30 patients not responding to the first aspiration.
The outcome was successful in seven of the 18 patients after the second and in
only one of 11 patients after the third attempt. Ten patients did not respond
even after three aspirations, and the outcome was considered failure of
treatment. In nine of the 10 patients, abscess collection was successfully
managed by catheter drainage. One patient had persistence of the abscess on
sonography along with fever and pain in the right upper quadrant of the
abdomen and abnormal laboratory test results. That patient underwent surgery
with a favorable outcome.
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TABLE 4: Clinical Outcome Among Patients with Liver Abscess Managed with
Percutaneous Catheter Drainage and Needle Aspiration
|
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In the percutaneous needle aspiration group, the average longest diameter
of the abscess collection was significantly greater in patients with
unsuccessful (97 ± 42 mm) than in patients with successful (62 ±
35 mm) needle aspiration (p = 0.02). Although the average volume of
frank pus was larger in patients who underwent unsuccessful percutaneous
needle aspiration (178 ± 98 mL) than in those who underwent successful
percutaneous needle aspiration (121 ± 96 mL), the difference was not
significant (p = 0.14). Intermittent needle aspiration was successful
for all patients with abscesses 50 mm in longest diameter or smaller. However,
this treatment was unsuccessful for all five patients with multiloculated
abscesses.
In the PCD group, all patients were successfully treated, clinical features
and laboratory abnormalities subsiding
(Table 4). In four of six
patients with multiloculated abscesses, catheter drainage was performed twice
because drainage was inadequate with the first attempt. Total duration of
catheter drainage for each patient in the drainage group ranged from 3 to 25
days with a mean of 11.0 ± 6.4 days.
At the end of treatment, the abscess cavity had disappeared completely in
25 of 50 successfully treated patients and had decreased more than 50% in the
other 25 patients (Table 4). On
final control examination 6 months after the beginning of treatment, abscesses
were absent in all successfully treated patients. Hospital stay did not differ
significantly between the groups (Mann-Whitney U test; Z = -0.02;
p = 0.98) (Table 4).
Neither group of patients had procedure-related complications such as bleeding
of any degree or septicemia.
Discussion
The trend in management of liver abscesses has been moving strongly toward
nonsurgical methods. Several investigations
[1-9]
have shown that a large proportion of patients can be treated with excellent
results with a combination of parenteral antibiotics and image-guided
percutaneous treatment. Whether to perform percutaneous catheter drainage or
intermittent needle aspiration remains controversial.
In two early randomized studies
[4,
8] in which use of continuous
catheter drainage was compared with repeated needle aspiration in the
management of liver abscess, recommendations for first-line percutaneous
treatment differed. Rajak and colleagues
[4] compared percutaneous
needle aspiration and PCD in a randomized study involving 50 patients with
liver abscess. Those investigators concluded that PCD was more effective than
percutaneous needle aspiration. In that study, lack of response to a second
attempt at percutaneous needle aspiration was considered failure of treatment.
Yu and colleagues [8] performed
a randomized trial involving 64 patients with pyogenic liver abscess.
Percutaneous needle aspiration was repeated if there was either lack of
clinical improvement or lack of size reduction of the abscess cavity. Those
investigators concluded that percutaneous needle aspiration was probably as
effective as continuous PCD. They recommended percutaneous needle aspiration
as a first-line approach because of procedure simplicity, patient comfort, and
reduced price and suggested a multicenter study to provide a definitive
answer.
Unlike the aforementioned investigators
[4,
8], we considered a third
unsuccessful attempt at percutaneous needle aspiration failure of treatment.
That only one of 11 aspirations was successful on the third attempt confirmed
that further needle aspiration is rarely successful. This result supported the
design of the study by Rajak et al.
[4]. The results of our study
confirmed that repeated percutaneous needle aspiration and PCD are equally
efficient in the management of liver abscesses 50 mm or less in longest
diameter. Percutaneous needle aspiration of all multiloculated abscesses
failed, and PCD was necessary. As in other investigations
[10-12],
K. pneumoniae was the most commonly isolated microorganism in our
series.
Some authors have presented their experience in nonrandomized studies
showing that percutaneous needle aspiration is a safe and effective approach
and should be considered a first-line treatment in the management of liver
abscess. Most of the abscesses required no more than two aspirations
irrespective of size
[6-9].
Use of catheters was reserved for cases of rapid reaccumulation of exudate and
for those without general improvement in the patient's condition
[13]. Other authors prefer
continuous catheter drainage as a reliable and effective approach to the
management of liver abscess
[14-17].
On the basis of previous findings, we excluded patients with coexisting
malignant disease of biliary origin, which is a poor prognostic factor and the
leading cause of death among patients with pyogenic liver abscess
[18,
19]. This exclusion is
probably why we had a better overall success rate with percutaneous treatment
(only one patient referred for surgery) than have other investigators
[11,
16,
20,
21] and is probably why there
were no deaths in our series.
In conclusion, continuous PCD is more efficient than intermittent
percutaneous needle aspiration. Intermittent percutaneous needle aspiration is
a valid alternative for abscesses 50 mm or less in longest diameter. PCD is
more efficient for multiloculated liver abscesses. The results of our study
together with previous findings contribute to answering whether first-line
management of liver abscess should be PCD or intermittent needle
aspiration.
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Abstract
Introduction
