Prospective randomized comparative study of pigtail catheter drainage versus percutaneous needle aspiration in treatment of liver abscess

Pyogenic liver abscess after Milligan-Morgan hemorrhoidectomy

Milligan-Morgan(M-M) hemorrhoidectomy is regarded as the primary treatment option for patients diagnosed with grade III or IV hemorrhoids. Here, we present the case of a 50-year-old male who developed pyogenic liver abscesses as an unusual complication following M-M hemorrhoidectomy. Severe complications subsequent to hemorrhoid surgery are infrequent. A review of the PubMed database spanning the 30-year period between 1994 and 2024 yielded only four publications documenting patients who experienced liver abscesses following open hemorrhoidectomy. Furthermore, the patient exhibited symptoms of a liver abscess as early as the second day post-surgery, despite having no history of diabetes or liver disease, making this occurrence truly uncommon.

Management of Pyogenic Liver Abscesses: Contemporary Strategies and Challenges

Pyogenic liver abscesses (PLAs) are a suppurative infection of the hepatic parenchyma responsible for significant morbidity and mortality. PLAs are categorized into a variety of mechanisms: (1) via the portal vein, (2) through the biliary tract, (3) via the hepatic artery, (4) from trauma, (5) contiguously via direct extension, and (6) cryptogenically. The pathogenesis of PLA, which informs treatment, can often be discerned based on host factors, clinical presentation, and causative microorganisms. The Streptococcus anginosus group, hypervirulent Klebsiella pneumoniae , and multidrug-resistant gram-negative pathogens have emerged as microbiologically challenging organisms to treat. The identification of hypervirulent K. pneumoniae should prompt for assessment for metastatic spread and consideration of prolonged antimicrobial treatment. Abdominal imaging is indispensable in characterizing PLAs and facilitating source control interventions. Source control remains the most critical aspect of PLA management, followed by antimicrobial therapy. Empiric antibiotics for PLAs are informed by the suspected etiology of PLA formation. Duration of antimicrobial therapy is individualized and dependent on multiple components, including the success of achieving source control, host factors, mechanism of PLA development, and the illness course of the individual-factoring in clinical, biochemical, and radiographic parameters.

Needle Aspiration Versus Catheter Drainage in Medium-Sized (5-10 cm) Liver Abscesses: A Comparative Study in Mumbai, India

Background Liver abscess is a disease known to mankind since ancient times and has been treated by various means. The introduction of radiology-guided interventional drainage procedures has reduced the mortality rate, which forms a significant part of management. However, there is still a dilemma regarding the procedure of choice in medium-sized liver abscesses mainly in resource-limited developing countries. Methods The study was conducted on 60 patients with moderate-sized (5-10 cm) liver abscess/abscesses, liquified, drainable and divided randomly into two groups with 30 patients each and subjected to either Ultrasound-guided needle aspiration or catheter drainage with identical medical treatment. Outcomes were compared within both groups concerning the need for analgesics, total duration of hospital stay, total days of leave from work and recurrence or residual collection. Results Both groups were comparable in age, gender, type of abscess and maximal diameter. The success rate was equal (80% and 84%). However, the need for analgesics, total duration of hospital stay and total days of leave from work showed a significant (p<0.05) decrease in the needle aspiration group with a mean stay of 9.3 ± 3.18 days and mean leave of 18.9 ± 5.13 days as compared to catheter drainage group with the mean of 14.8 ±5.95 days and 32.5 ±11.4 days respectively. Conclusion Based on our study's results, we conclude that percutaneous needle aspiration is a primary interventional treatment in moderate-sized (5-10 cm) liver abscesses. More multicentric and randomised trials should be done to confirm the inference of this study.

Double pigtail tube drainage for large multiloculated pyogenic liver abscesses

Background

This study aims to investigate the efficacy and safety of double pigtail tube drainage compared with single pigtail tube drainage for the treatment of multiloculated pyogenic liver abscesses greater than 5 cm.

Patients and Methods

This study retrospectively analyzed patients with pyogenic liver abscess admitted in the Affiliated Hospital of Chengde Medical College between May 2013 and May 2021. Patients with pyogenic liver abscess more than 5 cm in size, who underwent drainage of the abscess with either double pigtail or single pigtail tube, were included.

Results

A total of 97 patients with pyogenic liver abscesses larger than 5 cm were studied. These included 34 patients with double pigtail tube drainage and 63 patients with single pigtail tube drainage. The postoperative hospital stay (13.39 ± 4.21 days vs. 15.67 ± 7.50 days; P = 0.045), and time for removal of the catheter (17.23 ± 3.70 days vs. 24.11 ± 5.83 days; P = 0.038) were lower in the double pigtail tube group compared with the single pigtail tube group. The rate of reduction, in three days, of c-reactive protein levels was 26.61 ± 14.11 mg/L/day in the double pigtail tube group vs. 20.06 ± 11.74 mg/L/day in the single pigtail tube group (P = 0.025). The diameter of the abscess cavity at discharge was 3.1 ± 0.07 cm in the double pigtail tube group as compared with 3.7 ± 0.6 cm in the single pigtail tube group (P = 0.047). There was no bleeding in any of the patients despite abnormal coagulation profiles. There was no recurrence of abscess within six months of discharge and no death in the double pigtail tube group. Conclusion: Double pigtail tube drainage treatment in multiloculated pyogenic liver abscesses greater than 5 cm in size, is safe and effective.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: an updated systematic review and meta‐analysis

BACKGROUND

Liver abscesses differ in their aetiology, location, and number. Image-guided percutaneous drainage techniques are the currently used management for liver abscesses. We conducted our study to compare the clinical safety and efficacy of percutaneous needle aspiration (PNA) to percutaneous catheter drainage (PCD).

METHODS

A systematic review of major reference databases was undertaken in February 2022 for randomized controlled trials (RCTs) that compare PNA to PCD in treating liver abscess patients. The quality of the included trials was assessed using the Cochrane tool. Statistical meta-analysis was conducted using RevMan and open meta-analyst software.

RESULTS

Fifteen RCTs were included in this review, with 1676 patients enrolled. The overall quality of the included trials was moderate, with most domains of unclear risk. PCD was superior to PNA in the success rate (RR = 1.23; 95% CI [1.12, 1.36], P < 0.00001), time for achieving 50% reduction of cavity size (MD = -2.32; 95% CI [-3.07, -1.57], P < 0.00001), and time for clinical improvement (MD = -1.92; 95% CI [-2.55, -1.28], P < 0.00001). The two modalities did not differ in the days of hospital stay, duration of IV antibiotics, and time needed for total or subtotal reduction of cavity size (P = 0.36, P = 0.06 and P = 0.40, respectively). High heterogeneity levels were detected. Regarding major complications, the two modalities were equally safe (P = 0.39).

CONCLUSION

PCD has a higher success rate and results in a faster 50% reduction in the abscess cavity size and clinical improvement. The two modalities are equally safe.

Large Solitary Pyogenic Liver Abscesses: A Review of Their Management at a Tertiary Care Hospital

Background and objective

Liver abscesses are one of the common surgical diseases to be treated as an emergency in any tertiary care hospital in India. The formation of abscesses in the liver is still a major problem and associated with significant morbidity in developing countries. We come across all types of liver abscesses, such as amoebic (most common), pyogenic, mixed, and occasionally fungal. There have been several studies on the percutaneous modality of treatment for pyogenic liver abscesses. Most of the studies suggest that percutaneous catheter drainage (PCD) offers a better approach than aspirations for treating pyogenic liver abscesses. However, a few recent studies suggest that percutaneous aspiration leads to equally good results when compared to percutaneous drainage. In this study, we aimed to review the management of solitary large pyogenic liver abscesses and to assess the effectiveness of ultrasonography (USG)-guided aspiration in the procedure. 

Methods

A retrospective study was carried out at the Department of General Surgery of our institute. In this study, a total of 27 patients treated for solitary pyogenic liver abscess were included. All patients with a large liver abscess greater than 5 cm without the features of frank peritonitis were included. These patients were followed up regularly for six months.

Results

The single-attempt USG-guided aspiration was successful in 70.3% of patients. Repeat USG-guided aspiration was performed in 18.5% of patients. In 7.4% of patients, a USG-guided percutaneous pigtail catheter was placed. And only 3.7% of cases required exploratory laparotomy. 

Conclusion

Based on our findings, USG-guided aspiration is a fairly efficient method for treating a large solitary pyogenic abscess with acceptable results, shorter hospital stays, and minimal complications.

Efficacy of needle aspiration in patients with oral-maxillofacial abscesses: A retrospective study of 15 consecutive patients

The aim of this study was to determine the adequacy and safety of needle aspiration (NA) as an alternative to open surgical drainage for oral-maxillofacial abscesses. Fifteen consecutive patients who were diagnosed with oral-maxillofacial abscesses via contrast-enhanced CT from January 2020 to December 2020 were included. All patients were on antibiotics and treated with NA under local anaesthesia using a 20 mL syringe. Data collection included patient characteristics, signs and symptoms, physical examinations, laboratory tests, imaging findings, and outcomes. Next-generation sequencing (NGS) was used to identify the infectious microorganisms from the abscess samples. The study included 15 patients with oral-maxillofacial abscesses. None of our 15 patients required surgical incision and drainage, although repeat aspiration was required. However, after the first NA, the pain was reportedly extremely relieved for all patients. The average duration of antibiotic treatment was 9.20 ± 5.15 days (range 4-23 days). The abscess-affected spaces mainly included the masseter space and submandibular space. Odontogenic infection was the most common aetiology in 15 patients (10/15). The average volume of the abscesses on CT was 5866.26 ± 3627.18 mm³. The main pathogens identified in this study were Prevotella oris (5/15), Peptostreptococcus stomatis (4/15) and Porphyromonas endodontalis (2/15). According to the results of our study, the data support the use of NA as an effective, minimally invasive treatment modality for oral-maxillofacial abscesses. Surgeons should familiarise themselves with this technique, as it can easily be performed in the clinic using local anaesthesia, culture samples may be obtained, and airway obstruction and pain may be relieved.

Role of Pigtail Catheter Drainage Versus Percutaneous Needle Aspiration in the Management of Liver Abscess: A Retrospective Analysis

Introduction

A liver abscess is an important health concern in tropical countries. Effective management of liver abscesses includes appropriate antibiotics and drainage of the abscess cavity. Percutaneous abscess drainage by pigtail catheterization is now gaining popularity. We analyzed the role of pigtail catheter drainage over percutaneous aspiration in the treatment of liver abscesses.

Methods and material

This was a retrospective analytical study conducted in a tertiary care center in western India. Patients of age ≥ 18 years admitted with the diagnosis of liver abscess were included in this study. To find the effectiveness of different treatment modalities, data were analyzed in three groups: Group A (Conservative treatment), Group B (Percutaneous needle aspiration), and Group C (Pigtail catheter drainage).

Results

A total of 64 patients with a liver abscess were analyzed. There was male predominance (93.75%). Mean abscess volume in Group C (307.9 ± 212.8 ml) was significantly higher when compared to Group A (130.8 ± 72.9 ml, p = 0.03) and Group B (177.2 ± 129.5; p = 0.024). The duration of hospital stay and residual abscess volume at the time of discharge did not show a statistically significant difference between treatment groups. Pigtail catheterization of abscesses with volume >150 ml shortened the hospital stay, whereas it prolonged the hospital stay in patients with abscess volume <150 ml.

Conclusion

Percutaneous pigtail catheterization would be an operative decision for the management of liver abscess. We concluded that the use of pigtail catheterization of patients with abscess volume > 150 ml improved the clinical outcome.

Bleeding risk of image-guided percutaneous catheter drainage of pyogenic liver abscess in patients with coagulopathy

OBJECTIVE

Percutaneous catheter drainage (PCD) is the mainstream treatment for pyogenic liver abscess (PLA). However, in some patients with severe coagulopathy, there may increase the risk of bleeding complications related to PCD. Therefore, this study was aimed to evaluate the incidence of bleeding complications of PCD in PLA patients complicated with coagulopathy.

METHODS

Between January 2011 and September 2019, patients diagnosed with PLA who had undergone PCD were selected retrospectively. Based on the preoperative coagulation parameters, the patients were divided into the coagulopathy group (PLT ≤ 50 × 10⁹/L or INR ≥ 1.5) and the normal coagulation group. The major and minor bleeding complications related to PCD were compared between the two groups. The ICU occupancy and mortality rates in the coagulopathy group were assessed and compared with patients of normal coagulation group.

RESULTS

A total of 583 PLA patients subjected to PCD were selected. 522 patients were finally included in this study: 64 cases (12.26%) in the coagulopathy group and 458 cases (87.74%) in the normal coagulation group. No major bleeding complications related to PCD was observed. Two patients (0.38%) of minor bleeding complications, one patient in each group, showed no statistically significant difference (0.2% vs.1.6%, P > 0.05). The ICU occupancy rate of coagulopathy group was significantly higher than normal coagulation group (6.2% vs. 0.7%, P < 0.05). No significant difference in mortality rate was noted between the two groups (4.7% vs.1.5%, P > 0.05).

CONCLUSION

The incidence of bleeding complications related to PCD in PLA patients is rare even if complicated with coagulopathy.

Management Practices and Predictors of Outcome of Liver Abscess in Adults: A Series of 1630 Patients from a Liver Unit

BACKGROUND

The management practices of liver abscess (LA) have evolved over time. The precise diagnosis of etiology and complications is pivotal for appropriate management.

METHODS

Descriptive analyses of consecutive patients treated for LA using electronic medical records at a liver unit between years 2010 and 2020 and investigate relationships between clinical, imaging, laboratory and microbiological findings, treatment strategies and mortality.

RESULTS

Of 1630 LA patients, the most common aetiologies were amoebic liver abscess (ALA; 81%) and pyogenic liver abscess (PLA; 10.3%, mainly related to biliary disease and/or obstruction). Abdominal pain (86%) and fever (85.3%) were the commonest presenting symptoms (median duration-10 days). Almost 10% had jaundice at presentation, 31.1% were diabetic, 35.5% had chronic alcohol use and 3.3% had liver cirrhosis. Nearly 54% LA were solitary, 77.7% localized to the right liver lobe (most commonly segment VII/VIII). Patients with large LA (>10 cm, 11.9%) had more frequent jaundice and abscess rupture (p-0.01). Compared with ALA, patients with PLA were older, more often had multiple and bilobar abscesses with local complications. Over four-fifth of the patients received percutaneous interventions (catheter drainage [PCD; 36.1%] alone and needle aspiration [PNA] plus PCD [34.1%] as most common). Fifty-eight patients underwent endoscopic retrograde cholangiography for intrabiliary abscess rupture (n = 36) or cholangitic abscess (n = 22). The median duration of hospital stay and PCD were 7 (4-10) days and 5 (4-8 days), respectively. The overall in-hospital mortality was 1.1%. Presence of septic encephalopathy (HR: 20.8; 95% CI: 1.9-220.7; p-0.012), liver cirrhosis (HR: 20.1; 95% CI: 2.7-146.9; p-0.003) and jaundice (HR: 7.6; 95% CI:1.7-33.1; p-0.006) were independent predictors of mortality.

CONCLUSIONS

The commonest presentation was middle age male with right lobe solitary ALA. Patients with large, bilobar and/or pyogenic abscess had more complications. Nearly 70% patients require percutaneous interventions, which if given early improve treatment outcomes. Presence of jaundice, liver cirrhosis and septic encephalopathy were independent predictors of mortality.

Prospective randomized comparative study of percutaneous catheter drainage and percutaneous needle aspiration in the treatment of liver abscess

BACKGROUND

This study aimed to assess the effectiveness and safety of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the treatment of liver abscess.

METHODS

A prospective randomized study was conducted in the Department of Surgery, JN Medical College, Aligarh Muslim University, Aligarh, UP, India, between February 2018 and August 2019, after getting approval from the institutional ethics committee. A total of 543 patients with liver abscess were randomized into two groups using computer-generated randomization method. Appropriate details regarding patients' clinico-demographic profile and investigations were also collected. The effectiveness of either treatment was measured in terms of duration of intravenous antibiotic, clinical improvement, reduction in the size of cavity, treatment success rate, duration of hospital stay including long-term outcomes such as sonographic resolution of cavity and recurrence rate at 6 months post-treatment.

RESULTS

The PCD group had statistically significant rate of duration of antibiotics need, days for clinical improvement and time for 50% reduction in abscess cavity and treatment success rate with comparable long-term outcomes.

CONCLUSION

PCD is more efficient than PNA and can be used primarily in the treatment of both amoebic and pyogenic liver abscesses along with systemic antibiotics. However, PNA can serve as a safe alternative when PCD is not available.

Percutaneous fine-needle aspiration for pyogenic liver abscess (3-6 cm): a two-center retrospective study

BACKGROUND

The role of ultrasonography-guided percutaneous fine-needle aspiration (PNA) for pyogenic liver abscess (PLA) remains without consensus, especially in abscesses 3 to 6 cm in diameter. The objective of this study was to evaluate the comparative effectiveness and safety of PNA combined with antibiotics.

METHODS

This was a retrospective study of patients with PLA that were from 3 to 6 cm in diameter who treated at two medical centers in Shanghai, China, from January 2014 to March 2019. Patients were divided into groups treated by PNA plus antibiotics or antibiotics alone. Patients demographics and clinical data related diagnosis, antibiotic treatment, and patient outcomes were analyzed.

RESULTS

Out of a total of 94 PLA patients, 42 (44.7%) patients received PNA combined with antibiotics, and 52 (55.3%) received antibiotics alone. There were no complications related to PNA. In the PNA group, 13 (31.7%) patients with negative blood culture and 8 (19.5%) patients without blood culture were microbiologically confirmed via aspiration. The time for temperature normalization (P < 0.001) and the reduction rate of C-reactive protein within the first week (P = 0.031) were significantly lower in the PNA group. In the multivariate analysis, treatment with PNA was more likely to result in clinical improvement of PLA (odds ratio = 0.33, 95% confidence intervals (CI): 0.11-0.96, P = 0.043).

CONCLUSIONS

PNA combined with antibiotics appears to be a safe, effective, and promising treatment for PLA of 3-6 cm in size. Furthermore, the technique allows for direct microbial sample, which can improve the selection of antibiotics.

Entamoeba histolytica and amoebic liver abscess in northern Sri Lanka: a public health problem

Entamoeba histolytica (E. histolytica) is a facultative protozoan parasite implicated in amoebic liver abscesses (ALA), the most common extraintestinal manifestation of this infection. E. histolytica is endemic to sub-tropical and tropical countries and has been a major public health concern in northern Sri Lanka (SLK) for the last three decades. This has been attributed to a multitude of factors such as poor sanitation, hygiene, male sex, middle age, overcrowding, unsanitary practices in the production of indigenous alcoholic beverages, and alcohol consumption. Additionally, while rates of E. histolytica have declined substantially throughout the rest of the island, largely due to better infrastructure, it remains pervasive in the northern peninsula, which is generally less developed. Infection arises primarily from fecal-oral transmission through the consumption of contaminated drinking water containing cysts. Upon ingestion, cysts multiply into trophozoites and colonize the host colonic mucosa using lectin and cysteine proteases as virulence factors, leading to host invasion. Symptoms occur along a spectrum, from asymptomatology, to pyrexia, abdominal cramping, and amoebic dysentery. Colonization of the colon results in the formation of distinct flask-shaped ulcers along the epithelium, and eventual penetration of the lamina propria via the production of matrix metalloproteinases. ALA then develops through trophozoite migration via the mesenteric hepatic portal circulation, where microabscesses coalesce to form a single, large right-lobe abscess, commonly on the posterior aspect. The progression of infection to invasive disease is contingent on the unique interplay between host and pathogen factors, such as the strength of host-immunity to overcome infection and inherent pathogenicity of the Entamoeba species. As a preventable illness, E. histolytica complications such as ALA impose a significant burden on the healthcare system. This mini-review highlights epidemiological trends, risk factors, diagnostic modalities, treatment approaches, and opportunities for prevention of E. histolytica-induced ALA, to help address this endemic problem on the island of SLK.