Interventional Judith
L. Chezmar,
Gary
MD MD
L. Hertzler,
Liver
Lori
a
#{149} Michael
L. Keith, MD E. Bernardino,
Transplant
Rendon MD
a
Biopsies
The authors evaluated the safety and efficacy of a biopsy gun for performance of image-guided percutaneous biopsy of hepatic allografts in liver transplant recipients. Two hundred fifty-two liver biopsies were performed in 58 transplant recipients over a 27-month period by using this instrument with an 18gauge needle. Major complications occurred in two of the 252 biopsies (0.8%): One hemopneumothorax necessitated drainage with a chest tube, and one hemorrhage necessitated transfusion. No patient required surgical exploration because of a complication of the biopsy. Specimens were adequate for accurate histopathologic diagnosis in 248 of 252 procedures (98.4%). The authors conclude that image-guided percutaneous biopsy of hepatic allografts with use of the biopsy gun is a safe and accurate method of obtaming hepatic tissue from liver transplant recipients for histopathologic analysis.
orthotopic
FTER
terms:
761.69
Biopsies.
#{149} Liver,
technology.
biopsy,
transplantation,
761.459,
761.459,
suit sible
1991;
tation
may meof posrejec-
tion, ischemic injury, thrombosis of the transplant vessels, infection, biliamy complications, and drug-related hepatic injury. While laboratory and imaging studies may be useful for identifying the cause of graft dysfunction in some cases, hepatic biopsy is often
essential.
recipients
may,
Liver
risk for complications biopsy due to their
tus and, often, The biopsy logical,
be at high sta-
impaired coagulation. gun (Biopty; Bard UmoGa),
originally
developed for biopsy of the prostate (1), has recently been used for percutaneous biopsy of other solid organs, including the liver (2-5). The punpose of this study was to evaluate the safety and adequacy of this instmument for percutaneous biopsy of hepatic albogmafts.
AND
METHODS
761.459. 761.69
We began
#{149} Liver,
761.69
18-gauge
179:447-448
using
Radioplast,
opsy
device is fitted
needle Uppsala,
of hepatic
This that
the biopsy
Biopty-cut
gun with (Bard
for
in January
is a spring-loaded with an 18-gauge
Between
January
1988
bi-
1988.
instrument Biopty-cut
needle with a 17-mm sampling notch obtaining core specimens for histologic study.
an
Umolog-
Sweden)
allografts
and
for
April
1990, 252 liver biopsies were performed in 58 transplant recipients (32 female and 26 male patients; age mange, 16-61 years)
by
I
From
L.L.K.,
the
(C.L.H.), 1364
J.C.P.,
Emory
Clifton
the 1990 November ber
Departments
R.C.N., Rd.
of Radiology M.E.B.)
University NE,
RSNA scientific 5, 1990; revision
21;
revision
received
January
18. Address
RSNA,
School
Atlanta,
cepted J.L.C. C
and CA
(J.L.C.,
Pathology
of Medicine, 30322.
assembly. requested January
reprint
From
Received Decem15,
1991;
requests
ac-
to
this
device.
Review
of initial
pathologic specimens indicated that one pass with the needle was not consistently sufficient to obtain 10 portal tracts, the number of tracts believed to be necessary by our transplant pathologist to rule out the possibility of rejection; therefore, two passes with this device were routinely performed. The decision to perform a biopsy of the liver allograft in the early postoperative period was made on the basis
1991
using
data.
of the
clinical
In addition,
course
according
and
biochemical
to transplan-
protocol,
BS
a
biopsies
were
after
transplantation.
3 years
Twelve
patients
biopsy,
nine
performed
underwent
underwent
a single two
liver
biopsies,
eight underwent three biopsies, and 29 underwent four or more biopsies. Of these latter 29 patients, four underwent at least
10 biopsies.
Biopsies
were
performed
after
ultrason-
ic (US) marking in 247 cases and after computed tomographic (CT) marking
five. CT was performed
US
from hepatic postoperative
Covington,
Plaire,
Gun’
1, 2, and
when some
transplant
however,
Chadwick
a Biopsy
transplanta-
tion, graft dysfunction from any one of a number causes, including graft
ical; Radiology
liver
#{149} J.
MD
with
MATERIALS Index
C. Nelson,
Radiology
that other was
modality clinical
for marking
was being indication;
used for otherwise,
performed.
The physical approach was usually right lateral intercostal or subcostal, the
in
only
basis
of the
patient’s
for the biopsy or anterolateral, as determined hepatic
lobar
on and
vascular anatomy. Three biopsies of the left hepatic lobe were performed from an anterior approach because of the presence of infarction in the right lobe, which had previously been detected at US and confirmed at biopsy. A region with a sufficient amount of hepatic parenchyma free of large vessels or focal parenchymal abnormality was chosen as the site for biopsy;
the
depth
from
the
skin
surface
to this
region was measured by using electronic calipers, and the skin over this site was marked. The biopsy gun advanced the needle 2.3 cm when fired. This distance was taken into account when needle placement depth was determined. All
biopsies
were
performed
by
a madi-
ologist, a radiology fellow, or a resident under staff supervision. Many of the biopsies were performed by a resident who had only minimal or no previous interventional experience. Specimens were immediately immersed in Camnoy solution. All biopsy specimens were reviewed by
a pathologist
who
determined
their
adequacy and diagnosis. Complications were determined at a postbiopsy patient visit and on the basis of chart review. Postbiopsy chest radiographs were not routinely obtained.
RESULTS Biopsy
samples
for histologic tamed in 248
In two
biopsies,
that
were
diagnosis were of 252 patients
insufficient
adequate ob(98.4%).
tissue A A7
was obtained. In the other two cases, the specimen obtained was adequate in size and quality but contained fewer than 10 portal tracts. Two major complications occurred in the course of the 252 biopsies (0.8%): One hemopneumothorax necessitated
chest
tube
drainage,
and
one intrapemitoneal hemorrhage necessitated transfusion of 1 unit of packed red blood cells. Both of these complications occurred in the same patient who had undergone biopsies that were performed 1 month apart. Four subsequent biopsies were performed on this patient without complications. Minor complications occurred in 16 of 252 biopsies (6.3%). These cornplications included orthostatic hypotension (n = 7), oozing from the biopsy site (n 3), pain (n 3), decreased hematocrit (n 1), and swelling or hematoma at the biopsy site (n = 2). No patient required sumgical exploration because of a biopsyrelated complication. DISCUSSION The cause of hepatic dysfunction after liver transplantation must be correctly identified and rapidly treated if the ailogmaft is to be saved. This process is particularly important in the early postoperative period. Differentiation between several of the complications that may mesuit in graft dysfunction can be made accurately only on the basis of histologic evaluation of liver tissue (6,7). Liver biopsy is also essential for monitoring the response to immunosuppressive therapy (6). Therefore, the need for percutaneous biopsy is often indicated for patients in whom coagulation may be impaired and/or who may be in critical
condition
in the
early
post-
operative period. In some centers, to avoid needle-core biopsies with use of larger needles in patients with clotting abnormalities, fine-needle aspiration with 23-gauge needles has been performed to diagnose rejection (8,9). However, diagnosis of causes of hepatic dysfunction other than rejection often cannot be made by using the fine-needle aspiration technique and may require come biopsy for histobogic evaluation. The biopsy gun was originally developed for biopsy of the prostate (1) and has been successfully adapted for percutaneous biopsy of other solid organs (2-5). In a recent study (10),
448
#{149} Radiology
comparative analysis of specimens obtained from porcine livers with 15 different biopsy needles of various sizes rated the histopathobogic quality of tissue obtained with the biopsy gun to be second only to that obtamed with a 14-gauge Tru-Cut needie (Baxter Healthcare, Pharmaseal, Valencia, study,
Calif). use
In
of the
addition,
biopsy
gun
performed
with
a Jamshidi
group,
however,
biopsies
which
was
probably
due
to
in this
tolerated
perience little or no pain during the rapid excursion of the needle. However, pain is difficult to quantify, and the lack of procedure-related pain may be due in part to surgical denervation of the transplanted liver. In conclusion, our experience sugthat
patients
because
image-guided
they
biopsy
ex-
with
the biopsy gun is a safe and accurate method for obtaining core biopsy samples for histologic analysis after liver
transplantation.
U
Acknowledgments:
The
authors
gratefully
acknowledge the cooperation and support of J. Michael Henderson, MD, William J. Millikan, MD, John R. Galloway, MD, and the entire Liver Transplant Team. We also thank Shirley C. Wray for manuscript preparation.
References 1.
Ragde H, Aldape HC, sound-guided prostate 1988; 32:503-506.
2.
Parker
SH,
Hopper
Bagley biopsy.
KD,
CM. UltraUrology
Yakes
WF,
MD, Ownbey JL, Carter TE. rected percutaneous biopsies sy gun. 3.
4.
that
were required in patients with marginal clotting function were performed with direct visualization through the surgical incision. In another study, Colonna et al (7) reported a single episode of bleeding that required transfusion in a series of 114 percutaneous liver biopsies performed with an unspecified needle (major complication mate, 0.9%). We believe that the combination of image guidance and the technical properties of the biopsy gun contributed to the low complication rate in this challenging group of patients. Image-guided selection of the biopsy site allowed retrieval of adequate pamenchyma at a precise depth, away from major vessels or focal abnormalities such as infarction, abscess, or hematoma. In our series, this allowed three left hepatic lobe biopsies to be performed while avoiding an area of infarction in a portion of the right lobe. The automated operation of this device allowed a standardized specimen to be obtained while simplifying the biopsy procedure and making it easier to learn.
by
gests
nee-
die (Baxter Healthcare, Phammaseal), including one hemothorax that necessitated thoracotomy for control of diaphragmatic bleeding and one infected hematoma that necessitated percutaneous catheter drainage. In this
ments,
the rapid “split-second” sampling albowed by the gun. We were also impressed that this procedure was well
yielded
1% fewer biopsies with suboptimal tissue than did use of the 14-gauge Tru-Cut needle (7% vs 8%). At our institution, after successful use of the biopsy gun for biopsy of nontransplant livers, we implemented a program under which all liver transplant biopsies were performed by a radiologist who used this device with image guidance. The specimens obtained in this large series were judged by the pathologist to be adequate to establish a histologic diagnosis and to rule out the possibility of rejection in all but four cases. The complication rate we experienced in this large series compares favorably with complication rates in other biopsy series. Williams et al (6) reported major complications in three of 137 (2.2%) transplant biopsies
In addition to these advantages, Parker et al (2) reported less patient discomfort with this device than with conventional biopsy instru-
Radiology
171:663-669.
J, Binder S. Use of Biopty gun for transcutaneous testicular biopsies. J Urol 1989; 142:1021-1022. Tufveson C, Hanas E. Lindgren PC, et al. A review of the Uppsala experience of Rajfer
Biopty-cut
renal
Transplant 5.
1989;
Gibson
Image-diwith a biop-
Elvin
transplant
biopsies.
Proc 1989; 21:3581 -3582.
A, Anderson
T, Scheibenpflug
Lindgren PG. Biopsy of the with a Biopty gun. Radiology
L,
pancreas 1990;
176:667-679. 6.
Williams JW, Peters TG, Vera SR. Britt Van Voorst SJ, Haggitt RC. Biopsy-direct-
ed immunosuppression transplantation
7.
importance
opsy in transplant
1988;
the
JJ, Goldstein
management recipient.
liver
of the Transplant
I, HOckerstedt
Fine-needle
bi-
liver Proc
monitoring
of liver 1988;
K. Ahonen
aspiration
biopsy
allografts.
fine-needle
A, Pecorella transplant aspiration
I, et al. monitoring biopsy.
plant Proc 1989; 21:2311-2312. Hopper KD, Baird DE, Reddy VV, Efficacy conventional
of automated biopsy
my
Radiology
pig.
in
Trans-
46:47-52.
DiTondo U, Ciardi Postoperative liver with
LI, et al.
20:682-684.
plantation
10.
the
hepatic
Transplantation
of percutaneous
Lautenschlager
J, et al.
9.
man.
1985; 39:589-596. Colonna JO, Brems The
8.
following in
LG,
biopsy needles 1990;
Trans-
et al.
guns versus in the pyg-
176:671-676.
May
1991
L. Chezmar,
Gary
MD MD
L. Hertzler,
Liver
Lori
a
#{149} Michael
L. Keith, MD E. Bernardino,
Transplant
Rendon MD
a
Biopsies
The authors evaluated the safety and efficacy of a biopsy gun for performance of image-guided percutaneous biopsy of hepatic allografts in liver transplant recipients. Two hundred fifty-two liver biopsies were performed in 58 transplant recipients over a 27-month period by using this instrument with an 18gauge needle. Major complications occurred in two of the 252 biopsies (0.8%): One hemopneumothorax necessitated drainage with a chest tube, and one hemorrhage necessitated transfusion. No patient required surgical exploration because of a complication of the biopsy. Specimens were adequate for accurate histopathologic diagnosis in 248 of 252 procedures (98.4%). The authors conclude that image-guided percutaneous biopsy of hepatic allografts with use of the biopsy gun is a safe and accurate method of obtaming hepatic tissue from liver transplant recipients for histopathologic analysis.
orthotopic
FTER
terms:
761.69
Biopsies.
#{149} Liver,
technology.
biopsy,
transplantation,
761.459,
761.459,
suit sible
1991;
tation
may meof posrejec-
tion, ischemic injury, thrombosis of the transplant vessels, infection, biliamy complications, and drug-related hepatic injury. While laboratory and imaging studies may be useful for identifying the cause of graft dysfunction in some cases, hepatic biopsy is often
essential.
recipients
may,
Liver
risk for complications biopsy due to their
tus and, often, The biopsy logical,
be at high sta-
impaired coagulation. gun (Biopty; Bard UmoGa),
originally
developed for biopsy of the prostate (1), has recently been used for percutaneous biopsy of other solid organs, including the liver (2-5). The punpose of this study was to evaluate the safety and adequacy of this instmument for percutaneous biopsy of hepatic albogmafts.
AND
METHODS
761.459. 761.69
We began
#{149} Liver,
761.69
18-gauge
179:447-448
using
Radioplast,
opsy
device is fitted
needle Uppsala,
of hepatic
This that
the biopsy
Biopty-cut
gun with (Bard
for
in January
is a spring-loaded with an 18-gauge
Between
January
1988
bi-
1988.
instrument Biopty-cut
needle with a 17-mm sampling notch obtaining core specimens for histologic study.
an
Umolog-
Sweden)
allografts
and
for
April
1990, 252 liver biopsies were performed in 58 transplant recipients (32 female and 26 male patients; age mange, 16-61 years)
by
I
From
L.L.K.,
the
(C.L.H.), 1364
J.C.P.,
Emory
Clifton
the 1990 November ber
Departments
R.C.N., Rd.
of Radiology M.E.B.)
University NE,
RSNA scientific 5, 1990; revision
21;
revision
received
January
18. Address
RSNA,
School
Atlanta,
cepted J.L.C. C
and CA
(J.L.C.,
Pathology
of Medicine, 30322.
assembly. requested January
reprint
From
Received Decem15,
1991;
requests
ac-
to
this
device.
Review
of initial
pathologic specimens indicated that one pass with the needle was not consistently sufficient to obtain 10 portal tracts, the number of tracts believed to be necessary by our transplant pathologist to rule out the possibility of rejection; therefore, two passes with this device were routinely performed. The decision to perform a biopsy of the liver allograft in the early postoperative period was made on the basis
1991
using
data.
of the
clinical
In addition,
course
according
and
biochemical
to transplan-
protocol,
BS
a
biopsies
were
after
transplantation.
3 years
Twelve
patients
biopsy,
nine
performed
underwent
underwent
a single two
liver
biopsies,
eight underwent three biopsies, and 29 underwent four or more biopsies. Of these latter 29 patients, four underwent at least
10 biopsies.
Biopsies
were
performed
after
ultrason-
ic (US) marking in 247 cases and after computed tomographic (CT) marking
five. CT was performed
US
from hepatic postoperative
Covington,
Plaire,
Gun’
1, 2, and
when some
transplant
however,
Chadwick
a Biopsy
transplanta-
tion, graft dysfunction from any one of a number causes, including graft
ical; Radiology
liver
#{149} J.
MD
with
MATERIALS Index
C. Nelson,
Radiology
that other was
modality clinical
for marking
was being indication;
used for otherwise,
performed.
The physical approach was usually right lateral intercostal or subcostal, the
in
only
basis
of the
patient’s
for the biopsy or anterolateral, as determined hepatic
lobar
on and
vascular anatomy. Three biopsies of the left hepatic lobe were performed from an anterior approach because of the presence of infarction in the right lobe, which had previously been detected at US and confirmed at biopsy. A region with a sufficient amount of hepatic parenchyma free of large vessels or focal parenchymal abnormality was chosen as the site for biopsy;
the
depth
from
the
skin
surface
to this
region was measured by using electronic calipers, and the skin over this site was marked. The biopsy gun advanced the needle 2.3 cm when fired. This distance was taken into account when needle placement depth was determined. All
biopsies
were
performed
by
a madi-
ologist, a radiology fellow, or a resident under staff supervision. Many of the biopsies were performed by a resident who had only minimal or no previous interventional experience. Specimens were immediately immersed in Camnoy solution. All biopsy specimens were reviewed by
a pathologist
who
determined
their
adequacy and diagnosis. Complications were determined at a postbiopsy patient visit and on the basis of chart review. Postbiopsy chest radiographs were not routinely obtained.
RESULTS Biopsy
samples
for histologic tamed in 248
In two
biopsies,
that
were
diagnosis were of 252 patients
insufficient
adequate ob(98.4%).
tissue A A7
was obtained. In the other two cases, the specimen obtained was adequate in size and quality but contained fewer than 10 portal tracts. Two major complications occurred in the course of the 252 biopsies (0.8%): One hemopneumothorax necessitated
chest
tube
drainage,
and
one intrapemitoneal hemorrhage necessitated transfusion of 1 unit of packed red blood cells. Both of these complications occurred in the same patient who had undergone biopsies that were performed 1 month apart. Four subsequent biopsies were performed on this patient without complications. Minor complications occurred in 16 of 252 biopsies (6.3%). These cornplications included orthostatic hypotension (n = 7), oozing from the biopsy site (n 3), pain (n 3), decreased hematocrit (n 1), and swelling or hematoma at the biopsy site (n = 2). No patient required sumgical exploration because of a biopsyrelated complication. DISCUSSION The cause of hepatic dysfunction after liver transplantation must be correctly identified and rapidly treated if the ailogmaft is to be saved. This process is particularly important in the early postoperative period. Differentiation between several of the complications that may mesuit in graft dysfunction can be made accurately only on the basis of histologic evaluation of liver tissue (6,7). Liver biopsy is also essential for monitoring the response to immunosuppressive therapy (6). Therefore, the need for percutaneous biopsy is often indicated for patients in whom coagulation may be impaired and/or who may be in critical
condition
in the
early
post-
operative period. In some centers, to avoid needle-core biopsies with use of larger needles in patients with clotting abnormalities, fine-needle aspiration with 23-gauge needles has been performed to diagnose rejection (8,9). However, diagnosis of causes of hepatic dysfunction other than rejection often cannot be made by using the fine-needle aspiration technique and may require come biopsy for histobogic evaluation. The biopsy gun was originally developed for biopsy of the prostate (1) and has been successfully adapted for percutaneous biopsy of other solid organs (2-5). In a recent study (10),
448
#{149} Radiology
comparative analysis of specimens obtained from porcine livers with 15 different biopsy needles of various sizes rated the histopathobogic quality of tissue obtained with the biopsy gun to be second only to that obtamed with a 14-gauge Tru-Cut needie (Baxter Healthcare, Pharmaseal, Valencia, study,
Calif). use
In
of the
addition,
biopsy
gun
performed
with
a Jamshidi
group,
however,
biopsies
which
was
probably
due
to
in this
tolerated
perience little or no pain during the rapid excursion of the needle. However, pain is difficult to quantify, and the lack of procedure-related pain may be due in part to surgical denervation of the transplanted liver. In conclusion, our experience sugthat
patients
because
image-guided
they
biopsy
ex-
with
the biopsy gun is a safe and accurate method for obtaining core biopsy samples for histologic analysis after liver
transplantation.
U
Acknowledgments:
The
authors
gratefully
acknowledge the cooperation and support of J. Michael Henderson, MD, William J. Millikan, MD, John R. Galloway, MD, and the entire Liver Transplant Team. We also thank Shirley C. Wray for manuscript preparation.
References 1.
Ragde H, Aldape HC, sound-guided prostate 1988; 32:503-506.
2.
Parker
SH,
Hopper
Bagley biopsy.
KD,
CM. UltraUrology
Yakes
WF,
MD, Ownbey JL, Carter TE. rected percutaneous biopsies sy gun. 3.
4.
that
were required in patients with marginal clotting function were performed with direct visualization through the surgical incision. In another study, Colonna et al (7) reported a single episode of bleeding that required transfusion in a series of 114 percutaneous liver biopsies performed with an unspecified needle (major complication mate, 0.9%). We believe that the combination of image guidance and the technical properties of the biopsy gun contributed to the low complication rate in this challenging group of patients. Image-guided selection of the biopsy site allowed retrieval of adequate pamenchyma at a precise depth, away from major vessels or focal abnormalities such as infarction, abscess, or hematoma. In our series, this allowed three left hepatic lobe biopsies to be performed while avoiding an area of infarction in a portion of the right lobe. The automated operation of this device allowed a standardized specimen to be obtained while simplifying the biopsy procedure and making it easier to learn.
by
gests
nee-
die (Baxter Healthcare, Phammaseal), including one hemothorax that necessitated thoracotomy for control of diaphragmatic bleeding and one infected hematoma that necessitated percutaneous catheter drainage. In this
ments,
the rapid “split-second” sampling albowed by the gun. We were also impressed that this procedure was well
yielded
1% fewer biopsies with suboptimal tissue than did use of the 14-gauge Tru-Cut needle (7% vs 8%). At our institution, after successful use of the biopsy gun for biopsy of nontransplant livers, we implemented a program under which all liver transplant biopsies were performed by a radiologist who used this device with image guidance. The specimens obtained in this large series were judged by the pathologist to be adequate to establish a histologic diagnosis and to rule out the possibility of rejection in all but four cases. The complication rate we experienced in this large series compares favorably with complication rates in other biopsy series. Williams et al (6) reported major complications in three of 137 (2.2%) transplant biopsies
In addition to these advantages, Parker et al (2) reported less patient discomfort with this device than with conventional biopsy instru-
Radiology
171:663-669.
J, Binder S. Use of Biopty gun for transcutaneous testicular biopsies. J Urol 1989; 142:1021-1022. Tufveson C, Hanas E. Lindgren PC, et al. A review of the Uppsala experience of Rajfer
Biopty-cut
renal
Transplant 5.
1989;
Gibson
Image-diwith a biop-
Elvin
transplant
biopsies.
Proc 1989; 21:3581 -3582.
A, Anderson
T, Scheibenpflug
Lindgren PG. Biopsy of the with a Biopty gun. Radiology
L,
pancreas 1990;
176:667-679. 6.
Williams JW, Peters TG, Vera SR. Britt Van Voorst SJ, Haggitt RC. Biopsy-direct-
ed immunosuppression transplantation
7.
importance
opsy in transplant
1988;
the
JJ, Goldstein
management recipient.
liver
of the Transplant
I, HOckerstedt
Fine-needle
bi-
liver Proc
monitoring
of liver 1988;
K. Ahonen
aspiration
biopsy
allografts.
fine-needle
A, Pecorella transplant aspiration
I, et al. monitoring biopsy.
plant Proc 1989; 21:2311-2312. Hopper KD, Baird DE, Reddy VV, Efficacy conventional
of automated biopsy
my
Radiology
pig.
in
Trans-
46:47-52.
DiTondo U, Ciardi Postoperative liver with
LI, et al.
20:682-684.
plantation
10.
the
hepatic
Transplantation
of percutaneous
Lautenschlager
J, et al.
9.
man.
1985; 39:589-596. Colonna JO, Brems The
8.
following in
LG,
biopsy needles 1990;
Trans-
et al.
guns versus in the pyg-
176:671-676.
May
1991
