Superior diagnostic yield of mini-laparoscopy over transjugular liver biopsy in acute-on-chronic liver failure: a case-control study

Abstract Background & Aims Hepatic failure frequently requires liver biopsy for etiologic classification and delimitation from differential diagnoses to inform treatment decisions. Both mini-laparoscopic (MB) and transjugular liver biopsy (TB) are considered safe diagnostic modalities in liver cirrhosis (LC) patients but may associate with varying success and complication rates. We aimed to characterize the clinical values of MB and TB in patients with LC and particularly acute-on chronic liver failure (ACLF), where clinical acuity and patient risk are high. Methods In this retrospective study, we analyzed 73 consecutive adult ACLF patients undergoing liver biopsy (57x ACLF-MB, 16x ACLF-TB) and performed 1:2-matching with non-ACLF LC patients for either biopsy modality to assess technical success, complications, and diagnostic versatility. Results Baseline disease severity was comparable between biopsy modalities (MELD score: ACLF-MB 27 [22–33] vs. ACLF-TB 27 [19.75–32], p = 0.640). MB and TB were successfully completed in the large majority (MB 169/171 vs. TB 48/48; p = n.s.) of procedures. While the presence of ACLF associated with a higher rate of minor complications following MB (ACLF-MB: 80.7% vs. LC-MB: 52.6%, p < 0.001), major biopsy-related complications were generally rare, and their occurrence did not differ between biopsy modalities. MB-specimens were technically evaluable in 100% of successfully performed procedures, contrasting 31.3% of technical failures in ACLF-TB and 37.5% in LC-TB (all p < 0.001), respectively. In suitable biopsies, failure to obtain a histological diagnosis was observed in 3.6% of ACLF-MB, 6.2% of ACLF-TB, 17.7% of LC-MB, and 6.2% of LC-TB cases, ultimately resulting in higher rates of established or corrected diagnoses via MB than TB. Conclusions MB provides higher diagnostic yield than TB at the cost of increased minor complication rates in ACLF. Where locally available and technically feasible, MB may be considered the preferred route of liver biopsy in end-stage chronic liver disease.