A Comparative Evaluation of Percutaneous Catheter Drainage For Resistant Amebic Liver Abscesses

Jai Pal Singh, MS, Ajaya Kashyap, MS, NW Delhi, India

Resistance to drug treatment is a well-known prob- lem in the management of patients with amebic liv- er abscesses. We undertook a comparison of the various modalities of treatment currently used for such cases on a prospective, randomized basis. Fifty patients with 56 amebic liver absces found to be resistant to drug therapy were included in the study. Repeat trial of conservative therapy, thera- peutic needle aspirations, percutaneous catheter drainage, and open surgical drainage were the mo- dalities of treatment employed. The responses to the various modalities were compared for clinical relief, morbidity, failure of response, period of hos- pital stay, and resolution of abscess cavity. The most impressive results were seen with percutaneous catheter drainage. This new modality of treatment is recommended for all resistant cases of amebic liver abscess.

T he prevalence of amebic liver abscess continues to be high, particularly in tropical countries [I]. There are

a significant number of patients who fail to respond ade- quately to medical therapy or respond very slowly [2-141. Problems that continue to plague the management of this disease include difficulty in early and accurate diagnosis and the morbidity and mortality related to this delay [2,15-171. The resolution of the cavity is slow and often incomplete [18,19]. There is a need for prolonged hospi- tal stay [20]. Morbidity from this disease, as well as the cost of treatment in countries such as India, continues to be high.

We, like some other investigators, had resorted to open surgical drainage for resistant cases with catheter insertion [2Z-251. This gave us moderately good results besides offering greater certainty of diagnosis. With the advent of newer imaging modalities and success recently obtained in percutaneous aspiration of intraabdominal

From the Department of Surgery, Dr. Ram Manohar Lohia Hospital, New Delhi, India.

Requests for reprints should be addressed to Jai Pal Singh, MS, 5 1, Lodi Estate, New Delhi 110 003, India.

abscesses as well as with percutaneous catheter drainage, we thought of instituting ultrasound guided percutaneous catheter drainage of amebic liver abscesses in resistant cases [26,32]. We adopted this technique a few years back and found the results to be very satisfactory. To evaluate this new modality, we decided to compare the results obtained with those obtained when other thera- peutic modalities were used on a prospective, randomized basis. In this study percutaneous catheter drainage has been compared with repeat trial of conservative manage- ment, therapeutic needle aspirations, and open surgical drainage in 50 patients with resistant amebic liver ab- S%W?S.

PATIENTS AND METHODS A total of 50 patients with 56 resistant amebic liver

abscesses were studied from January 1986 through No- vember 1987. The age range of the patients was 21 to 72 years and there were 44 men and 6 women. Most of the patients had large solitary abscesses varying from 5 to 13 cm in diameter; four patients had two abscesses each and one had three abscesses. All the patients included in the study proved to have sterile pus on ultrasound guided thin needle aspiration, had highly positive amebic serologic tests (indirect hemagglutination test, indirect fluorescent antibody test, andBLISA test) and failed to respond to metronidazole therapy (800 mg 3 times daily) given for 5 to 10 days. These patients were randomly divided into four groups: Group 1 patients underwent repeat trial of conservative management with dehydroemetine (1.25 mg/kg body weight intramuscularly for 10 days); Group 2 patients underwent ultrasound guided therapeutic nee- dle aspirations, repeated as many times as necessary, based on clinical criteria; Group 3 patients underwent percutaneous catheter drainage under ultrasound guid- ance, with the help of trocar technique using 12F silastic catheters with multiple side holes (Figure 1); Group 4 patients underwent open surgical drainage with catheter insertion after thorough emptying of the cavity. Catheter care for effective drainage of pus and prevention of secon- dary bacterial infection included the use of completely closed system with facility for irrigation; daily estimation of amount, color, smell, and consistency of pus; daily microbiologic examination of draining pus; and sterile saline irrigation using 100 to 200 ml of dilute saline under strict asepsis performed every day.

The catheters, both after percutaneous catheter drain- age and open surgical drainage, were withdrawn on the basis of clinical (when the patients were asymptomatic), radiologic (empty collapsed cavity on cavitograms or on

58 THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989

ultrasonography), and catheter (less than 10 ml drainage in 24 hours) criteria [26l. The catheters were retained an average of 4.5 days (range 3 to 7 days). All the patients continued to receive antiamebic drugs (metronidazole in Groups 2, 3, and 4, dehydroemetine in Group l), until a full course was completed and at least for 2 days after the removal of catheters,

The patients were monitored for clinical relief after start of definitive treatment. Relief of pain, which was the dominant symptom in all cases, was taken as the single most important index for comparing the clinical response to treatment. The patients were asked to express the relief of pain each day as a percentage of the original intensity. Other symptoms and signs of the disease responded to treatment by the time the patients were relieved of their pain in all cases. The patients were carefully monitored for morbidity arising after institution of therapy and for any adverse effects of therapy. Patients who failed to respond to one modality were taken up for the next, that is, those not, responding in Group 1 were shifted forwards to Group 2, and from Group 2 to Group 3. Intraperitoneal rupture of the abscess was taken to be an absolute indica- tion for open surgical drainage (Group 4).

The size and extent of collapse of cavity were assessed periodically with the help of ultrasonography and injec- tion of radiopaque contrast into the abscess cavity (cavi- tograms) prior to withdrawal of catheters. The patients were discharged after they had been asymptomatic for 2 days.

After discharge, the patients were called for weekly follow-up for 6 weeks and monthly follow-up subsequent- ly. At each of these visits, the patients were assessed clinically for any recurrence or relapse of disease and ultrasonographic estimate of the size of the cavity was performed.

RESULTS Complete clinical relief was taken to be absence of

pain and fever for 24 hours and absence of hepatic tender- ness. On an average it took 10.3 days (range 3 to 14 days), 8.1 days (range 3 to 13 days), and 5.1 days (range 2 to 7 days) for complete clinical relief for patients in Groups 1, 2, and 4, respectively. Patients who underwent percutane- ous catheter drainage took only 2.4 days (range 1 to 4 days) on an average to obtain complete clinical relief.

Three patients in Group 1 failed to respond to repeat trial of conservative management with dehydroemetine and two of these were taken up for repeated needle aspira- tions. One of these two patients, having failed to respond to this modality also, subsequently underwent percutane- ous catheter drainage. The third patient had intraperito- neal rupture of the abscess and was taken up for surgical drainage. Three patients who failed to respond to repeat- ed therapeutic needle aspirations underwent percutane- ous catheter drainage and all of them responded to this modality of treatment.

The response observed for patients shifted from one group to the next was similar to that seen in patients placed in the latter group initially. No failure of therapy

F@ura 1. Uttraaonograph showing tube catheter (1) wtth muttlple side holes lying Lndde the abscess cavity (ABS).

was seen with percutaneous catheter drainage or open surgical drainage.

Morbidity of two kinds could be seen after commence- ment of therapy: morbidity and complications attribut- able to the therapy itself, and morbidity resulting from progression of the disease in spite of treatment. Morbidity attributable to therapy primarily included the morbidity invariably associated with surgery, the trauma of repeat- ed needle aspirations (4.5 aspirations on average), and the trauma of percutaneous catheter insertion. No major side effects of drug therapy were seen. In as many as five patients (42 percent) undergoing repeat trial of conserva- tive therapy, there appeared complications attributable to the progression of the disease process in spite of therapy. These were in the form of sympathetic pleural effusions in four patients and intraperitoneal rupture in one. Mor- bidity attributable to the progression of disease in other groups was 23 percent, 7.7 percent, and 33.3 percent in Groups 2, 3, and 4, respectively. Sympathetic pleural effusions appeared in three patients in Group 2, one pa- tient in Group 3, and three in Group 4. Another patient treated with open surgical drainage developed an abdom- inal wall sinus which healed by itself. There was, how- ever, no case of amebis cutis. Two patients with previous-

THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989 59

SINCH AND KASHYAP

TABLE I Resolution of Abscess Cavlty On Ultrasonography

Group

Mean Range (months) (months) Failures

1 5.8 3-9 3

2 5.7 2.5-8.5 3

3 2.8 l-4.5 0

4 3.3 1.2-4 0

ly sterile abscesses developed secondary infection after repeated needle aspirations. However, this resolved on its own without antibacterial treatment.

The mean period of hospital stay after inclusion into the study varied from 16.3 days (range 13 to 36 days) with repeat trial of conservative management to 5.4 days (range 4 to 7 days) with percutaneous catheter drainage. With repeated needle aspirations and open surgical drainage the mean was 14 days (range 9 to 23 days) and 12.75 days (range 3 to 38 days), respectively.

The ultrasonographic follow-up period varied be- tween 6 months to 2 years (median period 11 months). It

Figure 2. wed treatment tree for a case of liver afmess, Astwlsk lndkates no fallure seen byussofar.

60 THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989

took a mean duration of 5.8 months and 5.7 months for complete resolution of abscess cavities in patients treated with drugs alone and with repeated needle aspirations, respectively. Several patients (three each in Groups 1 and 2) had residual cavities. All patients treated with open surgical drainage or percutaneous catheter drainage showed complete resolution of abscess cavities taking 2.8 and 3.3 months on average, respectively (Table I).

COMMENTS Several therapeutic approaches are available for pa-

tients with amebic liver abscess who have failed to re- spond adequately to initial conservative therapy. We set out to compare the various available modalities so as to adopt a uniform treatment policy for such patients.

It has been reported that most patients eventually respond to conservative management alone, a second trial of drug therapy with a different group of drugs being recommended for resistant cases [I]. We chose dehydroe- metine and found that three-fourths of the resistant cases eventually responded. Besides a high failure rate, this modality of treatment is found to suffer from several shortcomings: slow response, morbidity related to pro- gress of the disease even after several days of treatment, and the need for prolonged hospital stay.

Needle aspirations for therapeutic purposes have been recommended since this is easy to perform, multiple smaller abscesses can be aspirated, and decompression of abscesses can be performed [20,25,33]. The therapeutic value of this modality in our study seems doubtful. It has not led to any advantages in terms of clinical relief, hospi- tal stay, morbidity, or rapidity of resolution over conser- vative management alone. The shortcomings of repeated trauma (4.5 aspirations on average) secondary infection (15.4 percent), and the failure to completely aspirate the thick pus often present have led us to abandon this modal- ity, except for the use of a fine-needle aspiration under ultrasound guidance for diagnostic purposes.

Open surgical drainage, a more radical approach, has been seen to have the advantages, particularly in endemic areas, of direct visualization of abscesses and other patho- logic conditions, a thorough and certain emptying of the abscesses, and also obtaining scrapings of abscess wall and tissue for histopathologic examination [21-241. It has the disadvantage of high morbidity, low-cost efficacy, and rather prolonged hospital stay. We have now re- served this modality for intraperitoneally ruptured amebic liver abscesses and an occasional case which may not respond to percutaneous catheter drainage.

Placement of catheters inside abscess cavity blindly or under guidance has been used for various indications [26-28,301. The experience with percutaneous catheter drainage for amebic liver abscesses has been with a very small number of patients. Our experience with percuta- neous catheter drainage has been with a total of 39 ab- scesses in 30 patients; 16 of these abscesses were in the 13 patients included for the prospective, randomized study for comparative evaluation. We have found that under ultrasound guidance with trocar technique, it is an easy

procedure resulting in minimal trauma, rapid clinical relief, short hospital stay, little morbidity, and early and complete resolution of cavity. Patient acceptance is high and the cost of treatment is low.

From this prospective, randomized study we can con- clude that at statistically significant levels (applying Stu- dent’s t test) percutaneous catheter drainage provides the most rapid clinical relief and results in the shortest hospi- tal stay as compared with other modalities. No statistical significance could be assigned to the lower morbidity and failure rates seen with this modality of treatment. Ultra- sonographic follow-up revealed a much faster and more complete resolution of abscess cavities after percutaneous catheter drainage and open surgical drainage compared with conservative therapy and repeated needle aspira- tions.

Based on this study, we have now standardized our treatment policy for liver abscesses (Figure 2). The cases seen by us are mostly those which are referred to us as having been found resistant to drug treatment. Some cases however, presenting as acute abdomen, are found to have impending rupture of the abscess. On ultrasono- graphy the thickness of the liver tissue around the periph- ery of the abscess is markedly decreased. A diagnostic pus aspiration gives an estimate of the pressure inside. In such cases we resort to immediate decompression of the ab scess with the help of percutaneous catheter insertion under antiamebic cover.

As many as 76 percent of the abscesses seen by us have been larger than 6 cm in diameter. Smaller abscess- es probably show a lesser incidence of resistance. How- ever, we have found no difficulty in inserting catheters into abscesses as small as 3.5 cm in diameter, using cathe- ters of suitable diameter.

We have now switched over completely to percutane- ous catheter drainage for all resistant cases of amebic liver abscess and feel that there is much to recommend it.

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