A Comparison of Transjugular and Plugged-Percutaneous Liver Biopsy in Patients with Contraindications to Ordinary Percutaneous Liver Biopsy and an “In-House” Protocol for Selecting the Procedure of Choice

Case Report: Differentiating hepatic desmoplastic small round cell tumor from hydatidosis in a school-aged boy: the role of contrast-enhanced and interventional ultrasound

Background

Desmoplastic small round cell tumor (DSRCT) is a rare and highly aggressive malignant neoplasm, typically associated with poor prognosis. It predominantly affects adolescents and young males, with a lower incidence in pediatric populations. Due to its rarity, our understanding of DSRCT remains limited, with only a small number of case reports available. The clinical presentation is often non-specific and varies depending on the extent of tumor invasion. Diagnosis relies primarily on histopathological evaluation through biopsy. Although imaging studies contribute to the diagnostic process, they often lack specificity. Nonetheless, certain imaging features can aid in refining differential diagnoses and assessing disease severity. Moreover, minimally invasive, image-guided tissue sampling plays a critical role in confirming the diagnosis through pathological analysis.

Case presentation

A 7-year-old boy presented with abdominal distension and anorexia, without significant abdominal pain, fever, or jaundice. Physical examination revealed abdominal enlargement with hepatosplenomegaly. Laboratory tests showed abnormal liver function (AST 128 U/L, ALP 648 U/L, GGT 885 U/L) and an elevated CA-125 level (170 U/ml). An abdominal CT scan performed at a local hospital identified multiple round, low-density lesions in the liver, suggestive of echinococcosis. The patient was initially diagnosed with suspected echinococcosis and started on albendazole; however, his symptoms did not improve. Upon further evaluation at our institution, ultrasound imaging revealed multiple thick-walled, hyperechoic lesions in the liver with no significant blood flow signals. Contrast-enhanced ultrasound demonstrated that the solid components of the lesion exhibited significant enhancement during the early arterial phase, with rapid attenuation during the early portal venous phase. A metastatic malignant tumor was suspected, prompting a percutaneous biopsy under real-time enhanced ultrasound guidance. Histopathological examination revealed small round tumor cells infiltrating adjacent tissues. Fluorescence in situ hybridization (FISH) confirmed the diagnosis of DSRCT, based on the presence of an EWSR1-WT1 rearrangement. The patient subsequently underwent multimodal treatment, including chemotherapy and radiation therapy, and achieved disease-free survival at the six-month follow-up.

Conclusions

Traditional ultrasound is a convenient, real-time, non-invasive, and radiation-free diagnostic tool, making it particularly well-suited for the diagnosis, screening, and clinical follow-up of focal liver lesions (FLLs) in pediatric patients. This modality enables real-time evaluation of the number, size, location, and morphology of FLLs while assisting in the differential diagnosis. Moreover, it facilitates the assessment of liver parenchyma involvement and portal vein structures. Color Doppler imaging provides valuable insights into the vascular characteristics of tumors, while contrast-enhanced ultrasound (CEUS) agents allow for real-time observation of dynamic tumor perfusion patterns, further refining differential diagnoses based on perfusion characteristics. Compared to the contrast agents used in CT or MRI-which may require sedation or carry risks of renal injury due to radiation exposure-ultrasound microbubble contrast agents are excreted via respiration and do not require sedation, making them especially suitable for pediatric patients. Additionally, ultrasound-guided biopsy is a well-established and reliable method for diagnosing liver lesions. However, the presence of extensive necrosis and the use of fine-needle biopsy can sometimes limit diagnostic accuracy. Incorporating CEUS before or during percutaneous biopsy can help optimize sampling site selection, thereby reducing the likelihood of false-negative results.

Miliary tuberculosis diagnosed by diffuse hepatic uptake on PET/CT and transjugular liver biopsy

The patient was an 81-year-old man. In his 20s, he had been treated with pharmacotherapy for pulmonary tuberculosis for 1 year. He presented to the Department of Respiratory Medicine with a chief complaint of dyspnea. The possibility of respiratory disease appeared to be low, but hepatic impairment was detected. The patient was thus referred to our department. Though the cause of hepatic impairment was unknown, the soluble interleukin-2 receptor level was elevated, suggesting malignant lymphoma. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) revealed diffuse, homogenous, intense FDG uptake in the entire liver, and transjugular liver biopsy confirmed the diagnosis. Histopathological examination revealed an epithelioid granuloma, and auramine staining was positive for bacilli suggestive of tuberculosis. CT revealed diffuse micronodular shadows in the lung, yielding a diagnosis of miliary tuberculosis. Therefore, the patient was prescribed antituberculosis medication by the Department of Respiratory Medicine. His subsequent clinical course was good. The miliary (hepatic) tuberculosis was typical based on the diffuse, homogenous, intense FDG uptake throughout the liver observed on PET-CT.

Comparison of the Safety of Transjugular and Percutaneous Liver Biopsies

PURPOSE

To compare adverse events (AEs) between the transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) approaches.

MATERIALS AND METHODS

A total of 1,300 patients who underwent liver biopsy between July 1, 2014 and January 31, 2018, were examined, and bivariate and multivariate analyses were used to determine predictors of the biopsy method used and AEs. To reduce bias in the comparison of the AE rates between patients who had TJLB or PLB, propensity score matching was used to control for baseline disease severity.

RESULTS

PLB and TJLB were performed in 601 and 699 patients, respectively. The mean Charlson Comorbidity Index score was 3 (±2), and antiplatelet or anticoagulation therapy at the time of biopsy was used in <10% of patients. Patients with suspected cirrhosis or portal hypertension (odds ratio [OR], 9.9), an international normalized ratio of >1.5 (OR, 5.9), or a platelet count of <100 × 103/mL (OR, 3.9) were more likely to undergo TJLB. After propensity matching, which identified a population of patients with a mean international normalized ratio of <1.5 and platelet count of >150 × 103/mL, the only difference in the AE rate was for pain, which was present in 8% and 10% of patients after TJLB and PLB, respectively (P < .001). Bleeding requiring transfusion occurred in 2 patients who underwent TJLB and 1 patient who underwent PLB. There was 1 case of death occurring after TJLB.

CONCLUSIONS

Severe/life-threatening AEs occurring after liver biopsy were uncommon, and the 2 liver biopsy approaches appeared to have similar safety profiles for low-risk patients. After matching for underlying disease severity, pain was the AE that was more likely to occur in patients who underwent PLB.

Decreased Bleeding-Related Adverse Events Using Track Embolization with Gelatin Sponge Slurry after Percutaneous Liver Biopsy: A Propensity Score-Matched Study

PURPOSE

To evaluate the effectiveness of track embolization using gelatin sponge slurry in percutaneous ultrasound (US)-guided liver biopsy.

MATERIALS AND METHODS

Among the 543 patients who underwent percutaneous US-guided liver biopsies between September 2018 and August 2021, 338 who did not undergo track embolization and 105 who underwent track embolization were included in the analysis. All procedures were performed with 18-gauge coaxial core biopsy needles. Patients' laboratory data were reviewed. Patients in both groups were subdivided into the following 2 groups: (a) those with targeted biopsy for a focal liver lesion and (b) those with nontargeted biopsy for a liver parenchyma. Moreover, postbiopsy events, such as transfusion and transarterial embolization, were assessed. To minimize selection bias, propensity score matching (PSM) was performed.

RESULTS

After PSM, all factors that could affect bleeding risk were well-matched and well-balanced between the 2 groups (P > .474). In the non-track embolization group, 17 (16.2%) patients experienced major or minor bleeding-related adverse events (AEs). In contrast, in the track embolization group, only 5 (4.8%) patients experienced major or minor bleeding-related AEs, which was significantly lower than that in the non-track embolization group (P = .007). All 5 (4.8%) cases of major bleeding-related AEs were observed in the non-track embolization group (P = .024).

CONCLUSIONS

In this study, a retrospective analysis was performed using PSM for percutaneous US-guided liver biopsy. Track embolization using gelatin sponge slurry is significantly superior in the prevention of bleeding-related AEs after US-guided liver biopsy.

Initial experience of coaxial percutaneous liver biopsy with tract embolization using N-Butyl cyanoacrylate

OBJECTIVE

Bleeding occurs after liver biopsy in up to 10.9% cases, and patients with impaired hemostasis or ascites are considered to have absolute or relative contraindications. N-butyl cyanoacrylate enables immediate hemostasis, even in lethal situations. Therefore, percutaneous liver biopsy combined with tract embolization using N-butyl cyanoacrylate is expected to enable safe biopsy, even in patients for whom conventional biopsy is contraindicated. Here we describe our initial experience with coaxial percutaneous biopsy with tract embolization using N-butyl cyanoacrylate.

MATERIALS AND METHODS

Eighty-six patients who underwent tract embolization using N-butyl cyanoacrylate between October 2014 and July 2020, including 21 patients who had absolute or relative contraindications for liver biopsy, were retrospectively analyzed. Tract embolization using N-butyl cyanoacrylate comprised two steps: (1) liver biopsy with a biopsy needle inserted via a coaxial introducer needle and (2) embolization of the puncture route by injecting N-butyl cyanoacrylate via the coaxial needle.

RESULTS

No complications occurred in any patient. The mean number of biopsies per patient was 3.30 (range, 1-7). Histologically adequate samples were acquired in all cases, and pathological diagnoses were obtained. The mean time required for tract embolization was 52.8 s (range, 6-132 s). The mean peak skin dose was 9.97 mGy (range, 2-68 mGy), which is far below the 3-Gy threshold dose for temporary erythema.

CONCLUSIONS

This proposed technique may be a promising and straightforward alternative to improve the management of patients with severe liver disease by allowing safer biopsy, including patients for whom conventional liver biopsy is contraindicated.

Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis

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.

Clinical significance of measuring hepatic venous pressure gradient on transjugular liver biopsy for patients with pre-cirrhotic bridging fibrosis liver disease

PURPOSE

To demonstrate that patients with pre-cirrhotic bridging fibrosis (Meta-analysis of Histological Data in Viral Hepatitis, METAVIR stage F3) and clinically significant portal hypertension (CSPH, Hepatic Venous Pressure Gradient ≥10 mmHg) experience a higher rate of clinical decompensation than patients without CSPH.

MATERIALS AND METHODS

128 consecutive patients with pathology proven bridging fibrosis without cirrhosis between 2012 and 2019 were reviewed. Inclusion criteria were patients with HVPG measurement obtained during the same outpatient transjugular liver biopsy and clinical follow up of at least two years. Primary endpoint included rate of overall complication related to portal hypertension including evidence of either ascites, presence of varices on imaging or endoscopy, or evidence of hepatic encephalopathy.

RESULTS

Among 128 patients with bridging fibrosis (67 females and 61 males; average age 56 years), 42 (33%) and 86 (67%) were with and without CSPH (HVPG ≥10 mmHg). Median follow-up time was 4 years. Rate of overall complication (either ascites, varices or hepatic encephalopathy) in patients with and without CSPH was 36/42 (86%) and 39/86 (45%) (p < .001) respectively. Rate of developing ascites, varices and hepatic encephalopathy in patients with and without CSPH was 21/42 (50%) vs 26/86 (30%) (p = .034), 32/42 (76%) vs 26/86 (30%) (p ≤ .001) and 18/42 (43%) vs 12/86 (14%) (p = .001) respectively.

CONCLUSION

Patients with pre-cirrhotic bridging fibrosis and CSPH were associated with higher rates of developing ascites, varices and hepatic encephalopathy. Measuring HVPG during transjugular liver biopsy provides additional prognostic value in anticipating clinical decompensation in patients with pre-cirrhotic bridging fibrosis.

Plugged percutaneous liver biopsy using Tru-cut needle and coils: A retrospective study

BACKGROUND

Plugged percutaneous liver biopsy, though has been in use for many years, is being used more frequently in patients in whom percutaneous liver biopsy is contraindicated due to proven or probable bleeding tendencies. We report our experience with this procedure, its indications, efficacy, and complications in Indian population over 2 years.

METHODS

A retrospective study of 127 consecutive patients who had undergone plug liver biopsy from April 2017 to May 2019 was done from the database maintained in our department. The indications, technical success, complications, and impact of histological diagnosis on the management of those patients were evaluated.

RESULTS

A total of 127 biopsies were performed of which 68 were males and 59 were females, aged between 7 and 73 years. No procedures were abandoned; however, 13 cases needed ultrasonography (USG) guidance because of small size of the liver or presence of right perihepatic fluid. Out of 127 biopsies, none of the samples was inadequate and yielded adequate tissue for histopathological diagnosis. Seven patients required repeat study only because underlying liver disease was suspected clinically and the previous biopsy report had turned out to be normal. Histopathological examination in our study showed autoimmune hepatitis in 61, cirrhotic changes either hepatitis B virus (HBV) or hepatitis C virus (HCV) related in 40, veno-occlusive disease in 3, cholestatic disease in 2, and Wilson's disease in 2 patients. The remaining 19 were normal. Complications occurred in 3 patients - arterioportal fistula, pneumothorax, and inadequate coiling causing mild hemoperitoneum.

CONCLUSION

Percutaneous liver biopsy followed by plugging of the tract with coils is a safe, easy, and effective method in patients with underlying bleeding tendencies, minimal ascites, and small liver.

Liver biopsy technique in the era of genomic cancer therapies: a single-center retrospective analysis

BACKGROUND

With the evolution of personalized medicine in the field of oncology, which includes optimal treatment selection using next-generation sequencing-based companion diagnostic systems and tumor-agnostic treatments according to common biomarkers, a liver tumor biopsy technique that can obtain a sufficient specimen volume must be established. The current study aimed to evaluate the safety and availability of a liver tumor biopsy technique with multiple puncture sites made using a coaxial introducer needle and embolization with gelatin sponge particles.

METHODS

Patients with primary or metastatic liver cancer who underwent liver tumor biopsies with puncture tract embolization using gelatin sponge (Spongel®) from October 2019 to September 2020 were included in the study. The complication and diagnostic rates were evaluated, and whether the specimen volume was sufficient for Foundation® CDx was investigated.

RESULTS

In total, 96 patients were enrolled in this analysis. The median total number of puncture times per patient was 3 (range 1-8). The pathological diagnostic rate was 79.2%. Using the FoundationOne® CDx, specimens with a sufficient volume required for genomic medicine were collected in 84.9% of patients. The incidence rate of bleeding was 4.2% (n = 4), and only one patient presented with major bleeding requiring transfusion.

CONCLUSIONS

Liver biopsy with puncture tract embolization using a gelatin sponge may be safe and effective for collecting specimens with a volume sufficient for modern cancer treatments.

Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access

Purpose

To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis.

Methods

We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared.

Results

Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding.

Conclusion

Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored.

Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Approaches to liver biopsy have changed over the past decade in patients with chronic liver disease.

AIMS

We conducted a systematic review and meta-analysis on the incidence of all complications and technical failure associated with percutaneous liver biopsy.

METHODS

We systematically searched PubMed and the Cochrane Library for cohort studies reporting on complications resulting from liver biopsy published between 2010 and 2020. Studies on participants of any age and sex, who underwent any percutaneous biopsy for non-focal liver disease, were selected. All events except mild pain, minor hematoma, vasovagal episodes, fever and fistula were defined as major complications. Random-effect model meta-analyses with and without covariates were performed, to examine the effect of publication year, patient characteristics, outcome collection, and biopsy type on incidences.

RESULTS

We identified 30 studies reporting on complications resulting from percutaneous liver biopsy procedures (n = 64,356). Incidence of major complications was 2.44% (95% CI 0.85, 6.75), with mortality at 0.01% (95% CI 0.00, 0.11), hospitalization at 0.65% (95% CI 0.38, 1.11), major bleeding at 0.48% (95% CI 0.22, 1.06), and moderate/severe pain at 0.34% (95% CI 0.08, 1.37). Minor complications at 9.53% (95% CI 3.68, 22.5) were mainly pain at 12.9% (95% CI 5.34, 27.9). Technical failure was high at 0.91% (95% CI 0.27, 3.00). Decreasing patient age significantly increased incidence of hospitalization and major bleeding (P < 0.0001). Hospitalization incidence also significantly increased with disease severity.

CONCLUSIONS

Incidence of major (2.4%) and minor (9.5%) complications, and technical failure (0.91%) in percutaneous liver biopsies continues.

Prevention of bleeding after percutaneous biopsy with a small intestinal submucosa hemostatic plug

Percutaneous biopsies (PBs) are the gold standard diagnostic procedures indicated for renal and hepatic disorders. Nevertheless, they can cause hemorrhages and are contraindicated for coagulopathic patients. In this study we designed, fabricated, and evaluated a small intestinal submucosa (SIS) plug to reduce, and potentially cease, bleeding to decrease death risk after percutaneous hepatic and renal biopsies in healthy and coagulopathic in vivo models. First, the plug's blocking capacity was determined with an increase in its diameter of 24 ± 11% after immersion in human blood, and the capacity to induce clotting on its surface. The plug's in vivo performance was evaluated in a healthy porcine model, which showed minimal inflammatory reaction without side effects confirmed by histological results after 30 days. The plug's response in the coagulopathic model was assessed using heparinized swine for 2 days, which revealed localized microhemorrhages and mild inflammatory response without any lesions to the surrounding tissue. No major adverse events nor macroscopic hemorrhages were detected in the animal models. Furthermore, we assessed the plug's efficacy to reduce and stop bleeding using a transplant-discarded human liver model (n = 14). In this case, the mass of blood lost was 43.8 ± 21.8% lower in plugged transplant-discarded human liver biopsies compared to control biopsies without a plug. The bleeding was stopped within three minutes in 92% of plugged cases, but only in 8% of non-plugged cases. We demonstrated the feasibility of making a hemostatic SIS plug, which does not induce major inflammatory reaction and can effectively reduce and stop bleeding after PBs in non-coagulopathic and coagulopathic in vivo models, and in a transplant-discarded human liver model. STATEMENT OF SIGNIFICANCE: Percutaneous biopsy (PB) is a gold standard diagnostic procedure, but it can provoke life-threatening complications and is contraindicated for patients with coagulopathic disorders. This study demonstrates that small intestinal submucosa (SIS) can be manufactured into a biocompatible thrombogenic plug, insertable through a commercial Tru-Cut needle sheath. This device takes advantage of the collagen-rich composition of SIS to stop and reduce bleeding more effectively than the traditional PB, indicating that it could be routinely employed in a traditional biopsy to increase safety, or as a cost and time-reducing alternative to transjugular biopsy for coagulopathic patients.

Percutaneous ultrasound-guided plugged liver biopsy - a single-centre experience

Background

Liver biopsy is a widely used, safe diagnostic tool utilised by clinicians for the histopathological assessment of the liver. Our study aims to report our experience in patients who underwent ultrasound-guided plugged percutaneous liver biopsy in a tertiary care hospital in India.

Material and methods

The Institutional Ethical Review Board approved this retrospective study, and informed consent was obtained from all the patients. A total of 830 liver biopsies were performed between January 2014 and December 2018, of which 782 were plugged percutaneous liver biopsies. The tract was plugged using Gelfoam slurry. Various observations related to the procedures were recorded.

Results

Seven hundred and eighty-two were plugged percutaneous liver biopsies, which were performed during the study period. Of the 782 patients, 163 were male, and 619 were female (20.8 % and 79.2 %, respectively), with a mean age of 49.6 ± 2 years (1 month to 86 years). A 100% technical success rate was seen. No immediate major complications were documented in any of the patients who underwent plugged biopsies. No significant complications were seen in any patient.

Conclusions

Percutaneous liver biopsy is an extensively performed diagnostic tool. We found that ultrasound-guided percutaneous plugged liver biopsy is an easy to perform procedure, which is associated with a lower risk of a bleeding complications.

Accuracy and Safety of 1,055 Transjugular Liver Biopsies in Postliver Transplant Patients

INTRODUCTION

The purpose of this study was to investigate the rates of complications and diagnostic yield of transjugular liver biopsy (TJLB) in deceased donor liver transplant (DDLT) recipients.

METHODS

From January 2009 to December 2019, 1,055 TJLBs were performed in 603 adult DDLT recipients with a mean age of 54 (±12 years). Data were retrospectively reviewed to determine the diagnostic efficacy and incidence of major and minor complications in the 3-day and 1-month period after TJLB. In addition, data were stratified according to platelet count and international normalized ratio to determine the safety of TJLB in patients with varying degrees of coagulopathy.

RESULTS

TJLB yielded diagnostic rate of 98.1% (1,035/1,055), with an overall complication rate of 8.3% (88/1,055). Major complications accounted for 0.85% (9/1,055), and minor complications occurred in 7.48% (79/1,055). When patients were stratified by platelet count (0-50, 51-100, 101-200, 201-300, and >300 × 103 platelets/μL), no significant difference was noted in complication rates (9.5%, 8.6%, 7.6%, 8.5%, and 10.7%, respectively). When grouped by international normalized ratio (0-1, 1.1-2.0, 2.1-3.0, and >3.0), there was no statistical difference in complication rates (8.3%, 8.5%, 7.7%, and 0%, respectively).

DISCUSSION

TJLB is a safe, adequate, and effective method to investigate hepatic disorders in DDLT recipients with severe coagulopathy.

Yield and Safety of Transjugular Versus Percutaneous Liver Biopsies in Suspected Cases of Diffuse Liver Disease and Correlation of Yield of Transjugular Liver Biopsy with Hepatic Venous Pressure Gradient

Background Liver biopsy is indicated in both diagnosis and prognosis of diffuse liver diseases. Conventionally, percutaneous liver biopsy (PLB) is used, as it is easily available, affordable and has a shorter procedure time, whereas transjugular liver biopsy (TJLB) is used in the setting of ascites and coagulopathy. Our aim is to evaluate the diagnostic yield of TJLB in comparison to PLB with tract embolization. Our secondary aims were to evaluate whether there is any difference in rate of major and minor complications between the two procedures and evaluate whether there is any correlation between diagnostic yield of TJLB and hepatic venous pressure gradient (HVPG).

Methods In this retrospective study, we included a total of consecutive 123 patients who underwent liver biopsy through percutaneous (n = 97) and transjugular route (n = 26). We compared the yield of the specimen based on the number of complete portal tracts (CPT).

Results There was no significant difference between mean CPT in TJLB and PLB specimens (mean CPT of TJLB and PLB were 10.9 ± 2.7 and 11.6 ±2.5, respectively [p = 0.566]). There was a moderate but significant negative correlation between the total number of CPT and HVPG in the TJLB group (Spearman’s rho − 0.58) (p = 0.002). There was no statistically significant difference in minor complication between the two procedures. Only one patient who underwent PLB developed major complication and none of TLJB procedure had any major complication.

Conclusion Yield of tissue and complication rates are comparable in TJLB and PLB groups. Yield of tissue in TJLB have intermediate but significant negative correlation with HVPG.

Transjugular Liver Biopsy: Safe Even in Patients With Severe Coagulopathies and Multiple Biopsies

To investigate the safety profile and diagnostic efficacy of transjugular liver biopsy (TJLB), with a focus on patients with severe coagulopathies and with multiple biopsies.

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.

The utility of liver biopsy in 2020

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.

Escalating interventional recanalization therapy in non-cirrhotic, non-malignant acute portal vein thrombosis

OBJECTIVE

To evaluate the effectiveness of interventional therapy in acute, non-malignant, non-cirrhotic portal vein thrombosis.

METHODS

We present a retrospective study of eight consecutive patients who presented with an acute non-malignant, non-cirrhotic portal vein thrombosis and were treated by mechanical recanalization using an escalating scheme including local aspiration, thrombolysis, rheolysis and the implantation of transjugular intrahepatic portosystemic shunt or other visceral stents.

RESULTS

Recanalization rates applying the escalating scheme were good, with a success rate of 75%. However, major complications occurred in 50% of patients, mostly due to bleeding at the percutaneous access site, and minor complications in 12.5% of patients.

CONCLUSION

Interventional therapy is effective in acute portal vein thrombosis, but should only be performed at specialized centers and based on an individual treatment decision.

Transjugular aspiration liver biopsy performed by hepatologists trained in HVPG measurements is safe and provides important diagnostic information

BACKGROUND

Transjugular liver biopsy (TJLB) represents an alternative to percutaneous liver biopsy especially in patients with impaired coagulation and ascites.

AIMS

To describe safety and diagnostic yield of aspiration TJLB performed by hepatologists experienced in hepatic venous pressure gradient (HVPG) measurements.

METHODS

445 TJLB of 399 patients between 01/2007-12/2016 were retrospectively assessed.

RESULTS

Histological diagnosis was obtained in 423 (95.1%) biopsies - including 11 (100%) patients with acute liver failure and 34 (97.1%) patients after liver transplantation. A median number of 5 portal tracts (interquartile range:2-9) was obtained. HVPG negatively correlated with sample length (Spearman ρ = -0.310; p < 0.001) and number of portal tracts (ρ = -0.212; p < 0.001). Among n = 151 patients with unknown etiology of liver disease, etiology was successfully identified on liver histology in 126 patients (83.4%). Complications occurred in 28 biopsies (6.3%) including 25 (5.6%) minor and 3 (0.7%) major complications. No deaths due to TJLB were observed. Neither the presence of ascites (6.6% complications) nor of coagulopathy (platelets<50G/L and/or prothrombin time<50%; 4.8% complications) increased the risk for complications.

CONCLUSIONS

TJLB performed by hepatologists experienced in HVPG measurements is safe - even in patients with ascites or coagulopathy. TJLB has good diagnostic value for histological evaluation of liver disease and acute liver failure.

Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures

RATIONALE AND OBJECTIVES

To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils.

MATERIALS AND METHODS

Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding.

RESULTS

No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications.

CONCLUSIONS

Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

Comparison of Transjugular Liver Biopsy and Percutaneous Liver Biopsy With Tract Embolization in Pediatric Patients

PURPOSE

The aim of the study was to compare safety and efficacy of transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) with tract embolization in pediatric patients with liver disease.

MATERIALS AND METHODS

TJLB and PLB between December 2009 and October 2015 were retrospectively reviewed. Primary endpoints were adequate sampling and complication rate. Patient age, weight, coagulation factors, ascites, blood transfusions, adequacy of biopsy sample, number of biopsy samples, and complications were compared.

RESULTS

There were 39 TJLB (average age 10.6 years) and 120 PLB (average age 7.1 years) (P value <0.05). Average weight was 40.2 kg for TJLB and 26.8 kg for PLB (P value <0.05). Average platelets were 155 for TJLB and 252 for PLB (P value <0.05). Average international normalized ratio was 1.7 for TJLB and 1.3 for PLB (P value <0.05). Mean postbiopsy hematocrit decrease was 0.8 and 0.9, for TJLB and PLB, respectively. Mean postbiopsy hemoglobin decrease was 0.3 in both groups. Number of core biopsy samples was 4.5 and 4.3, for TJLB and PLB, respectively. There was 1 biopsy yielding insufficient sample in each group. TJLB had 1 (2.6%) complication of supraventricular tachycardia. PLB had 4 (3.3%) complications, with 1 hemoperitoneum, 1 hypotension, 1 patient with decreased hemoglobin, and 1 patient with bilious drainage from the biopsy site.

CONCLUSIONS

TJLB and PLB with gelatin sponge pledget tract embolization are both safe and effective for the diagnosis of hepatic disease in pediatric patients. To avoid radiation, PLB may be considered as first-line approach in the pediatric population, even in the setting of coagulopathy.

Direct Injection of Blood Products Versus Gelatin Sponge as a Technique for Local Hemostasis

PURPOSE

To provide a method of reducing risk of minimally invasive procedures on patients with abnormal hemostasis and evaluate efficacy of direct fresh frozen plasma injection through a procedure needle tract compared to Gelfoam (gelatin sponge) administration.

MATERIALS AND METHODS

Eighty patients with elevated international standardized ratio (INR) undergoing minimally invasive procedures using imaging guidance were selected retrospectively. Forty patients had received Gelfoam as a means of tract embolization during the procedure. The other 40 received local fresh frozen plasma (FFP) through the needle tract. The number of complications and clinically significant bleeding events were recorded. A threshold of 30 cc of blood loss after a procedure was used to identify excess bleeding.

RESULTS

No patients experienced clinically significant bleeding after administration of FFP. Five patients experienced postoperative drops in hemoglobin or hematomas after administration of Gelfoam.

CONCLUSION

Local injection of blood products can reduce postprocedure bleeding in patients undergoing minimally invasive procedures and provides a safe alternative to the use of synthetic fibrin plugs.

Liver biopsy in children: position paper of the ESPGHAN Hepatology Committee

Liver biopsy (LB) is still the criterion standard procedure for obtaining liver tissue for histopathological examination and a valuable tool in the diagnosis, prognosis, and management of many parenchymal liver diseases. The aim of this position paper is to summarise the present practice of paediatric LB and make recommendations about its performance. Although histological evaluation of the liver is important in assessing prognosis and exploring treatment, noninvasive techniques (ie, imaging, laboratory markers) may replace use of liver histology. The indications for LB are changing as present knowledge of aetiologies, pathomechanism, and therapeutic options in paediatric liver disease is evolving. Adult and paediatric literature was reviewed to assess the existing clinical practice of LB with focus on the technique, indications, risk of complications, and contraindications in paediatrics. This position paper presents types of LB, indications, complications, contraindications, and an essential checklist for paediatric LB.

Transfemoral liver biopsy using a Quick-Core biopsy needle system in living donor liver transplantation recipients

The purpose of this study was to evaluate the efficacy and safety of transfemoral liver biopsy with a Quick-Core biopsy needle in select living donor liver transplantation (LDLT) recipients. Eight LDLT recipients underwent 9 transfemoral liver biopsy sessions. Six patients had undergone modified right lobe (mRL) LDLT, and 2 patients had undergone dual-left lobe LDLT. The indications for transfemoral liver biopsy were a hepatic vein (HV) at an acute angle to the inferior vena cava (IVC) on the coronal plane and a thin (<10-mm) liver parenchyma surrounding the HV to be biopsied on enhanced computed tomography. Under fluoroscopic guidance, the right inferior HV in the mRL or the left HV in the right-sided left lobe with a cranial orientation was negotiated with a 5-Fr catheter via the common femoral vein. Then, a stiffening cannula was introduced into the HV over a stiff guide wire. Needle passage was then performed with an 18- or 19-gauge Quick-Core biopsy needle. Technical success was achieved in all sessions without major complications. The median number of needle passages was 4 (range = 2-6). The median total length of obtained liver specimens in each session was 44 mm (range = 24-75 mm). The median number of portal tracts was 18 (range = 10-29), and the obtained liver specimens were adequate for histological diagnosis in all sessions. In conclusion, transfemoral liver biopsy with a Quick-Core biopsy needle is an effective and safe alternative for obtaining a liver specimen when standard transjugular liver biopsy is not feasible because of an unfavorable HV angle with respect to the IVC and/or a thin liver parenchyma surrounding the HV.

Assessment of the efficacy and potential complications of transjugular liver biopsy in canine cadavers

Background

Transjugular liver biopsy (TJLB) is used in humans at risk of bleeding. There are no reports of its use in veterinary medicine.

Objective

To assess the efficacy and potential complications of TJLB in canine cadavers, and compare with samples obtained via needle liver biopsy (NLB) and surgical liver biopsy (SLB).

Animals

Twenty‐five medium and large breed canine cadavers.

Methods

Prospective study. TJLBs were procured through the right jugular vein. After biopsy, intravenous contrast and gross inspection were used to assess the biopsy site. Minor and major complications were recorded. NLBs and SLBs were then obtained. Histopathology was performed, and TJLB and NLB were compared for number of complete portal tracts (CPTs), length, and fragmentation. Pathologic process and autolysis were assessed in all samples.

Results

All TJLBs yielded liver tissue. The proportion of minor complications was 12/25 (48%), and major complications 16/25 (64%); 13/16 (81%) of the major complications were liver capsule perforation. In 21/25 (84%), the histopathology in the SLB was reflected in the TJLBs. For cases with minimal autolysis, median number of CPTs in TJLBs was 7.5, compared with 4 in NLBs (P = .018). Median length of TJLB specimen was 28 mm compared to 22 mm in NLBs (P = .007). Fragmentation rate was median of 1.25 for TJLB compared to 1.50 in NLBs (P = .11).

Conclusions and Clinical Importance

TJLB is technically feasible and achieves comparable results to NLB and SLB. The number of complications, in particular liver capsule perforation, was greater than expected. Further studies are indicated before clinical use is recommended.

Alcoholic hepatitis: diagnosis and management in 2012

Alcoholic hepatitis is a severe form of alcohol-related liver injury and one of the most frequent liver presentations seen by acute medical services. The condition typically affects young and middle-aged adults who present with jaundice and coagulopathy. Many patients fulfil the criteria for acute-on-chronic liver failure, though often the diagnosis of cirrhosis is only made after hospitalization. Despite over four decades of study, controversy surrounds many aspects of diagnosis and management, and short-term mortality in severe disease remains high. This review summarizes recent and important literature of relevance to clinicians, including aids to diagnosis, clinical prognostic scores and evidence for current medical therapies. Contentious issues such as the need for liver biopsy in diagnosis and the role for liver transplantation in those who fail to respond to medical treatment are also discussed.

Transjugular liver biopsy in pediatric patients with left split liver transplantation and severe coagulation impairment

The aim of this study is to report our experience in TJLB performed in pediatric patients who underwent partial LT using a left lateral segments graft. Eight consecutive TJLBs were performed in six patients with contraindication to percutaneous biopsy owing to severe coagulation impairment and ascites. All procedures were performed using an 18-gauge automated core needle biopsy. Median age of the patients was 44 months (range, 11-198). Median patients' weight was 13 kg (range, 8-45). Technical success was achieved in all cases without complications. The specimens were adequate for the diagnosis in all cases.