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Editor,—We wish to comment on the paper by Shahet al (
) and subsequent correspondence (
) from Aspinall.
The case for the superior safety of ultrasound guided liver biopsy has not yet been proved and the British Society of Gastroenterology Guidelines (1999) do not advocate this as routine best practice. Perforation of the gall bladder is a very rare complication (eight times in 68 276 biopsies in the series reported by Piccinino and colleagues1) and one of us has seen the records of a case in which the gall bladder was punctured at liver biopsy done under real time ultrasound guidance. No technique is entirely safe. Until such time as the evidence clearly supports a change in standard practice, a bid for legal redress by patients who suffer a complication of “blind” liver biopsy is unlikely to succeed, assuming that the indication for the biopsy was sound, the usual precautions were observed, that detailed informed consent was obtained setting out the nature of the risks and their frequency, and that the operator had sufficient experience or supervision.
Editor,—We agree with Dr Murray-Lyon and Mr de Wilde that patients should be properly informed about how a procedure is performed, the complications and risks, as well as alternatives. It is in this area of alternatives that many “prudent patients” will choose to have an ultrasound guided biopsy. In the era of the Bristol Enquiry into deaths associated with cardiac surgery, any “reasonable doctor” can do no less.
It is important that members of the medical and legal profession appreciate the difference between an “act of god” and an “accident”. Everybody appreciates that complications arising from these procedures are not deliberate. Settlements for “acts of god” are unlikely to be successful whereas “accidents” (be it car, train, or medical) are considered appropriate to seek recompense if they could have potentially been avoided or the risks reduced.
We agree that death and/or gall bladder perforation is rare following liver biopsy. This does not remove the requirement however for best practice with the lowest possible risk to the patient. In layman's terms, Lindor et al reported a twofold higher risk of bleeding using the “blind” approach with the probability of this occurring by chance being one in 14.1-1We very much hope that practitioners such as Dr Murray-Lyon are advising their patients of figures such as these as part of their consent procedure so that the patient can make an informed decision as to which method they opt for.
An additional point of our original article, which has not been alluded to by Dr Murray-Lyon and Mr de Wilde, is that many centres no longer use the “blind approach”. The training available for registrars to become proficient in this approach is therefore declining. As stated in previous correspondence, the culture of “see one, do one, teach one” is no longer acceptable.
It is unfortunate that this discussion is unlikely to be settled until a legal action takes place. The scenario is becoming clearer: a civil court action (where most likely probability is the burden of proof) with a patient who has suffered a complication following a “blind” procedure. The case will be decided on the perceived competence and training of the doctor involved and on the details of the information provided to the patient and the consent obtained. What is clear however is that the unfortunate patient is unlikely to be a gastroenterologist or radiologist as, of the numerous colleagues we have asked, not a single one has opted for the blind approach if both were available.