Tubo-ovarian abscess: drainage spared a day in hospital but needed more reintervention

Design

Multicentre, randomised, open-label non-inferiority trial, 19 French hospitals

Population

208 women with tubo-ovarian abscess needing evacuation (130 per protocol)

Primary outcome

Cure at 6 weeks (no reintervention, no new antibiotics, collection resolved)

Effect

72.5% vs 77.0%; difference −4.6 points (95% CI −19.4 to 10.7)

The PACTOL trial randomised 208 women at 19 French hospitals to ultrasound-guided transvaginal drainage or laparoscopy for tubo-ovarian abscess, alongside antibiotics. It aimed to show that drainage was no worse than laparoscopy within a 12.5 percentage point margin.

At six weeks, 72.5% were cured after drainage and 77.0% after laparoscopy. The confidence interval for the difference extended beyond the margin, so non-inferiority was not shown. Reintervention was more common after drainage (13.0% vs 3.3%). Hospital stay was a day shorter with drainage, pain settled faster, and serious complications did not differ.

For the general surgeon who meets a tubo-ovarian abscess at an emergency laparoscopy, or the unit choosing between radiology and theatre, both routes remain reasonable. The trade is a less invasive procedure and a shorter stay against a higher chance of needing a second one. The per-protocol analysis included only 130 of 208 women, which weakens it.

• Offer either transvaginal drainage or laparoscopy for tubo-ovarian abscess, alongside antibiotics, depending on local expertise.
• Tell women choosing drainage that about one in eight needed a further procedure in this trial.
• Involve gynaecology early when a tubo-ovarian abscess is found at emergency surgery for presumed appendicitis.
• Arrange follow-up imaging to confirm the collection has resolved, whichever route is used.

Why it matters

It gives surgeons and patients real numbers for a choice that has mostly been made by habit.

Don't overread it

Non-inferiority was not established, but neither was inferiority — the result is inconclusive rather than negative.

The statistics, in plain English

The difference in cure was −4.6 percentage points, with a 95% confidence interval from −19.4 to +10.7. Because the lower end goes past the pre-set −12.5 margin, the trial cannot rule out that drainage is meaningfully worse — but it also cannot show that it is.

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