Diagnostic Laparoscopy: A 5-Year Experience in a Hepatology Training Program

Diagnostic laparoscopy continues to have a role in the evaluation and diagnosis of acute and chronic liver diseases, primary and metastatic liver tumors, and peritoneal diseases. We retrospectively reviewed the records of 1794 diagnostic laparoscopies performed at our institution from 1987 to 1992 to identify the indications, results, and safety of this procedure in our training program. A definitive diagnosis was made in 91% of cases with biopsy performed in 93%. Chronic liver disease was evaluated in 890 patients, and a diagnosis was made in 98%. Four hundred thirty-seven patients were evaluated for suspected primary or metastatic carcinoma, and a diagnosis was made in 85%. Ascites was evaluated in 73 patients, and a diagnosis was made in 82%. One-hundred sixty-four patients were evaluated for abnormal liver function tests, and a diagnosis was made in 91%. HIV-related liver function test abnormalities were evaluated in 67 patients, and a diagnosis was made in 81%. One hundred sixty-three patients underwent diagnostic laparoscopy for the evaluation of hepatomegaly, splenomegaly, unexplained portal hypertension, fever of unknown origin, and cholestasis, and a diagnosis was made in 74% of cases. Eight major complications (including abdominal viscus perforation, hemobilia, splenic laceration, bleeding) and thirty-one minor complications were seen. Our findings confirm that diagnostic laparoscopy is a safe and valuable procedure in the evaluation of chronic liver disease.     

Investigation of chronic hepatitis C infection in individuals with haemophilia: assessment of invasive and non-invasive methods

Hepatitis C virus (HCV) infection is the major cause of chronic liver disease in individuals with haemophilia. A wide spectrum of disease severity is found in this group, ranging from mild hepatitis to cirrhosis. We have studied a cohort of 87 anti-HCV positive haemophiliacs who have been infected with HCV for 10–25 years and assessed the relative value of invasive and non-invasive methods of evaluating liver disease. The severity of liver disease was assessed using ultrasound scan ( n  = 77), upper GI endoscopy ( n  = 50), laparoscopic liver inspection ( n  = 33) and liver biopsy ( n  = 22). Invasive investigations were performed without any significant bleeding complications.   Evidence of severe liver disease was found in approximately 25% of patients. There was agreement between the severity of liver histology and the information derived from the laparoscopic liver inspection, endoscopy and ultrasound in 86%. Co-infection with HIV was significantly associated with more severe liver disease ( P  = 0.006).   This study provides further evidence that liver disease is emerging as a major complication in haemophiliacs and severe liver disease is more common in those co-infected with HIV. We have shown the potential value of laparoscopic liver inspection, in combination with endoscopy and ultrasound, in staging the extent of liver disease, and suggest that most patients may be managed without resorting to liver biopsy.     

Ultrasound-assisted percutaneous liver biopsy performed by a physician assistant

OBJECTIVE: Percutaneous liver biopsy is an essential diagnostic tool utilized in the management of patients with liver disease. This procedure is generally performed by a physician and has a small but well-defined complication rate. We report on the complication rate and efficiency of ultrasound-assisted percutaneous liver biopsy performed by an experienced physician assistant. METHODS: One thousand eighty-six consecutive outpatient liver biopsies (847 hepatic allografts and 239 native livers) were performed at a single center by a physician assistant between June, 1996 and June, 2000. Patients with hepatic mass lesions, unusual hepatic anatomy, and uncorrectable coagulopathy (international normalized ratio > 1.7, platelet count < 50 x 10(9)/L) were excluded. Bedside ultrasonography was used to determine the optimal site for the liver biopsy. Liver biopsies were performed with a 15-gauge Jamshidi aspiration biopsy needle. Patients were observed for 3 h after biopsy, followed by dismissal with subsequent contact in 24 h to assess outcome and complications. RESULTS: Adequate tissue was obtained in 1084 cases (99.8%), with a mean tissue length of 3.2 cm. After the procedure, narcotic analgesia was necessary in 116 (10%) of the patients undergoing liver biopsies. The overall complication rate requiring hospitalization was 0.6%. Major complications requiring intervention occurred in four patients (0.4%). There were no deaths resulting from liver biopsies. CONCLUSION: We conclude that outpatient percutaneous liver biopsy can be safely and effectively performed by a trained physician assistant.     

Transjugular aspiration liver biopsy performed by hepatologists trained in HVPG measurements is safe and provides important diagnostic information

BackgroundTransjugular liver biopsy (TJLB) represents an alternative to percutaneous liver biopsy especially in patients with impaired coagulation and ascites.AimsTo describe safety and diagnostic yield of aspiration TJLB performed by hepatologists experienced in hepatic venous pressure gradient (HVPG) measurements.Methods445 TJLB of 399 patients between 01/2007–12/2016 were retrospectively assessed.ResultsHistological diagnosis was obtained in 423 (95.1%) biopsies — including 11 (100%) patients with acute liver failure and 34 (97.1%) patients after liver transplantation. A median number of 5 portal tracts (interquartile range:2–9) was obtained. HVPG negatively correlated with sample length (Spearman ρ = −0.310; p < 0.001) and number of portal tracts (ρ = −0.212; p < 0.001).Among n = 151 patients with unknown etiology of liver disease, etiology was successfully identified on liver histology in 126 patients (83.4%).Complications occurred in 28 biopsies (6.3%) including 25 (5.6%) minor and 3 (0.7%) major complications. No deaths due to TJLB were observed.Neither the presence of ascites (6.6% complications) nor of coagulopathy (platelets<50G/L and/or prothrombin time<50%; 4.8% complications) increased the risk for complications.ConclusionsTJLB performed by hepatologists experienced in HVPG measurements is safe - even in patients with ascites or coagulopathy. TJLB has good diagnostic value for histological evaluation of liver disease and acute liver failure.     

Comparison of a new aspiration needle device and the Quick-Core biopsy needle for transjugular liver biopsy

INTRODUCTION To diagnose the cause and stage of liver disease, tran- sjugular liver biopsy is an effective way to obtain a liver specimen in patients with a contraindication to percutaneous biopsy, such as coagulopathy or ascites[1-3]. Several different k…     

Liver biopsy in a district general hospital： Changes over two decades

AIM： To study liver biopsy practice over two decades in a district general hospital in the United Kingdom.
METHODS： We identified all patients who had at least one liver biopsy between 1986 and 2006 from the databases of the radiology and gastroenterology departments. Subjects with incomplete clinical data were excluded from the study.
RESULTS： A total of 103 liver biopsies were performed. Clinical data was available for 88 patients, with 95 biopsies. Between 1986 and 1996, 18 （95%） out of the 19 liver biopsies performed were blind and 6 （33%） were for primary biliary cirrhosis. Between 1996 and 2006, 14 （18%） out of 76 biopsies were blind; and the indications were abnormal liver tests （33%）, hepatitis C （12%） and targeted-biopsies （11%）. Liver biopsies were unhelpful in 5 （50） subjects. Pain was the most common complication of liver biopsy （5%）. No biopsy-related mortality was reported. There was a trend towards more technical failures and complications with the blind biopsy technique.
CONCLUSION： Liver biopsies performed in small district hospitals are safe and useful for diagnostic and staging purposes. Abnormal liver tests, non-alcoholic fatty liver disease and targeted biopsies are increasingly common indications. Ultrasound-guided liver biopsies are now the preferred method and are associated with fewer complications.     

Complications of ultrasonically guided fine-needle abdominal biopsy. Results of a multicenter Italian study and review of the literature. The Cooperative Italian Study Group

This report describes the complications following 10,766 ultrasonically guided fine-needle biopsies performed from 1979 to 1987 in 33 Italian echographic units. The mortality was 0.018%: the two reported deaths were due to hemoperitoneum and occurred in patients with hepatocellular carcinoma arising in a cirrhotic liver. Twenty patients (0.18%) had major complications. This series confirms that abdominal biopsy with fine needles is safe, even though our death rate was higher than in previous reports. Among the other nine fatalities following fine-needle abdominal biopsy reported in the literature, seven were secondary to hemorrhage. The biopsy of pancreatic carcinoma was more dangerous for needle-tract seeding (five of eight reported cases, including one in our series).     

Laparoscopy-guided biopsy in diagnosis of liver disorders in children

Abstract: To determine the safety and advantages of laparoscopic liver biopsy in pediatric liver disorders, we reviewed the medical records of 80 children affected by liver disease of various etiologies who underwent this procedure from 1986 to 1996. The main indicators for laparoscopic biopsy were increased risk of bleeding (i.e., mild to moderate coagulation abnormalities in patients probably affected by cirrhosis) and/or previous poorly informative blind needle liver biopsy (65 cases), and the need for a large amount of liver tissue for biochemical assays (10 cases). After inspection of the liver surface, at least two core biopsies were performed using a Tru-cut needle. We encountered difficulties with the biopsy in only four cases, due to a hard consistency of the liver. Bleeding time from the liver orifice was greatly reduced by positioning a fibrin plug (50–120 s vs 5–10 s, on average). In 15 patients, a large excisional biopsy was also successfully performed. Our results confirm an important role for laparoscopy in the diagnosis of cirrhosis (30% of bioptic false negative diagnoses in this series) and show that in selected cases laparoscopy-guided needle or excisional biopsy is an easy, useful and safe alternative to percutaneous blind liver biopsy.     

Gallbladder polyp as a manifestation of hemobilia caused by arterial-portal fistula aRer percutaneous liver biopsy： A case report

Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneous liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percutaneous liver biopsy complications, resulted rarely from arterio-portal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic arterio-portal fistula. After superselective embolization of the feeding artery, the patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.     

A prospective study about the usefulness of ultrasonographic monitoring after invasive liver procedures--liver biopsy and fine-needle aspiration (FNA)]

OBJECTIVE: To determine the need to perform ultrasound scans to all patients after liver biopsy or fine-needle aspiration (FNA) in order to detect complications with or without symptoms. MATERIAL AND METHODS: After liver biopsy or FNA using a regular protocol the patient is observed for 24 hours at the hospital, and all patients undergo an abdominal sonography at that time even in the absence of evident complications. RESULTS: 298 liver biopsies and 98 FNAs were performed. There were complications in 37 patients (9.34%): 36 (9.09%) were minor complications such as pain, vasovagal episodes, or small bleeding, and 1 (0.25%) was a major complication with severe hemorrhage. Only 1 out of all 396 procedures had a complication detected by ultrasounds (intrahepatic hematoma) while the patient was asymptomatic. CONCLUSIONS: The low incidence of complications occurring without symptoms, and their favorable course suggest that routine ultrasonography is not necessary after these techniques, and that it should be only performed when a complication is suspected.     

Liver assessment and biopsy in patients with marked coagulopathy: value of mini-laparoscopy and control of bleeding

OBJECTIVE: Evaluation of liver disease in patients with a high risk of postbiopsy bleeding presents a diagnostic challenge. Mini-laparoscopy offers the possibility of coagulation of biopsy site and the additional advantage of macroscopic liver assessment. We wished to assess the value and safety of mini-laparoscopy with guided biopsy as a diagnostic approach in patients in whom percutaneous liver biopsy is considered contraindicated because of a marked coagulopathy. METHODS: We investigated 61 consecutive patients with marked coagulopathy (prolonged international normalized ratio > 1.5, thrombocytopenia < 50/nl, or both; von Willebrand's disease/hemophilia). Diagnostic mini-laparoscopy with visually guided liver biopsy was undertaken for the evaluation of liver disease. Biopsy sites were coagulated prophylactically (n = 4) or therapeutically (n = 52). Safety, diagnostic yield, and therapeutic consequences were assessed. RESULTS: Macroscopic assessment of the liver was possible in 60/61 high-risk patients and was considered diagnostic in 1/61. In 58 of the remaining 60 patients, liver biopsy was technically feasible. There was no persistent postbiopsy bleeding. One patient with fulminant hepatic failure had self-limiting bleeding from the abdominal wall. Ninety-seven percent of the biopsies were of adequate size for diagnostic histological evaluation. CONCLUSIONS: Mini-laparoscopy with guided liver biopsy allows reliable and safe evaluation of liver disease in patients with severe coagulopathy.     

What is the role of diagnostic laparoscopy in a gastroenterology unit?

Background Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques. Methods We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications. Results No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two. Conclusions Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.     

Transjugular liver biopsy--experience in fifty patients.

OBJECTIVE: We evaluated the safety, adequacy, clinical impact and cost of transjugular liver biopsies performed at our institution. METHODS: Eighty-four biopsies performed in 50 consecutive patients with coagulopathy (INR >1.4; n=20), thrombocytopenia (platelet count <75,000/cmm; n=17), ascites (n=10), or coagulopathy and thrombocytopenia (n=3) from April 1999 to July 2002 were analyzed. Biopsy was performed under local anesthesia with fluoroscopic guidance, using the Quick Core biopsy needle. RESULTS: Ninety-two needle passes were made to obtain 84 samples. Biopsy was technically unsuccessful in two patients because of hepatic vein ostial block; however, the procedure established the diagnosis of blockage of hepatic vein ostia in these patients. Biopsy specimen was adequate for histological examination in 45 patients. The median number of biopsies performed with 18- and 19-gauge needles was 14 and 8, respectively. The biopsy provided diagnostic information in 23 of 50 (46%) patients, and helped in staging or providing prognostic information in 37 (74%) patients. There were no major complications. Minor complications included transient hepatic vein-to-portal vein fistula in 2, transient hepatic vein-biliary fistula in one, local hematoma in 5, and post-procedure fever in 5 patients. The approximate cost of the needle and accessories was Rs. 2000 per patient. CONCLUSIONS: Transjugular liver biopsy was safe, provided adequate tissue in 90% of patients, and helped frequently in diagnosis and in staging or prognostication of disease.     

Percutaneous liver biopsy: retrospective study over 15 years comparing 287 inpatients with 428 outpatients

Background and Aim:  Liver histology still represents the gold standard for the assessment of liver inflammation, necrosis, and fibrosis. The least cumbersome way of obtaining liver tissue is percutaneous liver biopsy. The aim of this retrospective study was to compare the complications following liver biopsy in in- and outpatients and to evaluate for which patients the benefit from liver biopsy is highest.
Methods:  All patients undergoing percutaneous liver biopsy at a teaching hospital between January 1990 and April 2005 were evaluated for indications, complications and impact of histology.
Results:  Liver biopsy was performed in 287 inpatients and 428 outpatients with a success rate of 99.4%. The total complication rate was 6.3% in inpatients and 11% in outpatients. Only two major complications, but no deaths occurred. Pain was the main complication, especially in young patients with chronic viral hepatitis. Despite normal alanine aminotransferase (ALT) levels advanced liver fibrosis was found in 9.3%, 2.6%, and 5.4% of all patients with HBV-, HCV infection, and non viral liver diseases, respectively. In 3% of all patients evaluated a previously unrecognized second liver disease was found. In 21.4% of the patients alkaline phosphatase (AP) levels were elevated, and in more than 90% of these patients liver biopsy led to the final diagnosis.
Conclusion:  Liver biopsy is safe in in- and outpatients. Biopsy is particularly helpful in patients suspected of having liver disease in spite of normal ALT levels or in patients exhibiting unexplained elevated AP levels.     

Feasibility, safety and cost-effectiveness of transjugular liver biopsy following major surgery in patients with haemophilia

Prior to the introduction of virally inactivated clotting factor concentrates, the majority of patients with haemophilia became infected with the hepatitis C virus. Although transjugular liver biopsy can be safely performed in these patients, the procedure is associated with a significant financial burden mainly related to replacement therapy with clotting factor. The purpose of this study was to evaluate the feasibility and safety of transjugular liver biopsy in patients with haemophilia substituted with clotting factor concentrates for major surgical procedures. Over the last 5 years, transjugular liver biopsy was performed in nine patients with haemophilia within 1-10 days after orthopaedic (7), thoracic (1) or abdominal surgery (1). All patients had abnormal liver function tests and persistent hepatitis C viraemia. At the time of the biopsy, patients received recombinant factor VIII delivered by dose-adjusted continuous infusion through a central catheter inserted preoperatively in the left internal jugular (n = 8) or in an ante-cubital vein (n = 1). Before the biopsy, basal FVIII levels were raised to 80-100% by a bolus infusion and maintained above 80% for 24 h. The biopsy was informative in all cases. Only one patient developed an episode of supraventricular dysrhythmia. No bleeding or infectious complications were observed. When compared with elective liver biopsy performed outside the postsurgical period, the cost-savings per biopsy were 19 875 +/- 2660 euro. This study shows that intensive replacement therapy required by surgical procedures provides a safe and cost-effective opportunity for transjugular liver biopsy in patients with haemophilia and active hepatitis C.     

Transjugular liver biopsy is a safe and effective intervention to guide management for patients with a congenital bleeding disorder infected with hepatitis C

The prevalence of hepatitis C virus (HCV) infection in adult patients with a congenital bleeding disorder (CBD) approaches 95% and is a major cause of morbidity and mortality. Histological examination of the liver remains the cornerstone of management decisions in patients without a CBD. The reluctance to perform liver biopsies in patients with a CBD has been a major limitation in the management of these patients. We are currently the only haemophilia centre in Australasia performing liver biopsies in patients with a CBD for the purpose of guiding prognostic and therapeutic decisions. We report here the results of our centre's experience with transjugular liver biopsy (TJLB) in patients with a CBD. An adequate specimen for histological assessment was attained from all of the patients. There were no major complications recorded. Patients were hospitalized for < or = 48 h for haemostasis prophylaxis. The diagnostic specimen obtained from patients was integral in guiding their future management. We suggest that with a coordinated multidisciplinary approach, TJLB can be performed in patients with a CBD.     

Utilization rates,complications and costs of percutaneous liver biopsy: a population‐based study including 4275 biopsies

Background: Liver biopsy is an important tool in the management of patients with liver disease. Because biopsy practices may be changing, we studied patterns of use in a large Canadian Health Region. We aimed to describe trends in biopsy utilization and the incidence and costs of complications from a population‐based perspective. Methods: Administrative databases were used to identify percutaneous liver biopsies performed between 1994 and 2002. Significant complications were identified by reviewing medical records of patients hospitalized within 7 days of a biopsy and those with a diagnostic code indicative of a procedural complication. Analyses of biopsy rates employed Poisson regression. Results: Between 1994 and 2002, 3627 patients had 4275 liver biopsies (median 1 per patient; range 1–12). Radiologists performed the majority (90%), particularly during the latter years (1994 vs. 2002: 73 vs. 98%; P<0.0001). The overall annual biopsy rate was 54.8 per 100 000 population with a 41% (95% CI 23–61%) increase between 1994 and 2002. Annual increases were greatest in males and patients 30–59 years. Thirty‐two patients (0.75%) had significant biopsy‐related complications (1994–1997 vs. 1998–2002: 1.28 vs. 0.44%; P=0.003). Pain requiring admission (0.51%) and bleeding (0.35%) were most common. Six patients (0.14%) died; all had malignancies. The median direct cost of a hospitalization for complications was $4579 (range $1164–29 641). Conclusions: Liver biopsy rates are increasing likely owing to the changing epidemiology and management of common liver diseases. The similarity of the complication rate in our population‐based study with estimates from specialized centres supports the safety of this important procedure.     

Ultrasound-guided liver biopsy in real life: comparison of same-day prebiopsy versus real-time ultrasound approach

BACKGROUND AND AIM: Currently, an increasing number of liver biopsies are performed by radiologists under real-time ultrasound control. A routine ultrasound assessment of a puncture site before performing percutaneous biopsy is reported to increase diagnostic yield and decrease complication rates. It is not clear if real-time ultrasound is superior to marking the puncture site before biopsy as regards reducing biopsy size and avoiding fragmentation and complications. The aim of this study was to compare ultrasound assessment of the puncture site before performing percutaneous liver biopsy with real-time ultrasound liver biopsy for suspected diffuse liver disease. METHODS: Consecutive percutaneous liver biopsies (n = 631) for diffuse liver disease were evaluated. Group A consisted of patients who had real-time guided-ultrasound biopsy performed by radiologists (241 patients; M/F, 35/106; median age 48 year [range, 17-76]; needle 18 G). Group B patients were assessed by radiologists using ultrasound of the puncture site on the same day that biopsies were performed by experienced gastroenterologists/hepatologists on the ward using the marked site (390 patients; M/F, 276/114; median age 43 year [range, 15-75]; needle 16 G). RESULTS: There were no differences in severity of liver disease, establishing a diagnosis (OR, 1.92 [95% CI, 0.84-4.34]; P = 0.12), length of liver biopsy specimens, number of fragments or complications. Two independent variables were significantly associated with a histological diagnosis: longer biopsy length (P < 0001) and fragment number of two or less (P < 0.001). CONCLUSION: Real-time ultrasound did not improve diagnostic yield or result in fewer complications. Marking the puncture site seems adequate and has the practical advantage that it takes up less of the radiologists' time.     

Transjugular liver biopsy. An update

Transjugular liver biopsy was first reported in 1967. Since then, this technique has been broadly performed in many medical centers around the world. The number of its indications has increased, and by modifying the needles, the quality of the liver tissue sample has improved. The advantage of transjugular biopsy is that it can be performed in patients in whom the use of percutaneous biopsy is contraindicated Indications for transjugular liver biopsy are, precisely, most of the contraindications for percutaneous liver biopsy. This fact increases the number of patients that can benefit from this procedure. In most cases, the procedure is successfully performed. Minor complications may occur in 1% to 15% and major complications (perforation of the hepatic capsule, cholangitis, and intra-peritoneal bleeding) are observed in 1-3% of the cases. Mortality related to the procedure varies form 0.2 to 0.3%. It has been reported that diagnosis yielded by transjugular liver biopsy induced changes of treatment in 50% of patients with an acute hepatic illness, in 62% of the patients with a chronic hepatic illness, and in 87% of the patients with liver transplants. In conclusion, transjugular liver biopsy is a useful procedure in the diagnosis of hepatic diseases. Its success rate is high; it is a very safe procedure because complications and mortality are rare; and it is well tolerated by patients.     

Transjugular liver biopsy in children.

Transjugular liver biopsy is widely used in adult patients with liver disease when transthoracic needle liver biopsy is contraindicated by severe coagulopathy or ascites. It has not been used extensively in children. We report our experience with 30 consecutive transjugular liver biopsy procedures performed in 27 young patients at the Hospital for Sick Children in Toronto. Patient weights ranged from 14 to 91 kg (median = 42 kg); most patients had not yet attained adult size. A 9F catheter was used except in very small children, for whom we developed a 7F biopsy needle catheter. Most procedures were done with patients under general anesthesia. Specimens were obtained in all patients, and the procedure was tolerated well. A major complication occurred only once: perforation of the inferior vena cava, which was later repaired at liver transplantation. Minor complications included subcapsular extravasation of contrast agent in five patients and a small intrahepatic hematoma in one. Results of transjugular liver biopsy changed the diagnosis in 30% of patients and added valuable information about the disease process in most patients. Transjugular liver biopsy was an important component of emergency assessment for liver transplantation. Our results indicate that transjugular liver biopsy can be performed safely in children with liver disease if a skilled interventional radiologist and a well-equipped angiography suite are available. Histological studies in these patients enhance our understanding of the natural history of pediatric liver diseases.