A comparison of four- versus three-pass transjugular biopsy using a 19-G Tru-Cut needle and a randomized study using a cassette to prevent biopsy fragmentation.

Recently, it has been shown that transjugular liver biopsy (TJLB) with three passes gives comparable specimens to percutaneous liver biopsy (PLB). The aim of this study was to evaluate the adequacy of TJLB using four passes in a consecutive series of patients, and whether using a supportive cassette can prevent fragmentation. One hundred consecutive TJLBs in 92 patients (48 transplanted), always using four passes (19-G Tru-Cut), were compared to three-pass TJLBs. The four-pass TJLB specimens were randomized at a 1:1 ratio of liver cores placed in a cassette versus not. The four-pass TJLBs, compared to three-pass TJLBs, resulted in better specimens for length (>or=25 mm: 50% vs. 35%; p = 0.026) and number of complete portal tracts (CPTs) (>or=11: 40% vs. 26%; p = 0.027), without a higher complication rate. The four-pass TJLB with >or=11 CPTs had a median length of 27 mm, and 57% of them longer than 28 mm contained >or=11 CPTs. Putting the liver biopsy cores into a cassette did not improve the fragmentation rate or adequacy of the specimen (length and number of CPTs) of TJLB. We conclude that at least four passes with TJLB should be performed when liver specimens are needed for grading and staging. Using a supportive cassette did not reduce fragmentation.

Transjugular liver biopsy--indications, adequacy, quality of specimens, and complications--a systematic review.

Transjugular liver biopsy (TJLB) is considered an inferior biopsy, used when percutaneous liver biopsy (PLB) is contraindicated. According to recent literature, specimens with 6 complete portal tracts (CPTs) are needed for histological diagnosis of chronic liver disease but 11 CPTs to reliably stage and grade. Mean CPT number in PLB series is 7.5; more passes increase complications. Sixty-four series reporting 7649 TJLBs were evaluated for quality of specimen and safety. Major indications were coagulation disorders and/or ascites. Success rate was 96.8%. Fragmentation rate was 34.3%, not correlating with length or diagnostic adequacy. With a mean of 2.7 passes, mean CPT number was 6.8. Histological diagnosis was achieved in 96.1% of TJLBs, correlating with length (p=0.007) and CPT number (p=0.04). Tru-Cut specimens had a mean CPT number of 7.5 and, compared to Menghini specimens, were longer (p<0.008), less fragmented (p<0.001) and more diagnostic (p<0.001). Thinner needles (>16-G) provided significantly longer and less fragmented specimens. Minor and major complication rates were 6.5% and 0.56%, respectively, and increased in children, but not with additional passes. In adults, mortality was 0.09% (haemorrhage 0.06%; ventricular arrhythmia 0.03%). TJLB is safe, providing specimens qualitatively comparable to PLB, and may improve further using > or = 18-G Tru-Cut needle and >3 passes.