Safety of 1-h discharge after percutaneous liver biopsy: A systematic review and meta-analysis

INTRODUCTION

Percutaneous liver biopsy continues to be the gold standard for diagnosing liver conditions such as hepatitis, cirrhosis, and liver malignancies.^[1] Despite advancements in non-invasive diagnostics such as elastography and imaging, liver biopsy remains clinically relevant due to its accurate histopathological results.^[2] However, its invasive nature introduces inherent risks, including bleeding, pain, and, in rare cases, bile peritonitis or pneumothorax.^[3,4]

Conventionally, patients are monitored for 4–6 h after the procedure to detect complications.^[5,6] However, increasing pressure on healthcare systems to optimize efficiency has led to growing interest in reducing post-procedural observation times without compromising patient safety.^[7] Early discharge protocols have been successfully implemented in settings such as endoscopic procedures and minor surgeries, where appropriate patient selection and post-procedural monitoring have enabled shorter recovery times.^[8] Adopting similar protocols for percutaneous liver biopsy could reduce healthcare costs, improve patient throughput, and increase patient comfort.^[2,7]

Uncertainty persists regarding the practice of early discharge, with some studies supporting the safety of 1-h discharge following liver biopsy.^[8-12] In contrast, other studies have raised concerns about potential risks, especially the likelihood of undetected complications during a shorter observation period.^[2,4] To date, no comprehensive meta-analysis has assessed the safety of 1-h discharge following percutaneous liver biopsy. This meta-analysis aims to evaluate the safety of discharging patients after 1 h, offering clinician’s evidence-based guidance on the feasibility of implementing such practices in clinical settings.

MATERIAL AND METHODS

This systematic review was conducted and reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.^[13]

RESULTS

A total of 555 studies were identified through database searches. After screening, six cohort studies met the inclusion criteria, encompassing 2,621 patients who underwent percutaneous liver biopsy with a 1-h discharge protocol [Figure 1]. These studies, which were conducted between 2002 and 2019, included both prospective and historical cohort designs.

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Figure 1:

PRISMA flow diagram showing the studies selection process.

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Patient ages ranged from 18 to 77 years, with the male-to-female ratio varying across studies. Most biopsies were performed under ultrasound guidance using 14G–18G needles, and the follow-up durations ranged from 24 h to 1 month. Patients with contraindications (e.g., severe coagulopathy, thrombocytopenia, or ascites) were excluded from the study. A detailed summary of the characteristics of these studies is provided in Table 1.

Major complications

The meta-analysis assessed the incidence of major complications across six studies, comprising 2,621 observations and 18 reported events. The pooled incidence of major complications was estimated at 0.48% (95% CI: 0.22–0.75%), with low heterogeneity (I² = 11.1%), indicating a high level of consistency across the included studies [Figure 2].

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Figure 2:

Forest plot displaying pooled incidence of major complications. (CI: Confidence Interval, IV: Inverse variance.)

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The most frequently observed major complications included bleeding and hospitalization. The highest incidence was reported by Firpi et al.^[8] (2005) (0.7%), whereas Bicknell et al.^[9] (2002) reported no major complications [Table 2].

Table 2: Complications and follow-up duration for patients undergoing 1-h discharge after percutaneous liver biopsy.

Study (Year)	Major complications	Minor complications	Follow-up duration	Main conclusion
Huang et al.[10](2015)	2 bleeding cases	None reported	11 days–1 month	A fast-track approach to biopsy optimizes
	(1%)			patient flow, reduces diagnostic delays, and is safe for selected cases.
Liane et al.[11](2019)	1 hospitalization	Pain (5.2%), vomiting	24 h–1 week	Major complications are detectable within an
	(0.2%), 3	(0.4%)		hour post-procedure, supporting a reduced
	Emergency department visits (0.6%)			observation time.
Firpi et al.[8](2005)	10 major	Not specified	24 h	A shorter, 1-h recovery after an outpatient
	complications			liver biopsy enhances efficiency without
	(0.7%)			compromising safety.
Pokorny and	1 subcapsular	Severe pain (1.2%),	1–2 weeks	Performing liver biopsy in an outpatient
Waterland[12](2002)	hematoma (0.4%)	moderate (2.4%), mild		setting with short observation is a safe option
		(21.5%)		for stable patients.
Bicknell et al.[9]	No major	Pain (62%)	2 weeks	Ultrasound-guided biopsies allow early
(2002)	complications			discharge, ensuring safety while minimizing hospital resource use.
Beddy et al.[16](2007)	1 hemorrhagic	Pain (22%), 15 required	Time not	A 1-h observation period is a viable and safe
	complication	analgesia (3%),	specified	approach for outpatient percutaneous liver
	requiring	3 observed for an		biopsies.
	admission (0.2%)	additional hour (0.6%)

DISCUSSION

This meta-analysis is the first to evaluate the safety of a 1-h discharge protocol following percutaneous liver biopsy. The pooled incidence of major complications was 0.48%, primarily involving bleeding and hospitalization, with no procedure-related deaths reported. Minor complications, such as pain or nausea, were mild, resolved within 24 h, and responded well to conservative management. In addition to safety, early discharge offers several operational benefits. It enhances procedural efficiency, reduces healthcare costs, and optimizes resource allocation – particularly in high-volume centers.

Importantly, no major complications occurred beyond the1^st h in low-risk patients, challenging the necessity of the traditional 4–6 h observation period, which was initially designed to detect delayed bleeding.^[8] A randomized controlled trial (RCT) by Nodarse- Pérez et al.^[17] found no significant difference in complication rates between patients observed for two versus 6 h.^[17] This supports our conclusion that prolonged monitoring may not be necessary for carefully selected patients, further strengthening the case for a 1-h discharge protocol.

However, the successful implementation of a 1-h discharge protocol hinges on strict patient selection criteria. Patients eligible for early discharge should not have significant comorbidities such as coagulopathy or thrombocytopenia. The biopsy procedure must be ultrasound-guided, and performed with 14G–18G needles, which have been shown to minimize procedural complications. In addition, high-risk groups – such as patients with severe liver disease or those with large lesions – should be excluded. A minimum of 1 h of observation remains essential to monitor for any immediate complications such as bleeding or pain.

While early discharge has several advantages, these benefits are only applicable when strict inclusion criteria are met. It’s important to note the considerable variability observed across the studies included in this meta-analysis. Factors such as patient demographics, biopsy techniques, and follow-up durations differed between studies. Nonetheless, all studies utilized ultrasonography – either for initial access or throughout the procedure. For example, Firpi et al.^[8] reported a higher incidence of hemothorax, a major cause of mortality, before the widespread adoption of ultrasound guidance. Post-procedure ultrasound is essential for detecting major bleeding complications early, as demonstrated by Huang et al.,^[10] who employed focused assessment with sonography for trauma (FAST-Ultra Sound) to identify ongoing hemorrhage prior to discharge. While FAST-US was effective in detecting immediate hemorrhage, it failed to detect delayed bleeding that could accumulate over time. These findings were independently confirmed by Pokorny and Waterland.^[12]

Despite its valuable insights, our study has limitations. The included studies were of moderate quality and lacked control groups, limiting the strength of the comparisons. The absence of RCTs is a key shortcoming. In addition, heterogeneity in biopsy techniques, needle sizes, and exclusion criteria may have influenced outcomes. Our study also excluded patients on antiplatelet or anticoagulant therapy, a population requiring tailored protocols. Future research should assess safety in this subgroup using standardized drug cessation protocols and strengthen evidence through diverse populations and RCT designs.

CONCLUSION

Our findings support the growing body of evidence suggesting the safety and efficiency of early discharge after percutaneous liver biopsy, particularly in patients with stable liver conditions and appropriate coagulation profiles. However, the current evidence is limited by the moderate quality of the included studies and the absence of RCTs, highlighting the need for further research to confirm the broader applicability of these findings, especially in diverse populations and healthcare settings.