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.