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Surgical performance for specialties undertaking temportal artery biopsies: who should perform them?
  1. Gavin D Galloway1,
  2. Bernhard Klebe2,
  3. Paul Riordan-Eva3
  1. 1Ophthalmology Department, West Suffolk Hospital, Bury St Edmunds, IP33 3QZ, UK
  2. 2Department of Internal Medicine, Kent and Canterbury Hospital, Canterbury CT1 3NG, UK
  3. 3Department of Ophthalmology, King's College Hospital, London SE5 9RS, UK
  1. Correspondence to: Mr Gavin Galloway; gavgal{at}doctors.org.uk

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The management of temporal arteritis carries a large burden on resources and commits the patient to long term anti-inflammatory medication with its concomitant side effects. We undertook a retrospective survey of the recent surgical practice at King's College Hospital, London. This was to compare performance for the specialties involved in biopsying temporal arteries. We are unaware of any previous publication specifically addressing surgical efficiency. Biopsies of long specimens could help reduce morbidity and mortality associated with false negative results and avoid further unnecessary and expensive investigation.1–3 Information was obtained by cross referencing clinical, surgical, and histopathological records for all the temporal artery biopsies done during a 2 year period from March 1998 to March 2000. Arterial specimen length was taken as the performance indicator. Analysis of the biopsy rates for years 1 and 2 was done and then individual lengths were compared.

Results

Thirty nine patients underwent 41 biopsies, yielding an average of 19.5 per year or 1.6 per month. Of these, six were positive. This implies a 14.6% positive biopsy rate. Of the two re-biopsies, one revealed a repeat negative result and the other a positive result. The five departments performing surgery were: ophthalmology—14 biopsies (34%) from 13 patients; neurosurgery—14 biopsies (34%); maxillofacial surgery (MFS)—six biopsies (14.6%) from five patients; general surgery (GS)—five biopsies (12.2%); and vascular surgery (VS)—two biopsies (4.9%). For analysis MFS, GS, and VS are grouped together as they performed relatively few biopsies. Analysis of biopsy rates is depicted in Table 1. Overall, 14 biopsies were done in year 1, with an average length of 13.8 mm, and 27 in year 2, with an average of 13.1 mm. Regarding specimen lengths, ophthalmology averaged 15 mm in year 1 and 16.4 mm in year 2. Total average was 16.1 mm. This ranged from 5 mm to 30 mm. The 5 mm specimen was deemed too short and re-biopsy yielded a specimen of 23 mm. There were no failed biopsies. Neurosurgeons averaged 10.8 mm in year 1 and 9 mm in year 2, with a total average of 9.6 mm. Specimens ranged from no artery to 20 mm. No re-biopsy of the unsuccessful sample took place. The last group averaged 15.7 mm in year 1 with one specimen containing no artery and 13.1 mm in year 2, also with one unsuccessful procedure. Total average length was 14.3 mm with a range of no artery to 28 mm. These data are summarised in Table 2. The average across all 41 specimens was 13.3 mm. The average length of the six positive results was 16 mm with a range of 10 to 28 mm. The average length of the 35 negative results was 12.9 mm.

Table 1

Annual biopsy rates per department

Table 2

Performance indicator—average arterial length (mm)

Comment

It would appear that our ophthalmology unit is best suited to perform the majority of biopsies. They already perform one third of all biopsies and achieve the longest average length. They also re-biopsy when specimen length is inappropriately short. Our hospital supplies a relatively large neuroscience service, thus the finding that they perform 34% of biopsies may be a regional bias. The third group is not regularly performing biopsies. The biopsy rates done by ophthalmology and the neurosciences were increased in year 2. This may represent a trend that they are performing an increasing proportion of biopsies. The average length of 13.3 mm is disappointing considering the well known “skip lesion” phenomenon.4,5 One obviously would like a length as long as possible but realistically an average length of 20 mm should be sufficient. Miller also recommends 20 mm.6 In summary, we propose that the ophthalmology service should perform a larger proportion of biopsies. This would increase our diagnostic efficiency and reduce the impact that temporal arteritis has on our resources.

REFERENCES

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