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Salamo RM, Miller J. Quick, Safe, Effective: Ultrasound-Guided Percutaneous Liver Biopsy in the Pediatric Patient. Cardiovasc Intervent Radiol 2024; 47:87-91. [PMID: 38129337 PMCID: PMC10769957 DOI: 10.1007/s00270-023-03631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Percutaneous liver biopsy has proven to be a valuable tool in the workup of pediatric acute liver failure and the management of post-transplant rejection. However, consensus regarding pre-procedure laboratory values and post-procedure monitoring is lacking. OBJECTIVE To characterize the incidence of complications, procedural time, and specimen adequacy for percutaneous liver biopsy in the pediatric patient. METHODS Retrospective review of percutaneous liver biopsies at a single institution was performed for a 5-year span. Procedural notes and anesthesia records were sampled for patient weight and procedural factors across a continuous 6-month period, as well as for the subgroup of patients under 24 months of age. A representative continuous subset of pathology reports comprising 376 patients were reviewed for estimation of specimen adequacy. RESULTS Eight hundred and sixty-seven ultrasound-guided percutaneous liver biopsies were performed in a 5-year period, 450 of which were in the post-transplant setting with about a 3:1 ratio of split: whole liver transplant. Patient ages ranged from 1 month to 21 years old, with weight ranging from 2.7 to 125 kg. Of the 376 pathology reports available, none were found to be inadequate for evaluation. Two major complications occurred, both of which were biliary leaks in the setting split-liver transplant. There were no incidences of post-procedure hemorrhage. Of the sample reviewed, mean "skin-to-skin" procedure time was under 8.5 min (median of 7 min). Solely among transplant patients, biopsies for split livers averaged 9.2 min, biopsies for whole livers averaged 6.2 min (two-tailed independent t test, p = 0.0426). CONCLUSION Ultrasound guided percutaneous liver biopsy is fast, useful, and safe in pediatric patients on an outpatient basis with same day discharge. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Russell M Salamo
- Department of Radiology, LAC+USC Medical Center, 2051 Marengo St., Los Angeles, CA, 90033, USA.
| | - Joseph Miller
- Department of Radiology, Children's Hospital Los Angeles, USC, Los Angeles, CA, USA
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Smayra K, Miangul S, Yap N, Shi A, Abdulsalam F, Adra M, Nakanishi H, Ball J, Betts TA, Than CA, Parthipun A. Technical Success, Sample Adequacy, and Complications of Pediatric Transjugular Liver Biopsy: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:3846-3856. [PMID: 37555881 PMCID: PMC10517041 DOI: 10.1007/s10620-023-08071-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/23/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Transjugular liver biopsy (TJLB) procedurally samples liver tissue through the internal jugular vein. It is indicated in the presence of coagulopathies and/or ascites. AIMS This meta-analysis aimed to assess the safety and efficacy of TJLB in children. METHODS A literature search of several databases was conducted from inception to August 2022. Eligible studies reported pediatric patients (< 18 years old) who underwent TJLB. The pooled proportion was analyzed using a random-effects model. This review was registered in PROSPERO (CRD42022354421). RESULTS From 921 initial studies screened, eight met the eligibility criteria, with a total of 361 pediatric patients who underwent 374 TJLBs. All eight studies reported pooled rates of technical success at 99.1% (95% CI 0.982, 1.001; I2 = 0%) and histological adequacy of sampling at 97.5% (95% CI 0.954, 0.995; I2 = 27.66%). A total of 49 complications were reported across six studies, the most common being bleeding from the entry site (38.78%), fevers for less than 24 h (12.24%), red blood cells transfusion requirement (10.2%), supraventricular tachycardia (8.16%), and pain requiring analgesia (8.16%). CONCLUSION Pediatric TJLB demonstrates high rates of technical success and adequate liver core biopsy samples, with a low rate of complications. These results suggest that TJLB is an effective method for diagnostic yield and postprocedural outcomes, especially in patients with preexisting coagulopathies and ascites where percutaneous liver biopsy is contraindicated. Additional studies evaluating larger groups of pediatric patients may provide further support for the use of TJLB in this population.
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Affiliation(s)
- Karen Smayra
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Shahid Miangul
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Nathanael Yap
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Ao Shi
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Fatma Abdulsalam
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Maamoun Adra
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Hayato Nakanishi
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Jake Ball
- Department of Medical Imaging, John Hunter Hospital, Newcastle, Australia
- Faculty of Health, University of Newcastle, Newcastle, Australia
| | - Tara A Betts
- Cardiff and Vale University Health Board, Heath Park, Cardiff, CF14 4XW, UK
| | - Christian A Than
- St George's University of London, London, SW17 0RE, UK.
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus.
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, QLD, 4072, Australia.
| | - Aneeta Parthipun
- Guy's, St. Thomas' and Evelina Children's Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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Reis J, Koo KSH, Shivaram GM, Shaw DW, Monroe EJ. Safety of Periprocedural Antithrombotics during Pediatric Transplant Liver Biopsies. J Vasc Interv Radiol 2023; 34:460-465. [PMID: 36521790 DOI: 10.1016/j.jvir.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/16/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022] Open
Abstract
The purpose of this study was to compare the adverse event (AE) rates of percutaneous pediatric transplant liver biopsies in patients receiving periprocedural antithrombotic agents with those in patients not receiving them. A 19-year retrospective single-center study of ultrasound-guided transplant liver biopsies was conducted. Patients who received aspirin for <5 days (n = 51) or heparin <4 hours (n = 15) before biopsy were separately grouped. AEs were reported using the Society of Interventional Radiology classification. In 276 biopsy samples from patients with a mean age of 6.75 years ± 5.80, the overall AE (P = .72) and moderate AE (P = .78) rates for control and antithrombotic groups were not significantly different. No severe AEs or deaths occurred. In conclusion, aspirin continuation during percutaneous pediatric transplant liver biopsies may be safe, but more studies are necessary to confirm the safety of periprocedural heparin.
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Affiliation(s)
- Joseph Reis
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington.
| | - Kevin S H Koo
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Giri M Shivaram
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Dennis W Shaw
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Eric J Monroe
- University of Wisconsin Health Services, Madison, Wisconsin
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Giri S, Agrawal D, Gopan A, Varghese J, Tripathy T. Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis. Acta Radiol 2023; 64:1775-1782. [PMID: 36694955 DOI: 10.1177/02841851231151513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Percutaneous liver biopsy is the gold standard test for the assessment of liver disease. In patients with coagulopathy, ascites, post-transplantation, and hypervascular tumors, biopsy is associated with increased risk of adverse events (AEs). Transjugular liver biopsy (TJLB) is recommended in these conditions but is expensive and unavailable at many centers. Plugged liver biopsy (PLB) provides an alternate diagnostic modality in these high-risk cases. PURPOSE To analyze the pooled diagnostic outcome and safety of PLB in high-risk cases. MATERIAL AND METHODS A literature search of various databases from January 1990 to July 2022 was conducted for studies evaluating the outcome of PLB in high-risk cases. The primary outcomes were pooled sample adequacy and AEs. Pooled event rates across studies were expressed with summative statistics. RESULTS A total of 17 studies (2329 patients) were included in the meta-analysis. The pooled proportion of sample adequacy was 98.9% (95% confidence interval [CI]=98.2-99.6). Severe AEs, major bleeding, and minor AEs were seen in 0.7% (95% CI=0.1-1.3), 0.4% (95% CI=0.1-0.8), and 11.5% (95% CI=2.4-20.6) of the patients. There was only one reported mortality, giving a pooled incidence of 0.0002% (95% CI=0.0-0.0038). Compared to TJLB (5 studies, n = 336), there was no difference in either sample adequacy (odds ratio [OR]=2.34, 95% CI=0.83-6.58) or risk of serious AEs (OR=0.47, 95% CI=0.173-1.31). CONCLUSION PLB can be safely performed on patients with coagulopathy and/or ascites with high sample adequacy rates and low incidence of AEs and mortality.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Dhiraj Agrawal
- Department of Gastroenterology, PACE Hospital, Hyderabad, India
| | - Amrit Gopan
- Department of Gastroenterology, 29549Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Jijo Varghese
- Department of Gastroenterology, KM Cherian Institute of Medical Sciences, Kallissery, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
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Padua H, Cahill AM, Chewning R, Himes EA, Kukreja K, Kumar R, Marshalleck F, Monroe E, Patel S, Samelson-Jones BJ, Shaikh R. Appendix to the Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions: Pediatric Considerations. J Vasc Interv Radiol 2022; 33:1424-1431. [PMID: 35842024 DOI: 10.1016/j.jvir.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To provide guidance on the use of anticoagulant and antithrombotic agents in pediatric patients undergoing interventional radiology procedures. MATERIALS AND METHODS A multidisciplinary writing group conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were developed for procedural risk and medication dosage and withholding. A modified Delphi technique was used to achieve consensus agreement on the recommendations. RESULTS A total of 24 studies, including systematic reviews and meta-analyses, randomized controlled trials, and prospective and retrospective cohort studies, were identified as relevant. The expert writing group agreed on procedural risk categorization, laboratory testing thresholds, and medication dosage and withholding recommendations specific to pediatric practice. They additionally described the nuances of anticoagulation in clinical conditions specific to pediatrics. CONCLUSIONS The Society of Interventional Radiology recommends following the guidance provided in the document when developing multidisciplinary management protocols for anticoagulation and antithrombotic treatment in pediatric patients undergoing interventional radiology procedures.
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Affiliation(s)
- Horacio Padua
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Anne Marie Cahill
- Department of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rush Chewning
- Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Kamlesh Kukreja
- Department of Radiology (K.K.), Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Francis Marshalleck
- Department of Radiology, Indiana University Health-Riley Hospital for Children, Indianapolis, Indiana
| | - Eric Monroe
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Sheena Patel
- Society of Interventional Radiology, Fairfax, Virginia
| | - Benjamin J Samelson-Jones
- Division of Hematology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Raja Shaikh
- Division of Interventional Radiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Maria A, Lal BB, Khanna R, Sood V, Mukund A, Bajpai M, Alam S. Rotational thromboelastometry-guided blood component use in cirrhotic children undergoing invasive procedures: Randomized controlled trial. Liver Int 2022; 42:2492-2500. [PMID: 35977053 DOI: 10.1111/liv.15398] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/28/2022] [Accepted: 08/12/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS This randomized controlled trial (RCT) was conducted with the aim to evaluate the efficacy and safety of using ROTEM-based transfusion strategy in cirrhotic children undergoing invasive procedures. METHODS This was an open-label, RCT which included (i) children under 18 years of age with liver cirrhosis; (ii) INR between 1.5 and 2.5; and/or (iii) platelet count between 20 × 109 /L and 50 × 109 /L (for procedures other than liver biopsy) and between 40 × 109 /L and 60 × 109 /L (for liver biopsy); and (iv) listed for invasive procedures. Stratified randomization was done for children undergoing liver biopsies. Patients randomized to the ROTEM and conventional groups received blood component transfusion using predefined criteria. RESULTS A total of 423 invasive procedures were screened for inclusion of which 60 were randomized (30 in each group with comparable baseline parameters). The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group (p < .001). The requirement of FFP (ROTEM: 43.3%, Conventional: 83.3%, p = .001) was significantly lower in the patients receiving ROTEM-guided transfusions. There was no difference in procedure-related bleed and transfusion-related complications between the two groups. ROTEM was cost-effective (p = .002) despite the additional cost of the test. CONCLUSION ROTEM-based transfusion strategies result in lower blood component transfusion in cirrhotic children undergoing invasive procedures without an increase in risk of procedure-related bleed. ROTEM-guided transfusion strategy is cost-effective.
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Affiliation(s)
- Arjun Maria
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant B Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Lal BB, Sood V, Rastogi A, Mukund A, Khanna R, Sharma MK, Alam S. Safety, Feasibility, Yield, Diagnostic and Prognostic Implications of Transjugular Liver Biopsy in Children and Adolescents. J Pediatr Gastroenterol Nutr 2021; 73:e109-e114. [PMID: 34310440 DOI: 10.1097/mpg.0000000000003249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objectives of the study were to evaluate the indications, feasibility, complications and clinical implications of transjugular liver biopsy (TJLB) in children. METHODS Data of all TJLB performed in children <18 years old was retrieved from the computerized hospital information system. TJLB was done using a 19 G quick-core needle biopsy system with 20 mm throw length. Hepatic venous pressure gradient was additionally measured in children with portal hypertension. A single pathologist reviewed all the biopsies again and provided structured information. RESULTS A total of 102 children, including 5 with acute liver failure underwent TJLB with technical success in 101 (99%). A mean of 2.3 ± 0.9 passes (range: 1-5) was taken for the biopsy. The most common indications for TJLB in our cohort were elevated international normalized ratio >1.5 (66, 64.7%), ascites (46, 45.1%) and thrombocytopenia (platelet count < 60,000/mm3) (42, 41.2%). Mean size of the tissue received was 14.5 ± 5.6 mm with an average of 10.2 ± 4.7 portal tracts. Only one child developed major (category D) complication (hemobilia) and 12 (11.8%) developed minor complications post-procedure. Etiological diagnosis could be made in a total of 64 (63.9%) children undergoing TJLB, the most common diagnosis being autoimmune hepatitis (n = 31), non-cirrhotic portal fibrosis (n = 16) and drug-induced liver injury (n = 4). CONCLUSION TJLB is well tolerated, feasible and helps make a diagnosis in close to 64% children allowing timely medical and/or surgical intervention. It is especially useful for diagnosis of autoimmune liver diseases, drug-induced liver injury and non-cirrhotic portal fibrosis.
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Affiliation(s)
| | | | | | | | | | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Maji P, Malik R, Madhusudhan KS, Sharma S. Utility and Safety of Transjugular Liver Biopsy in Children. Indian J Pediatr 2021; 88:709-711. [PMID: 33533007 DOI: 10.1007/s12098-020-03650-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Transjugular liver biopsy (TJLB) is widely used in adults when percutaneous liver biopsy (PLB) is contraindicated. The authors evaluated the safety, efficacy and utility of TJLB in pediatric patients with contraindications to PLB. Twenty-three children and adolescents (13 male) underwent 24 (one patient had two separate biopsies) consecutive biopsies (TJLB) under general anaesthesia (18) or intravenous sedation (6). PLB was contraindicated because of elevated prothrombin time (PT)/international normalized ratio (INR) (˃ 15.5/1.5) in 19 (79.2%) and thrombocytopenia (< 60,000/dL) in 15 (62.5%) procedures. Derangement in both INR and platelet count were found in 12 (50%) cases. Significant ascites was present in 10 (41.7%) procedures. Technical success rate with adequate biopsy sample was 95.8% (23/24) with no major complications. A new diagnosis was established in 9 (37.5%) cases. Another 14 (58.34%) biopsies confirmed the initial diagnoses. Four cases also revealed additional information guiding overall management and prognosis. Thus, TJLB is a safe and useful procedure in children.
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Affiliation(s)
- Prabir Maji
- Division of Gastroenterology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rohan Malik
- Division of Gastroenterology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - K S Madhusudhan
- Department of Radiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sanjay Sharma
- Department of Radiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Lavian JD, Thornton LM, Zybulewski A, Kim E, Nowakowski SF, Ranade M, Patel RS, Lookstein RA, Fischman A, Bishay V. Safety of percutaneous versus transjugular liver biopsy: A propensity score matched analysis. Eur J Radiol 2020; 133:109399. [PMID: 33202374 DOI: 10.1016/j.ejrad.2020.109399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE This study sought to identify the complication, mortality, and readmission rates of patients undergoing either percutaneous (PCLB) or transjugular liver biopsy (TJLB) when propensity matched for demographics and hepatic comorbidities. METHODS A retrospective review of New York's Statewide Planning and Research Cooperative System ICD9 coded database from the years 2009-2013 was conducted. Patients over the age of 18 undergoing either PCLB or TJLB were included. Patients with hepatic neoplasm or metastasis were excluded. 2:1 PCLB:TJLB propensity match for age, race, payment, coagulopathy, thrombocytopenia/purpura, hypercoagulability, ascites, acute liver failure, chronic hepatitis, cirrhosis, and bone marrow disease was conducted. Univariate analysis compared demographics, complications, readmissions, and mortality. RESULTS 1467 patients met inclusion criteria (PCLB = 978, TJLB = 489). Propensity match was successful in that there were no significant differences in demographics or hepatic comorbidities. TJLB had significantly lower rates of hematoma (0.20 % vs 1.20 %, p = 0.049) and higher rates of cardiac complications (0.40 % vs 0.00 %, p = 0.045). Other complication, readmission, and mortality rates did not differ significantly. Logistic regression found no significant predictors of readmission within 7 days or any complication within 5 days. CONCLUSION This retrospective, multi-center database review of adult patients undergoing PCLB or TJLB propensity matched for demographics and hepatic comorbidities found that TJLB patients had a significantly higher rate of cardiac complications while PCLB patients had a significantly higher rate of hematoma. These findings support prior literature suggesting a trend towards safety of TJLB compared to PCLB in patients with hemostatic disorders and/or advanced liver disease.
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Affiliation(s)
- J D Lavian
- Department of Diagnostic and Interventional Radiology, State University of New York ‑ Downstate Medical Center, Brooklyn, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - L M Thornton
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - A Zybulewski
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - E Kim
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - S F Nowakowski
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - M Ranade
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - R S Patel
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - R A Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - A Fischman
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - V Bishay
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; State University of New York, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, USA; Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
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Abstract
PURPOSE OF REVIEW Over the past decade, imaging modalities and serological tests have emerged as important tools in the evaluation of liver diseases, in many cases supplanting the use of liver biopsy and histological examination. Nonetheless, the accuracy and diagnostic value of these methods may not always be conclusive and the assessment of liver histology often remains the gold standard for diagnostic evaluation. The purpose of this review is to summarize the current role of liver biopsy in contemporary hepatology practice. RECENT FINDINGS Technical factors were found to influence the diagnostic value of liver biopsy and histological examination of the liver, including specimen number and size (preferably ≥3 nonfragmented specimens of >20 mm in length), needle diameter (1.6 mm Menghini), number of passes (mean 2.5), imaging-guidance, and operator experience. Liver biopsy was demonstrated to be diagnostically valuable in the evaluation of persistently abnormal liver tests of unclear cause, with histology pointing to a specific diagnosis in 84% of patients. Although coagulation abnormalities continue to be an important concern when performing liver biopsy, their influence on complication risk remains unclear. Implementation of less stringent preprocedural coagulation thresholds decreased preprocedural transfusions without increasing the bleeding rate. Serious complications associated with percutaneous liver-biopsy (PLB) and transjugular liver-biopsy are similar, but pain appears to be more common with PLB. SUMMARY Histopathological evaluation continues to be fundamentally important in assessing hepatic disease, and liver histology remains the most accurate approach to assess fibrosis and assign prognosis.
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Affiliation(s)
- Ali Khalifa
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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Transjugular Versus Percutaneous Liver Biopsy in Children: Indication, Success, Yield, and Complications. J Pediatr Gastroenterol Nutr 2020; 70:417-422. [PMID: 31821233 DOI: 10.1097/mpg.0000000000002587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVE Percutaneous biopsy (PB) and transjugular liver biopsy (TJLB) are 2 main ways of obtaining liver tissue. We evaluated the indications, success rate, tissue yield, and complications of TJLB in comparison to PB in children. METHODS Electronic records of children undergoing liver biopsy (LB) were reviewed. Clinico laboratory data including indication, type of biopsy, complications, and tissue yield (length and number of complete portal tracts [CPT]) were noted. RESULTS Five hundred forty LB (indication: neonatal cholestasis [42.9%], chronic liver disease [43.7%], liver failure [3.7%], focal lesions [3.3%] and others [6.3%]) were done. Four hundred seventy-three were PB (317 boys, 14 [1--216] months) done by percussion (322 [68%]), real-time ultrasound guidance (125 [26.4%]), or plugged method [26 (5.5%)]. Sixty-seven (12.4%) were TJLB [38 boys, 140 (24--216) months], done in patients with contraindications for PB. Technical success (67/68 vs 473/473; P = 0.7) and complications (4 [6%]; vs 15 [3.3%]; P = 0.2) of TJLB and PB were similar. Major complications (0.5%) included supraventricular tachycardia (n = 1) in TJLB and hemoperitoneum (n = 2) in PB. Tissue yield of TJLB was poorer in terms of length (1.0 [0.2--2.0] vs 1.1 [0.4--2.1] cm; P < 0.001), CPT (4 [0--9] vs 5 [2--17]; P < 0.001) and adequacy for reporting (56/67 vs 459/473; P < 0.001). Biopsy yield of <6 CPT was predicted by cirrhosis at histology and TJLB. No factor identified risk of complications with LB. CONCLUSIONS LB is a safe procedure and only 12% children require TJLB because of contraindications of PB. Technical success and complications are similar but tissue yield is poorer in TJLB than PB. Presence of cirrhosis and TJLB adversely affected tissue yield.
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Transjugular Liver Biopsy Following Left Lobe or Lateral Segment Transplantation in Pediatric Patients. Cardiovasc Intervent Radiol 2019; 42:1545-1550. [DOI: 10.1007/s00270-019-02301-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 02/08/2023]
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Transjugular Liver Biopsy Versus Percutaneous Liver Biopsy With Tract Embolization in Children With Coagulopathy. J Pediatr Gastroenterol Nutr 2019; 68:e71. [PMID: 30676524 DOI: 10.1097/mpg.0000000000002289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Srinivasan A, Guzman AK, Rand EB, Rychik J, Goldberg DJ, Russo PA, Cahill AM. Percutaneous liver biopsy in Fontan patients. Pediatr Radiol 2019; 49:342-350. [PMID: 30506328 DOI: 10.1007/s00247-018-4311-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/06/2018] [Accepted: 11/09/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients who have undergone the Fontan operation for palliation of congenital heart disease with single-ventricle pathophysiology are at high risk for developing progressive liver fibrosis. Pathological assessment from percutaneous liver biopsy is central to the management of Fontan-associated liver disease, but liver biopsy in this vulnerable population poses unique challenges and potential risks. OBJECTIVE This retrospective study describes our experience with percutaneous liver biopsy performed to assess changes of Fontan-associated liver disease, with particular regard to procedural outcomes. MATERIALS AND METHODS Data from liver biopsy procedure reports, pathology reports, cardiac angiography pressure measurements and laboratory values of patients with single ventricle heart disease after the Fontan operation who underwent ultrasound-guided percutaneous liver biopsy performed in interventional radiology at a pediatric tertiary care center during a 3-year period were retrospectively analyzed. RESULTS Sixty-eight liver biopsies were performed in 67 patients (mean age: 20.2 years, range: 7.2-39 years). The technical success rate was 100%, and tissue was adequate for assessing liver disease in 100% of the procedures, including biopsies performed with a single pass. Anticoagulation was routinely suspended before biopsy, and no cardiac complications were encountered due to this suspension. A coaxial biopsy system using an 18-gauge (G) full-core instrument through a 17-G introducer trocar was most commonly used, in 41/68 cases (60%). The most common trough length was 2.3 cm, used in 37 cases (54%). One pass was made in 27 procedures (40%) and two passes in 30 (44%); tract embolization with gelatin sponge was performed in 52 (76%). The only complication was hemorrhage, which occurred in 5/68 (7.4%) of the biopsies, minor in four (5.9%) and major in one (1.5%) -- similar to rates reported for liver biopsy in non-Fontan patients. Hemorrhage had a delayed presentation in three of these five cases. Immediate post-biopsy hemoglobin decrease of ≥2 mg/dL showed a low sensitivity for hemorrhage. The mean Fontan pressure measured during cardiac angiography was 13.8 mmHg, and shunt pressures were not associated with an increased risk of hemorrhage. CONCLUSION Percutaneous liver biopsy in Fontan patients can be performed safely with high technical success rates and without increased complication rates. Meticulous technique and close observation are recommended to reduce post-biopsy complications. The degree of right heart pressure elevation was not associated with hemorrhage.
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Affiliation(s)
- Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Radiology 3NW47, Philadelphia, PA, 19104, USA. .,Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.
| | - Anthony K Guzman
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
| | - Elizabeth B Rand
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Cardiology, University of Pennsylvania Peralman School of Medicine, Philadelphia, PA, USA
| | - David J Goldberg
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Cardiology, University of Pennsylvania Peralman School of Medicine, Philadelphia, PA, USA
| | - Pierre A Russo
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Radiology 3NW47, Philadelphia, PA, 19104, USA.,Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
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Chiu KW, Lin TL, Yong CC, Lin CC, Cheng YF, Chen CL. Complications of percutaneous liver biopsy in living donor liver transplantation: Two case reports. Medicine (Baltimore) 2018; 97:e12742. [PMID: 30290687 PMCID: PMC6200465 DOI: 10.1097/md.0000000000012742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
RATIONALE According to previously published studies, major complications arising from a percutaneous liver biopsy are rare and occur in less than 0.1% of cases. This report describes an approach to percutaneous liver biopsy that can help avoid damage to the liver in a living donor liver transplantation (LDLT) setting. PATIENT CONCERNS Case 1: In the first case a donor percutaneous liver biopsy (PLB) of both lobes of the liver was performed for pre-LDLT evaluation. The ultrasonography (US)-guided epigastric right-angle approach and an automatic one-handed cocking disposable 18G biopsy gun was used to puncture the left liver lobe to determine the presence of fatty liver. A penetrating liver injury occurred, accompanied by massive bloody ascites (about 700 cc) and subcapsular hematoma at the left lateral segment. The bleeding was managed by bi-polar coagulation during the transplant and the following liver donation procedure proceeded smoothly without any subsequent complications. Case 2: In the second case, selective right lobe PLB for clinical assessment after LDLT was performed in the recipient. Hemorrhagic shock occurred following a puncture of the right posterior branch of the right hepatic artery when using the biopsy-gun via the right lateral intercostal approach. DIAGNOSES Extravasation was documented by angiography and emergent transhepatic arterial embolization was performed. INTERVENTION Extravasation was documented by angiography and emergent transhepatic arterial embolization with glue:lipiodol (1:4) was performed to stop bleeding. OUTCOMES The recipient survived after medical management. LESSONS To prevent complications, the right-angle approach of PLB may be changed to an oblique angle using a one-fire biopsy-gun. Use of a manual Menghini's needle should be considered for left lobe liver biopsies. Since US-guided manual Menghini's needle for PLB can be observed with the needle tip inserted in the liver, needle-mediated compromising of the major vessels or biliary tree can be prevented, and it does not penetrate the liver again. A superficial puncture less than 0.5 cm away from the liver surface should be made during right lobe liver biopsy. This approach can help to avoid damage to the hepatic artery.
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Affiliation(s)
- King-Wah Chiu
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of Internal Medicine
| | - Ting-Lung Lin
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital
| | - Chee-Chien Yong
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital
| | - Chih-Che Lin
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital
| | - Yu-Fan Cheng
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Koahsiung, Taiwan
| | - Chao-Long Chen
- Chang Gung University, College of Medicine, Taiwan
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital
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