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Editor,—As a gastroenterologist/hepatologist, I appreciate the anxiety expressed by Shah et al(Gut1999;45:628–629) about having to surrender liver biopsy samples to radiologists as a result of reduced training opportunities. The desire of an overwhelming number of gastroenterology trainees to become proficient in ultrasound techniques1should send a loud and clear message to the relevant regulatory training bodies. Once ultrasound has been introduced into gastroenterology training programmes in the United Kingdom, such as in Europe2 or the USA,3 the questions raised by Shah et al would have been partially solved, albeit indirectly.
The purpose of ultrasound guidance in liver biopsy is threefold: (i) to target the liver, (ii) to target the lesion, and (iii) to avoid the gall bladder.4 In this day and age, it would be unthinkable to perform a blind liver biopsy on a patient who has a discrete liver lesion. However when it comes to diffuse or generalised disease, “X marks the spot” or ultrasound assisted technique should suffice. Although the liver is a large and superficial organ, targeting it, even for diffuse or generalised disease, should not be left completely to chance. In the ultrasound assisted technique, the procedural aspect of liver biopsy is essentially blind subsequent to the initial ultrasound to mark the spot. Therefore becoming proficient in this technique would prevent loss of expertise in the blind approach, and yet the medicolegal position remains sound.
Inadvertent biopsy of the gall bladder can be minimised by allowing the patient to have a light breakfast, as the gall bladder becomes contracted following a meal.4 However, the more cautious would prefer patients to be fasted, in case they develop a complication requiring operative intervention.
Editor,—Dr Chuah makes some valuable points about the problems of training in gastroenterology in relation to ultrasound. One of the key messages of our article was to differentiate the “X marks the spot” ultrasound technique from the real time ultrasound guided method, which is in standard use within our hospitals. Using this technique, the needle is continuously visualised throughout its time within the liver and therefore there is minimal risk of biopsy of gall bladder or intrahepatic vessels. We consider this to be the safest technique to use but it is also the most difficult method in which to become proficient. Most training schemes for specialist registrars in gastroenterology will have difficulty in accommodating the additional time required to learn this technique.
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