Endoscopy 2003; 35(12): 1079-1080
DOI: 10.1055/s-2003-44605
Letter to the Editor
© Georg Thieme Verlag Stuttgart · New York

Laparoscopy and Guided Liver Biopsy in the Diagnosis of Cirrhosis: Conventional Technique vs. Minilaparoscopy

R.  Orlando1 , F.  Lirussi1
  • 1Dept. of Medical and Surgical Sciences, University of Padua, Padua, Italy
Further Information

Publication History

Publication Date:
29 April 2004 (online)

We read with interest the paper by Helmreich-Becker et al. on the role of minilaparoscopy in the diagnosis of liver cirrhosis [1] and the excellent editorial discussing the article by Manns et al. [2]. We would like to contribute further information on this issue, based on experience with conventional laparoscopy and guided liver biopsy in a total of 1003 patients [3].

In the paper by Helmreich-Becker et al. [1], minilaparoscopy with biopsy was carried out in 226 patients with chronic liver disease. The biopsy was inadequate in 22 of the 226 patients. In a total of 204 liver biopsies, liver cirrhosis was identified macroscopically in 94 (46 %) and histologically in 68 (33 %). In addition, four of the 204 biopsies (2 %) showed histological cirrhosis in the absence of macroscopic evidence of cirrhosis. The authors concluded that minilaparoscopy combined with biopsy is a superior method for the staging of chronic liver disease. We agree with Helmreich-Becker and co-workers that a combination of the two techniques can further improve the diagnostic accuracy for cirrhosis. Moreover, minilaparoscopy is associated with a subjective impression of a lower degree of invasiveness, while providing results comparable to those of conventional laparoscopy [4] [5].

In our series, 1003 patients underwent conventional laparoscopy and hepatic biopsy under direct vision for assessment of the type and severity of chronic liver disease [3]. All laparoscopies were carried out under local anesthesia. Macroscopic diagnosis of liver cirrhosis was based on the finding of the characteristic diffuse or zonal nodules [6] [7]. A smooth, or rough irregular, or finely granular liver surface was not in itself regarded as laparoscopic evidence of cirrhosis. After macroscopic observation, all patients were submitted to hepatic biopsy under direct vision. The histological diagnosis was made in accordance with conventional criteria [8] [9]. The biopsy material was inadequate (either too small in diameter or fragmented) in 22 of the 1003 patients (2.1 %), a much lower figure than that reported by Helmreich-Becker et al. (9.7 %) [1]. Helmreich-Becker et al. noted that 15 % of the inadequate specimens derived from patients with macroscopic evidence of liver cirrhosis. We found no cases of inadequate sampling in a total of 322 patients with a nodular liver surface. This difference might relate to the technique used by Helmreich-Becker and co-workers [1], who used a 1.8-mm Silverman needle, whereas we used a Tru-Cut, which has the advantage of providing non-fragmented biopsies in patients with cirrhosis. In our series, the diagnosis of cirrhosis (with either one or both procedures positive) was made in 411 of 981 patients and was excluded in the remaining 570. On histological evaluation, 324 of the 981 patients were classified as having cirrhosis (33 %) - exactly the same percentage as observed by Helmreich-Becker [1]. Laparoscopy detected 322 cases of cirrhosis, accounting for 33.2 %, a lower figure than that observed by Helmreich-Becker et al. (46 %) [1]. The high percentage of liver cirrhosis reported in their series may be due to selection criteria leading to the inclusion mostly of patients with clinical and biochemical data suggestive of cirrhosis, as emphasized by Manns et al. [2]. Alternatively, the low rate of laparoscopic cirrhosis observed in our series may have been due to the criteria used for the diagnosis of cirrhosis, which are not yet standardized [2]. In fact, the assessment of nodularity is not always objective, either because of borderline cases or because of the presence of micronodular and macronodular cirrhosis (termed ”mixed cirrhosis”) in the same patient. Indeed, the 65 cases of histological cirrhosis associated with a granular hepatic surface in our series might correspond to the cases of micronodular cirrhosis reported by Helmreich-Becker et al. [1], thus increasing the rate of laparoscopic cirrhosis to 39.4 % (387 of 981).

Another point for discussion relates to the false-negative findings of cirrhosis detected at laparoscopy. Helmreich-Becker et al. [1] observed only four false-negative findings in 204 cases of histological cirrhosis (2 %), whereas the ”smooth cirrhosis” or ”histological cirrhosis” in our series accounted for 5.8 %, a figure that is in keeping with data reported in the literature (5 - 11 %) [3]. In our opinion, their low percentage of histological cirrhosis would suggest a low number of cases of steatosis or steatofibrosis in their series, as fatty liver is believed to ”smooth out” the nodularity of the liver surface and reduce the liver’s regenerative capacity [10].

Another way to increase the rate of macroscopic diagnosis of cirrhosis is to identify intra-abdominal signs of portal hypertension, such as splenomegaly, dilated lymphatic vessels, and microcysts on the liver surface, or the presence of large veins in the falciform ligament. It is not clear whether Helmreich-Becker et al. [1] investigated these features in their patients or looked for esophageal varices on upper gastrointestinal endoscopy. The detection of laparoscopic signs of portal hypertension is important, as they may precede the onset of macroscopic cirrhosis. Thus, laparoscopy leads to a better appreciation of smooth cirrhosis and provides a useful tool for recognizing the development of chronic hepatitis into cirrhosis at an early stage.

References

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  • 8 Anthony P P, Ishak K G, Nayak N C. et al . The morphology of cirrhosis.  J Clin Pathol. 1978;  31 395-414
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  • 10 Orlando R, Lirussi F, Muraca M. et al . Smooth liver surface may conceal cirrhosis: evidence for the late development of nodular surface of the cirrhotic liver.  Endoscopy. 1988;  20 323-325

F. Lirussi, M. D., Ph. D. 

Dept. of Medical and Surgical Sciences
University of Padua

Via Giustiniani 2
35128 Padua
Italy

Fax: +39-049-8212151

Email: flavio.lirussi@ unipd.it

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