Hepatology, February 1999, p. 610-610, Vol. 29, No. 2
Correspondence
Cost-Effectiveness of Ultrasonography in Percutaneous Liver Biopsy
To the Editor:
We read with interest the recent report by Pasha et al.,1
evaluating the cost-effectiveness
of ultrasound-guided liver biopsy. The cost-effective analysis was
primarily based on observations made by Lindor et al. in a randomized
study comparing ultrasound-guided biopsy with a "blind" percutaneous liver
biopsy.2 In the study by Lindor et al., postbiopsy
pain requiring hospitalization was considered one of the major complications.
Other major complications included bleeding and hypotension. Although
pain requiring hospitalization was more frequent in the ultrasonography
group compared with the nonultrasonography group, there was no statistically
significant difference in bleeding and hypotension episodes. In the randomized
study that had 836 patients, gallbladder laceration requiring surgery
occurred in only 1 patient who had a "blind" attempt at percutaneous
biopsy.
There are a few comments that we have concerning the design of the study
and subsequent observations made by Lindor et al. The investigators were
aware of whether a particular patient had an ultrasound-guided or a "blind"
liver biopsy and, therefore, bias could have entered the decision to hospitalize
a patient. No guidelines for hospitalization and no objective way of evaluating
the degree of pain perceived by an individual were mentioned in this study.
More often, hypotension can be used as an objective parameter for hospitalizing
a patient, and this was not statistically significant between the ultrasonography
group and the group that did not have biopsy done under ultrasound guidance.
Hypotension and gallbladder laceration should only truly be considered
as the major complications and not pain. Furthermore, it is unclear as
to how ultrasound guidance is likely to reduce subsequent development
of pain. A more practical approach may be with the use of premedication
with Meperidine and Midazolam, and anecdotally there has been less pain
perception in our experience. Finally, Pasha et al. referred to a mean
duration of hospital stay of 3.5 days from the Lindor et al. study,
which is rather long for a patient who has only pain without bleeding.
Because of the several concerns that have been raised, we differ with
the conclusion reached by Lindor et al. that the use of ultrasonography
for guidance of percutaneous liver biopsy will lead to a lower rate of
complications. Such a conclusion could have various ramifications that
include change in approach to liver biopsy, legal consequences, and added
cost. There has been a tremendous precedence in safety of a liver biopsy
being done "blindly,"3 and we are not convinced
that there is a need to change our practice.
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Coleman I. Smith, M.D.
Minnesota Clinical Research Center
and University of Minnesota
St. Paul, MN
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Rajender Reddy, M.D.
University of Miami
Miami, FL
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REFERENCES
| 1. |
Pasha T, Gabrielle S, Therneau T, Dickinson ER, Lindor
KD. Cost effectiveness of ultrasound-guided liver biopsy. HEPATOLOGY
1998;27:1220-1226 Full Text |
| 2. |
Lindor KD, Bru C, Jorgensen RA, Rakela J, Bordas JM,
Gross JB, Rodes J, et al. The role of ultrasonography and automatic
needle biopsy in outpatient percutaneous liver biopsy. HEPATOLOGY
1996;23:1079-1083 |
| 3. |
Piccinino F, Sagnelli E, Pasquale G, Giusti G, Battochia
A, Bernard M, Bertolazzi R, et al. Complications following percutaneous
liver biopsy, a multicentre retrospective study on 68,276 biopsies.
J Hepatol 1986;2:165-173 |
Copyright © 1999 by the American Association for the
Study of Liver Diseases
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