Introduction

Liver biopsy (LB) remains essential for the diagnosis and staging of parenchymal liver diseases. Endoscopic ultrasound-guided LB (EUS-LB) has emerged as an attractive alternative to percutaneous and transjugular routes.

Aims & Methods

Our aim is to compare the sample adequacy of EUS-LB with percutaneous LB.
Methods: A single-centre, randomized, controlled clinical trial was designed. Patients undergoing LB were randomly assigned to EUS-LB or percutaneous LB. EUS-LB was performed with a 19-gauge Franseen core needle through transduodenal and transgastric route. Percutaneous LB was done with a 16-gauge Tru-cut needle. Main outcome was the percentage of adequate samples obtained. Secondary outcomes were the percentage of accurate histological diagnosis, number of complete portal tracts (CPT), total and longest specimen length (TSL, LSL), sample fragmentation, adverse events (AE), and patients’ satisfaction. An adequate specimen was defined as TSL≥20 mm and including ≥11 CPT.

Results

90 patients were randomized (44 to EUS-LB and 46 to percutaneous LB) and included in the analysis. Percentage of adequate tissue samples was 32.6% and 70.4% for percutaneous LB and EUS-LB respectively (p<0.001). A final histological diagnosis was provided in all cases but one. TSL was longer after EUS-LB (23.5 mm vs 17.5 mm, p=0.01), while number of CPT was similar in both groups. Sample fragmentation occurred more often after EUS-LB (p<0.001). No differences in AE were found. Satisfaction reported with both procedures was high

Conclusion

EUS-LB is safe and accurate, and may be considered as an alternative to percutaneous LB for the evaluation of parenchymal liver diseases.

Introduction

Percutaneous liver biopsy (PC-LB) is the gold standard for the study of chronic liver disease. However, it is limited to patients with appropriate clinical and hematological conditions. Transjugular liver biopsy (TJ-LB) represents a less invasive yet less available technique. Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a minimally invasive readily available technique. To the best of our knowledge, no network meta-analysis has compared LB quality and related adverse events among these techniques.

Aims & Methods

A systematic search was run in PubMed, Embase, Web of Science and Cochrane. The search included studies from inception to November 2023, in adult patients, which compared at least two of the following techniques: EUS-LB, PC-LB or TJ-LB. The analyzed endpoints were mean total sample length (TSL), mean number of complete portal triads (CPT), rate of appropriate sample for diagnosis, sample fragmentation and major adverse events (hematomas, bleeding, perforation, death). There was no distinction regarding study design, biopsy needle type or assistance with additional imaging methods. The studies with insufficient data, without any reported endpoint, or case series were excluded. The PC-LB was the reference. Data was analyzed in Rv4.0.

Results

Over the last thirty years (1993 to 2023), 21 original studies were analyzed being: 18/21 full manuscripts; 15/21 retrospective, 3/21 prospective, 3/21 randomized clinical trials (RCT); 11/21 EUS-LB, 21/21 PC-LB and 16/21 TJ-LB; 5/21 EUS-LB vs PC-LB, 10/21 PC-LB vs TJ-LB, and 6/21 compared the three techniques. We scrutinized 620 EUS-LB patients, 3347 PC-LB, and 1901 TJ-LB. TSL pooled mean for EUS-LB, PC-LB, and TJ-LB was 28.6 ± 10.6 mm, 23.3 ± 13.5 mm, and 15.7 ± 9.0 mm, respectively. Pooled rate of appropriate sample for diagnosis was 96.6%, 89.2%, and 85.4%, with a major adverse events pooled rate of 4%, 2.9%, and 3.5%, respectively. Between 14 studies and 24 pairwise comparisons, TSL EUS-LB mean was 0.17 mm longer (p=.932), but TJ-LB 4.93 mm shorter (p=.0025) (I²=95%). Between 3 studies and 5 pairwise comparisons, relative risk (RR) of sample fragmentation was significantly higher for EUS-LB (RR 4.55; 95% CI 2.72 – 7.61; p<.001) and TJ-LB (RR 2.72; 95% CI 1.54 - 4.80; p<.001) (I²=0%). There was not significant difference among mean number of CPT (I²=97.3%), rate of appropriate sample for diagnosis (I²=48.7%) or major adverse events (I²=10.5%).

Conclusion

EUS-LB quality is comparable to PC-LB and superior to TJ-LB in terms of TSL. These techniques are comparable in terms of the mean number of CPT, rate of appropriate sample for diagnosis, and major adverse events. Further original studies are needed to define the sample fragmentation rate of the aforementioned.

References

McCarty TR, Bazarbashi AN, Njei B, Ryou M, Aslanian HR, Muniraj T. Endoscopic Ultrasound-Guided, Percutaneous, and Transjugular Liver Biopsy: A Comparative Systematic Review and Meta-Analysis. Clin Endosc. 2020 Sep;53(5):583-593. doi: 10.5946/ce.2019.211. Epub 2020 Sep 29. PMID: 33027584; PMCID: PMC7548145.
Chandan S, Deliwala S, Khan SR, Mohan BP, Dhindsa BS, Bapaye J, Goyal H, Kassab LL, Kamal F, Sayles HR, Kochhar GS, Adler DG. EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes. Endosc Ultrasound. 2023 Mar-Apr;12(2):171-180. doi: 10.4103/EUS-D-21-00268. PMID: 36204798; PMCID: PMC10237604.

Introduction

Liver biopsy is a crucial diagnostic procedure for assessing hepatic pathologies, providing valuable insights into the etiology, severity, and prognosis of liver diseases. In recent years, Endoscopic Ultrasound-Guided Liver Biopsy (EUS-LB) using 22G- fine needle biopsy ( FNB) needle has emerged as a promising alternative, leveraging the superior imaging capabilities of endoscopic ultrasound (EUS) to guide biopsy with increased precision and safety. The 22G- FNB needle features a crown tip with three symmetrical cutting edges that enable swift core tissue procurement for histological analysis. The 22G- FNB needle provide greater than 95% tissue adequacy and an excellent diagnostic accuracy.

Aims & Methods

The aim of our study is to evaluate the diagnostic utility and safety of a 22G-FNB needle using the slow -pull technique for EUS-LB of parenchymal and focal liver lesions.
We performed a retrospective analysis of prospective data basefrom January 2021 to March 2024. Each patient underwent anendoscopic ultrasound by using linear scope (Fujifilm EG-580UT) and fine needle biopsy using 22G - tip needle with the slow-pull aspiration technique:

• For 33 patients we used a 22G Trident™ - tip FNB needle (Micro-Tech Endoscopy);
• For 26 patients we used a 22G Acquire- tip FNB needle (Boston Scientific Corp.);
  
• For 4 patients we used a 22G SonoTip Top Gain - tip FNB needle ( MediGlobe);

Results

We identified 63 patients who underwent EUS-LB of the liver during the study period(28 men and 35 women): 47 (74.6%)of them were with malignant and 16 (25.4%)–with benign disease. The medium age of the patients was 56.9 years. The specimen was considered adequate in all 63 patients.
We classified the EUS-FNB of liver diseases into EUS-FNB of parenchymal and focal liver lesions.

• EUS-FNB of parenchymal liver disease were performed to 13 (20.6%) of the patients: cirrhosis was found in 2 (3.17%), nonalcoholic fatty liver disease – in 5 (7.9%) and cholestasis in 6 (9.5%).
• We performed EUS-FNB of focal liver lesions in 50 ( 79.36%) of the patients.
  
  • Metastasis were found in 39 (61,9%): pancreatic ductal adenocarcinoma was detected in 27 (42.8%), pancreatic acinar cell carcinoma – in 1 (1.58%), pancreatic neuroendocrine carcinoma – in 5 (7.9%), lung adenocarcinoma – in 3 (4.7%), ductal adenocarcinoma of breast – in 2 (3.17%) , colorectal adenocarcinoma – in 1 (1.58%) and Ewing sarcoma – in 1 (1.58%).
  • Primary liver cancer - hepatocellular cancer was diagnosed in 4 (6.34%) patients.
    
  • Cholangiocarcinoma was found in 3 (4.7%) patients.
  • There were 3 (4.7%) patients with negative histology for tumor cells in the specimen: in 2 (3.17%) cases liver abscess was proved and 1 (1.58%) hepatic cyst.
    

Conclusion

Our study illustrates that ЕUS-guided liver biopsy using a 22 G- FNB needle provides adequate specimen for histologic analysis, lesser postprocedural recovery time and it is a safe, highly effective alternative to other methods of liver biopsy. The use of real time imaging guidance with doppler also helps to reduce the adverse events.

Introduction

Recent developments in endoscopic ultrasound (EUS) have proven the effectiveness of endoscopic methods for performing liver biopsies, but there is still scarce and conflicting evidence on the comparison between EUS and percutaneous (PC)-guided liver biopsy (LB).

Aims & Methods

The aim of this study was to compare the routine method and analysis of PC-LB samples against the newly introduced EUS-LB in a series of patients with parenchymal liver lesions in a tertiary hospital between 2022-2024. EUS-LB was performed with a 19-gauge core biopsy needle (Acquire, Boston Scientific) via one pass/three actuation, wet suction technique in Propofol sedation. These samples were analyzed by a dedicated liver pathologist. PC-LB procedures were performed using a 16-gauge Menghini needle via one pass without sedation. Samples from the PC-LB group were analyzed by a non-dedicated liver pathologist. The primary outcome was diagnostic adequacy rate. The secondary outcomes were sample adequacy (assessed based on total specimen length (TSL), number of complete portal tracts (CPTs)), and adverse events. Data were retrospectively assessed by reviewing the hospital information system data.

Results

The study included 56 patients, 35 in the PC-LB group and 21 in the EUS-LB group. The median age of the patients at the time of liver biopsy was 52 years, 55% were female. Predominant diagnoses were nonalcoholic fatty liver disease (25%), primary biliary cholangitis (18%) and autoimmune hepatitis (18%). The rate of establishing histological diagnosis was significantly higher in the EUS-LB group (100% vs. 77%; p=0.019). Adequate biopsy rate (according to European Association for the Study of Liver Disease criteria) and optimal biopsy rate (according to American Association for the Study of Liver Diseases criteria) were 100% and 90.5% in the EUS-LB group vs. 68.6% and 40% in the PC-LB group, crossing the significance threshold (p=0.004 and p=0.0002, respectively). The median number of CPTs was significantly greater in the EUS-LB group, with a median of 35 CPTs (IQR 22-47) compared to 11 CPTs (IQR 8-14) in the PC-LB group (p<<0.05). Among all participants in this study, patients whose histological diagnosis was not established had a lower median number of CPTs, with 10 (5-18), compared to 14 (10-29) for those who were diagnosed. However, this difference was not statistically significant (p=0.11). Both methods had similar safety profiles regarding post-procedural bleeding, which was clinically non-significant (one patient in each group). Additionally, fewer patients in the EUS-LB group required postprocedural analgesics compared to the PC-LB group (5% vs. 26%; p=0.07).

Conclusion

EUS-LB can reliably provide samples suitable for a histopathologic diagnosis in patients with parenchymal liver disease. In our setting EUS-LB proved to be superior to PC-LB in terms of diagnostic yield, tissue adequacy, and occurrence of minor adverse events, respecting the fact that EUS-LB samples were analyzed by a dedicated pathologist. As such, the method was easily incorporated into the workflow of our endoscopy unit.

Introduction

Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for hepatic solid lesions has emerged as a safe technique to obtain an adequate liver tissue for diagnosis of parenchymal liver disease. However, the optimal FNB techniques have not been evaluated. Out study aimed to compare the diagnostic yield and specimen adequacy for EUS-FNB in hepatic solid lesions using different FNB techniques.

Aims & Methods

This is a single center retrospective study of EUS-FNB for hepatic solid lesions between Mar. 2015 and Jun. 2022. Each one needle pass of suction and slow-pull suction was applied for the same hepatic lesions and the sequence was randomly assigned. The primary outcomes were diagnostic yield to attain a histological diagnosis and rate of adequate specimen acquisition.

Results

A total of 119 patients (40 female, median age 70 years) underwent EUS-FNB for hepatic solid lesions. The mean size of hepatic solid lesion was 34.9+27.3 mm (range 7-150). Solid live lesions were located at S1 in 5 (4.2%), S2/3 in 97 (81.5%), S4 in 13 (10.9%), and S5/6/7/8 in 4 (3.3%). Needle puncture was approached at esophagus in 5 (4.2%), stomach in 108 (90.8%), and duodenum in 6 (5.0%). The use of needle was 20G ProCore in 44 (37.0%) and 22G in 75 (63.0%). The final diagnosis of solid liver lesions was benign in 3 (2.5%) and malignancy in 116 (97.5%) including cholangiocarcinoma (49, 41.2%), metastasis (63, 52.9%), hepatocellular carcinoma (2, 1.7%), and lymphoma (2, 1.7%). The overall diagnostic yield to obtain a tissue diagnosis was 90.8%. There was statistically no difference in diagnostic accuracy between suction and slow-pull suction (79.8% vs. 84.9%, P=0.308). Slow-pull suction obtained more adequate specimen comparing to suction (95.0% vs. 87.4%, P=0.040).

Table 1. Comparison of specimen adequacy and diagnostic performances according to EUS-FNB techniques

Conclusion

The use of slow-pull suction EUS-FNB demonstrated improved specimen adequacy compared with suction technique with no difference in diagnostic accuracy.

References

Madhok, I. K., et al. (2022). "Endoscopic Ultrasound-Guided Liver Biopsy." Clin Liver Dis 26(1): 127-138.
Gheorghiu, M., et al. (2022). "Endoscopic Ultrasound-Guided Fine-Needle Biopsy versus Fine-Needle Aspiration in the Diagnosis of Focal Liver Lesions: Prospective Head-to-Head Comparison." Diagnostics (Basel) 12(9).

Introduction

Despite the increasing diffusion of non-invasive tests for the diagnosis of liver diseases, histological assessment through liver biopsy (LB) is still often mandatory especially in unclear cases. Actually, percutaneous approach (PC-LB) is the gold standard. Nowadays, endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as an established method to achieve liver tissue sampling. EUS-LB has several advantages such as: sampling of both liver lobes, it allows to obtain liver tissue sampling in case of ascites and toavoid damage to nearby organs and vessels.

Aims & Methods

e performed a systematic review with meta-analysis (MA) to evaluate the diagnostic outcomes and safety for liver tissue acquisition of PC-LB and EUS-LB in patients with liver diseases and focal liver lesions. Studies that compare diagnostic outcomes of PC-LB and EUS-LB were identified through literature search usign MEDLINE, Embase and Scopus until January 2024. MA was performed according to a frequentist approach.

Results

Overall, diagnostic adequacy was 94 % (CI 95%, 0.91-0.98, I² = 83.92 %, P < 0.001) for EUS-LB, while 96 % (CI 95%, 0.93-0.99, I² = 91.58 %, P < 0.001) for PC-LB. Moreover, based on eight studies comparison between the two procedures showed an OR 1.89 (95% CI, 0.44 – 8.12, I² = 62.33 %, P=0.003) when comparing PC-LB to EUS-LB. Based on four studies, pooled accuracy was OR 2.45 (95% CI, 0.38 – 15.97, I² = 49.74 %, P=0.0114) when comparing PC-LB to EUS-LB. Regarding safety, based on nine studies, pooled rate of overall adverse events was slightly higher in PC-LB compared to EUS-LB, OR: 1.25 (CI 95%, 0.51 – 3.09 I² = 26.13 %, P=0.212). Technical success for EUS-LB was 99 % (CI 95%, 0.99 - 1.00, I² = 0 %, P = 0.973) while 100 % (CI 95%, 0.99-1.00, I² = 0 %, P =0.973) for PC-LB, with an OR 1.11 (95% CI, 0.26-4.70, I² = 0 %, P=0.988) when comparing PC-LB to EUS-LB. Overall no differences between the two procedures were observed I term of total length specimen with a standardized mean difference of 0.89 (95% CI, -0.87 – 2.64, I² = 98.95 %, P < 0.001) and in term of complete portal tract with a standardized mean difference of 0.50 (95% CI, -0.55 – 1.55, I² = 97.42 %, P < 0.001).

Conclusion

In conclusion, our meta-analysis does not show significant differences between PC-LB and EUS-LB in terms of diagnostic outcomes, albeit EUS-LB is slightly safer than PC-LB.

Introduction

Despite the introduction into clinical practice of serological neoplastic biomarkers and typical radiological characteristics, useful for the differential diagnosis of focal liver lesions, liver biopsy (LB) is still often necessary, especially in unclear cases, to achieve histological diagnosis. Nowadays, LB via percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonograpy (US) guidance, is the route of choice. However, there are focal liver lesions that are poorly reachable via percutaneous approach. In these cases endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) may be represents an attractive minimally invasive alternative.

Aims & Methods

Aim of this retrospective observational study was to evaluate the efficacy, diagnostic performances and safety of EUS-FNB of focal liver lesions. The indication to perform EUS-LB was the presence of a focal liver lesion poorly accessible via a percutaneous approach or incidentally found during an EUS examination

Results

58 patients were included, 43 patients had a final diagnosis of malignancy. The localization of lesions was 72.4 % (42 cases) in the left lobe and 27.6 % (16 cases) in the right lobe. The focal liver lesions localizations were summarized in Table 2. The median number of needle passes was 2 (IQR: 3–4). Only in 3 cases (5 %) the specimen was suboptimal for histological evaluation and in all of these, the focal liver lesions were located in right lobe. The overall sensitivity and specificity were 95% and 100% respectively while overall adequacy and accuracy were 95 % and 96% respectively. Subgroup analysis, conducted for different gauge FNB needles used, showed different diagnostic yeld. In particular, adequacy and accuracy for 19-gauge FNB needle were 100% and 95%, adequacy and accuracy were both 100 % for 20-gauge FNB needle and were 90% and 96% for 22-gauge FNB needle. Of note, all three inadequate biopsies were performed with a 22-gauge needle. On the other hand, subgroup analysis for different FNB needle type used, showed adequacy and accuracy of 94 % and 95% respectively for Acquire needle (Boston Scientific, Natick, MA, United States) and, adequacy and accuracy of both 100% for ProCore needle (Cook Medical Inc., Winston-Salem, North Carolina, United States). Technical success was 100% both for right and left liver lobe. Adequacy for focal liver lesion located in left and right lobe was 100 % and 81.2 % respectively and the difference was statistically significant [p= 0.001]. We also compared the diagnostic yield of EUS‑LB between the right lobe and left lobe mass. Median size of lesions on EUS and median number of needle passes did not differ significantly between the left and right lobes. Sensitivity for lesions located in left liver lobe and right liver lobe were 96 % and 91% respectively [p=0.001]. Specificity was 100% for lesions located in left and right liver lobe. Predictive positive value (PPV) was 100% for lesions located in both liver lobe. Predictive negative value (PPV) for lesions located in left liver lobe and right liver lobe were 90% and 50% respectively [p= 0.001]. No intra/postprocedural adverse events were recorded according to AGREE classification.

Conclusion

EUS-guided focal liver lesions biopsy using FNB is effective in achieving accurate diagnosis with an excellent safety profile. The main indication for EUS-FNB of focal liver lesions could be to obtain a specimen from the lesions located in the left liver lobe, close to big vessels or in obese patients which are more difficult to obtain by other techniques.