Evaluation of ultrasound-assisted Menghini technique in liver graft biopsy Avaliação da técnica de Menghini auxiliada por ultrassonografia em biópsias de fígado transplantado

August 13, 2017 | Autor: Marcos Roberto | Categoria: Ultrasound, Ultrasonography, Liver Transplantation, Graft Rejection
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Evaluation of ultrasound-assisted Menghini technique in liver graft biopsy Avaliação da técnica de Menghini auxiliada por ultrassonografia em biópsias de fígado transplantado Marcel Vieira da Nóbrega1, Carlos Leite de Macedo Filho2, Rodrigo Gobbo Garcia3, Alexandre Maurano4,  Marcos Roberto Gomes de Queiroz5, Miguel José Francisco Neto6, Marcelo Buarque Gusmão de Funari7

ABSTRACT Objective: To report on the experience of implementing ultrasoundassisted Menghini technique in the evaluation of liver transplant dysfunction. Methods: Menghini technique uses a suction needle, through percutaneous access, allowing a fast puncture (less than one second), which can help reduce the incidence of complications. Results: A total of 87 biopsies performed with 16-gauge suction needles were studied in a period of 15 months. Ultrasound was used to access the presence of perihepatic liquid or collections, biliary and vascular disorders, to mark a safe puncture site and for postprocedure control. The main biopsy indication was elevation of liver enzymes. In 81 cases, one fragment was collected and satisfactory samples were obtained in 85 procedures (97.7%). Minor complications occurred in six patients (6.9%), five with local pain and one with vagal reaction. There was a major complication (1.1%), hemothorax, which was diagnosed by clinical and radiological control examination and then treated. Conclusions: Menghini technique to obtain liver tissue is quick, effective and safe, but it has always to follow the general care aspects of any intervention procedure. The ultrasound before and after the procedure helps marking an appropriate puncture site, may enhance the effectiveness of the method and is useful to identify possible early complications. Keywords: Liver transplantation; Biopsy; Needle; Ultrasonography; Graft rejection

RESUMO Objetivo: Relatar experiência com a execução da técnica de Menghini auxiliada por ultrassom na avaliação da disfunção de enxertos

hepáticos. Métodos: A técnica de Menghini utiliza uma agulha de sucção, por via percutânea, permitindo uma punção rápida (em menos de um segundo), o que pode contribuir para diminuir a incidência de complicações. Resultados: Foram estudadas 87 biópsias realizadas com uma agulha de sucção 16 gauge em um período de um ano e três meses. Utilizou-se a ultrassonografia para avaliação da presença de líquido ou coleções peri-hepáticas, disfunções biliares e vasculares antes do procedimento, para marcação de um local seguro de punção e, finalmente, para controle pós-biópsia. A principal indicação de biópsia foi elevação de enzimas hepáticas. Em 81 casos foi colhido um fragmento e foram obtidas amostras satisfatórias em 85 procedimentos (97,7%). Complicações menores ocorreram em seis pacientes (6,9%): cinco com dor local e um com reação vagal. Houve uma complicação maior (1,1%), com hemotórax, que foi diagnosticado por controle clínico-radiológico e em seguida tratado. Conclusões: A técnica de Menghini para obtenção de tecido hepático é rápida, efetiva e segura, embora devam sempre ser respeitados os cuidados gerais de qualquer procedimento intervencionista. A ultrassonografia antes e após o procedimento auxilia na marcação do lugar mais adequado para a punção e demonstrou ser útil no aumento da eficácia do método e na identificação precoce de eventuais complicações. Descritores: Transplante de fígado; Biópsia; Biópsia por agulha; Ultra-sonografia; Rejeição de enxerto

INTRODUCTION Patients undergoing liver transplantation require a meticulous clinical, laboratory and imaging followup. This vigilance is useful to identify liver graft

Study carried out at the Department of Radiology of Hospital Israelita Albert Einstein –HIAE, São Paulo (SP), Brazil.  1

Resident of Radiology and Imaging Diagnosis of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist; Coordinator of the Ultrasonography Service at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.


MD radiologist; Head of the Radiology Service at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. 

Corresponding author: Marcel Vieira da Nóbrega – Avenida Albert Einstein, 627/701 – Departamento de Radiologia, 4o andar – Morumbi – CEP 05651-901 – São Paulo (SP), Brasil – Tel.: 11 3589-9623 – e-mail: [email protected] Received on: Aug 31, 2008 – Accepted on: Dec 5, 2008 einstein. 2009; 7(1 Pt 1):5-8


Nóbrega MV, Macedo Filho CL, Garcia RG, Maurano A, Queiroz MRG, Francisco Neto MJ, Funari MBG

dysfunctions, which can be caused by several factors including rejection, ischemia, vascular occlusions, biliary complications, drug reactions and infections. The latter can be fungal, viral and bacterial infections, opportunistic or not, and be related to viral relapse (hepatitis B or C virus). It is important that these dysfunctions are rapidly identified and their causes clarified, so that an appropriate treatment is administered for graft preservation. Vascular and biliary occlusions can often be understood through the joint analysis of clinical, laboratory and Doppler ultrasound findings (Figure 1). In other cases, histopathological examination is the main tool to clarify the cause of dysfunction(1).

Figure 1. Liver transplant complications. (A) Doppler of portal system, shows patent portal vein with preserved flow (in red), but with the hepatic artery is not identified. (B) Tomography with intravenous contrast of patient (in “A”) shows partial enhancement of hepatic artery, suggesting stenosis (arrows). (C) Ultrasound reveals dilation of the common bile duct, an indirect sign of biliary obstruction. (D) Ultrasound with Doppler demonstrates absence of flow in the portal vein on Doppler, indicating thrombosis (arrow)

There are three main techniques to obtain hepatic tissue: transjugular, percutaneous and surgical (open surgery or laparoscopic surgery)(2). Percutaneous techniques vary according to the type of needle (manual, automatic cutting, or suction) and type of orientation (blind or guided by imaging methods)(3). The main suction technique was described by Menghini, in 1958(4), and its main advantage is an important reduction of the time that the needle remains in the liver parenchyma. The time of puncture is reduced to less than a second, which can contribute to decreased incidence of complications(5). In this study, it was evaluated the ultrasoundassisted Menghini technique in the context of liver transplantation, and the safety and efficacy of the method were primarily assessed. einstein. 2009; 7(1 Pt 1):5-8

METHODS It was evaluated liver transplant patients who were referred to biopsy of the liver graft from December 2006 until March 2008. Data related to age, gender, and histopathological results were obtained from electronic records. The indication of this procedure was obtained from medical requests as well as from laboratory records. Pre-procedure ultrasound was carried out with a Phillips instrument, Envisor model, with an abdominal convex transducer of 3 to 5 MHz. Its purpose was to evaluate the presence of abdominal collections, the biliary tract and the flow in the hepatic artery; if signs of biliary tract obstruction were detected or in the absence of hepatic artery flow, the hepatic transplantation team was contacted and the procedure was suspended. Ultrasound was also used for marking the appropriate sites on the skin for puncture which should be free of great vessels and away from the movement of the diaphragmatic cupula. All biopsies were performed with suction needles Hepafix® 16 gauge, according Menghini technique (Figure 2), by a single specialized radiologist with five years of experience in interventions guided by radiological methods. Assessment of adequacy of fragments for histological study was carried out from a microscopic analysis in which the size and tissue





Figure 2. Schematic representation of the Menghini technique. (A) Needle point in the appropriate position, through the skin and subcutaneous tissue. (B) Performing pre-puncture vacuum. (C) Advancing needle in the hepatic parenchyma, under aspiration. (D) Removing the set, with hepatic fragment in the needle lumen

Evaluation of ultrasound-assisted Menghini technique in liver graft biopsy


appearance were taken into account. Adequate samples were those that measured at least approximately 2 cm and had coloration and texture suggestive of liver parenchyma. Fragments were fixed in formaldehyde and sent to histological examination. The specimen generating relevant data in the histopathological report were considered enough. Control ultrasound was performed soon after the procedure.

RESULTS A total of 87 cases were assessed, 49 (56.3%) men and 38 (43.7%) women with a mean age of 53 years (24 to 71 years old) and a mean transplantation time of 15 months (from 10 days to 72 months). The indications for biopsy were increased levels of liver enzymes (78.2%) or transplantation follow-up protocol which consists on an annual biopsy after the said transplantation (21.8%). In 93.1% of cases only one fragment was removed, with satisfactory samples being obtained in 85 (97.7%) procedures. Of the two cases considered unsatisfactory, one consisted of liver capsule tissue and the other was composed of unspecific centrolobular necrosis. The other findings obtained included reactional findings (40.2%), different grades of chronic hepatitis (40.2%), rejection (11.5%) and others (7%, including steatohepatitis, acute hepatitis C, centrolobular cholestasis and cytomegalovirus infection). Post-procedure complications were divided into minor and major ones, according to clinical repercussions on the affected patients. There were 6.9% mild complications, of which the main ones were pain at the puncture site (5.8%) and, in one case (1.1%), the patient presented hypotension which was rapidly responsive to hydration and postural changes, and it was attributed to vagal reaction. One case (1.1%) showed a severe complication characterized by progressive respiratory discomfort and decreased vesicular breath sounds in the right lower lung field. In this patient, a new ultrasound control and a chest X ray (Figure 3) were compatible with right hemothorax as per recent biopsy. The patient was transferred to a hospital unit in which he underwent chest drainage which confirmed the clinical and radiological suspect. These results are summarized in Table 1.

Figure 3. Severe complication of hepatic biopsy by Menghini technique. (A) Ultrasound after procedure showing echogenic material filling the right costophrenic sinus. (B) Corresponding finding in chest x-ray. The patient was submitted to thoracic drainage, which showed hemothorax

Table 1. Summary of results Characteristics Transplantation time (months) Age (years) Sex Indication for biopsy


DISCUSSION Despite the great development of several imaging examinations and laboratory tests, liver biopsy remains the gold standard for the diagnosis of focal hepatic lesions and diffuse liver disorders. The vast majority


Mean 15

Minimum 0.3

Maximum 72




n 49 38 68

% 56.3 43.7 78.2

19 35 35 10 7 6 1 80

21.8 40.2 40.2 11.6 8.0 6.9 1.1 92

Male Female Increased levels of liver enzymes Transplant protocol Reactional findings Chronic hepatitis Rejection Others Mild Severe Without complications

einstein. 2009; 7(1 Pt 1):5-8


Nóbrega MV, Macedo Filho CL, Garcia RG, Maurano A, Queiroz MRG, Francisco Neto MJ, Funari MBG

of procedures are performed for the study of chronic liver disorders and among those, a large number due to hepatitis B and C infection(6). Therefore, most patients undergoing liver transplantation are also victims of infection caused by this virus. In face of an episode of graft dysfunction, it is imperative to differentiate the etiology such as relapse of these infections, phenomena related to rejection, other infections (cytomegalovirus, for example), toxic and metabolic reactions, once the surgical vascular and biliary causes have been ruled out. In general, selection of the technique depends on the surgeon’s preference, availability at the service and clinical setting(3). However, there is certain agreement that cutting needles have a better diagnostic performance in diffuse liver disorders(7-8), although these studies were carried out for the diagnosis of cirrhosis. It was chosen the Menghini technique due to evidences of being effective in successfully obtaining hepatic fragments and on the trend of being considered safer than those using cutting needles(3), although some studies showed that the quality of fragments obtained by cutting needles is better(9). The safety aspect is also reinforced by some studies showing a positive correlation between the duration of needle permanence in the liver parenchyma and the number of punctures with the incidence of complications(5) and, in this sense, Menghini technique is the fastest one. The overall complication rate (6.9%), with only one case (1.1%) of a severe event (hemothorax), reinforces the method safety and that iatrogenic effects related to it are already well described, since all complications reported had already been previously reported in other studies(10). As to the quality of the material obtained, it was possible to observe that the technique associated with the simple macroscopic inspection of the fragment showed good results. Similar data were also reproduced by other groups(11). Pre- and post-procedure ultrasonography is helpful for marking the most appropriate puncture site, for providing increased method accuracy and it is important for early identification of eventual complications in addition to presenting possible contribution to decreasing the incidence of the latter(12). It is well known that the technique used in this study has a limitation regarding the acquisition of fragments of focal liver lesions since, although it is possible to mark an appropriate puncture site, the procedure per se is

einstein. 2009; 7(1 Pt 1):5-8

not guided in real time. However, this disadvantage has little effect on the studied population because the great majority of transplanted patients referred to biopsy are suspect of a diffuse graft involvement.

CONCLUSIONS Respecting the general care of any interventional procedure, the aspiration biopsy (Menghini technique) of liver grafts is fast, effective and safe. It is believed that the specific advantages of this technique, such as significant reduction (less than one second) of the time of the needle’s permanence in the liver parenchyma and less discomfort to the patient, added to the use of auxiliary ultrasound, represent an important tool to this end. REFERENCES 1. Portmann B. Liver allograft pathology and biopsy interpretation. Verh Dtsch Ges Pathol. 2004;88:29-38. 2. Amesur NB, Zajko AB. Interventional radiology in liver transplantation. Liver Transpl. 2006;12(3):330-51. 3. Sporea I, Popescu A, Sirli R. Why, who and how should perform liver biopsy in chronic liver diseases. World J Gastroenterol. 2008;14(21):3396-402. 4. Menghini G. One-second biopsy of the liver – problems of its clinical application. N Engl J Med. 1970;283(11):582-5. 5. Copel L, Sosna J, Kruskal JB, Kane RA. Ultrasound-guided percutaneous liver biopsy: indications, risks, and technique. Surg Technol Int. 2003;11: 154-60. 6. Rivera-Sanfeliz G, Kinney TB, Rose SC, Agha AK, Valji K, Miller FJ, et al. Single-pass percutaneous liver biopsy for diffuse liver disease using an automated device: experience in 154 procedures. Cardiovasc Intervent Radiol. 2005;28(5):584-8. 7. Colombo M, Del Ninno E, de Franchis R, De Fazio C, Festorazzi S, Ronchi G, et al. Ultrasound-assisted percutaneous liver biopsy: superiority of the TruCut over the Menghini needle for diagnosis of cirrhosis. Gastroenterology. 1988;95(2):487-9. 8. Vargas-Tank L, Martínez V, Jirón MI, Soto JR, Armas-Merino R. Tru-cut and Menghini needles: different yield in the histological diagnosis of liver disease. Liver. 1985;5(3):178-81. 9. Judmaier G, Prior C, Klimpfinger M, Bernklau E, Vogel W, Dietze O, et al. Is percutaneous liver biopsy using the Trucut (Travenol) needle superior to Menghini puncture? Z Gastroenterol. 1989;27(11):657-61. 10. Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol. 1986;2(2):165-73. 11. Sporea I, Popescu A, Stirli R, Danila M, Strain M. Ultrasound assisted liver biopsy for the staging of diffuse chronic hepatopathies. Rom J Gastroenterol. 2004;13(4):287-90. 12. Al Knawy B, Shiffman M. Percutaneous liver biopsy in clinical practice. Liver Int. 2007;27(9):1166-73.

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