Ultrasound Guided Abdominal Biopsies: Lessons Learned - Part 4

Retroperitoneal Biopsies

In terms of retroperitoneal biopsies, again, you can have the patient in the prone position, supine or decubitus.

Again, we're usually going after lymph nodes, either trying to decide whether they're mets or lymphoma or in terms of them being a primary retroperitoneal malignancy.

One would like to obviously keep out of the way of the ureter to avoid producing a oma.

Example of a Retroperitoneal Biopsy Complication

Here's an example of a very large retroperitoneal mass, which I felt would be easy to perform by doing ultrasound guidance.

So using my CT scan as a roadmap, I inserted the needle down into the lesion here, and I felt I had done a good job until the patient developed abdominal pain following the procedure.

And upon doing a CT scan because of continued pain, I found out that I had actually lacerated his pancreas and given him a extra pancreatic fluid collection, which actually required percutaneous drainage for a number of weeks.

So that obviously wasn't a very good decision to make.

I probably should have decided to actually do this biopsy using CT guidance from the back, in which case I wouldn't have caused this problem.

Peritoneal and Mesenteric Biopsies

Now, in terms of peritoneal and mesentary biopsies, again, we would put the patient in the supine position.

Usually we're going after either omental implants or lymph nodes in the mesentary.

We're actually pretty good at making this diagnosis not as good as some things, but I think a diagnosis overall of 90% would be pretty good with a minor complication rate of only 3%.

As you can see in this instance here, we have a CT scan on the left demonstrating extensive on mental caking in this patient with suspected carcinomatosis.

And then when you put your coaxial needle in, you can do a biopsy of the of the peritoneum like this.

Obviously, one would try to avoid B bowel.

I would also like to make a commentary.

When you have a ES like this, you can actually see bleeding coming from the site of biopsy, and that happens in every patient, but usually if their coagulation status is normal, you won't have any trouble.

Here's another example of a small implant, again, using your CT as a roadmap.

And this patient did have a history of lymphoma and so we were trying to prove that this was in fact a lymphoma deposit.

You can see the image on the right here shows you that this is easily graphically visible.

And then on the next slide, we inserted the needle into this an FNA into this mass and proved that it was in fact a lymphoma of the omentum.

Pelvic Biopsies

Pelvic biopsies.

Again, we're trying to make a diagnosis of tumor metastases or lymphoma.

We generally will go through the abdominal wall.

Actually, we can also put the patient prone and go through the sciatic notch if that's the best way to reach the mass.

And again, I'll be using CT to make this diagnosis.

You can also do transrectal and transvaginal biopsies.

This is just an example of a patient with lymphoma who has got some external lymph nodes that are easily seen on CT scanning.

And we're biopsied using a ultrasound approach.

And again, I tend to as I said I tend to like to use the coaxial needle.

We're getting your FNAs out of this lesion, and also we follow through with core biopsies.

Transrectal and Transvaginal Biopsies

Now, in terms of doing transrectal or transvaginal biopsies, if I'm doing a transrectal biopsy to get after a lymph node or a mass, I will generally give the patient antibiotics 24 hours before and on the day of the procedure.

In terms of doing transvaginal biopsies, you have to use probably conscious sedation 'cause these do hurt, and so therefore I tend not to do those myself and I refer them to a colleague of mine who administers conscious sedation.

In this instance here, you can see we are using a transect approach to biopsy a lymph node in a patient who had a prior resection for a rectal carcinoma, thus proving that this was in fact a metastatic lesion in this patient.

Post-Biopsy Care

Now, in terms of the post biopsy care of these patients, we generally will keep patients for at least two hours of patient monitoring in our postsurgical unit.

After two hours, they're discharged home with instructions regarding the resumption of their medications.

Especially this will be true of their anticoagulants.

We also tell them to restrict activity for at least five to seven days, and we tell them that the small nick in the skin, which we cover with a bandaid, can be left alone until the bandaid usually falls off often within in the shower.

If however, the patient after discharge develops any dizziness or severe pain, they're instructed to call us.

And in fact, we do give them a phone number to call, which is a 24 7 number.

So as we can take care of these complications ourselves, if this should occur.

Complications

Minor Complications

Now, minor complications include pain.

This is usually a self-limiting problem.

Usually it's gone within two hours.

It rarely needs pain medications.

In terms of va a vasovagal reaction, I think the fact that we tend to let our patients eat before doing our biopsies, we talk to them and reassure them throughout and that we give them a liberal amount of local anesthesia has in fact reduced the incidence of vasovagal reactions.

And I rarely now have a vasovagal reaction, whereas in the past I would have one also.

I would have one of these reactions maybe every couple of months or so.

Now it's a rare occurrence, so that's why I've gone to this way of doing biopsies anyway.

If they do develop a vasovagal reaction, I just lower the head, elevate the legs and weight, and I will give them IV fluids if needed.

And I must say, I forgot to mention this earlier on, but we do have venous access in all of our biopsy patients.

Should this complication arise.

Major Complications

Now, major complications would be obviously doing a retroperitoneal biopsy would be a oma, which might require the placement of a catheter in the ureter.

Peritonitis is a very rare complication, and in fact, I had my first case just recently when I biopsy the patient who had mesothelioma.

But it really is extremely rare.

Obviously, it's unfortunate when it does occur, and obviously one should try and avoid going through bowel, especially colon when doing these types of biopsies.

In terms of tumor seeding, I must say this is an extremely rare occurrence and thank goodness I've never had this happen in my career.

Summary

So in summary, ultrasound guided biopsies for me in the abdomen and pel are safe.

They are accurate and they're cost effect.

My recommendations are you do not need to fast a patient and you can use a liberal amount of local anesthesia and use ultrasound to make sure you cover all of the abdominal walls.

When you put the needle in, it will not hurt the patient.

I also like using a coaxing needle approach as you put the needle in once and that's it.

You don't have to put it in many times.

Also, it allows you to put a 22 gauge or a core needle through that needle and to do as many biopsies as you like without having to continually reinsert the needle.

The other thing I would advise you to do is that over time you should look at your results in terms of your accuracy rate in getting a diagnosis in these patients, because obviously if your your numbers are not up to that report in the literature, then you need to look for ways to improve your future practice.

I've talked a lot about a lot of things here, so please see the reference list and the original article that I referenced for any more details.

Thank you very much.