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Management of ruptured amoebic liver abscess: can we afford surgical drainage today?
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  1. Ramesh Kumar1,
  2. Rajeev Nayan Priyadarshi2,
  3. Utpal Anand3
  1. 1 Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
  2. 2 Radiodiagnosis, All India Institute of Medical Sciences, Patna, Bihar, India
  3. 3 Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
  1. Correspondence to Dr Ramesh Kumar, Gastroenterology, All India Institute of Medical Sciences, Patna 801505, India; docrameshkr{at}gmail.com

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We read with great interest the article by Trillos-Almanza and Restrepo Gutierrez1 that provides a comprehensive review on the management of liver abscess. In the algorithm for management of ruptured amoebic liver abscess (ALA), the authors have advocated an immediate surgical drainage unless the rupture is contained. Because ALA is highly endemic in many states of India, we have a considerable experience on managing such patients and we would like to share our view on this aspect.

Surgical drainage used to be the choice of treatment modalities for ruptured ALA in the past. The first published report came in 1982, in which Egglestonet al 2 reported a mortality rate of 42% following surgical therapy in 19 patients who had ruptured ALA with intraperitoneal spread. In the subsequent studies, the mortality rates following surgical drainage of freely ruptured ALA varied from 26% to 50%.3 Although with the improvements in surgical techniques, anaesthesia and postoperative critical care, the mortality rates have improved from 50% in year 1989 to 26% in year 2017, it is still considerably high.3 Patients with ruptured ALA are usually sick, malnourished, hypoalbuminemic and have systemic inflammatory response, which may get worsened after surgery leading to poor outcomes. Ultrasound-guided percutaneous catheter drainage (PCD) is now accepted as standard of care for management of complicated ALA. It is minimally invasive, easily accessible, less expensive, safe and effective with high success rate.3 The contents of ruptured ALA are mostly sterile brown acellular debris, which are easily amenable to drainage in the hands of experienced radiologists. Ken et al 4 were the first to demonstrate the successful treatment with PCD in five severely ill patients with ruptured ALA. Our group has recently published a large study on 117 patients with ruptured ALA successfully managed by ultrasound-guided PCD. Notably, 32 (27.3%) such patients had free intraperitoneal rupture with diffuse spread and despite complex septations, majority of them could be treated with PCD with success rate of 97% and mortality rate of only 3%.5 Patients with free rupture required more catheters and longer hospital stay compared with those with contained rupture. In other studies too, where patients had diffuse intraperitoneal rupture, the mortality rates following PCD varied form 0% to 5% with excellent success rates.3 Thus, surgery in such patients appears to cause more harm than good.

Therefore, we would like to conclude that PCD should be the preferred option in all patients with ruptured ALA, whether contained or free, and surgical drainage should be reserved for the rare instance where adequate drainage in not achievable with PCD.

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Footnotes

  • Contributors RK: concept, literature review and draft writing. RNP: literature review and draft writing. UA: concept and critically revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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