Renal biopsy in children: comparison of two techniques

Two hundred and thirty-five children who underwent percutaneous renal biopsy under real-time ultrasound guidance at The Hospital for Sick Children, between 1 January 1991 and 31 March 1993, were studied to compare the incidence of complications after biopsies with the Trucut needle (TN) and the Bard Biopty gun (BG). Of the 190 cases for which full clinical details were available and in which a single instrument was used for renal biopsy, 157 were biopsied with the BG and 33 with the TN. There was no significant difference between the two groups in variables such as age, weight, sex, number of needle passes and number of tissue cores obtained. The proportion of native and allograft biopsies in each group was similar. More children in the TN group underwent biopsy under general anaesthesia. Adequate diagnostic tissue samples were obtained in 189 of 190 cases. There were more complications in the TN group than in the BG group (P<0.001). When allograft and native kidney biopsies were analysed separately, this difference in complications remained highly significant for the native kidney group (P<0.005), though not for the allograft group. When the effect of needle size alone was investigated, there was no significant difference in the incidence of complications when TN biopsies were compared with 14-gauge BG biopsies or when 14- and 18-gauge BG biopsies were compared with each other.HSC price May 1993, Trucut needle Canadian $ 11.15, Biopty needle Canadian $ 30.50.     

Clinical and economic consequences of early discharge of patients following supratentorial stereotactic brain biopsy.

OBJECT: The goal of this study was to determine the clinical and economic consequences of early discharge (< 8 hours) of patients following stereotactic brain biopsy (SBB). METHODS: The records of all patients who underwent percutaneous SBB at The Cleveland Clinic Foundation, a tertiary care teaching hospital, during 1994 and 1995 (Group A) were retrospectively reviewed to collect data on the nature and timing of perioperative (< 48 hours) clinical and radiological complications. Biopsies were performed using image-guided stereotaxy either with or without a frame. Based on the results, guidelines for early discharge of patients following SBB were implemented. Information on the nature and timing of perioperative complications was also collected prospectively in all patients who underwent percutaneous SBB from January 1996 through July 1998 (Group B). Hospital financial records for patients who underwent SBB in 1997 and 1998 were also reviewed and assessed for net revenue stratified by discharge status: early discharge (< 8 hours), extended outpatient observation (> or = 8 and < 24 hours). and inpatient hospitalization (> or = 24 hours). In Group A, 130 biopsies were performed. There were five serious complications (3.8%), of which four were transient, and there was one death (0.8%). The death and any sustained deficit occurred in patients in whom a clot had been demonstrated on postoperative CT scans. All complications were detected within 6 hours after surgery. Intraoperative bleeding occurred in 12 patients (9.2%), but was associated with only 40% of cases in which hemorrhage appeared on postoperative CT scans. Guidelines for early discharge (< 8 hours) following SBB were developed and stipulated the absence of the following: 1) intraoperative hemorrhage; 2) new postoperative deficit; and 3) clot on a postoperative CT scan. In Group B, 139 biopsies were performed. There were three serious complications (2.2%), one of which was sustained due to a clot that had been demonstrated on the postoperative CT scan. All complications were detected within 6 hours postsurgery. There were no deaths in this group. Intraoperative bleeding occurred in 11 patients (7.9%), requiring intraoperative craniotomy to control bleeding in one case. Hospital financial records were available for 96 patients, of whom 22 were discharged from the hospital early, 11 were observed for an extended outpatient period, and the remainder were retained for inpatient hospitalization. Average net hospital incomes on technical charges for patients in the inpatient hospitalization, extended outpatient observation, and short-stay (early discharge) groups were $1778, $1175, and $1219, respectively, in 1997, but declined to -$889, -$1339, and $671, respectively, in 1998. The ratios of indirect costs to direct technical costs were 132.5%, 128.7%, and 103.7%, respectively. CONCLUSIONS: Early discharge of patients following SBB of supratentorial lesions is safe in the absence of excessive intraoperative bleeding, new postoperative deficit, and clot on a postoperative CT scan. Extended outpatient observation (8-23 hours) is not clinically necessary and may be economically prohibitive in the setting of a teaching hospital.     

Percutaneous renal biopsy: comparison of blind and real-time ultrasound-guided technique

The use of real-time ultrasound-guided renal biopsy is believed to be superior to blind biopsy, but there are few reports comparing the two techniques. The goal of the present study was to compare the outcomes of ultrasound-guided and blind renal biopsies at a single teaching institution, in terms of adequacy of tissue yield and frequency of hemorrhagic complications. We reviewed retrospectively the outcomes of all patients undergoing a percutaneous native kidney biopsy during a 2-year period (January 1, 2004 to December 31, 2005). Of 129 renal biopsies, 65 were ultrasound-guided and 64 were performed by the blind technique. All biopsies were performed by nephrology fellows under direct faculty supervision. The two patient groups were comparable in terms of age, sex, race, diabetes, hypertension, serum creatinine, and hematocrit. The mean number of glomeruli per biopsy was higher in the ultrasound-guided group than in the patients with a blind biopsy (18 +/- 9 versus 11 +/- 9, p = 0.0001). An inadequate tissue sample requiring repeat biopsy occurred in 0% of the ultrasound-guided biopsies and 16% of the blind biopsies (p = 0.0006). Large hematomas requiring vascular intervention or transfusion were less frequent in the ultrasound-guided biopsies (0% versus 11%, p = 0.006). The hematocrit 24 hours postbiopsy was higher in the ultrasound-guided biopsies when compared with the blind biopsies (32 +/- 5% versus 30 +/- 4%, p = 0.04). When compared with blind renal biopsy, real-time ultrasound-guided percutaneous renal biopsy provides a superior yield of kidney tissue and results in fewer hemorrhagic complications. Real-time ultrasound-guided renal biopsy is the preferred technique.     

Modification of a disposable needle for renal biopsy in children and transplant recipients

While use of a disposable biopsy needle (Tru-Cut) has been shown to result in less distortion of glomerular architecture than the reusable Franklin-Vim-Silverman needle, the long specimen notch (20 mm) makes it less desirable for use in small children or renal allograft biopsy. A simple modification of the cannula handle permits selection of any desired specimen length. Four percutaneous renal biopsies of nephrotics under 4 years of age and an additional four renal allograft biopsies were performed using this technique, resulting in adequate specimens and no complications. It is concluded that the described modification of the Tru-Cut needle may increase the safety of renal biopsy in patients at higher risk for hemorrhagic complications.     

Standards for renal biopsies: comparison of inpatient and day care procedures

There are no national standards for the adequacy and complications of percutaneous renal biopsies. We developed local standards that have been used in a prospective audit of biopsies undertaken in a tertiary pediatric nephrology unit between January 1997 and December 2000. We compared outcomes of biopsies performed on inpatients with day care procedures. A total of 251 biopsies (113 transplant) were undertaken, 114 (46%) as day care procedures. Adequate tissue for diagnosis was obtained in 245 (97.6%), with a standard set at >95%. This was also achieved for a mean number of passes in native (<3 in 80%) and transplanted (<2 in 80%) kidneys. Eleven patients (4%) developed macroscopic hematuria (standard <5%) and none required transfusion. Delay in discharge occurred in 4 patients, and a further 4 returned to the ward post discharge. There was no significant difference in complication rates between inpatient and day care patients. Our local biopsy standards were met in this audit. Such standards could provide useful comparisons between units in national audit programs, as well as permitting the monitoring of individual performance as part of clinical governance. Day care procedures benefit the patient and family, as well as significantly reducing costs.     

Experience with a new method for percutaneous renal biopsy.

Between January 1989 and August 1990 a new technique for percutaneous renal biopsy was evaluated in all patients undergoing native kidney biopsy in our hospital. The method combines the use of an automated biopsy device, disposable biopsy needles, and a needle guide attached to an ultrasound probe. This allows real-time ultrasound scanning throughout the procedure. All biopsies were performed by trainee nephrologists. The success of the technique was evaluated by analysis of histopathological data, and the complications of the procedure from case-notes and nursing records. During the study 192 biopsies were attempted, of which 188 (97.8%) were successful. For each biopsy a mean of 2.8 needle passes were required and 75% of these obtained cores of tissue. An average of 25 glomeruli (range 1-90) were seen per biopsy. Although microscopic haematuria was almost invariable, there were no episodes of frank haematuria and no blood transfusion or surgical intervention was required. The new method is simple, providing accurate localisation of the kidney coupled with direct visualisation of the biopsy, and results in a very high success rate. Intrarenal needle dwell time is kept to a minimum and there were only minor complications. This technique deserves more widespread use.     

Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys

The diagnostic usefulness of the biopsy cylinder and biopsy-inducedcomplications were investigated for 458 percutaneous renal biopsies(315 native, 143 transplant kidneys) on 339 patients (averageage, 44.6±18.5 years) under two different biopsy regimes(regime I, manual biopsy technique with Tru-Cut needle, 14 gauge;regime II, automated biopsy technique using a Biopty instrumentand adapted biopsy needle, 18 gauge). In 435 (95%) of the biopsies, kidney tissue with 9.09 ±5.28 glomeruli was obtained (regime I, 93.5%, 9.5±4.9glomeruli; regime II, 96.5%, 8.7 + 5.6 glomeruli; p>0.05).Neither with native nor with transplant kidneys was there anyevident advantage for a particular regime in terms of the diagnosticusefulness of the cylinder. Bleeding complications (perirenalhaemat-omas, bleeding into the renal pelvis, blood clots inthe urinary bladder) were observed in 69 (15.1%) patients (regimeI, 15.6%; regime II, 14.6% P>0.05). Clinically relevant bleedingcomplications were significantly rarer under regime II (9.1%versus 3.5%; P<0.05). Complications were less frequent withtransplant than with native kidneys (12.6% versus 16.2%). Dopplersonography of the biopsied transplant kidneys revealed arteriovenousfistulae in nine cases (6.3%; regime I, 8.0%; regime II, 5.4%). In general, use of an automated biopsy instrument and a thinnerbiopsy needle reduced the number of significant complicationsfollowing percutaneous renal biopsy, while achieving comparablydiagnostic efficacy.     

Efficacy of video assisted thoracoscopic lung biopsy: an historical comparison with open lung biopsy.

BACKGROUND--Video assisted thoracoscopic lung biopsies were compared with historical controls undergoing open lung biopsy to determine the diagnostic accuracy, effect on length of postoperative stay, and cost effectiveness of the new thoracoscopic technique. METHODS--The first 25 video assisted thoracoscopic lung biopsies performed in the Edinburgh Thoracic Unit were compared with 25 historical controls for complications, diagnostic accuracy, and length of postoperative stay. RESULTS--Statistical comparison showed equal diagnostic accuracy in both groups (96% v 92%), but mean (SD) inpatient stay was reduced in the video assisted thoracoscopic group (1.4 (0.7) days) compared with those undergoing open lung biopsy (3.1 (1.8) days). No postoperative complications were reported in the group which underwent video assisted thoracoscopic lung biopsies but three patients had postoperative complications in the open lung biopsy group. CONCLUSIONS--Video assisted thoracoscopic lung biopsy is as effective in providing histological diagnosis as is open lung biopsy. All postoperative complications were related to post thoracotomy pain and occurred only in patients undergoing open lung biopsy. Reduced postoperative disability in the video assisted thoracoscopic group decreased hospital stay, offsetting the increased cost in disposables. The overall cost of video assisted thoracoscopic and open lung biopsy was 712 pounds and 1114 pounds, respectively.     

Percutaneous Renal Biopsy: Outpatient Observation without Hospitalization Is Safe

Percutaneous renal biopsy may be complicated by hemorrhage. Patients are frequently hospitalized for overnight observation. We evaluated prospectively the feasibility and safety of an outpatient renal biopsy protocol. During a 20-month period, 100 consecutive patients underwent outpatient renal biopsy using a standardized protocol. The biopsy was performed by Nephrology Fellows, under direct faculty supervision. All biopsies were carried out under real-time ultrasound guidance with a 16-gauge spring-loaded biopsy gun, and followed immediately by color Doppler ultrasound to exclude active bleeding. Blood pressure, heart rate, hemoglobin, and hematocrit were monitored for 8 hours postbiopsy. If there were no complications, the patients were discharged home after the observation period. A total of 91 patients required one or two needle passes, and nine needed three or four passes. A mean of 12.7 ± 9.7 glomeruli were obtained per patient. No major complications were encountered. A small (<2 × 2 cm) perinephric hematoma was observed postbiopsy in 13 patients. Four patients were hospitalized for overnight observation due to a >4% decrease in their hematocrit, but none required a transfusion or intervention. No patient experienced a delayed biopsy-related complication. Outpatient, real-time, ultrasound-guided percutaneous renal biopsy is safe and effective, and minimizes the need for postbiopsy hospitalization. It can result in significant cost savings without exposing the patients to an increased risk of complications.     

Pediatric renal biopsy: should this procedure be performed in an outpatient setting?

Although several retrospective reports suggest that pediatric outpatient renal biopsies may be done in a safe and cost-effective manner, risk factors and the natural history of major complications following this procedure have not been clearly delineated. In an effort to determine the minimal observation period required to detect major post-renal biopsy complications in children and to establish clinical parameters predictive of these complications, a retrospective review of 177 percutaneous renal biopsies was performed. The overall major complication rate was 3.4%, while the minor complication rate was 14.1%. The mean percentage change in hemoglobin 4 – 10 h postbiopsy in patients with major bleeding complications was significantly greater than patients with minor bleeding complications. Using a 16% drop in hemoglobin 4 – 10 h postbiopsy, the sensitivity and specificity of identifying a major bleeding complication was 100% and 98%, respectively, while the positive and negative predictive value was 68% and 100%, respectively. All patients with major complications due to excess sedation or immediate bleeding were diagnosed within 11 h of the biopsy. Automated renal biopsies offered several safety and efficiency advantages compared with non-automated methods. Our results suggest that outpatient pediatric renal biopsies should be encouraged provided certain precautions are taken to reduce the risk of developing major complications. Received July 1, 1997; received in revised form October 9, 1997; accepted October 10, 1997     

Percutaneous renal biopsy with the use of real-time ultrasound

We describe our experience with real-time ultrasound as a localization and guidance tool for percutaneous renal biopsy. Two hundred biopsies performed between June 1983 and January 1990 were reviewed retrospectively. Nephrology fellows performed 83.5% of the biopsies. The average age of the patients was 43 +/- 17 years (range 6-80) and renal insufficiency (serum creatinine greater than or equal to 1.3 mg, %) was present in approximately 60% of patients biopsied. Primary indications for biopsy were to evaluate proteinuria (46.5%) and renal manifestation of systemic lupus erythematosus (24%). Material for light microscopy, immunofluorescence, and electron microscopy was obtained in 99.5, 95.0 and 98.0% of cases, respectively. Adequate tissue for histologic diagnosis was obtained in 97.5% of patients. Primary diagnosis was glomerulonephritis in 77.9% of cases. Complications were assessed and separated by severity. Total complications were observed in 13.7% of patients with 8.1% of these being minor complications (not requiring blood transfusion) and 5.6% being major complications which required blood transfusions. Bleeding complications requiring massive blood transfusion and/or therapeutic radiologic intervention were seen in 1.5% of patients. We could find no significant difference with respect to age, serum creatinine, or coagulation parameters between patients with or without complications due to percutaneous renal biopsy. We conclude that real-time ultrasound is a safe, accurate method in localizing the kidney for percutaneous renal biopsy. However, patients must still be observed carefully post biopsy for potential complications.     

Day care renal biopsy

Over the 6 years 1989–1994, 384 percutaneous renal biopsies were performed, 329 on native and 55 on transplanted kidneys. Biopsy was undertaken on a day care basis in 304 instances (79.2%). Failure to obtain 5 or more glomeruli was experienced in 23 (6.0%) of the 304 day care biopsies. There were no significant differences in technical failure rates between day care patients and inpatients, local analgesia and general anaesthetic, or native and transplanted kidneys, but a higher rate was observed in biopsies performed unaided by trainees than by experienced operators (P = 0.002). Six patients were detained overnight for minor complications and a seventh for unrelated reasons. Two patients discharged on the day of biopsy despite gross haematuria were readmitted 8–10 days later with secondary haemorrhage. The complication rate of 2.6% compares favourably with published data. Few paediatric renal units currently perform day care renal biopsy, and we recommend its wider acceptance. Received August 4, 1995; received in revised form November 6, 1995; accepted November 17, 1995     

Influence of aspirin on early allograft thrombosis and chronic allograft nephropathy following renal transplantation

BACKGROUND: Primary thrombosis and chronic allograft nephropathy are important causes of early and late graft loss, respectively, following renal transplantation. This study examined the potential for aspirin therapy to reduce these complications. METHODS: A consecutive series of 105 cadaveric renal transplants treated with aspirin 150 mg daily for the first 3 months after transplantation was compared with an untreated historical control group (n = 121). Protocol needle-core biopsies were performed on all transplants in both groups at 1 week and 12 months after transplantation. Needle-core allograft biopsies were performed at 3, 6 and 12 months after transplantation, and serum creatinine was measured at each outpatient attendance for the duration of follow-up. RESULTS: There was a significantly lower rate of primary allograft thrombosis in patients treated with aspirin (none of 105) compared with that in the control group (six (5 per cent) of 121; P = 0.03). There were no differences in renal function or 2-year allograft survival between the two groups. Aspirin-treated patients had a lower incidence of chronic allograft nephropathy at 1 year than controls although this did not reach statistical significance (16 versus 26 per cent; P = 0.075). There were no major bleeding complications in either group in association with peptic ulcer disease or following renal transplant biopsy. CONCLUSION: Aspirin reduced the rate of early graft thrombosis of renal transplants in this series but did not improve renal function or graft survival. A trend towards a lower rate of chronic allograft nephropathy was noted with aspirin treatment. These findings require confirmation in a prospective randomized trial.     

Arthroscopic versus Open Ankle Arthrodesis: A Retrospective Cost Analysis

Compared with traditional open arthrodesis, arthroscopic ankle arthrodesis has been associated with similar rates of fusion, decreased time to union, decreased pain, shorter hospital stay, earlier mobilization, reliable clinical results, and fewer complications. The aim of this case-control study was to analyze cost differences between outpatient arthroscopic and inpatient open ankle arthrodesis. To this end, the authors analyzed 20 ankle arthrodesis procedures: 10 performed by one surgeon on an inpatient basis using an open approach, and 10 performed by another surgeon on an outpatient basis arthroscopically. Patient age, body mass index, tourniquet time, length of stay, complications, days to clinical union, and insurance type, as well as charges and reimbursements for the surgeons and the hospital or surgery center were abstracted from the records. Statistically significant differences were observed between the outpatient arthroscopic and inpatient open arthrodesis groups for total site charges ($3898 ± 0.00 versus $32,683 ± $12,762, respectively, P < .0001), reimbursement to the surgeon ($1567 ± $320 versus $1107 ± $278, respectively, P = .003), and reimbursement to the hospital or ambulatory surgery center ($1110 ± $287 versus $8432 ± $2626, respectively); the ratio of hospital/surgery center charges to hospital/surgery center reimbursements was 28.48% for the inpatient arthroscopic group and 25.80% for the inpatient open arthrodesis group. Outpatient arthroscopic ankle arthrodesis, compared with inpatient open ankle arthrodesis, appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.     

Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter

BACKGROUND: Previous studies have shown that a chronic indwelling pleural catheter (PC) safely and effectively relieved dyspnea, maintained quality of life, and reduced hospitalization in patients with malignant pleural effusions. Outpatient management of malignant pleural effusion with a PC may reduce length of stay and early (7-day) charges compared with inpatient management with chest tube and sclerosis. METHODS: A retrospective review of consecutive PC patients (n = 100; 60 outpatient, 40 inpatient) were treated from July 1, 1994 to September 2, 1998 and compared with 68 consecutive inpatients treated with chest tube and sclerosis between January 1, 1994 and December 31, 1997. Hospital charges were obtained from date of insertion (day 0) through day 7. RESULTS: Demographics were similar in both groups. Pretreatment cytology was positive in 126 of 168 patients (75%), negative in 21 (12.5%), and unknown in 21 (12.5%). Primary histology included lung (n = 61, 36%), breast (n = 39, 23%), lymphoma (n = 12, 7%), or other (n = 56, 34%). Median survival was 3.4 months and did not differ significantly between treatment groups. Overall median length of stay was 7.0 days for inpatient chest tube and inpatient PC versus 0.0 days for outpatient Pleurx. No mortality occurred related to the PC. Eighty-one percent (81/100) of PC patients had no complications. One or more complications occurred in 19 patients (19%). Patients treated with outpatient PC (n = 60) had early (7-day) mean charges of $3,391 +/- $1,753 compared with inpatient PC (n = 40, $11,188 +/- $7,964) or inpatient chest tube (n = 68, $7,830 +/- $4,497, SD) (p < 0.001). CONCLUSIONS: Outpatient PC may be used effectively and safely to treat malignant pleural effusions. Hospitalization is not required in selected patients. Early (7-day) charges for malignant pleural effusion are reduced in outpatient PC patients compared with inpatient PC patients or chest tube plus sclerosis patients.     

Safety and risk stratification of percutaneous biopsies of adult-sized renal allografts in infant and older pediatric recipients

BACKGROUND: Allograft biopsies are the gold standard for evaluating renal graft dysfunction. Adult-sized kidney (ASK) allografts are placed extraperitoneally in older children and adults and transperitoneally in infant recipients. Transperitoneal graft biopsies may be accompanied by a greater risk of bleeding and bowel injury, although no standardized pediatric study of procedure risk relating to transplant placement exists. METHODS: A retrospective single-center study of 328 consecutive ASK biopsies (277 extraperitoneal and 51 transperitoneal) performed since 1995 was conducted to stringently categorize all identified biopsy procedure complications (bleeding, transfusion requirement, bowel perforation, surgical intervention, and graft loss) relating to allograft placement, surveillance versus protocol biopsies, recipient age, and biopsy needle use, with risk stratification and recommendations for improving procedure safety. Two distinct methods of real-time ultrasound guidance were used. RESULTS: The overall incidence of all adverse effects was 16.1%, with perinephric hematomas accounting for 13.4% and gross hematuria accounting for 2.7%. Hematomas less than 1 cm accounted for 81.4% of all hematomas. Complications of transperitoneal biopsies (using a modified patient placement approach) paralleled those seen in extraperitoneally placed allografts (15.7% vs. 15.5%, P=0.976). Hematomas occurred more frequently (17.8% vs. 8.3%, P=0.010) in clinically indicated versus surveillance biopsies and with 16- versus 18-gauge biopsy needle use (43% vs. 13.3%, P=0.19). CONCLUSION: Pediatric allograft ASK biopsies can be performed with minimal adverse outcomes. Transperitoneal ASK placement is not a contraindication for percutaneous biopsy. Strategies to improve biopsy safety include recommendations for patient positioning for transperitoneal ASKs, improved techniques for real-time ultrasound guidance, and use of finer gauge needles.     

A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery

The feasibility of outpatient anterior cruciate ligament (ACL) surgery has not been reported in the literature. We evaluated outpatient ACL surgery by comparing outpatient versus inpatient pain control, narcotic consumption, postoperative complications, recovery time, and cost analysis. Thirty-seven ACL reconstructions were performed in 37 patients over a 16-month period. Twenty-five of the patients had surgery performed as outpatients and 12 as inpatients. One of the outpatients required hospitalization because of excessive nausea and vomiting and another for urinary retention. Only 2 of the 25 outpatients (8%) believed that they should have been hospitalized for pain control. Based on a visual analog scale, pain severity, pain frequency, and pain relief were measured, and no statistically significant difference (P < .05) was noted between the groups, although the data suggested that the inpatients were slightly more comfortable. There were no differences in rehabilitation or in regaining full range of motion of the operated knee. Also, the only postoperative complication in both groups occurred in an inpatient who developed arthrofibrosis. Cost analysis showed that outpatient ACL reconstruction was cost effective. The average inpatient cost was $9,220 (2.4 hospital days) compared with the average outpatient cost of $3,905. This reflected a savings of 58%. These results show that outpatient ACL reconstruction surgery is possible in the appropriate patient without harm to the patient and with a significant cost savings.     

Breast biopsy. A comparison of outpatient and inpatient experience.

Nine hundred ninety-seven breast biopsies that were performed at one hospital over the five-year period from 1971 through 1975 were reviewed because of a changing pattern in the use of breast biopsies on outpatients who were under local anesthesia. In 1971, 17% of all breast biopsies were performed as outpatient procedures; by 1975, the figure was 60%. In 1971, 5% of all malignant neoplasms were diagnosed by the use of biopsies as outpatient procedures and 30% in 1975. Hospital charges for biopsy on an inpatient basis of benign breast disease were 7.2 times higher than for biopsy on an outpatient basis. Interviews of 102 patients clearly suggested that most patients were satisfied with the outpatient breast biopsy experience. Outpatient breast biopsy under local anesthesia is a safe procedure that is more economical in terms of medical cost, surgeons' time, and patients' time away from home and/or job. Preliminary biopsy of malignant lesions using local anesthesia permits more efficient use of diagnostic procedures to stage the extent of disease prior to treatment. Patient acceptance of breast biopsy as an outpatient procedure under local anesthesia was similar to their acceptance of biopsy on an inpatient basis under general anesthesia.     

Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications,Readmissions, and Costs

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.     

Percutaneous needle biopsy of the renal allograft. A clinical safety evaluation of 1129 biopsies

In many transplant centers there is a reluctance to perform percutaneous core needle biopsies in renal allografts for fear of complications that may jeopardize the graft. We have evaluated the safety of percutaneous renal allograft biopsy by retrospectively studying 1129 biopsy specimens in 513 patients between 1974 and 1988. All biopsies were performed with a conventional 2.0 mm TruCut disposable needle (Travenol Labs.; Deerfield, IL) without radiographic aid for localization of the kidney. Kidney tissue was obtained in 1095 cases (97.0%). In 1037 biopsies (91.9%) enough renal tissue for histological evaluation was obtained. In 34 biopsies (3.0%) no renal tissue and in 58 (5.1%) only renal medulla was found. All the complications were demonstrated by with macroscopic bleeding into the urinary tract system. Thirty-two patients (2.8%) developed hematuria requiring hospitalization and some type of active treatment (catheter-à-demeure, n = 14; cystoscopy, n = 11; percutaneous nephrostomy, n = 3; surgery, n = 4). On 8 biopsy occasions blood transfusion was required. Three graft removals (0.3%) were attributed to the procedure of biopsy for emergency diagnostic purposes. All three grafts were severely damaged by rejection and had little or no function. No grafts were lost among the biopsies taken for long-term follow-up. No deaths occurred. Biopsies yielding only renal medulla were found to carry a greater risk of bleeding than adequate biopsy specimens (P less than 0.001), as did biopsies from transplants with acute vascular rejection. Conversely, biopsies taken for routine check-ups of long-term renal allografts were associated with a lower risk than biopsies taken because of poor or deteriorating renal function (P less than 0.05). An analysis of 340 biopsies, taken in accordance with a protocol during periods of stable renal function, revealed no deterioration in graft function at 1 and 12 months after the biopsy. In this study, we have found that conventional percutaneous needle biopsy of the renal allograft involves a certain risk of complications, even including graft loss. We have also defined a number of risk factors for such complications. However, we think that the benefits outweigh the risks, and needle biopsy should therefore remain an important diagnostic tool among all the others in the posttransplantation management of the renal transplant recipient.