Hemorrhagic complications following open surgical biopsy in pediatric liver tumors: 3 cases, a review of literature and a plea for image-guided core needle biopsy

Background Histopathological confirmation remains an important component of the diagnostic workup of pediatric liver tumors. Despite the growing consensus that image-guided core needle biopsy is the least traumatic strategy, open surgical biopsy or intraoperative tumor manipulation is still performed in a selected group of patients. The potential complications associated with surgical manipulation of pediatric liver tumors may be underappreciated in current diagnostic algorithms. Methods Here, we report three consecutive cases of children referred to our tertiary pediatric liver center following severe hemorrhagic complications and requiring intensive care management after open surgical biopsy or manipulation. A narrative review of the literature regarding pediatric liver tumor biopsy was performed, focusing on indications, technical considerations, periinterventional management, and rescue management. Results All three children developed severe hemorrhagic complications following open surgical biopsy or manipulation of a liver tumor. Complications included hemorrhage and coagulopathy, which required abdominal packing, temporary abdominal wall non-closure, mechanical ventilation and intensive care treatment, sequentially leading to referral to our pediatric liver center. One child developed hemorrhagic shock with acute liver and kidney failure and required high-urgency liver transplantation for hepatoblastoma. Final diagnoses were hepatoblastoma, hepatocellular neoplasm not otherwise specified (HCN-NOS) and malignant rhabdoid tumor of the liver. Conclusion Open surgical biopsy of pediatric liver tumors should not be regarded as a minor diagnostic procedure. If feasible, biopsy should be carefully planned in a multidisciplinary setting and performed as image-guided core needle biopsy with coaxial technique, controlled pediatric anesthesia and a predefined hemorrhage rescue pathway. Avoiding open biopsy whenever feasible may significantly improve patient safety.