2 Transjugular and plugged liver biopsies JAMES E. JACKSON ANDREAS ADAM DAVID J. ALLISON

INTRODUCTION

The first published series of liver biopsies was that by Schtipfer in 1907 (Schtipfer, 1907), but it was not until the 1930s that the procedure gained popularity. It is now one of the most commonly performed invasive investigations and the majority of junior doctors will have learnt the procedure at some time during their training. A variety of different liver biopsy needles are available for use via a transabdominal approach. The Menghini biopsy needle obtains a specimen by aspiration. It is a 1.4-mm (outer diameter) needle which is introduced into the liver and withdrawn again in one continuous movement (the ‘l-second needle biopsy’) while aspiration is applied. It is a rapid, cheap and easily learnt procedure which delivers adequate samples in the majority of cases. The specimen is often fragmented, however, particularly in cirrhotic livers. The Tru-Cut needle, which is a modification of the Vim-Silverman needle, is designed to produce a tissue sample from deep within the liver substance. The biopsy technique using this needle is slower than with the Menghini needle; the patient must therefore be cooperative so as to avoid breathing during the biopsy with the subsequent risk of liver laceration. The specimens are generally larger, however, and the success rate of the procedure, particularly in cirrhotic livers, is higher. These advantages are offset by a slightly higher incidence of complications. Biopty needles, which are available in a variety of different diameters, use a Tru-Cut action but are fired by a hand-held ‘gun’, and the length of time that the needle is within the liver is subsequently reduced when compared with the manual Tru-Cut needle. Fine-needle aspiration biopsies are usually performed with a 22-gauge ‘skinny’ needle and are becoming increasingly popular because of their extreme safety. Interpretation of the specimen requires an experienced cytopathologist. This biopsy technique has found its major role in imageguided biopsies of focal intrahepatic masses (using ultrasound, computed tomography or fluoroscopy) and is of limited usefulness in diffuse hepatic disease when a core of tissue is generally required. BaiNi&re’s

Clinical

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Indications for liver biopsy It must be remembered that ‘the best protection for the patient is the most careful consideration of the reasons for performing the procedure in the first place’ (McGill, 1981). The majority of jaundiced patients do not require a liver biopsy. Non-invasive investigations such as ultrasound and computed tomography together with endoscopic retrograde and percutaneous cholangiography have made liver biopsy an inappropriate procedure in the majority of patients with extrahepatic biliary obstruction. Liver biopsy remains a valuable tool, however, in the following conditions: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Chronic hepatitis with or without cirrhosis and portal hypertension. This remains the most important indication. Drug-related liver disease. Acute hepatitis and its sequelae. There is no indication nowadays for liver biopsy in the majority of patients with acute hepatitis of type A or type B. Liver disease in the alcoholic. Unexplained hepatomegaly or abnormalities of liver function. Storage diseases (e.g. amyloid and glycogen storage diseases). Infections (e.g. tuberculosis, syphilis, histoplasmosis). Assessment of therapy (e.g. cytotoxics in transplantation, venesection in patients with haemochromatosis). Space-occupying lesions.

Contraindications

to percutaneous tramabdominal

The following are the major contraindications

liver biopsy

to percutaneous liver biopsy:

1. Bleeding diatheses. The prothrombin time should not be prolonged over control values by more than 4 seconds (Sherlock, 1989; Wilber and Foulk, 1967) or 6 seconds (Hegarty and Williams, 1984) after the administration of 10 mg vitamin K intramuscularly. The platelet count should exceed 40000 per mm3 (Hegarty and Williams, 1984) or 80000 per mm3 (Sherlock, 1989). Haemophiliac patients and particularly those with haemophilia A should not undergo a percutaneous liver biopsy unless there are very definite indications. Clinically significant haemorrhage occurs in 12.5% of these patients (Aledort et al, 1985). When biopsy is absolutely necessary, patients with haemophilia A should have their factor VIII levels raised and maintained to about 50% of the normal value prior to the biopsy and for 48 hours afterwards (Sherlock, 1989). 2. Tense ascites. This makes a successful biopsy much less likely and increases the risk of haemorrhage. The latter probably occurs because the fluid surrounding the liver prevents tamponading of the biopsy site by the abdominal wall. 3. Suspected hydatid disease. 4. Known or suspected vascular lesions such as haemangioma.

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The majority of articles and textbooks describing liver biopsy techniques state that measurement of the prothrombin time and the platelet count are mandatory prior to the procedure. There is no firm evidence, however, that abnormal values of these two measurements correlate with an increased risk of post-biopsy haemorrhage. Indeed, some authors believe that bleeding after liver biopsy is often a random event and that indices of coagulation in the peripheral blood are unreliable guides to the risk of bleeding (Ewe, 1981; McGill, 1981). Losowsky and Walker (1968) commented that ‘Although thrombocytopenia is stated to be a contraindication to liver biopsy. . . there seems little evidence in support of this’ and concluded that a low platelet count should not be an absolute contraindication to liver biopsy. Mahal et al (1981), however, contend that some of the 22 bleeding episodes that they saw in 3080 liver biopsies would not have occurred had more careful attention been paid to the contraindications to biopsy. Ten of the 22 subjects who bled had more than one contraindication to liver biopsy as compared with only 1 of the subjects who did not bleed, a finding that achieved statistical significance. Most physicians would be unhappy to proceed with a percutaneous liver biopsy in an individual with one or more of the above contraindications, though it is often in just such a patient that a biopsy is most needed to plan further management and to monitor the effects of therapy. In addition, it is likely that there will be a greater need for liver biopsy in haemophiliac patients in view of the recent increase in the incidence of hepatitis B and human immunodeficiency virus infection in these individuals. The introduction of transvenous and, more recently, plugged liver biopsy techniques means that biopsy specimens may be obtained safely even when clotting is seriously deranged. A laparoscopic approach is an alternative method which allows direct compression of the liver following the biopsy.

Complications

of percutaneous transabdominal

liver biopsy

Several large series have shown that liver biopsy is an extremely safe technique with very low morbidity and mortality rates (Terry, 1952; Zamcheck and Klausenstock, 1953). The complications of this procedure are listed in Table 1. The reported mortality is about 0.01% (Sherlock, 1989) with haemorrhage being the most common cause of death, although this usually occurs in patients with a hopeless prognosis. Haemorrhage is relatively common, with intrahepatic and subscapular haematomas being visible on ultrasound in as many as 23% of patients (Minuk et al, 1987). The majority of these haematomas are small and asymptomatic, but they may be associated with pain, hypotension or a falling haematocrit, and (less commonly) with obstructive jaundice (Chiprut et al, 1978) or delayed haemorrhage (Reichert et al, 1983). Haematobilia is uncommon but may be massive and fatal. It usually occurs within a few days of liver biopsy and may be due to rupture of an intrahepatic haematoma into the biliary tree (Sherlock, 1989). It is usually best managed by transcatheter hepatic arterial embolization.

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1. Complications of percutaneous transabdominal liver biopsy.

Haemorrhage

Intrahepatic: haematoma haematobilia Subcapsular Extrahepatic: intraperitoneal haemothorax 2. 3. 4. 5.

Bile peritonitis Hepatic arterioportal venous fistulae Puncture of other organs (e.g. kidney, Bacteraemia

colon)

Relatively common (up to 13%) Patients with valvular heart disease should receive prophylactic antibiotics 6.

Septicaemia

Rare. Cultures are usually positive for Escherichia coli Both bacteraemia and septicaemia are more common in patients with cholangitis 7.

Local

or referred

pain

A mild degree of intraperitoneal bleeding is probably very common and is often associated with upper abdominal pain and a perihepatic rub. It may occasionally be life-threatening. Biliary peritonitis is the second most common complication after haemorrhage and usually occurs following inadvertent puncture of the gallbladder or dilated intrahepatic bile ducts. Angiographically demonstrable arteriovenous fistulae follow 5.4% of biopsies (Wallace et al, 1972). Many of these will close spontaneously, and treatment by transcatheter embolization is rarely required. TRANSJUGULAR

LIVER

BIOPSY

History Dotter (1964) first reported successful liver biopsies performed via a transvenous approach in the laboratory. Hanafee and Weiner introduced transvenous cholangiography in 1967 and in their second paper on the same subject (Weiner and Hanafee, 1970) suggested that this approach might successfully be used for liver biopsy. The first clinical series of liver biopsies performed via a transjugular approach was reported in 1973 by Rijsch and his co-workers (Rosch et al, 1973). They attempted the procedure in 44 patients and were able to obtain samples in 39 (89%). Since then several further series have been reported with success rates for the procedure of between 62% and 97% (Table 2). In recent years the popularity of the technique has waned with the introduction of the less cumbersome method of percutaneous plugged liver biopsy. Technique The patient should have a peripheral venous line inserted prior to the procedure for resuscitation if required. Sedation is usually unnecessary.

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Table 2. Success rates of transjugular liver biopsies. Reference Rijsch et al, 1975 Gilmore et al, 1977 Goldman et al, 1978 Choy et al, 1978 Matzen et al, 1979 Lebrec et al, 1982 Maillet et al, 1982 Reding, 1983 Bataille & Bercoff, 1983 Bull et al, 1983 Gamble et al, 1985 Steadman et al, 1988 Total

No. of biopsies

Successful biopsies*

%

a3 26 65 32 21 1033 42 100 215 193 461 67 2338

71 26 63 28 13 709 41 95 136 188 425 62 1857

86 100 97 88 ii 98 95 63 97 92 93 79

* Biopsy adequate for histological diagnosis.

Catheterization of either internal jugular vein (preferably the right as it affords a more direct line into the hepatic veins) is performed using an aseptic technique. Free and wedged hepatic vein pressures, hepatic venography and inferior vena cavography may be obtained initially, if necessary, using a 5-FG or 7-FG femoral-visceral shaped catheter. For the biopsy itself, an angled 9-FG guiding catheter is introduced into a hepatic vein. The right hepatic vein is most commonly used as it is large and because it usually drains at an acute angle into the inferior vena cava. One of the most serious complications of the transjugular biopsy technique is perforation of the liver capsule and subsequent intraperitoneal bleeding. This complication can be avoided by using biplane screening so that the exact position of the needle in the liver is known prior to biopsy. The original description of the technique suggested that the biopsy was performed with the guiding catheter in a wedged position in the hepatic vein. Capsular perforation is reported to be less common, however, if the biopsy is performed with the guiding catheter free within the main hepatic vein within a few centimetres of the inferior vena cava. The biopsy may then be performed with the needle facing anteriorly, posteriorly or laterally with little chance of its puncturing the liver capsule (Colapinto, 1985). Two major needle types are used for transjugular liver biopsy. Biopsies were originally performed using a S-cm long modified Ross transseptal needle which had a curved tip that extended about 5 cm beyond the guiding catheter (Hanafee and Weiner, 1967). The biopsy specimens obtained with this needle were often fragmented; but by changing its cutting edge (Henrikson et al, 1979) and by adding a Menghini-style inner stylet to prevent aspiration of the specimen into the syringe (Colapinto and Blendis, 1983), compression and fragmentation artefacts have become less common. Biopsies with this needle are obtained using a Menghini ‘l-second’ technique whereby the needle is plunged into the hepatic parenchyma and removed in one continuous motion while suction is maintained with a lo-ml syringe. The needle is withdrawn from the guiding catheter and the specimen can then be gently flushed out with saline into a container.

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Gilmore et al (1978) have developed a transjugular needle which obtains a sample using a Tru-Cut technique. They mounted a Tru-Cut needle on the end of a flexible endoscopic forceps coaxial wire, and reported that biopsy was much easier to perform and that the specimens were larger and less fragmented than those obtained with a Menghini needle. The flexible cable means that the biopsy has to be performed with the guiding catheter in a wedged position to allow the liver substance to be punctured. Whichever needle is used, it is important that contrast medium is injected via the guiding catheter following the biopsy to ensure that the capsule has not been perforated. If contrast extravasation is seen then embolization of the track should be performed (Gamble et al, 1985). Complications

The most serious complication of transjugular liver biopsy is puncture of the liver capsule and intraperitoneal haemorrhage. As the amount of intraperitoneal bleeding is often small, breaching of the liver capsule by the biopsy needle will often go unrecognized unless contrast medium is injected via the guiding catheter after the biopsy has been performed. In the series of biopsies performed at Toronto General Hospital where this was routinely practised (Gamble et al, 1985), capsular perforation was documented in 18 out of 461(3.9%) patients. In 17 of these patients extravasation was noted at the time of biopsy and the needle tract was embolized with gelatin sponge (Gelfoam). Despite this, 4 of their patients (3 of whom underwent embolization) had clinically significant bleeding, an incidence of 0.9%. The overall incidence of clinically significant bleeding in 2338 transjugular biopsies reported to date is 0.34% (Colapinto, 1985; Steadman et al, 1988). There have been 3 deaths reported in the literature related to a transjugular liver biopsy (Lebrec et al, 1982; Bull et al, 1983; Gamble et al, 1985), an incidence of 0.13%. Cardiac arrhythmias may occur during the passage of the catheter through the right atrium. A cardiac monitor should be used in all patients and facilities for cardiac resuscitation must always be available. Transient abdominal pain without evidence of clinically significant bleeding is relatively common. A transient Horner’s syndrome, pneumothorax, haematoma at the site of the jugular vein puncture (Lebrec et al, 1982), loss of the guiding catheter sheath into the internal jugular vein (Steadman et al, 1988), transient pyrexia and asymptomatic arterioportal fistulae may uncommonly occur. Results

The success rates for transjugular liver biopsy are shown in Table 2. This procedure may occasionally fail because of difficulty in catheterizing either the jugular or hepatic veins. The latter problem is most commonly encountered in the case of a small, cirrhotic liver where the hepatic veins often enter the inferior vena cava at an obtuse angle. Although such veins may be relatively easy to catheterize with a conventional catheter, the stiff

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modified Ross needle will not be able to negotiate the angle, and biopsies in such patients may therefore prove easier with the Tru-Cut needle described by Gilmore et al (1978). Manipulation of the biopsy needle into a hepatic vein is, however, possible in more than 90% of cases. The most common cause of an unsuccessful procedure is that the biopsy specimen is either too small or too fragmented for histological examination. Different needles that attempt to overcome this have been described above and it would certainly appear that the Tru-Cut action needle described by Gilmore et al (1978) is more successful in this regard than other needles. Colapinto (1985) comments that technique may be important and that the use of a longer intrahepatic course of the biopsy needle is likely to produce a better sample even though this may increase the risk of capsular perforation. Probably the most important factor influencing the success of the method, however, is the collaboration of a highly skilled pathologist who is able to make an accurate diagnosis from a minute tissue sample.

PLUGGED

LIVER

BIOPSY

History Plugging of the needle track following percutaneous liver biopsy was first reported by Riley et al (1984) who used absorbable gelatin sponge. The authors generously acknowledged that ‘the basic principle of performing a conventional liver biopsy with plugging of the needle track was the idea of Dr D. J. Irving of Lewisham Hospital’. Embolization of needle tracks had been described previously by Probst et al (1978) who had shown that in fully heparinized dogs, the embolization of a splenic puncture with absorbable gelatin sponge (Gelfoam) could successfully prevent bleeding. It is of interest that they found that significant bleeding still occurred if only the track, and not the splenic capsule, was plugged. They concluded that care must be taken that Gelfoam plugs are deposited along the whole needle track beyond the splenic capsule. They subsequently ‘plugged’ the needle tracks following direct splenoportography in 5 patients with decreased platelet counts and severe portal hypertension. None of these patients had significant bleeding and in 4 of them who proceeded to surgery, successful plugging of the needle tracks with Gelfoam was confirmed. Riley et al (1984) described both ‘sheathed’ and ‘non-sheathed’ needle methods (see below) of track embolization, and used absorbable gelatin sponge as the embolic agent. Since then there have been several reports, most of which are based on these two techniques although a variety of different embolic materials have been used. Rodriguez Fuchs and Bruno (1987) described a technique using coagulation factors (I, IIa, XIII) plus calcium chloride (Tissucol, Immuno) as an embolic agent. The first few biopsies were performed at laparotomy and liver bleeding times were recorded. The liver bleeding time was always zero for the site of Tissucol embolization but was 2-5 minutes for the control

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puncture sites. Chisholm et al (1989) used a similar agent (Tisseel, Immuno) following biopsy with an l&gauge Biopty gun and needle in 5 high-risk patients. There were no bleeding complications. (Tisseel has now been withdrawn because of concern over its safety in relation to the possible transmission of viral infection.) Chuang and Alspaugh (1988) described track embolization using a sheathed needle technique and Gelfoam, and stressed the importance of ensuring that the final Gelfoam plug is placed across the liver capsule as was described in the paper on splenic embolization following splenoportography (Probst et al, 1978). They had no episodes of bleeding over a 3-year period in 22 patients with contraindications to conventional liver biopsy. Allison and Adam (1988) also described a sheathed needle technique but used steel coils for embolization of the track. They observed no complications in 8 patients with grossly deranged prothrombin times, 2 of whom were also thrombocytopenic. Crummy et al (1989) described a non-sheathed needle technique and embolized the track with a combination of agents including steel coils and Gelfoam plugs. Tobin and Gilmore (1989) also used a non-sheathed needle technique with absorbable gelatin sponge. In their series of 100 high-risk patients there was clinically significant bleeding in 1. Gazelle et al (1990) described a haemostatic protein polymer sheath (PPS) for plugged biopsy. In its dry state the PPS is extremely rigid, but it softens rapidly and expands when it comes into contact with liquid at body temperature. The PPS sheath can be introduced through the outer cannula of a Tru-Cut needle to achieve haemostasis after a biopsy. This method has proved to be rapid and effective in pigs, but the sheath is not yet commercially available. Technique Whichever technique is used, every patient must have an intravenous line inserted prior to the biopsy, and platelets and/or coagulation factors should be administered as necessary. Sedation is generally not required. The biopsy is usually performed under fluoroscopic control although it has been described using ultrasound guidance (Chisholm et al, 1989). A right intercostal approach in the midaxillary line is generally performed. The biopsy site is chosen using preliminary fluoroscopy and the skin is infiltrated down to the liver capsule with local anaesthetic. Either a sheath or nonsheath needle technique may be used. Sheathed needle biopsy technique Biopsy. A 1Cgauge needle with a Tru-Cut action is normally used, together with a sheath which fits snugly around it. A specially designed biopsy and coil embolization kit (William Cook Europe, Bjaeverskov, Denmark) is equipped with a needle which is 20cm long and an 8-FG sheath. Alternatively, a Tru-Cut needle (Travenol Laboratories Inc., Deerfield, Ill, USA) may be used which fits snugly through a 6-FG Kimal vascular sheath (Kimal

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BIOPSIES

253

Scientific Products Ltd, Uxbridge, UK). A small sheath which fits around an l&gauge Biopty needle is also now available. The needle and sheath assembly are introduced 4-5 cm into the liver under suspended respiration. (It is best to perform the biopsy at midinspiration so that there is less excursion of the sheath during subsequent respiration while the track is being embolized. This reduces the risk of liver laceration.) The needle is opened beyond the tip of the sheath and the outer metal cannula and sheath are then pushed over the cutting notch of the inner stylet. The needle is then withdrawn leaving the sheath in place in the liver. The patient is asked to breathe gently while the biopsy specimen is examined. If the specimen is inadequate the needle may be reinserted down the sheath, although great care has to be taken that the sheath is not damaged while doing this. A further biopsy may then be performed after minor repositioning of the needle. When an adequate specimen has been obtained the track is embolized. Truck embofization. There is often profuse bleeding from the sheath after withdrawal of the needle. Contrast medium injected via the sheath usually shows that this is because the biopsy track communicates with a portal or hepatic vein radicle. It is important to ensure that the tip of the sheath does not lie within a vessel at the time of embolization so as to avoid the risk of migration of embolic material into either a peripheral portal venous radicle or, possibly more seriously, a hepatic vein and thence into the right heart and pulmonary arteries. If the sheath is in such a position it should be carefully withdrawn and repositioned so that its tip is within the biopsy track itself peripheral to the vessel (Figure 1). Embolization may then be performed with any of the agents discussed above. Coil embolization (Allison and Adam, 1988). A specially designed needle (20 gauge, 28.6cm cannula with a 0.24mm inner core; William Cook Europe, Bjaeverskov, Denmark) which carries a preloaded embolization coil (1 mm wire, 4cm uncoiled length, 3 mm coiled diameter) is introduced into the sheath and the coil is deposited into the biopsy track close to the point of communication between the track and the damaged vein. A further gentle injection of contrast medium will usually show that the vessel responsible for the bleeding is no longer visible. If bleeding continues further coils may be introduced. The sheath is then gradually withdrawn and contrast medium is injected to define any further hepatic vessels that are in communication with the biopsy track, and may be embolized in the same way. Coils may be introduced using a distal coil delivery wire or via a catheter inserted into the biopsy sheath rather than with the special preloaded needle described above. Both these methods are, however, more cumbersome and are much more difficult to perform without an assistant. Occasionally Spongostan pledgets (Johnson & Johnson Care Products, Ascot, UK) may be used in addition to the coils. The coil embolization technique offers the advantage .over methods employing particulate materials (such as Gelfoam) that the embolizing agent can be positioned very precisely in the biopsy track. This obviates the

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(4 Figure1. Plugged liver biopsy using a sheathed needle technique. (a) Biopsy has been performed using a Tru-Cut type needle introduced via a 6-FG sheath. The needle has been removed with the biopsy specimen leaving the sheath in place. There was brisk bleeding from the sheath. Contrast medium injected via the sheath shows filling of a main hepatic vein. (b) The sheath was partially withdrawn prior to embolization of the biopsy track with steel coils. These have been placed within the track peripheral to the main hepaticvein. There was immediate cessation of bleeding from the sheath. (c) Contrast medium injected via the sheath after embolization shows no further filling of any major vascular structure. The sheath was removed.

risk intrinsic in the other methods of injecting embolic material into the portal or hepatic venous systems. Gelatin sponge embolization. Gelfoam is no longer commercially available in the UK. Spongostan may be used in a similar manner. It is important when particulate materials such as Spongostan are used that the emboli are not so small that they are washed out of the biopsy track by briskly flowing blood. It may also be difficult to deposit these agents within the track without injecting at least some of them either into the portal radicles or into the hepatic veins and thence into the pulmonary circulation. Although the small amounts injected are unlikely to cause any significant problem this occurrence is probably best avoided. Spongostan ‘should be cut up into pledgets measuring about 5 mm x 5 mm X 2Omm, which are then inserted into the tip of a l-ml tuberculin syringe. The syringe is then loaded with contrast medium and the first pledget is injected into the sheath under fluoroscopic guidance. Care must again be taken that the tip of the sheath is not lying within a hepatic or

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portal venous radicle. The sheath is then withdrawn approximately 2 cm and a second Spongostan pledget is introduced into the biopsy tract. The final pledget is introduced so that it crosses the liver capsule and thus prevents subcapsular haematoma formation; this last pledget is considered to be the most important and care has to be taken that the sheath is not withdrawn too much before it is introduced. Chuang and Alspaugh (1988) suggested that, at the time of anaesthetizing the skin prior to the biopsy, a small amount of contrast medium may be injected to outline the liver capsule to aid in the placement of the final embolization pledget. Non-sheathed

needle biopsy technique

Plugged liver biopsy may be performed without the use of an outer sheath, a technique which has been described using either a 1Cgauge Tru-Cut needle (Riley et al, 1984; Crummy et al, 1989; Tobin and Gilmore, 1989) or an 18-gauge Biopty needle (Chisholm et al, 1989). The biopsy is performed in the routine way but the outer cannula of the needle is left in situ following the biopsy and only the inner stylet is removed together with the biopsy specimen. If an inadequate specimen is obtained the inner stylet may be replaced and a repeat biopsy performed after minor adjustment of the needle position. After a successful biopsy, embolization is performed through the outer cannula using similar methods and embolic agents to those described above with the sheath needle technique. The disadvantage of this technique is that a fairly stiff cannula is left within the liver for a moderate period of time and the risk of liver laceration is likely to be greater than with the soft sheath. This risk may be partially offset by the smaller liver puncture required with the non-sheathed needle technique. Complications The major complication remains haemorrhage. In the relatively few plugged liver biopsies which have been reported, clinically significant bleeding occurred in 1.2% (2 out of 166 biopsies). One death has been recorded in a patient who was ‘. . . moribund at the time of the biopsy’ and in whom effective plugging of the track was not achieved because of the inability of the patient to cooperate in breath holding (Riley et al, 1984). Transient pain at the biopsy site or in the shoulder tip has been reported (Tobin and Gilmore, 1989). The other complications of percutaneous liver biopsy (Table 1) have not been reported with the plugged methods so far as the author is aware, but it seems likely that they will be at least as common as those that occur in patients with normal coagulation undergoing an unplugged liver biopsy. COMPARISON BETWEEN LIVER BIOPSIES

PLUGGED

AND TRANSJUGULAR

An insufficient number of plugged liver biopsies have been performed to allow any significant conclusion to be drawn regarding the relative safety of

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J. E. JACKSON ET AL Table 3. Success rates of plugged liver biopsies.

Reference Riley et al, 1984 Chuang & Alspaugh, 1988 Allison & Adam, 1988 Chisholm et al, 1989 Tobin & Gilmore, 1989 Crummy et al, 1989

No. of biopsies

Successful biopsies*

%

20 22 8 5 100 11

19 21 8 not recorded 100 not recorded

95 95 100 100

* Biopsy adequate for histological diagnosis.

this technique compared with the transjugular approach (Table 3). It is likely, however, in view of the experience with ‘conventional’ transabdominal liver biopsy, that the plugged method will result in less fragmented and larger specimens than those obtained via a transjugular route, but whether this is offset by a higher complication rate has yet to be seen. Uncooperative or agitated patients are difficult to biopsy using either technique, and such individuals may require sedation or general anaesthesia if a successful biopsy is to be performed. If a patient becomes restless during a transabdominal biopsy, embolization of the track is likely to prove difficult, and a large respiratory excusion in such individuals may lacerate the liver, particularly if a non-sheathed needle technique is performed. This complication is less likely with the transjugular approach. The plugged technique is generally easier to perform, however, and guided biopsies of focal hepatic abnormalities will be much simpler than with the transjugular method. In addition, most patients much prefer the plugged technique over the transjugular approach. The transjugular method has the advantage that hepatic venography and free and wedged hepatic venous pressure measurement may easily be performed, which may provide useful information in certain patients. It is a more difficult technique, however, and requires much greater expertise and experience to perform safely and successfully.

SUMMARY When a liver biopsy is indicated the transabdominal approach using either a Menghini or Tru-Cut needle has been shown to be an extremely safe procedure with very low morbidity and mortality rates inpatients with normal or only mildly disturbed coagulation. When the coagulation status is severely deranged, however, several methods of obtaining a liver biopsy have been devised to circumvent the increased risk of bleeding. The transjugular approach has been shown to be both successful and relatively safe. The less cumbersome technique of plugging the needle track after percutaneous transabdominal biopsy has been reported relatively recently. Although it is likely that the latter method will produce good biopsy samples in the majority of cases (and in this regard it may prove to be better than the transjugular route), considerably more experience is required before its true complication rate is known.

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In a hospital where large numbers of transjugular biopsies are performed by experienced radiologists and in which skilled pathologists are used to interpreting the histological appearances of small, crushed liver samples, there is no compelling reason to change to the plugged biopsy technique. The more difficult question is whether hospitals in which the radiological and histological skills necessary for consistent success with the transjugular approach are not available should adopt the plugged biopsy method. The answer to this question is probably in the affirmative, but will depend on the confidence and interventional experience of the local operator and on more detailed factual information concerning the safety of the plugged method. With regard to the latter point, the publication of a large controlled study on the safety and efficacy of plugged liver biopsy would be a valuable contribution to the world literature on the subject.

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Chuang VP & Alspaugh JP (1988) Sheath needle for liver biopsy in high-risk patients. Radiology 166: 261-262. Colapinto RF (1985) Transjugular biopsy of the liver. Clinics in Gastroenterology 14: 451-467. Colapinto RF & Blendis LM (1983) Liver biopsy through the transjugular approach. Modification of instruments. Radiology 148: 306. Crummy AB, McDermott JC & Wojtowycz M (1989) A technique for embolization of biopsy tracts. American Journal of Roentgenology 153: 67-68. Dotter CT (1964) Catheter biopsy. Experimental technic for transvenous liver biopsy. Radiology 82: 312-314. Ewe K (1981) Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Digestive Diseases and Sciences 26: 388-393. Gamble P, Colapinto RF, Stronell RD, Colman JC & Blendis L (1985) Transjugular liver biopsy: a review of 461 biopsies. Radiology 157: 589-593. Gazelle GS, Haaga JR & Neuhanser D (1990) Hemostatic protein-polymer sheath: new method to enhance hemostasis at percutaneous biopsy. Radiology 175: 671-674. Gilmore IT, Bradley RD & Thompson RPH (1977) Transjugular liver biopsy. British Medical Journal 2: 100-101. Gilmore IT, Bradley RD & Thompson RPH (1978) Improved method of transvenous liver biopsy. British Medical Journal 2: 249. Goldman ML, Gonzalez AC, Galambos JT et al (1978) The transjugular technique of hepatic

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