Background:
The optimal management of TOA is unclear. Medical management can result in a prolonged clinical course and treatment failure is up to 30%1. However, there is insufficient data on optimal surgical treatment. The aim of this study was to compare medical treatment with surgical treatment to identify characteristics of treatment failure and understand the role and timing of surgery.
Methods:
A retrospective cohort study of all admissions to the Royal Women’s Hospital between 2012-2016 of imaging confirmed tubo-ovarian abscess was performed. Clinical characteristics, treatment modality, outcomes and complications were reviewed.
Results:
Eighty-two clinical files were reviewed and 49 met the study criteria; 19 received medical treatment whilst 30 had surgical management during their treatment course. Sixteen patients underwent same admission surgery, and 14 had delayed surgery. The mean age was 37 years. The main presenting feature was abdominal pain (98%). All patients received intravenous antibiotics as first initial therapy.
In comparison to those who received medical treatment, surgical patients were more likely to be clinically unwell with temperature >38 (36.7% versus 15.8%), have a higher mean white cell count (14.7 x109/L versus 11.5x109/L ) and higher mean C-reactive protein (168.7mg/L versus 97.4mg/L). The main indication for immediate surgery was clinical deterioration, with 25% diagnosed with septic shock or abscess rupture. All patients in the delayed treatment group were discharged on oral antibiotics after first admission. However, there was over 50% representation rate and 28.6% required emergency surgery.
Of patients who had surgery, 86.7% underwent laparoscopy and the remainder had laparotomy. Forty-three percent received drainage and/or washout only and 6.7% had a diagnostic laparoscopy only due to complex surgical findings. There was a 3.3% visceral injury rate. All surgically treated patients were symptom free at discharge.
In the medical group, all patients were discharged home on oral antibiotics. There was a 21% representation rate. Of the 37% who attended follow up, 86% had persistent collections on ultrasound at discharge.
Conclusion: This study suggests that surgery focusing on minimising infective load is associated with more complete resolution of symptoms and low complication rates. Consideration should be given to early surgery as delay may be associated with higher representation rates, emergency surgery and persistent pain. Medical treatment alone is associated with persisting pelvic collection. Data collection is ongoing to continue to appraise patient outcomes.