The percutaneous cecostomy tube in the management of fecal incontinence in children.

PURPOSE: To retrospectively evaluate experience with percutaneous cecostomies and their long-term outcomes. MATERIALS AND METHODS: Between June 1994 and March 2009, 290 patients (mean age, 10.1 y) with fecal incontinence underwent percutaneous cecostomy tube placement and subsequent tube management. Technical success, procedural complications, and long-term follow-up until March 2012 were evaluated. RESULTS: A cecostomy was successfully placed in 284 patients (98%), and 257 of 280 patients (92%) underwent a successful exchange to a low-profile tube. A total of 1,431 routine exchanges to low-profile tubes were reviewed in 258 patients (mean, 1.6 ± 1.3 routine tube changes per 1,000 days). Eighty-five patients (29%) experienced one or more early problems after cecostomy, and 10 (3%) had major complications. In the total 463,507 tube-days, 938 late problems were noted: 917 (98%) minor and 22 (2%) major. Forty patients had the cecostomy catheter removed and 141 "graduated" to an adult health care facility. CONCLUSIONS: The percutaneous cecostomy procedure provides a safe management option for fecal incontinence in the pediatric population.

Heparin-bonded central venous catheters do not reduce thrombosis in infants with congenital heart disease: a blinded randomized, controlled trial.

BACKGROUND: Infants with congenital heart disease who require central venous lines are at increased risk of thrombosis. Heparin-bonded catheters provide protection from thrombotic events in some children. However, heparin-bonded catheters may not be as effective in infants

The experience of conducting Mortality and Morbidity reviews in a pediatric interventional radiology service: a retrospective study.

PURPOSE: To review the experience and impact of conducting multidisciplinary Morbidity and Mortality (M&M) reviews in pediatric interventional radiology (IR) and describe issues, lessons, and recommendations. MATERIALS AND METHODS: A dedicated functionality of an existing database was developed to retrospectively analyze pediatric IR M&M issues. Patient demographics, sedation/anesthesia, and procedure type were recorded. M&M issues were assigned to at least one of 10 categories and graded as major or minor per Society of Interventional Radiology (SIR) guidelines. Issues could result in recommendations, which were divided into six categories; each was classified as implemented or not implemented. RESULTS: Of 31,983 patient encounters over a period of 10 years, 516 patient events (1.6%) were discussed at M&M reviews. A total of 772 categories were assigned; they related to the procedure (34%), patient comorbidity (20%), processes (15%), device (10%), management (8%), sedation/anesthesia (4%), medication (2%), ethical issues (1%), "near-misses" (1%), and other (5%). A total of 292 issues (57%) were graded as minor (SIR class A, n = 202; class B, n = 90) and 224 (43%) as major (SIR class C, n = 42; class D, n = 151; class E, n = 6; class F, n = 27). Twenty-seven deaths were reviewed. Of 397 recommendations made, 80% were fully implemented, 11% partially implemented, and 9% not implemented. Recommendations made related to process improvements (49%), technical changes (20%), interdisciplinary discussions (15%), educational endeavors (9%), contacting manufacturers (6%), and other issues (1%). CONCLUSIONS: As a result of regular multidisciplinary M&M reviews being conducted, a large number of practical recommendations were made for improvements in quality of care, and implemented over a 10-year period. M&M reviews provide a useful forum for team discussions and are a vehicle for change and potential improvement in the delivery of care in a pediatric IR service.

Ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum in a newborn with pyloric atresia, annular pancreas and congenital short bowel syndrome.

We report a newborn with bilious vomiting and the rare combination of pyloric atresia, annular pancreas and ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum. Radiologic, sonographic and percutaneous transhepatic transcholecystic cholangiographic (PTTC) findings, with surgical correlation, are presented.

Safety and effectiveness of radiologic percutaneous gastrostomy and gastro jejunostomy in children with cardiac disease.

OBJECTIVE: The purpose of our study was to evaluate the safety and effectiveness of radiologic percutaneous gastrostomy and gastrojejunostomy for providing nutritional support in children with cardiac disease. MATERIALS AND METHODS: Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated. RESULTS: The mean weight-for-age z-score increased from -2.79 at the time of radiologic percutaneous gastrostomy insertion to -2.33 (p = 0.05) at 6 months after insertion, -1.89 (p = 0.001) at 12 months, -1.65 (p = 0.0002) at 18 months, and -1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%). CONCLUSION: Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.

Growth outcomes and complications after radiologic gastrostomy in 120 children.

BACKGROUND: Enteral feeding is ideal for children with low caloric intake. It can be provided through different methods, including nasogastric, nasojejunal, gastrostomy, or gastrojejunostomy tubes. OBJECTIVE: To assess growth outcomes of pediatric patients following retrograde percutaneous gastrostomy (RPG) and compare complications with those following other gastrostomy methods. MATERIALS AND METHODS: We retrospectively reviewed 120 random RPG patients from 2002 to 2003 (mean follow-up, 2.7 years). Patient weights and growth percentiles were recorded at insertion, and at 0-5 months, 6-12 months, and 18-24 months after insertion, and then compared using a Student's t-test. Complications and tube maintenance issues (TMIs) were recorded. RESULTS: Gastrostomy tube insertion was successful in all 120 patients (59 boys, 61 girls; mean age 4.3 years). The most common underlying diagnosis was neurologic disease (29%, 35/120) and the main indication was inadequate caloric intake (24%, 29/120). Significant increases in growth percentile for the entire population were demonstrated between insertion and 0-5 months (18.7-25.3; P<0.001) and between insertion and 18-24 months (18.7-25.8; P<0.001). In boys and girls significant growth increases occurred between insertion and 0-5 months (boys P=0.004; girls P=0.01). There were 11 major postprocedural complications, 100 minor complications and 169 TMIs. CONCLUSION: RPG provides long-term enteral nutrition in the pediatric population and increases growth significantly 6 and 24 months after insertion. Minor complications and TMIs are frequent.

Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.

PURPOSE: To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1-20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test. RESULTS: Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029). CONCLUSION: Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.

Percutaneous cholangiography for the treatment of parenteral nutrition-associated cholestasis in surgical neonates: preliminary experience.

OBJECTIVE: Parenteral nutrition-associated cholestasis (PNAC) occurs in up to 60% of surgical neonates with intestinal failure, and 10% will develop end-stage liver failure. Our aim was to evaluate the effectiveness of percutaneous transhepatic transcholecystic cholangiography (PTTC) in the treatment of PNAC in surgical neonates. METHODS: A retrospective double cohort study of surgical neonates with PNAC was conducted. Patients with PNAC who received PTTC were compared to controls matched by gestational age, birth weight, sex, and parenteral nutrition duration. Percutaneous transhepatic transcholecystic cholangiography was performed under general anesthesia with ultrasound guidance. Analysis was performed using paired Student's t test and McNemar chi2 test. RESULTS: Nine PTTC patients and 9 controls were similar in mean age (35.5 +/- 3.1 vs 35.6 +/- 4.2 weeks, P = .85), birth weight (2531 +/- 879 vs 2692 +/- 1052 g, P = .28), sex (all males), and parenteral nutrition duration (51.2 +/- 29.8 vs 53.3 +/- 33.3 days, P = .74). Percutaneous transhepatic transcholecystic cholangiography was performed in 9 patients at mean corrected age of 5.5 +/- 3.4 weeks and weight of 3621 +/- 546 g. All control patients and 8 (88.9%) of 9 PTTC patients had eventual resolution of hyperbilirubinemia. Percutaneous transhepatic transcholecystic cholangiography patients experienced a more rapid rate of resolution of their cholestasis, and the mean time to resolution of conjugated bilirubin was less in the PTTC group (8.5 +/- 3.2 vs 18.5 +/- 7.6 weeks, P = .02). CONCLUSION: Therapeutic PTTC results in a 50% reduction in the time to PNAC resolution. Percutaneous transhepatic transcholecystic cholangiography may have a role as active therapy to slow progression of PNAC in surgical neonates with intestinal failure.

Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida.

OBJECTIVES: At our institution, the use of cecostomy tubes has provided a successful method for managing severe constipation in patients with spina bifida, with good patient and caretaker satisfaction and minimal morbidity. We have developed a modified technique to allow placement of the cecostomy tube under direct vision during laparoscopic appendicovesicostomy. We present our initial experience and technique. METHODS: Patients with a normal bladder capacity and compliance who were scheduled for creation of an appendicovesicostomy and who also had refractory constipation were offered concurrent cecostomy tube placement. At the laparoscopic procedure, we performed percutaneous placement of the cecostomy tube through the abdominal wall under direct visualization. Subsequently, dissection of the appendix with its mesentery was performed. The detrusor muscle was dissected and a trough for the appendix created. Laparoscopic anastomosis of the appendix to the bladder mucosa and approximation of the detrusor over the appendix created a nonrefluxing channel. RESULTS: Three patients have undergone concurrent cecostomy tube placement at appendicovesicostomy. No complications have been encountered thus far. On follow-up, the cecostomy tube scar has been well concealed and appears no different from the ones placed under radiologic guidance. The patients have been using the catheterizable channel to access the bladder and dry performing intermittent catheterization without difficulties. CONCLUSIONS: In patients with a neurogenic bladder who do not qualify for major bladder reconstructive procedures, such as augmentation cystoplasty or bladder neck repair, social continence and independence can be achieved with minimally invasive surgery. Concomitant laparoscopic appendicovesicostomy and cecostomy tube placement may be a suitable surgical option.

Retrograde percutaneous enterostomies in children using a needle system with valve mechanism.

The technique of enterostomy access frequently uses a needle preloaded with a suture anchor to appose the bowel wall to the abdominal wall. Two of the intrinsic disadvantages of this method are the possible dislodgment of the suture anchor out of the needle hub during the process of guide-wire insertion and the escape of air with subsequent deflation of the viscus, which may necessitate a second puncture. The use of a Check-Flo performer assembly with a valve mechanism provides a leakproof system. It avoids possible dislodgment of the suture anchor during deployment, maintains viscus distension, and may be useful for trainees to do the procedure in a controlled manner.

Image-guided percutaneous biopsy of musculoskeletal lesions in children.

BACKGROUND: Percutaneous core needle biopsy (PCNB) of musculoskeletal lesions can provide early and definitive diagnosis and guide decisions on management. The technique is less invasive than open biopsy and has a low complication rate. OBJECTIVES: The purpose of this study was to assess the diagnostic accuracy and safety of image-guided PCNB of musculoskeletal lesions in children. MATERIALS AND METHODS: Retrospective review of the medical records of patients referred for PCNB of musculoskeletal lesions was performed. Data collected included tumor type and complication rates. Lesion "hit" or "missed", and core adequacy and ability to reach a definitive pathological diagnosis were reviewed and used to determine whether the biopsy was overall successful or unsuccessful. RESULTS: A total of 127 biopsies were performed in 111 patients. Of the 127 PCNB procedures, 114 "hit" the lesion and 13 "missed," and 120 of the cores provided for analysis were deemed adequate for pathological interpretation and 7 were deemed inadequate. A definitive pathological diagnosis was possible in 97 of the 127 PCNB preocedures and not possible in 30. Overall 76% of the PCNB procedures were successful. The diagnostic success of biopsy in primary malignant tumors was significantly higher (92%) than in primary benign tumors (65%; P=0.008). Six minor complications resulted from PCNB. CONCLUSION: This study showed that PCNB is accurate and safe for the diagnosis of musculoskeletal lesions in pediatric patients, and its results are comparable to those in adult studies.

Sonographically guided percutaneous liver biopsy in infants: a retrospective review.

OBJECTIVE: The purpose of our study was to assess the technical success and complication rate of sonographically guided percutaneous liver biopsies performed in infants under 1 year old at a tertiary pediatric center. MATERIALS AND METHODS: Retrospective analysis of 65 biopsies performed in 61 infants between January 1999 and December 2003 was conducted. Data collected included patient demographics; details of the biopsy procedure including indication, needle type and size, number of passes, and samples; pathology results; and procedure-related complications. RESULTS: The 61 infants studied included 37 males and 24 females with a mean age of 119 days (age range, 7-348 days; median age, 83 days) and a mean weight of 4.5 kg (1.9-8.3 kg). A total of 65 biopsies were performed in these 61 infants. General anesthesia was used in 66.1% of procedures. An 18-gauge needle was used in 47 (72.3%) procedures. Coaxial technique was used in seven procedures, and five biopsy tracts were embolized. In 63 of 65 procedures, the mean number of passes was 1.8. In two procedures, using a coaxial technique, 11 and 12 passes were made. One biopsy was considered technically unsuccessful, and 64 of 65 (98.5%) of the biopsies provided adequate tissue for pathologic analysis. There were three (4.6%) major complications related to bleeding: one requiring a blood transfusion, one requiring surgery, and one arteriobiliary fistula requiring transarterial embolization. Three (4.6%) minor complications also occurred. There were no deaths. CONCLUSION: Sonographically guided percutaneous liver biopsy in infants is a good and effective diagnostic tool. The complication rate, however, even when performed by an experienced physician, is not insignificant in this age group of patients.

Percutaneous thoracic drainage in neonates: catheter drainage versus treatment with aspiration alone.

PURPOSE: To retrospectively compare thoracic drainage in neonates by using catheter and aspiration techniques. MATERIALS AND METHODS: Approval was obtained from the institutional research ethics board; informed consent from parents was waived. Retrospective review of 21 neonates (19 boys, two girls; mean gestational age, 39.3 weeks) who underwent percutaneous thoracic drainage during a 9-year period was performed. Data such as indication for drainage, type of drainage, age and weight at birth, corrected age and weight at the time of drainage, use of mechanical ventilation at the time of drainage, and outcomes were collected. Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. Fisher exact test and two-tailed unpaired student t test with a confidence level of 95% (unequal variances assumed) were used to compare neonates treated with a catheter and those treated with aspiration. RESULTS: Image-guided therapy was used to treat pleural effusion (29%, n = 6), chylothorax (24%, n = 5), empyema (19%, n = 4), pneumothorax (14%, n = 3), mediastinal seroma (10%, n = 3), and congenital cystic adenomatoid malformation (5%, n = 1). Sixteen (76%) infants were treated with catheter placement, with a success rate of 81% (13 of 16). Five (24%) infants were treated with simple aspiration with no success. The difference in success rates was significant (P = .003). There was no significant difference between the catheter placement and aspiration groups in terms of average age, average weight, and percentage dependent on mechanical ventilation. One complication (cellulitis) was directly related to catheter drainage. In cases where treatment was successful, the mean length of the chest tube placement was 13.5 days, and there were no deaths at follow-up. In cases where treatment failed, the long-term mortality rate was 50% (four of eight). CONCLUSION: Image-guided percutaneous thoracic drainage success rates are improved if drainage catheters are placed rather than if aspiration alone is performed.

Influence of arm movement on central tip location of peripherally inserted central catheters (PICCs).

BACKGROUND: PICCs are increasingly employed in children. Some of their risks relate to the location of the central tip. Despite care when placing lines, they sometimes move. OBJECTIVE: To evaluate the influence of arm movement on the central tip location of PICCs placed in children. MATERIALS AND METHODS: The central tip location of PICCs was studied in 85 children, with the arm placed in six positions. The variables of side, vein, site and arm position were examined to measure the direction and range of tip movement. RESULTS: The side, site or vein used did not influence the range of movement of the central tip. Change in position of the arm had a significant influence on the central tip location, moving it an average of 2.2 rib spaces, a maximum of 3.5 ribs. Elbow bending and adduction of the arm caused the central tip to move deeper into the chest, compared to when the arm was straight and abducted 90 degrees . CONCLUSION: Arm position is the significant variable influencing PICC movement. Side, site and vein do not influence the range of movement significantly. Most PICCs descend deeper into the chest with arm adduction and elbow bending.

A novel treatment of congenital duodenal stenosis: image-guided treatment of congenital and acquired bowel strictures in children.

BACKGROUND: Image-guided balloon dilatation has been used in adults as an alternative to standard surgical treatment of intestinal stricture. The experience in children is limited. We report our results with this procedure in the management of both congenital and acquired intestinal stenosis in children. MATERIALS AND METHODS: A retrospective analysis was done of children younger than 2 years of age who underwent balloon dilatation of small and large intestinal stenosis between 1994 and 2003. RESULTS: Eleven children underwent dilatation during the study period. Two of these children had congenital duodenal stenosis, and this represents the first report of nonoperative management of this condition. Three children underwent dilatation of small bowel strictures and 6 had dilatation of colonic and rectal strictures. Necrotizing enterocolitis was the most common (6/9) etiology of stricture. Ten of 11 patients did not require subsequent operative management although 3 children required further dilatations. The mean follow-up was 36.5 months (range, 13 days-103 months). One patient underwent a subsequent dilatation that was unsuccessful, and required operative resection of a 5-cm stricture. There was one complication, a small leak that was managed nonoperatively. CONCLUSION: Image-guided balloon dilatation holds promise as an alternative to surgical treatment in children with congenital or acquired stenosis of the small or large bowel, and should be considered in select patients with short strictures.

Image-guided therapy and minimally invasive surgery in children: a merging future.

Minimally invasive image-guided therapy for children, also known as pediatric interventional radiology (PIR), is a new and exciting field of medicine. Two key elements that helped the rapid evolution and dissemination of this specialty were the creation of devices appropriate for the pediatric population and the development of more cost-effective and minimally invasive techniques. Despite its clear advantages to children, many questions are raised regarding who should be performing these procedures. Unfortunately, this is a gray zone with no clear answer. Surgeons fear that interventional radiologists will take over additional aspects of the surgical/procedural spectrum. Interventional radiologists, on the other hand, struggle to avoid becoming highly specialized technicians rather than physicians who are responsible for complete care of their patients. In this article, we briefly discuss some of the current aspects of minimally invasive image-guided therapy in children and innovations that are expected to be incorporated into clinical practice in the near future. Then, we approach the current interspecialty battles over the control of this field and suggest some solutions to these issues. Finally, we propose the development of a generation of physicians with both surgical and imaging skills.

Percutaneous US-guided biopsies of peripheral pulmonary lesions in children.

BACKGROUND: A wide variety of diseases in children can present with peripheral lung lesions. Minimally invasive percutaneous techniques are preferred diagnostic tools when thoracoscopic resection is not indicated. Significant improvements in US resolution have increased the range of its applications for many diagnostic and therapeutic purposes. OBJECTIVE: To determine the adequacy and safety of US-guided biopsy of peripheral pulmonary lesions in children. MATERIALS AND METHODS: A retrospective review was performed of the clinical, imaging and pathology records of 33 children (13 females and 20 males) in whom 38 US-guided percutaneous lung lesion biopsies had been performed between January 1996 and March 2004. Their mean age was 8.3 years (range 1-19 years, median 6.6 years). All procedures were done under general anesthesia and controlled respiration. Two techniques were used: a single-needle technique and a coaxial-needle technique. In each case, the data recorded included age, sex, lesion's location and size, number of cores, pathology results (adequate, inadequate and indeterminate), and complications. In order to categorize the sample, the lesions were divided into four groups based on the size of the pleural surface: group 1 1-5 mm, group 2 6-10 mm, group 3 11-20 mm, and group 4 21 mm or more. RESULTS: The mean pleural surface size of the lesions was 12 mm (range 2.3-24 mm). The coaxial-needle technique was used for 13 biopsies and the single-needle technique for 25 biopsies. Of the 38 biopsies, 32 were considered adequate (technical success 84%), 4 were truly inadequate, and 2 were indeterminate at the time of the biopsy, requiring surgical biopsy for confirmation. Minor complications occurred following 44% of the procedures, including: pain (n=5), small pneumothorax (n=4), pulmonary hematoma (n=4), atelectasis (n=4), small hemothorax (n=3), respiratory distress (n=1) and hemoptysis (n=1). No major complications occurred. No significant correlation was found between the size of the pleural surface and technical success (P=0.106) or the incidence of complications (P=0.23). Minor complications occurred following 6 out of 13 procedures using the coaxial-needle technique (16% of total) and following 11 out of 25 procedures using the single-needle technique (28% of total), with no statistically significant difference (P=0.1081). CONCLUSION: This small retrospective study suggests that US-guided lung biopsies are a safe and adequate method to sample peripheral pulmonary lesions in children, with a high rate of technical success and low morbidity, even for lesions with a small pleural surface (<5 mm).

Saliva control issues in the neurologically challenged. A 30 year experience in team management.

OBJECTIVE: The objective of this paper is to report the experience of a multidisciplinary team (otolaryngologist, speech-language pathologists, pediatric dentist, and social worker) functioning at a pediatric rehabilitation center have had in the management of 1487 neurologically challenged individuals with saliva control issues assessed from 1976 to the end of 2004. METHOD: The role of each team member is outlined. Management decisions have consisted of no treatment, utilization of oral-motor training program, elimination of contributing situational factors, utilization of medication, surgery and Botox injections of the major salivary glands. RESULTS: Oral-motor programs to improve oral-motor function is essential initially if there is patient compliance. Surgery was recommended in the majority of patients. Submandibular duct relocation with simultaneous sublingual gland excision remains the procedure of first choice for persistent significant drooling. Aspiration is much less common than drooling and is more problematic to treat. Simultaneous ligation of the submandibular and parotid ducts (aka 4-duct ligation) is promising. A recent initiative to inject the major salivary glands with Botox is being evaluated. CONCLUSIONS: Team evaluation with consensus decision making has worked well in this patient population with complex medical conditions.

Analysis of needle versus open biopsy for the diagnosis of advanced stage pediatric neuroblastoma.

BACKGROUND: Adequate tissue biopsy is necessary for the appropriate diagnosis and risk stratification of pediatric neuroblastoma (NB). We compared the quality and adequacy of biopsy tissue and complication rates in children with NB who underwent open (OBX) and image-guided needle biopsy (NBX) at our center. METHODS: We retrospectively reviewed all patients diagnosed with stage III and IV NB from September 2001 to August 2004. The 24 patients were divided into two groups: those in whom the diagnosis was initiated using NBX, and those diagnosed using OBX. In addition to demographic data, we collected data pertaining to sufficiency of biopsy tissue for biology studies including: Shimada Classification, MYC-N amplification, and DNA index analysis and complications associated with the procedure. Chi-Square and Student's t-test were used to analyze the categorical and continuous variables, respectively. RESULTS: Of 24 patients, 11 underwent NBX, and 13 patients underwent OBX. Eighteen patients had stage IV disease, 5 patients had stage III disease, and 1 stage IVS. Ten major complications occurred in four NBX patients and six OBX patients. There was no difference in days of narcotic use, time to DAT, or hospital stay between the two groups. Ten patients (seven NBX and three OBX, P = 0.045) had tissue that was insufficient for biology studies. Three of the seven NBX patients underwent a second biopsy for clarification of risk group. CONCLUSIONS: This study demonstrated that more than half of patients undergoing NBX for NB had insufficient tissue for complete histological and molecular classification and that the incidence of procedural complications between NBX and OBX are similar.