Findings of the UK National Audit Evaluating Image-guided or Image-assisted Liver Biopsy. Part I. Procedural Aspects, Diagnostic Adequacy, and Accuracy
Department of Radiology, Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex, England BN21 2UD Radiology
(Impact Factor: 6.87).
12/2012; 265(3):819-31. DOI: 10.1148/radiol.12111562
Purpose: To assess procedural aspects, diagnostic adequacy, and accuracy of liver biopsy across the United Kingdom. Materials and Methods: Institutional review board approval for this type of study is not required in the United Kingdom. All radiology departments with an approved leader for departmental audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients who underwent image-guided or image-assisted liver biopsy in 2008 were included. Audit standards relating to procedural aspects of biopsy, sample adequacy, and accuracy were prepared with reference to published data. Sensitivity, specificity, positive and negative likelihood ratios, and accuracy were calculated. Organizational and clinical variables were investigated for their association with diagnostic specimen quality. Results: Eighty-seven (41%) of 210 departments supplied data for this study, with a total of 3496 cases (1225 focal disease, 2262 nonfocal disease, nine unspecified). Ultrasonographic (US) guidance was the technique most commonly used for focal lesions and for cases of nonfocal disease (2808 [96.38%] of 3490 cases). The audit standard for sample adequacy (98%) was narrowly missed in practice (3401 [97.96%] of 3472 cases); however, the standard for diagnostic accuracy (90%) was met (3187 [98.55%] of 3234 cases). Poor compliance with postbiopsy documentation was observed. Conclusion: The majority of liver biopsies in this audit were performed by radiologists using image guidance or assistance, usually in the form of US. Biopsies were performed with a high degree of accuracy. Some postprocedural aspects of biopsy failed to meet required standards and would merit reaudit after practice changes. © RSNA, 2012 Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12111562/-/DC1.
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ABSTRACT: Purpose:To determine the frequency of complications and death following image-guided and/or image-assisted liver biopsy and to identify significant variables associated with an increased risk of complications or death.Materials and Methods:Institutional review board approval for this type of study is not required in the United Kingdom. United Kingdom radiology departments with a department leader for audit registered with the Royal College of Radiologists were invited to participate. The first 50 consecutive patients who underwent liver biopsy in 2008 were included. Audit standards were developed for minor pain (<30%), severe pain (<3%), vasovagal hypotension (<3%), significant hemorrhage (<0.5%), hemobilia (<0.1%), puncture of another organ (<0.1%), and death (<0.1%). Organizational, clinical, and coagulation variables were investigated statistically for their association with complications and/or death.Results:Data were obtained from 87 of 210 departments (41%). Audit standards were met for pain, hypotension, hemorrhage, hemobilia, and puncture of another organ. There were four hemorrhage-related deaths, and this target was narrowly missed (rate achieved in practice, 0.11% [four of 3486 patients]). Fifteen additional patients experienced at least one major complication. The international normalized ratio (INR) was absent in 3% of cases (97 of 2951 patients), the platelet count was absent in 1% (32 of 2986 patients), the INR was more than 1 week old in 8% (229 of 2888 patients), and the platelet count was more than 1 week old in 10% (291 of 2955 patients).Conclusion:Results of this audit confirm that image-guided and image-assisted biopsy is performed safely in United Kingdom radiology departments, with complication rates within expected parameters. Preprocedural clotting assessment was inadequate in some cases and would merit repeat audit.© RSNA, 2012Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120224/-/DC1.
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ABSTRACT: Most medical liver biopsies in the UK are now taken in radiology departments using 18 g biopsy needles. Subjectively, the resulting biopsies are narrow and fragile.
To compare the quality of liver biopsy tissue sections obtained from 16 and 18 g biopsy needles.
Fifty consecutive routine medical liver biopsies obtained with 16 and 18 g needles, processed identically in the same laboratory, were measured using digital pathology software. We recorded their fragmentation, length, width, area and number of portal tracts.
Biopsies obtained with 16 g needles more often resulted in an intact core in tissue sections than those with 18 g needles (71% vs 24%, p<0.001) and were significantly wider (average width of tissue 0.88 vs 0.53 mm, p<0.001). The average total area of tissue per pass was 11.38 mm(2) compared with 8.34 mm(2) (p<0.001). The number of complete portal tracts per length of biopsy was very variable, but double for 16 vs 18 g biopsies. Routinely taking two passes with the 18 g needle compensated for the reduced area, but the resulting liver in tissue sections was fragmented and distorted.
Our results support the routine use of 16 g rather than 18 g biopsy needles for routine ultrasound-guided medical liver biopsies. A second pass should be considered if the first biopsy core is short, especially for investigation of disease stage.
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ABSTRACT: Image-guided hepatic biopsies have been performed safely and accurately for a number of years. The advantages of sonographic or CT guidance in avoiding major vital structures, such as large vessels, the gallbladder, or pleura, have been confirmed many times. However, the safety and accuracy of certified nurse practitioners' performing these biopsies have not been described. The authors describe a retrospective review of 418 image-guided hepatic biopsies that demonstrated no significant difference in accuracy or complication rates between biopsies performed by certified nurse practitioners and those performed by radiologists in a single-institution, multihospital academic setting. Appropriately trained advanced practice providers can perform image-guided hepatic biopsies safely and accurately.
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