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 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 339-341

EUS-guided versus percutaneous liver biopsy: Do we have a winner?

1 Department of Gastroenterology, Geisinger Medical Center, Danville PA, United States
2 Department of Gastroenterology, Centura Health, Denver CO, United States

Date of Submission23-Jun-2022
Date of Acceptance15-Aug-2022
Date of Web Publication14-Oct-2022

Correspondence Address:
David L Diehl
Geisinger Medical Center, Danville, PA
United States
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-22-00102

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How to cite this article:
Diehl DL, Confer B, Adler DG, Khara HS, Johal AS. EUS-guided versus percutaneous liver biopsy: Do we have a winner?. Endosc Ultrasound 2022;11:339-41

How to cite this URL:
Diehl DL, Confer B, Adler DG, Khara HS, Johal AS. EUS-guided versus percutaneous liver biopsy: Do we have a winner?. Endosc Ultrasound [serial online] 2022 [cited 2022 Nov 30];11:339-41. Available from: http://www.eusjournal.com/text.asp?2022/11/5/339/358627

Liver biopsy (LB) remains a valuable diagnostic procedure despite advancements in noninvasive assessment of hepatic parenchymal disease. It is likely that demand will continue to grow in the near term as the number of patients with nonalcoholic steatohepatitis continues to increase. LB was first described by Ehrlich in 1883, but the current technique of percutaneous LB can be traced to Menghini's 1958 paper with the intriguing title “One-second needle biopsy of the liver.”[1] However, even today, many percutaneous liver biopsies are done without “real-time” image guidance, and not infrequently without any image guidance at all.

In the last several years, the use of endoscopic ultrasound (EUS) guidance for LB has gained traction. The potential benefits for EUS-LB are numerous and include a more comfortable experience for the patient, the ability to do bilobar biopsies (decreasing sampling error),[2] and the availability of real-time imaging during the biopsy. Current needles and biopsy techniques provide liver cores that are comparable, or better than, samples obtained by the percutaneous or transjugular approaches in terms of standard outcome metrics regarding sample length and number of portal triads.[3] Adequacy for pathologic interpretation is nearly 100% across multiple studies.[4],[5],[6]

We would like to bring attention to a recent prospective randomized trial by Bang et al. that sought to compare percutaneous LB to EUS-guided LB.[7] The results of this study are a significant outlier in the literature, and we have several concerns with the manuscript's methodology. The authors created came up with a definition of an “optimal” LB as one being 25 mm long with >10 complete portal triads (CPTs). The meaning of “optimal” as the authors define it is unclear and without precedent in the literature. By the authors' own criteria, only 57.9% of percutaneous LBs were “optimal,” which further underscores the nebulous and misleading use of this term. Importantly, the study showed that both percutaneous and EUS-guided techniques yielded samples that could be evaluated by a pathologist in 100% of cases.

The length of what is considered an adequate LB has been something of a moving target. A highly cited reference states that a specimen length of 15 mm is adequate for diagnosis.[8] A widely cited review from the American Association for the Study of Liver Disease[9] concluded that 20 mm of tissue is adequate in length, as well as one that contains ≥10 CPTs. The 2020 multisociety British guidelines use the benchmark of 20 mm in length and more than 10 portal tracts.[10] The latest Royal College of Pathologists (RCP) guidelines also recommend LB specimens >20 mm in length.[11] Only the 2014 RCP guidelines[12] used the ≥25 mm criterion, and this was revised down to 20 mm with the latest version.

Another important limitation of the study by Bang et al. is the method utilized for sample size calculation. The author's power analysis is based on a meta-analysis,[13] which weighted use of a 19G TruCut needle, which is inferior to regular 19G needles, and is no longer used in clinical practice. Our previously published work with Franseen needles demonstrated adequate histologic yield in 78% of patients from single lobe biopsy and 100% of patients with bilobar specimens.[14],[15] If 78% adequacy was used for the power analysis, the sample size needed would be 290 patients (145 patients in each group) compared to only 40 in Bang's study. Based on this, the study is significantly underpowered.

A third concern is that the wrong technique was used for the EUS-guided needle biopsies in this study. The authors used a no suction technique, which has never been evaluated in a prospective study. In our experience, no suction yields inadequate specimens. We conducted a prospective randomized study of “dry” versus “wet” suction for EUS-LB.[16] (Wet suction involves priming the needle lumen with fluid and using suction with the vacuum syringe). Wet suction was superior (98% adequacy versus 80% for dry suction). Suction did not lead to tissue fragmentation. The no-suction needling technique used for this study likely contributed to lower percentage of “optimal” biopsies in the EUS-LB group.

The Bang et al.'s study did a cost analysis of the two methods of LB, and not surprisingly, the percutaneous method was less expensive. This is mainly due to the added cost of sedation for an endoscopic procedure. However, the cost estimates do not consider instances in which there is an indication for an endoscopy, EUS, or colonoscopy in addition to the LB. This is a common event, and cost savings would result from doing these combined procedures. In addition, many liver biopsies done by interventional radiologists utilize a transjugular or computed tomography-guided approach, which would cost more than an ultrasound-guided biopsy which was the assumption in the cost analysis. However, providing a better patient experience is increasingly important, even if there might be a higher procedure cost. A good example is propofol sedation for endoscopic procedures, such as ERCP or colonoscopy. While it is true that many of these could be done with “conscious sedation,” deeper levels of monitored sedation provide a better patient experience, allow the endoscopist to optimize the technical aspects of their procedure, and are overall safer for the patient.

EUS-LB is now widely performed around the world. Many endosonographers have embraced the EUS-LB technique and have had excellent results with an outstanding safety profile. EUS-guided LB with optimal technique can achieve outstanding histologic yields. The recent comparative study has several critical shortcomings in design and technique and cannot be relied upon for clinical decision-making.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Menghini G. One-second needle biopsy of the liver. Gastroenterology 1958;35:190-9.  Back to cited text no. 1
Khurana S, Butt W, Khara HS, et al. Bi-lobar liver biopsy via EUS enhances the assessment of disease severity in patients with non-alcoholic steatohepatitis. Hepatol Int 2019;13:323-9.  Back to cited text no. 2
Pineda JJ, Diehl DL, Miao CL, et al. EUS-guided liver biopsy provides diagnostic samples comparable with those via the percutaneous or transjugular route. Gastrointest Endosc 2016;83:360-5.  Back to cited text no. 3
Diehl DL, Johal AS, Khara HS, et al. Endoscopic ultrasound-guided liver biopsy: A multicenter experience. Endosc Int Open 2015;3:E210-5.  Back to cited text no. 4
Bazerbachi F, Vargas EJ, Matar R, et al. EUS-guided core liver biopsy sampling using a 22-gauge fork-tip needle: A prospective blinded trial for histologic and lipidomic evaluation in nonalcoholic fatty liver disease. Gastrointest Endosc 2019;90:926-32.  Back to cited text no. 5
Nieto J, Khaleel H, Challita Y, et al. EUS-guided fine-needle core liver biopsy sampling using a novel 19-gauge needle with modified 1-pass, 1 actuation wet suction technique. Gastrointest Endosc 2018;87:469-75.  Back to cited text no. 6
Bang JY, Ward TJ, Guirguis S, et al. Radiology-guided percutaneous approach is superior to EUS for performing liver biopsies. Gut 2021;70:2224-6.  Back to cited text no. 7
Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001.15;344:495-500  Back to cited text no. 8
Rockey DC, Caldwell SH, Goodman ZD, et al. Liver biopsy. Hepatology 2009;49:1017-44.  Back to cited text no. 9
Neuberger J, Patel J, Caldwell H, et al. Guidelines on the use of liver biopsy in clinical practice from the British society of gastroenterology, the royal college of radiologists and the royal college of pathology. Gut 2020;69:1382-403.  Back to cited text no. 10
Wyatt J, Hubscher S, Bellamy C, et al. Tissue Pathways for Liver Biopsies for the Investigation of Medical Disease and for Focal Lesions. The Royal College of Pathologists; 2014. Available from: https://www.rcpath.org/uploads/assets/2921c666-0f66-4272-820c16db2acaff99/32ca2ca1-cd3b-4692- a6b260aa49ddbbbe/G064-Tissue-pathways-for-liver-biopsies-for-publication.pdf. [Last accessed on 2022 Sep 28].  Back to cited text no. 11
Wyatt J, Hubscher S, Bellamy C, et al. Tissue Pathways for Liver Biopsies for the Investigation of Medical Disease and for Focal Lesions. The Royal College of Pathologists; 2014. Available from: https://citeseerx.ist.psu.edu/viewdoc/download?doi= [Last accessed on 2022 Oct 02].  Back to cited text no. 12
Mohan BP, Shakhatreh M, Garg R, et al. Efficacy and safety of EUS-guided liver biopsy: A systematic review and meta-analysis. Gastrointest Endosc 2019;89:238-46.e3.  Back to cited text no. 13
Ching-Companioni RA, Diehl DL, Johal AS, et al. 19G aspiration needle versus 19G core biopsy needle for endoscopic ultrasound-guided liver biopsy: A prospective randomized trial. Endoscopy 2019;51:1059-65.  Back to cited text no. 14
Ching-Companioni RA, Johal AS, Confer BD, et al. Single-pass 1-needle actuation versus single-pass 3-needle actuation technique for EUS-guided liver biopsy sampling: A randomized prospective trial (with video). Gastrointest Endosc 2021;94:551-8.  Back to cited text no. 15
Mok SR, Diehl DL, Johal AS, et al. A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos). Gastrointest Endosc 2018;88:919-25.  Back to cited text no. 16


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