15283-B-Blokker

60 Chapter 4 DISCUSSION This is one of few systematic reviews to analyse the accuracy of alternatives to the conventional methods of autopsy in natural deaths, and the first to focus on naturally deceased adults. Although none of the alternative methods performed as well as conventional autopsy, higher agreement and sensitivity percentages demonstrated that minimally invasive autopsy methods were more accurate than non-invasive autopsy methods, especially those including tissue biopsies. Comparison with the literature A similar systematic review has been performed by Thayyil et al., 88 who found better overall pooled sensitivity and specificity of post-mortem MRI in foetuses (69% and 95%) than in children and adults. As an alternative to conventional autopsy, however, its diagnostic accuracy was insufficient in all patient groups. Since then, more studies have been published, and the diagnostic performance of alternative methods has improved significantly, as our study shows. With the introduction of minimally invasive autopsy methods, including imaging and tissue biopsies, remarkable improvements in accuracy were achieved. Themerit of histological examination of vital organ tissue, in particular obtained under image-guidance, is also addressed in forensic studies. 115 When comparing cost, minimally invasive autopsy may be less expensive than conventional autopsy. According to the reviewed studies, a minimally invasive autopsy including both biopsies and CT-angiography costs $1649 to $1945, whereas autopsy costs $2170 to $2378. In Switzerland each autopsy is preceded by at least CT, and Flach et al. 116 recently calculated a cost of $820 to $1150 per post-mortemexamination including CT, CT-angiography, MRI, and forensic expert opinion. Even though post-mortem endoscopic methods (thoracoscopy and laparoscopy) appear to be very accurate alternatives to conventional autopsy, 112,113 we hesitate to draw conclusions. Both studies included a fairly small number of cases and did not report whether the examiners were blinded to the conventional autopsy findings. One study states that it induced selection bias by selecting cases in order to maximize the benefit of the alternative autopsy. 112 Avrahami et al. 117 support our doubts, and state that findings from an endoscopic autopsy are insufficient to establish a definite cause of death. They recommend performing endoscopic autopsy only in cases in which there are objections to conventional autopsy and in order to rule out or identify major thoracic or abdominal pathology leading to death.