Hepatitis Central

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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Copyright © 1999 by the American Association for the Study of Liver Diseases