Is percutaneous liver biopsy using the Trucut (Travenol) needle superior to Menghini puncture?

The aim of this study was to compare the quality of biopsy cylinders obtained by the Menghini or Trucut liver biopsy-method as well as the frequency of complications observed with both these methods. For this purpose, 74 Menghini and 62 Trucut biopsies were analyzed. Both groups were comparable with respect to histologic diagnosis, but no final diagnosis could be made in eight cases of Menghini biopsy because of insufficiency of the material obtained. Fragmentation of the sample occurred significantly more often in the Menghini group (p less than 0.05; chi 2 test). Trucut biopsies were significantly longer (12 mm versus 8 mm mean value; p less than 0.001; Wilcoxon rank sum test) and contained significantly more portal tracts (16 versus 6 mean value; p less than 0.001). None of the total 136 biopsies led to serious complications. We conclude that Trucut liver biopsy is superior to the Menghini method since tissue yield is better and both methods are equally safe.     

Surecut® 0.6 mm liver biopsy in the diagnosis of cirrhosis

Abstract— Liver biopsy with the 0.6 mm (23 gauge) Surecut® needle was compared to conventional Menghini biopsy in the diagnosis of cirrhosis. Seventy-seven consecutive patients (mainly alcoholics) with a clinical indication for liver biopsy had both biopsies performed simultaneously. In 71 patients sufficient material for a morphological diagnosis concerning liver architecture was obtained with both biopsy techniques (Surecut insufficient in 5 cases and Menghini insufficient in 2 cases). The biopsies were classified as cirrhosis or non-cirrhosis. There was agreement in 69 cases (97%, confidence limits 90–100%). Using the result of the Menghini biopsy as the final diagnosis, the predictive values for a positive and negative diagnosis for the Surecut needle were 96% and 98%, respectively. There were no complications to either of the biopsies. It is suggested that the 0.6 mm Surecut biopsy may be used in the diagnosis of cirrhosis in cases where conventional Menghini needle biopsy is contraindicated.     

Surecut 0.6 mm liver biopsy in the diagnosis of cirrhosis

Liver biopsy with the 0.6 mm (23 gauge) Surecut needle was compared to conventional Menghini biopsy in the diagnosis of cirrhosis. Seventy-seven consecutive patients (mainly alcoholics) with a clinical indication for liver biopsy had both biopsies performed simultaneously. In 71 patients sufficient material for a morphological diagnosis concerning liver architecture was obtained with both biopsy techniques (Surecut insufficient in 5 cases and Menghini insufficient in 2 cases). The biopsies were classified as cirrhosis or non-cirrhosis. There was agreement in 69 cases (97%, confidence limits 90-100%). Using the result of the Menghini biopsy as the final diagnosis, the predictive values for a positive and negative diagnosis for the Surecut needle were 96% and 98%, respectively. There were no complications to either of the biopsies. It is suggested that the 0.6 mm Surecut biopsy may be used in the diagnosis of cirrhosis in cases where conventional Menghini needle biopsy is contraindicated.     

Percutaneous liver biopsy: A safe outpatient procedure

Percutaneous liver biopsy with Menghini or Trucut needle as an outpatient procedure was performed on 159 patients over a 3.5-year period. No major complications were observed. Liver biopsy is recommended as an outpatient procedure, which would reduce the patient load on limited hospital beds and economize on the hospital resources.     

A new technical of liver biopsy with plugging of the needle track using a double channel biopsy device. An experimental study

A new liver biopsy technique with plugging of the intrahepatic needle track in one procedure using a double channel biopsy device (Austrian patent No 384,165 invented by K. Zatloukal and H.P. Dinges) is presented in an experimental study. This technique is similar to that described by Menghini, but is combined with a fibrin sealing system (Tissucol, Tisseel). Biopsy and sealing of the biopsy site is performed within less than two seconds. 15 liver biopsies were performed on 6 heparinized dogs after laparotomy. Heparinization was maintained for 6 hours and the efficiency of the sealing in preventing biopsy-related bleeding was checked before the abdominal wound was closed. No bleeding occurred after biopsy with the new needle system and occlusion of the needle track with fibrin sealant. The livers with the sealed needle tracks and all biopsies obtained were examined histologically. It was found that the needle tracks were filled with the fibrin sealant which was almost completely replaced by granulation tissue after 8 days. Biopsies performed with a conventional Menghini needle led to continuous bleeding from the needle track. The results show that this new biopsy device efficiently prevents bleeding from the biopsy site in animals with severely impaired blood coagulation. Therefore, application of this biopsy technique in humans might reduce bleeding complications particularly in patients with severe liver diseases and disturbed blood coagulation.     

A study of liver biopsies and liver disease among hemophiliacs

Hepatic histologic materials (biopsy or autopsy) and associated clinical data from 155 hemophiliacs were collected by an ad hoc hemophilia study group and analyzed retrospectively in an effort to determine the spectrum of liver disease in this population and to examine the relationship between the severity of liver disease and treatment history. Clinical information on the frequency of complications from 126 biopsies in 115 hemophilic patients provided a unique opportunity to assess the safety of liver biopsy in such patients. The incidence of cirrhosis (15%) and chronic active hepatitis (7%) was lower than previously reported. The frequency of severe liver disease (chronic active hepatitis or cirrhosis) in patients receiving large pooled concentrates was no greater than in patients treated principally with cryoprecipitate or plasma. The risks of liver biopsy in this setting are relatively high: clinically significant hemorrhage followed 12.5% of the procedures.     

Does the size of the needle influence the number of portal tracts obtained through percutaneous liver biopsy?

Aim. Liver biopsy (LB) is often essential for the diagnosis and staging of chronic viral hepatitis. The aim of our paper was to establish if the size of the biopsy needle influences the number of portal tracts obtained through LB. Material and methods. We conducted a retrospective study on 596 echoassisted percutaneous LBs performed in the Department of Gastroenterology and Hepatology Timisoara during a 4 years period. We included only those biopsy results that had mentioned both the type of needle and the number of portal tracts. All LBs were echoassisted and performed with Menghini modified needles 1.4 and 1.6 mm in diameter (technique with two passages into the liver). The liver fragments were analyzed by a senior pathologist and Knodell score was used to describe necroinflammatory activity as well as fibrosis. We compared the number of portal tracts obtained with 1.4 vs. 1.6 Menghini needles. Results. Type 1.4 mm Menghini needles were used for 80 LBs, while 1.6 mm type were used in 516 LBs. Liver fragments obtained with 1.6 mm Menghini needles had a significantly higher mean number of portal tracts as compared to those obtained with 1.4 needles (24.5 ± 10.6 vs. 20.8 ± 8.6, p = 0.003). Conclusion. The 1.6 mm Menghini needles provide better liver biopsy specimens, with higher number of portal tracts, as compared to 1.4 mm Menghini needles.     

Percutaneous myocardial and pericardial biopsy with the Menghini needle

A simple, safe method of obtaining myocardial or pericardial tissue for analysis by light or electron microscopy or for culture has obvious application. The Menghini needle has been demonstrated to be a safe and effective instrument for the aspiration biopsy of liver and kidney. Therefore, application of aspiration biopsy with a 17 gauge Menghini needle to the heart by means of the left ventricular apical percutaneous approach has been evaluated in humans in 27 myocardial and 8 pericardial biopsies. Adequate tissue was obtained in all except one pericardial and two myocardial biopsy attempts. Of the eight pericardial biopsies, the diagnosis of tuberculous pericarditis was made in two cases and carcinomatous invasion of the pericardium was made in another two cases. Three cases showed nonspecific pericarditis. Of the 27 myocardial biopsies, 6 were examined by light microscopy and 21 were examined by electron microscopy. Light microscopy revealed no specific findings. However, electron microscopy showed moderate to severe intracellular abnormalities, the significance of which remains to be determined. Biopsy procedure takes 5 minutes or less under local anesthesia following mild premedication. Pneumothorax occurred in two patients and transient mild pleuritic chest pain occurred in four patients. Both complications were well tolerated. The technique seems effective and safe. Its utility and application remain to be determined.     

The value of Chiba fine-needle aspiration biopsy in the diagnosis of hepatic malignancy: a comparison with Menghini needle biopsy

The detection or exclusion of metastatic liver involvement is critical in the management and prognosis of patients with malignant disease. Noninvasive imaging modalities such as computed tomography, ultrasound, and technetium colloid liver scan are highly sensitive but nonspecific. Serum alkaline phosphatase is of similar value. A blind liver biopsy by the Menghini technique is often done to confirm the diagnosis, but its yield is low. We prospectively evaluated 74 patients using blind Menghini needle biopsy and concurrent Chiba fine-needle aspiration biopsy (FNAB) techniques. A positive diagnosis of malignancy was made in 30 patients (41%). In only 25 (34%) was the diagnosis made by Menghini biopsy, while Chiba FNAB confirmed the diagnosis in all 30 patients. Thus, concurrent use of both needles increased the diagnostic accuracy by 7%. Seven additional patients, considered to have one or more contraindications for the Menghini biopsy, underwent Chiba FNAB alone; the diagnosis was confirmed in all without complication. We conclude that FNAB alone or in combination with Menghini biopsy is valuable and safe in the diagnosis of metastatic liver disease.     

Outpatient Blind Percutaneous Liver Biopsy in Infants and Children: Is it Safe?

Background/Aim:

We aim to investigate the safety of outpatient blind percutaneous liver biopsy (BPLB) in infants and children with chronic liver disease (CLD).

Patients and Methods:

BPLB was performed as an outpatient procedure using the aspiration Menghini technique in 80 infants and children, aged 2 months to 14 yrs, for diagnosis of their CLD. Patients were divided into three groups: Group 1 (<1 year), group 2 (1–6 yrs), and group 3 (6–14 yrs). The vital signs were closely monitored 1 hr before biopsy, and then 1, 2, 6, and 24 hrs after biopsy. Twenty-four hours pre- and post-biopsy complete blood counts, liver enzymes, prothrombin time (PT), and abdominal ultrasonography, searching for a biopsy-induced hematoma, were done for all patients.

Results:

No mortality or major morbidities were encountered after BPLB. The rate of minor complications was 17.5% including irritability or “pain” requiring analgesia in 10%, mild fever in 5%, and drowsiness for >6 hrs due to oversedation in 2.5%. There was a statistically significant rise in the 1-hr post-biopsy mean heart and respiratory rates, but the rise was non-significant at 6 and 24 hrs except for group 2 where heart rate and respiratory rates significantly dropped at 24 hrs. No statistically significant difference was noted between the mean pre-biopsy and the 1, 6, and 24-hrs post-biopsy values of blood pressure in all groups. The 24-hrs post-biopsy mean hemoglobin and hematocrit showed a significant decrease, while the 24-hrs post-biopsy mean total leucocyte and platelet counts showed non-significant changes. The 24-hrs post-biopsy mean liver enzymes were non-significantly changed except the 24-hrs post-biopsy mean PT which was found to be significantly prolonged, for a yet unknown reason(s).

Conclusions:

Outpatient BPLB performed by the Menghini technique is safe and well tolerated even in infants and young children. Frequent, close monitoring of patients is strongly recommended to achieve optimal patient safety and avoid potential complications.     

Transjugular liver biopsy. An update

Transjugular liver biopsy was first reported in 1967. Since then, this technique has been broadly performed in many medical centers around the world. The number of its indications has increased, and by modifying the needles, the quality of the liver tissue sample has improved. The advantage of transjugular biopsy is that it can be performed in patients in whom the use of percutaneous biopsy is contraindicated Indications for transjugular liver biopsy are, precisely, most of the contraindications for percutaneous liver biopsy. This fact increases the number of patients that can benefit from this procedure. In most cases, the procedure is successfully performed. Minor complications may occur in 1% to 15% and major complications (perforation of the hepatic capsule, cholangitis, and intra-peritoneal bleeding) are observed in 1-3% of the cases. Mortality related to the procedure varies form 0.2 to 0.3%. It has been reported that diagnosis yielded by transjugular liver biopsy induced changes of treatment in 50% of patients with an acute hepatic illness, in 62% of the patients with a chronic hepatic illness, and in 87% of the patients with liver transplants. In conclusion, transjugular liver biopsy is a useful procedure in the diagnosis of hepatic diseases. Its success rate is high; it is a very safe procedure because complications and mortality are rare; and it is well tolerated by patients.     

Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London.

The liver section of the British Society of Gastroenterology and the research unit of the Royal College of Physicians collaborated to set up a nationwide audit to investigate the practice of percutaneous liver biopsy in England and Wales. Each of 189 health districts in England and Wales was approached to provide a list of 10 consecutive percutaneous biopsies performed during 1991, and details of demographic data, indications, suspected diagnosis, investigations, biopsy technique, outcome, and influence on patient management were collected. Data were retrieved on 1500 (79%). The age distribution showed 6% of biopsies were done in those over 80 years of age and as many over 90 as under 10 years of age. Suspected malignancy and chronic liver disease each contributed one third of the indications. In 34% the procedure was carried out by radiologists under ultrasound image control. The remainder were done by general physicians and gastroenterologists, with the operator in the second group being more senior and experienced. The Trucut biopsy needle accounted for two thirds of biopsies, the remainder being the Menghini type. For both needles the samples were recorded as excellent or satisfactory in 83% and inadequate in only 5%. Bleeding complicated 26 procedures (1.7%), requiring transfusion in 11, and was commoner when clotting was impaired or serum bilirubin raised. There were two definite and three possible procedure related, given an overall mortality of 0.13-0.33%. The diagnosis made before biopsy was confirmed in 63% of patients, and the clinician found the biopsy helpful in treatment in 75%. Day case biopsy and techniques to reduce the risk of bleeding were surprisingly rare in this series, which has given a unique opportunity to examine everyday practice across a wide range of hospitals.     

Why, who and how should perform liver biopsy in chronic liver diseases

Chronic viral hepatitis is a common disease in the general population.During chronic hepatitis,the prognosis and clinical management are highly dependent on the extent of liver fibrosis.The fibrosis evaluation can be performed by FibroTest（using serological markers）,by Elastography or FibroScan（a noninvasive percutaneous technique using the elastic properties of the hepatic tissue） and by liver biopsy（LB）,considered to be the ＂gold standard＂.Currently,there are three techniques for performing LB：percutaneous,transjugular and laparoscopic.The percutaneous LB can be performed blind,ultrasound（US） guided or US assisted.There are two main categories of specialists who perform LB：gastroenterologists（hepatologists） and radiologists,and the specialty of the individual who performs the LB determines if the LB is performed under ultrasound guidance or not.There are two types of biopsy needles used for LB：cutting needles（Tru-Cut,Vim-Silverman） and suction needles（Menghini,Klatzkin,Jamshidi）.The rate of major complications after percutaneous LB ranges from 0.09% to 2.3%,but the echoguided percutaneous liver biopsy is a safe method for the diagnosis of chronic diffuse hepatitis（cost-effective as compared to blind biopsy） and the rate of complications seems to be related to the experience of the physician and the type of the needle used（Menghini type needle seems to be safer）.Maybe,in a few years we will use non-invasive markers of fibrosis,but at this time,most authorities in the field consider that the LB is useful and necessary for the evaluation of chronic hepatopathies,despite the fact that it is not a perfect test.     

Prospective study comparing the results obtained by liver puncture biopsy with Chiba fine needle and Menghini needle in some tumors of the liver

Seventy-eight consecutive patients (mean age 59 years) have been submitted to concomitant liver biopsy with Menghini and Chiba needles. The same place in the liver was reached by both needles. In 54 cases there was a clinical suspicion of malignancy and in 24 patients biopsy was indicated by other reasons. In 60 cases the biopsies were oriented by laparoscopy. Comparing the results attained by Menghini needle ("gold standard") and the results of the cytologic study of the material obtained with Chiba needle, the last method has proved to be sensible (92.7%), specific (97.3%) and reliable (accuracy = 94.9%).     

Complications of percutaneous liver biopsy in patients after liver transplantation

Percutaneous liver biopsy is an important diagnostic tool for the management of patients following liver transplantation. However, it may be associated with severe complications. To evaluate the incidence and type of complications after liver biopsy, we retrospectively analyzed 919 patients who underwent orthotopic liver transplantation (OLT) from September 1988 to May 1998. A total 3,670 biopsies were performed with ultrasound guidance and use of the Menghini needle (1.6 mm diameter). The biopsies were performed according to the protocol on the 7th postoperative day and one, three, five years after OLT, or when clinically indicated. Patients with severe coagulopathy (thrombocytes < 30,000/nl and Quick < 40%) were excluded from this protocol. Biopsy was complicated by bleeding in 13 of 919 patients (1.41%). The incidence of procedure related complications was 13 of 3,670 (0.35%). Five patients showed intrahepatic hematoma, four patients developed a hematothorax, three patients had intraabdominal bleeding and one patient suffered from hemobilia. Seven of 13 patients (53%) required surgical intervention (laparotomy four, thoracotomy two, retransplantation one). Graft dysfunction after liver transplantation requires rapid assessment and specific treatment to achieve good results. Percutaneous liver biopsy is an important procedure in the evaluation and identification of graft dysfunction such as acute rejection, hepatitis reinfection or toxic alterations. From our data we conclude that percutaneous liver biopsy is a safe procedure and advocate is liberal use.     

Transjugular and plugged liver biopsies

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 in patients 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.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.     

慢性乙型肝炎合并脂肪肝126例病理与临床

目的:调查慢性乙型肝炎(慢乙肝)中脂肪肝的发生率.方法:采用Menghini型快速肝穿取得肝组织,10%甲醛固定,常规制片,HE染色.结果:550例慢乙肝中有126例病理证实合并有脂肪肝,占22.91%(126/550),其中83例为B超检出,检出率为15.1%(83/550),B超与病理诊断符合率为65.87%(83/126).结论:慢性乙型肝炎易合并脂肪肝,无创伤性B超检查为脂肪肝诊断首选,肝组织活检是目前唯一的确诊方法.     

98例慢性肝病快速肝活检的常见并发症状及处理

用日产“ISK ACECUT”型单人操作快速肝穿针,对98例慢性肝炎患者进行快速肝穿106次,一次成功率92.45%,二次成功率98.97%.术前精神紧张者18例(18.37%),术后精神紧张11例(11.22%),进针局部及周围较明显疼痛8例(8.16%),恶心,上腹疼痛或较明显的不适6例(6.12%),术后血压下降3例(3.06%),诱发慢性胆囊炎急性发作1例(1.02%),未发现气胸、出血、胆汁性腹膜炎等并发症.以上并发症状多经精神安慰、细心解释及肝穿病人之间沟通等,配合对症处理迅速缓解.这一结果提示,快速肝活检是一种比较安全、简单、实用的诊断技术,但手术前后部分患者仍会出现心理或身体不适,严密观察及对症处理十分重要.     

Practices of liver biopsy in France: results of a prospective nationwide survey. For the Group of Epidemiology of the French Association for the Study of the Liver (AFEF)

A nationwide prospective study was conducted in France in 89 university and primary referral hospitals' liver units to evaluate practices of liver biopsy and the occurrence of complications. A total of 2,084 biopsies were analyzed, recording the indication, hemostasis parameters, experience of operator, route of biopsy, use of ultrasonography (US), type of hospitalization, side effects, and complications. Pain, anxiety, and discomfort were evaluated by patients by visual analogue scale (VAS). Biopsies were performed by experienced physicians (>150 procedures performed) in 72%, and hepato-gastroenterologists in 89% of the cases. Hepatitis C was the indication in 54%. Sedation or premedication (atropine) was given in 46%. US-guidance was used in 56% of the cases. A day-care procedure was used in 27%. No deaths occurred, but severe complications were observed in 0.57% and increased with the number of passes and decreased with experience of operator, use of atropine, and US-guidance. Pain was independently related to general anesthesia, experience of the operator, female sex, and hepatitis C. Anxiety was increased in women. Discomfort was increased by venous access and decreased with an experienced operator. Acceptance of additional biopsies was related to a day-care procedure and independently related to general anesthesia and multiples passes. This study showed that (1) liver biopsy procedures vary greatly in France, (2) hepatitis C is the main indication for liver biopsy at present, (3) US-guidance should be developed to reduce severe complications, and (4) day-care procedures increase acceptance of a future biopsy and should also be used more often.     

Prospective study of the incidence of ultrasound-detected hepatic hematomas 2 and 24 hours after percutaneous liver biopsy

Recently, a high incidence of hepatic hematomas following percutaneous liver biopsy was reported. This induced us to undertake this prospective ultrasound examination before, as well as 2 and 24 h after, percutaneous liver biopsy, using a Menghini needle (O 1.4 mm), in 93 patients for diagnostic purposes. Two hours after biopsy a small subcapsular fluid margin was found in one patient (1.1%) which disappeared within 24 h. We conclude that hepatic hematomas are not frequent following percutaneous liver biopsy and that it remains a safe diagnostic procedure to find out the reason for chronically elevated liver enzymes and evaluate suspected diffuse parenchymal lesions of the liver.