Outcome Analysis of Conservative Management With Pigtail Catheter Insertion in Intraperitoneal Rupture of Liver Abscess: A Prospective Observational Cohort Study

Technical Summary: Outcome Analysis of Conservative Management with Pigtail Catheter Insertion in Intraperitoneal Rupture of Liver Abscess

Problem Statement
Intraperitoneal rupture of a liver abscess is a life-threatening complication where purulent material breaches the hepatic capsule, leading to secondary peritonitis, sepsis, and multi-organ dysfunction. Traditionally, this condition has been managed via exploratory laparotomy with abscess drainage and peritoneal lavage. However, surgical intervention is invasive, requires general anesthesia, and carries high morbidity and mortality rates, particularly in critically ill or high-risk patients. While ultrasound-guided percutaneous drainage has emerged as a less invasive alternative for uncomplicated abscesses, its specific effectiveness in managing ruptured cases—where significant peritoneal contamination exists—has not been extensively studied. There is a need to evaluate whether a conservative, minimally invasive approach can serve as a viable first-line treatment to reduce surgical morbidity and mortality.

Methodology
This study was a prospective, observational cohort study conducted over 18 months (July 1, 2023, to December 31, 2024) at the Department of General Surgery, SBKS Medical Institute and Research Centre, Vadodara, India.

• Cohort: The study included 35 adult patients (≥18 years) with radiologically confirmed pyogenic liver abscesses and overt intraperitoneal rupture. Patients were hemodynamically stable (or stabilized after resuscitation) and provided informed consent.
• Exclusion Criteria: Pregnant/lactating women, hepatobiliary malignancy, un-drainable multiloculated abscesses (>10 cm with >3 non-communicating cavities), decompensated cirrhosis, uncorrectable coagulopathy, prior upper abdominal surgery precluding access, or inability to follow up.
• Intervention Protocol:
  1. Resuscitation & Antibiotics: Immediate fluid resuscitation and empirical intravenous antibiotics (third-generation cephalosporin + metronidazole) within one hour of admission.
  2. Drainage: Ultrasound-guided pigtail catheter insertion (8–12 Fr) under local anesthesia, preferably via a transhepatic approach.
  3. Peritoneal Management: In cases with significant intraperitoneal contamination, a large-bore (36F) peritoneal drain was placed in the right iliac fossa.
  4. Microbiology: Aspirated pus was sent for Gram stain, culture, and sensitivity. Antibiotics were adjusted based on culture results (14 days IV, followed by 7 days oral).
  5. Removal Criteria: Catheters were removed when drainage was <10 mL/day for 48 hours, fever/pain resolved, and abscess size reduced by ≥80% on ultrasound.
  6. Failure Definition: Patients showing no clinical/biochemical improvement within 72 hours were reviewed for rescue laparotomy.
• Follow-up: Patients were monitored fortnightly for two months and monthly for six months to assess complications, recurrence, and mortality.

Key Results

• Demographics: The cohort had a mean age of 46 ± 13 years, with a male predominance (74%). Risk factors included chronic alcohol use (51%) and diabetes (34%).
• Clinical Presentation: Fever (86%) and right-upper-quadrant pain (80%) were the most common symptoms. Right-lobe involvement was predominant (77%).
• Microbiology: Klebsiella pneumoniae was the most common isolate (34%), followed by Escherichia coli (20%). One-third of cultures showed no growth, likely due to prior antibiotic exposure.
• Technical Success: Catheter placement was technically successful in 100% of cases.
• Outcomes:
  • Clinical Success: 91% of patients achieved asymptomatic status without the need for surgery.
  • Mortality: 30-day mortality was 3% (1 patient).
  • Complications: Early complications occurred in 17% of patients (9% catheter blockage, 6% secondary peritonitis, 3% pleural effusion). Late complications occurred in 9% (6% recurrence, 3% incisional hernia).
  • Hospital Stay: The median hospital stay was 5.28 days, with 80% of patients discharged within 5–7 days.

Key Contributions
The study provides prospective evidence supporting a specific, minimally invasive protocol for a condition traditionally treated with major surgery. The primary contribution is the demonstration that a combination of ultrasound-guided pigtail drainage, peritoneal drain placement (for contamination), and targeted intravenous antibiotics can achieve high clinical success rates (91%) and low mortality (3%) in ruptured liver abscesses. The protocol details specific criteria for catheter removal and management of peritoneal contamination, offering a standardized approach for tertiary care centers.

Significance and Claims
The authors claim that this study offers practical evidence supporting a "minimally invasive, cost-effective treatment strategy" for intraperitoneally ruptured liver abscesses. The study concludes that early ultrasound-guided pigtail catheter drainage is a "safe, effective, and practice-changing first-line treatment" for this condition. By avoiding exploratory laparotomy in selected patients, this approach potentially reduces surgical morbidity, shortens hospital stays, and alleviates the healthcare burden, challenging the conventional surgical paradigm for ruptured liver abscesses.