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Short Recovery Time After Percutaneous Liver Biopsy: Should We Change Our Current Practices?

2005; Elsevier BV; Volume: 3; Issue: 9 Linguagem: Inglês

10.1016/s1542-3565(05)00294-6

1542-7714

R FIRPI, C. Soldevila‐Pico, Manal F. Abdelmalek, G. Morelli, Joel Judah, David R. Nelson,

Pancreatitis Pathology and Treatment

Background & Aims: Percutaneous liver biopsy is the gold standard in the diagnosis and staging of a wide variety of hepatic disorders. Complications, post-procedure monitoring, and recovery time have limited the ability for liver biopsies to be performed in a busy gastroenterology community practice. The aim of this study was to determine whether ambulatory patients requiring percutaneous liver biopsy can be safely discharged after a short recovery time period. Methods: All ambulatory patients undergoing a percutaneous liver biopsy at the University of Florida between February 1995 and June 2004 were evaluated in this study. A 15-gauge Jamshidi needle was used after percussion (before February 2002) or ultrasound guidance (starting February 2002). Major complications were defined as those events that required either immediate or delayed hospitalization or resulted in death within 2 weeks after the liver biopsy. Results: Three thousand two hundred fourteen outpatient liver biopsies were performed at our institution from March 1995 to June 2004. During this time, our recovery time was gradually decreased from 6 hours before 1997 to 1 hour in 2002. The majority of the complications occurred within 1 hour of the observation period or within 24 hours after discharge. The major complication rate was ≤1.7%, regardless of the observation period. Conclusions: A shorter observation time after ambulatory percutaneous liver biopsy is safe and might facilitate the physician's ability to optimally utilize procedural space and ancillary staff in a busy ambulatory care unit. Background & Aims: Percutaneous liver biopsy is the gold standard in the diagnosis and staging of a wide variety of hepatic disorders. Complications, post-procedure monitoring, and recovery time have limited the ability for liver biopsies to be performed in a busy gastroenterology community practice. The aim of this study was to determine whether ambulatory patients requiring percutaneous liver biopsy can be safely discharged after a short recovery time period. Methods: All ambulatory patients undergoing a percutaneous liver biopsy at the University of Florida between February 1995 and June 2004 were evaluated in this study. A 15-gauge Jamshidi needle was used after percussion (before February 2002) or ultrasound guidance (starting February 2002). Major complications were defined as those events that required either immediate or delayed hospitalization or resulted in death within 2 weeks after the liver biopsy. Results: Three thousand two hundred fourteen outpatient liver biopsies were performed at our institution from March 1995 to June 2004. During this time, our recovery time was gradually decreased from 6 hours before 1997 to 1 hour in 2002. The majority of the complications occurred within 1 hour of the observation period or within 24 hours after discharge. The major complication rate was ≤1.7%, regardless of the observation period. Conclusions: A shorter observation time after ambulatory percutaneous liver biopsy is safe and might facilitate the physician's ability to optimally utilize procedural space and ancillary staff in a busy ambulatory care unit. Liver biopsy is an important tool for gastroenterologists and hepatologists to diagnose and assess different liver conditions. One of the major concerns with liver biopsies is the risk of complications during and after the procedure and the recovery time in a busy clinical practice or academic center. Several complications have been reported with the use of percutaneous needle liver biopsy including hematomas, gallbladder puncture, hemobilia, infections, hemothorax, and even death.1Elte P.M. van Aken W.G. Agenant D.M. et al.Hemobilia after liver biopsy early detection in a patient with mild hemophilia A.Arch Intern Med. 1980; 140: 839-840Crossref PubMed Scopus (31) Google Scholar, 2Perrault J. McGill D.B. Ott B.J. et al.Liver biopsy complications in 1000 inpatients and outpatients.Gastroenterology. 1978; 74: 103-106PubMed Scopus (354) Google Scholar, 3Piccinino F. Sagnelli E. Pasquale G. et al.Complications following percutaneous liver biopsy a multicentre retrospective study on 68,276 biopsies.J Hepatol. 1986; 2: 165-173Abstract Full Text PDF PubMed Scopus (1039) Google Scholar, 4Viranuvatti V. Plengvanit U. Kalayasiri C. et al.Needle liver biopsy with particular reference to complications.Am J Gastroenterol. 1964; 59: 529-536Google Scholar The life-threatening complications have been more frequently observed in patients with malignant diseases and/or cirrhosis. The risk of complications and death varies and might depend on the type of needle used, stage of liver disease, and the use of imaging studies for guidance. The risk of death as a result of liver biopsies is reported to be very infrequent (9 in 100,000 biopsies).3Piccinino F. Sagnelli E. Pasquale G. et al.Complications following percutaneous liver biopsy a multicentre retrospective study on 68,276 biopsies.J Hepatol. 1986; 2: 165-173Abstract Full Text PDF PubMed Scopus (1039) Google Scholar A study by Piccinino et al3Piccinino F. Sagnelli E. Pasquale G. et al.Complications following percutaneous liver biopsy a multicentre retrospective study on 68,276 biopsies.J Hepatol. 1986; 2: 165-173Abstract Full Text PDF PubMed Scopus (1039) Google Scholar demonstrated that complications after liver biopsy have been more common in those biopsies done with Trucut needles than with the use of Jamshidi's needles. A study published by Lindor et al5Lindor K.D. Bru C. Jorgensen R.A. et al.The role of ultrasonography and automatic-needle biopsy in outpatient percutaneous liver biopsy.Hepatology. 1996; 23: 1079-1083Crossref PubMed Google Scholar in 1996 showed that ultrasound-guided liver biopsies reduced the risk of complications compared with biopsies done without guidance. The routine use of ultrasound-guided biopsies remains controversial because of efficacy and increased procedural costs. Nevertheless, ultrasound-guided liver biopsies potentially decrease morbidity and the costs as a result of lower hospitalization rates from major complications. It is well recognized that most of the radiologists use ultrasound and conscious sedation to perform liver biopsies, whereas only half of the gastroenterologists and hepatologists follow this routine.6Pembrook L. Gastroenterologists and radiologists vary in approach to percutaneous liver biopsy.Gastroenterol Endosc News. 1998; 10: 30-32Google Scholar In addition to the possible complications with this procedure, recovery time is also a challenge because of hospital costs and scheduling difficulties. In a recent small study, Bicknell et al7Bicknell S.G. Richenberg J. Cooperberg P.L. et al.Early discharge after core liver biopsy is it safe and cost-effective?.Can Assoc Radiol J. 2002; 53: 205-209PubMed Google Scholar concluded that a post–liver biopsy observation period of 4 hours is not necessary, and that early discharge with continued observation and management at home is feasible. The objective of this study was to determine whether ambulatory patients requiring percutaneous liver biopsy can be safely discharged after a short recovery time and to report the incidence of complications after liver biopsies in patients with various recovery times. We conducted a historical cohort study of all patients including transplant recipients who underwent outpatient percutaneous liver biopsies at the University of Florida between February 1995 to June 2004. The study was approved by the Institutional Review Board at the University of Florida, Gainesville, Florida. All procedure-related documentation and/or associated hospitalization records were reviewed for recovery time and any potential post-procedure complications. Inpatient and transjugular liver biopsies were not included in this analysis. Minor complications were defined as mild/moderate pain for which limited analgesia was administered, site bleed, transient hypotension not requiring medication, nausea, or vomiting. Major complications were defined as any event resulting in death or hospitalization either immediately or up to 2 weeks after the liver biopsy. Indications for hospitalization included intravenous narcotic requirement for severe abdominal pain; suspected gallbladder puncture with associated bile leak, hemothorax, pneumothorax, or bleeding (subcapsular hematoma, hemoperitoneum, and/or hemobilia). All patients undergoing an outpatient percutaneous liver biopsy are instructed not to take aspirin, aspirin containing products, or nonsteroidal anti-inflammatory medications for at least 3–5 days before the procedure. Pre-biopsy laboratory tests are done within 4 weeks of the biopsy day (prothrombin time, international normalized ratio, and a complete blood count). Standard laboratory criteria required before liver biopsy include hemoglobin >10 mg/dL, platelets >50,000/mL, prothrombin time <14 seconds, and international normalized ratio <1.5. On the morning of the procedure, the patient can have a light breakfast and take daily medications as prescribed, excluding all medications mentioned above. Each patient must be accompanied by a family member or friend for the purpose of driving the patient home and assisting in the post-procedure care and monitoring the day of the biopsy. Percussion of the right upper quadrant is performed to identify the upper and lower borders of liver. Subsequently, aseptic technique is used, and 1% lidocaine (5–10 mL) for local anesthesia is injected. Liver biopsies are performed with a 15-gauge (100 × 1.9 mm) Jamshidi Menghini soft tissue biopsy needle (Allegiance Healthcare Corporation, McGaw Park, IL) after percussion (before February 2002) or by percussion and after ultrasound marking (starting in February 2002). The core tissue is placed in a sterile formalin-filled container and sent for histologic evaluation. After the procedure, the patient is instructed to remain in the recumbent position for the duration of post-procedure monitoring: 6 hours (before 1997), 4 hours (1997–2000), 2.5 hours (2000–2001), 1 hour (2001–2004). The previously noted recovery time is typically extended by an additional half hour if intravenous conscious sedation with an anxiolytic medication is administered before the procedure. Hemodynamic monitoring included an assessment of resting vital signs every 15 minutes and orthostatic blood pressure and pulse measurements every half hour for the entire time patient spent in recovery. If orthostatic hypotension or tachycardia is noted, the patient receives 500 mL of normal saline and is re-evaluated by the nurse and the physician. During the final half hour before discharge, the patient is required to sit up in a chair. The site of the biopsy is also inspected for possible development of hematomas or bleeding. The standard management of post-procedure localized abdominal pain or discomfort, or pain radiating to the shoulder with no associated hemodynamic changes is intravenous meperidine 25–50 mg given at 10- to 15-minute intervals to a maximum dose of 100 mg. If no improvement in symptoms is noted, the patient is reassessed by the physician who performed the liver biopsy, and appropriate laboratory and/or further diagnostic studies are obtained for the purpose of triaging the patient to home or to the hospital for further observation or care. Patients are only discharged from the endoscopy suite if they are hemodynamically stable, there is no evidence of orthostatic blood pressure or pulse changes, and no complaints of severe pain or shortness of breath. All patients undergoing percutaneous liver biopsy are given specific instructions regarding further monitoring and daily activities before discharge. Patients are instructed to rest the remainder of the day and not to drive any motor vehicles or operate any heavy machinery the day of the biopsy. Someone should be available at all times during the following 24 hours. Strenuous physical activities such as jogging, contact sports, or heavy lifting for 48 hours after the biopsy are discouraged. The bandage might be removed the night of the biopsy, and the site left uncovered. All hospital and on-call physician contact information is provided to the patient and/or the patient's assistant at the time of discharge. The patient is instructed to call if symptoms of chills or fever higher than 100.5°F (38.6°C), difficulty breathing, excessive bright red bleeding from the biopsy site, severe pain in the chest, shoulder, or abdomen, passing blood in the stool, increasing abdominal swelling, or bloating occurs. A designated nurse calls all patients 24 hours after the procedure to ensure that the patient is not experiencing any procedure-related complications. A total of 3214 outpatient liver biopsies were performed at the University of Florida between March 1995 and June 2004. Two needle passes were required in 20% of the patient biopsies (16 before the use of ultrasound) and 3 needle passes in .2% of the cases. Major complications, those events requiring hospitalization, were observed in 34 of 3214 biopsies (.9%) (Table 1). Shortening the post–liver biopsy recovery time did not impact the incidence of post-procedure complications. Most of the complications were recognized during the first hour after the procedure. Severe abdominal pain (18%) and perihepatic bleeding (18%) were the most common major complications seen. Of note, hemothorax was a complication that was seen more frequently before the use of ultrasound-guided biopsies but not seen after 2002 (8 vs 0, P = .1). Death occurred in 2 patients, one caused by hemothorax and the other one as a result of blood loss (both before 1999).Table 1Number of Complications per YearRecovery time6 h4 h2.5 h1 hP valueYear1995–19961997–19992000–20012002–2004Number of liver biopsies34899610621358<.05Major complications612610NSTotal % major complications1.71.2.6.7NS Open table in a new tab Mild to moderate pain requiring limited analgesia and no hospitalization was the most common minor complication. Our analysis of mild complications noted mild to moderate pain at the biopsy site in 13% of the patients, minor bleeding at the biopsy site in 4% of the patients, and .5% of the patients experienced nausea and vomiting. The use of sedation was also analyzed. Midazolam (Versed) and meperidine (Demerol) were the 2 more common medications used for pain control or sedation. Midazolam was administered to 34% of patients and meperidine to 4% of patients. Of note, there were more patients who required sedation than patients who experienced abdominal pain during their recovery time. This is explained by a group of patients who asked for conscious sedation to reduce anxiety before their procedure. Before 1997, patient's recovery time was at least 6 hours for observation for possible complications after the procedure. This policy has been changed to shorter recovery time of 1 hour in 2002. The recovery time protocol (6 hours, 4 hours, 2.5 hours, and 1 hour) did not impact the incidence of either major or minor complications; however, facility fee cost savings of $240 per liver biopsy procedure was noted, mainly related to decrease in nursing staff utilization. Potential for significant cost savings exists as a result of more efficient use of facility, space, and nursing staff. A more comprehensive cost-effectiveness analysis is beyond the scope of this article. The complication rate after liver biopsies in most of the studies published in the literature range from .5%–2.8%.8Garcia-Tsao G. Boyer J.L. Outpatient liver biopsy how safe is it?.Ann Intern Med. 1993; 118: 150-153Crossref PubMed Scopus (146) Google Scholar, 9Janes C.H. Lindor K.D. Outcome of patients hospitalized for complications after outpatient liver biopsy.Ann Intern Med. 1993; 118: 96-98Crossref PubMed Scopus (250) Google Scholar, 10Papini E. Pacella C.M. Rossi Z. et al.A randomized trial of ultrasound-guided anterior subcostal liver biopsy versus the conventional Menghini technique.J Hepatol. 1991; 13: 291-297Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 11Smith B.C. Desmond P.V. Outpatient liver biopsy using ultrasound guidance and the Biopty gun is safe and cost effective.Aust N Z J Med. 1995; 25: 209-211Crossref PubMed Scopus (17) Google Scholar, 12Vivas S. Palacio M.A. Rodriguez M. et al.Ambulatory liver biopsy complications and evolution in 264 cases.Rev Esp Enferm Dig. 1998; 90: 175-182PubMed Google Scholar Monitoring the patient's vital signs and clinical condition can help identify early complications. Complications such as intrahepatic and subcapsular hematomas are common after percutaneous liver biopsy, and the length of recovery (6 vs 24 hours) does not appear to influence the frequency of these complications.13Minuk G.Y. Sutherland L.R. Wiseman D.A. et al.Prospective study of the incidence of ultrasound-detected intrahepatic and subcapsular hematomas in patients randomized to 6 or 24 hours of bed rest after percutaneous liver biopsy.Gastroenterology. 1987; 92: 290-293PubMed Google Scholar Late complications are forewarned in both written and verbal form before discharge from our outpatient unit with specific instructions to seek attention if they occur. Two previous published randomized-controlled studies pointed out that the incidence of complications is reduced when ultrasound-guided biopsies are performed.5Lindor K.D. Bru C. Jorgensen R.A. et al.The role of ultrasonography and automatic-needle biopsy in outpatient percutaneous liver biopsy.Hepatology. 1996; 23: 1079-1083Crossref PubMed Google Scholar, 10Papini E. Pacella C.M. Rossi Z. et al.A randomized trial of ultrasound-guided anterior subcostal liver biopsy versus the conventional Menghini technique.J Hepatol. 1991; 13: 291-297Abstract Full Text PDF PubMed Scopus (50) Google Scholar The use of imaging studies to guide the biopsy needle has not made any difference in terms of complication rate in our center. The only significant finding was the absence of hemothorax in patients who underwent procedure with ultrasound guidance. The other advantages for the imaging guidance were the facilitation of a good site for needle insertion in obese patients, finding of unsuspected ascites, gallbladder identification, and visualization of prominent vessels or lesions on the liver. Shortening our observation time has important implications for busy outpatient endoscopy centers. Shortening post–liver biopsy recovery periods at our institution has led to a marked improvement in the efficient use of our recovery area, thus allowing for us to accommodate an increased number of patients referred for liver biopsies. It has also led to patient satisfaction because it provides them the ability to go home and recover in their own environment. Our data support a safe and more efficient change to implement shorter recovery times to our post–liver biopsy monitoring. Instead, an early discharge with careful instructions to the patient might be sufficient to minimize hospital costs related to longer observation periods and allow for an efficient utilization of outpatient ambulatory care suites.