**2. Percutaneous Liver Biopsy (PLB)**

PLB is performed either blind or under imaging guidance. In the latter context, ultrasound (US) or computed tomographic (CT) guidance is used. Although these results of US-guided PLB depend greatly on the skills of the gastroenterologist, hepatologist or radiologist and the technical capabilities and quality of the US instrument, the available data indicate that it has a lower complication rate, requires a lower number of passes, is associated with less pain and pain-related morbidity, has a lower likelihood of the need for a repeat procedure, affords better-quality tissue specimens, and has only a marginally increased cost in compari‐ son with blind PLB [21].

© 2012 Tagaya et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

PLB under image guidance essentially eliminates the risk of pneumothorax, or injury to the gallbladder or other viscera because the needle track is directly visualize of organ. Pain is the commonest complication, and up to 75% of patients suffer some discomfort after LB [21]. However, complications after PLB require careful observation. Piccinino et al. [22] reported that 61% of such complications appeared in the first 2 hours after the biopsy, 82% in the first 10 hours, and 96% in the first 24 hours. Strict observation is therefore required for the first 24 hours after PLB. Several large studies have shown rates of major complication after PLB ranging from 0.09% to 2.3%, severe complications in 0.57%, and mortality ranging from 0.03% to 0.11% [23-25]. Hardman et al. [4] reported one patient with graft vs. host disease and hypertension who died after PLB. This patient had multi-organ system failure at the time of biopsy and died within 24 hours of the biopsy. Furthermore, the complications of PLB seem to be related to the type of technique employed. In fact, the complications associ‐ ated with US-guided PLB are significantly lower than those associated with blind PLB: 0.5% vs. 2.2% for severe complications [26], 2% vs. 4% [27] and 1.8% vs. 7.7% [28] for total compli‐ cations. PLB under US guidance is recommended as a reasonable and cost-efficient proce‐ dure [1, 26, 28]. However, EI-Shabrawi et al. [5] have reported that blind PLB performed by the Menghini aspiration technique is safe even in infants and small children without mortal‐ ity or major complications such as bile leakage, pneumothorax, and bleeding requiring blood transfusion. Szymczak et al. [6] also reported the safety and effectiveness of blind PLB based on an analysis of 1412 procedures, and showed that the rates of complications and failure were dependent on the experience of the operator. Moreover, the needle used was the Menghini-type suction needle, which carries a smaller risk of bleeding than cutting nee‐ dles such as the widely employed Tru-cut needle. They concluded that the risk of complica‐ tions and failure rate are low if the indications and contraindications are considered carefully and the biopsy is performed by a skilled and experienced operator.

applied for patients in whom PLB has failed, or those with morbid obesity, a small cirrhotic liver, suspected vascular tumor or peliosis hepatitis, or medical conditions associated with bleeding disorders such as hemophilia for whom PLB is contraindicated [11, 30, 31], as any

Types of Liver Biopsy

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http://dx.doi.org/10.5772/52914

However, there are several particular complications associated with TJLB, including hemor‐ rhage, subcapsular or neck hematoma and ventricular arrhythmia. The rate of such compli‐ cations ranges from 0% to 20% [11]. Hardman et al. [4] reported a large subcapsular hematoma caused by TJLB requiring embolization and prolonged admission. Lebrec et al. [9] also reported a fatal case of intraperitoneal hemorrhage due to perforation of the liver capsule caused by excessive of the needle. Therefore, such forward rotation must be avoided or carefully limited. Furthermore, there have been several direct instances of perforation of the liver capsule that resulted in aspiration of ascitic fluid, bile from the gallbladder, or renal tissue in patients with a small cirrhotic liver. In such patients, TJLB should be avoided or employed only with caution by advancing the needle into the liver parenchyma by only 1 cm instead of the usual 2 cm, or contrast medium should be injected after the biopsy to eval‐ uate the integrity of liver capsule. The major drawback of TJLB is the size of the biopsy specimens obtained; they are generally smaller (p <0.001) and more fragmented (p <0.01) than those obtained by PLB [12]. Pathologically, in terms of the number of portal tracts (p <0.0001) and the utility of specimens for histological evaluation (p <0.05), the quality of TJLB samples appears to be significantly lower compared than those of PLB and LLB specimens [14]. With regard to technical success rate, that of TJLB (82%: 84/102) is significantly lower (P=0.005) than PLB (100%: 100/100) or LLB (99%: 111/112) [14]. However, Bull et al. [10] re‐ ported a success rate of 97% (188/197) in 1983, and a recent meta-analysis including more than 7500 cases revealed a technical success rate of 96.8% [13]. These reports suggest that there is no significant difference between TJLB and others techniques in terms of success rate. The most common reason for failure was inability to catheterize the right hepatic vein. In actual practice, TJLB requires a longer procedure time (40 min) than PLB. A few deaths after TJLB have been reported, with a mortality rate of 0-0.5% [10, 32, 33]; mortality was due

Therefore, TJLB should be attempted only by a skilled interventional radiologist or physi‐ cian experienced in catheterization and cannulation of the internal jugular vein due to its more time-consuming nature, use of intravenous contrast, and the need for a dedicated fluo‐ roscopy suite. In fact, TJLB can be valuable in cases for which PLB is hazardous, or when pressure measurement or venography is also required [34]. Despite the smaller biopsy sam‐ ples obtained, the impact of TJLB on clinical decision-making appears to be comparable to that of PLB and LLB. In particular, it may help to determine the need for liver transplanta‐

There are several approaches for LLB, including PLB under laparoscopic observation, LB through an additional port under laparoscopic observation, or LB combined with another

bleeding is returned to the venous system rather than leaking into the abdomen.

to hemorrhage from the liver or ventricular arrhythmia.

tion in patients with acute liver failure.

**4. Laparoscopic Liver Biopsy (LLB)**

Furthermore, with regard to bleeding after PLB, Alotaibi et al. [3] have reported that a posi‐ tive color Doppler sign in US indicates bleeding along the biopsy tract, and that US-guided compression is effective for achieving appropriate hemostasis. Also, tract-plugging of the bi‐ opsy tract with Gelfoam or other thrombotic agents, is an important procedure for reducing the risk of bleeding and subcapsular hematoma in PLB [2]. Nevertheless, in patients with as‐ cites or abnormal coagulation profiles, another procedure should be considered because of the high risk of possible bleeding complications.
