Adequacy of endoscopic ultrasound core needle biopsy specimen of nonmalignant hepatic parenchymal disease

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion

In patients with liver tumors, the histopathology examination can assist in diagnosis, staging, prognosis, and therapeutic management strategy. Endoscopic ultrasound (EUS)-guided tissue acquisition using fine needle aspiration (FNA) or more newly fine needle biopsy (FNB) is a well-developed technique in order to evaluate and differentiate the liver masses. The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination. Therefore, malignant tumors such as hepatocarcinoma, cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma, focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition. EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA. Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously, ultrasound, computer tomography or transjugulary-guided liver biopsies. This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples. The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented. The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis, especially for those who require endoscopy.

Distinct ways to perform a liver biopsy: The core technique setups and updated understanding of these modalities

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

Endoscopic ultrasound-guided liver biopsy using a single-pass, slow-pull technique with a 19-G Franseen tip fine-needle biopsy needle: A prospective study

BACKGROUND AND AIMS

Endoscopic ultrasound-guided liver biopsy (EUS-LB) is considered to be safe and effective. Commonly a 19-G fine-needle aspiration or biopsy needle is used. But, the results vary with different techniques that are used. Herein, we report the results of liver biopsy with a single-pass, three actuations (1:3) using the slow-pull technique.

METHODS

In this prospective study, 50 consecutive patients with indications for liver biopsy underwent EUS-LB with a 19-gauge fine-needle biopsy (FNB) needle from both right and left lobes. The primary outcome was the adequacy of the specimen for histological diagnosis. Total specimen length (TSL), longest specimen length (LSL), complete portal tracts (CPTs) and comparison of these outcomes between the left lobe and right lobe specimens were secondary outcomes. Adverse events (AEs) were also measured during this study.

RESULTS

Adequate tissue for histological diagnosis was obtained in all 50 patients (100%). The median number of CPTs was 32.5 (range, 11-58), while the median of TSL was 58 mm (range, 35-190) and the median LSL was 15 mm (range, 5-40). There was no significant difference in CPTs, TSL and LSL between left and right lobe biopsies. There was no major complication; one of the patients (2%) had bleed from the duodenal puncture site, which was managed endoscopically without the need for blood transfusion.

CONCLUSIONS

Endoscopic ultrasound-guided liver biopsy using a 19-gauge Franseen tip needle with a single pass, three actuation (1:3) and slow-pull technique provides adequate tissue yield and has a good safety profile.

Diagnostic and interventional EUS in hepatology: An updated review

EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.

Update on endoscopic ultrasound-guided liver biopsy

Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a minimally-invasive alternative to the traditional (percutaneous or transjugular) liver biopsy techniques for the diagnosis of liver parenchymal diseases. Po-tentially, EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure. Additionally, EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy. Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield, increased acquisition of complete portal tracts, and longer specimen length as compared to the traditional approaches. EUS-LB is associated with lesser post-procedural pain and shorter recovery time, while providing lower risk of complications when compared to traditional liver biopsy. Innovations in needle types, needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique. This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB, and compares EUS-LB with traditional methods of liver biopsy.

Role of endoscopic ultrasound-guided liver biopsy: a meta-analysis

BACKGROUND

Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an evolving technique. In this meta-analysis, we aimed to evaluate the value of EUS-LB for parenchymal and focal liver lesions. Besides, we aimed to assess the influences of needle-related factors on the performance of EUS-LB. Additionally, we aimed to assess the influence of various criteria on specimen adequacy.

METHODS

We searched the PubMed, Embase, Cochrane Library databases up to 10 October 2021. The primary outcome was diagnostic yield, specimen adequacy, qualified specimens evaluated by rapid on-site evaluation (ROSE). The secondary outcome was adverse events. Subgroup analyses were based on needle type, needle size, fine-needle biopsy (FNB) needle type. A sensitivity analysis was conducted on specimen adequacy based on two definition criteria.

RESULTS

In total, 33 studies were included. Pooled rates of diagnostic yield, specimen adequacy, qualified specimen by ROSE, adverse events were 95%, 84%, 93%, 3%. Subgroup analyses showed that Acquire needles generated higher diagnostic yield than SharkCore needles (99% vs. 88%, p = .047). Additionally, FNB needles demonstrated a higher rate of adverse events than FNA needles (6% vs. 1%, p = .028). Sensitivity analysis on specimen adequacy based on various criteria demonstrated that the specimen adequacy rate defined by the AASLD criterion was lower than that of the commonly-used criterion (37% vs. 84%, p = .001).

CONCLUSION

EUS-LB is effective and safe for liver biopsy. Acquire needles provide better specimens than SharkCore needles. FNB needles may increase the risk of adverse events compared with FNA needles. The AASLD criterion is harder to achieve than the commonly-used criterion.

Endoscopic Ultrasound-Guided Liver Biopsy

Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a safe and effective alternative to percutaneous and trans-jugular approaches for hepatic tissue acquisition. It has shown superior diagnostic yield for the targeted approach of focal lesions, less sampling variability, improved patient comfort, and safety profile. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. In this review, we provide an update on the recent evidence of EUS-LB for the evaluation of liver disease.

EUS-guided fine-needle liver biopsy in pediatric patients using a modified technique with one-pass, one-actuation wet suction

BACKGROUND AND AIMS

Liver biopsy (LB) can be a valuable tool to determine the etiology of pediatric liver disease. There is limited data of the role of EUS-LB in children. We have evaluated the efficacy and the safety of a modified technique (M)LB in high risk or obese children. Additionally, we aimed to compare the tissue yield of EUS-(M)LB and percutaneous (PC) approach.

METHODS

A retrospective analysis comparing EUS-(M)LB and PC-LB in children at a tertiary referral center. All consecutive children referred for PC-LB and EUS-LB who had an unexplained liver test abnormality after exclusion of biliary disorders from march-2017 to August-2018 were included. EUS-(M)LB consists of a one pass wet suction technique using a 19-gauche core needle. Comparison between total specimen length (TSL) and number of complete portal triads (CPTs) between the groups were performed.

RESULTS

There were 28 EUS-(M)LB and 28 PC-LB pediatric cases. The median (IQR) age was 14.5 years (13.4-16). The median TSL was 8.6 (5.8-9.6) in EUS-(M)LB cases and 7 cm (7-9) in PC-LB cases (P =0.788). The maximum intact specimen was 2.8 cm (EUS-(M)LB) and 1.6 cm (PC-LB) (P =0.009). The mean (SD) number of CPTs per sample was 28.2 (7.3) and 11.6 (2.1), respectively (P =0.001). Adverse events included once case of self-limited abdominal pain in the PC-LB group.

CONCLUSION

EUS-(M)LB has the potential to be a safe and effective alternative diagnostic modality, at when compared to PC-LB, to evaluate children with unexplained liver test abnormalities who undergo EUS to evaluate biliary disorders.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of "Endo-hepatology" encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

Comparison of Two Specialized Histology Needles for Endoscopic Ultrasound (EUS)-Guided Liver Biopsy: A Pilot Study

BACKGROUND

EUS-guided liver biopsy (EUS-LB) has been shown to be a safe and effective alternative to percutaneous liver biopsy. The optimal needle device and technique for EUS-LB is still evolving. The aim of this study was to compare the efficacy of two second-generation 19G fine-needle biopsy (FNB) (Franseen- and Fork-tip) devices for EUS-LB.

METHODS

This is a repeated-measure crossover study with a prospectively maintained cohort of patients. We performed EUS-LB with a one-pass and single-actuation method using two 19G FNB needles in 22 consecutive patients between 10/2018 and 9/2019. Patients were randomized to left vs right liver lobes to be biopsied as well as the needle sequence. The specimens obtained were evaluated for adequacy for histologic diagnosis. The primary outcome was number of complete portal tracts (CPTs), post-fix aggregate, and longest specimen length. Secondary outcomes were prefix aggregate specimen length and the specimen adequacy judged by two expert pathologists.

RESULTS

A total of 44 liver biopsies were performed in 22 patients. The CPTs were higher in the Franseen-tip needle group compared to the Fork-tip needle group (14.4 vs 9.5, p = 0.043). Post-fix aggregate specimen length (44.9 mm vs 34.6 mm, p = 0.097), the post-fix longest specimen length (19.9 mm vs 13.7 mm, p = 0.175), and prefix aggregate specimen length (51.7 mm vs 45 mm, p = 0.265) were not significantly different. Both needles showed similarly high histologic adequacy (100% vs 95.5%, p = 0.312). Interestingly, the right of the liver showed higher yield of CPTs with both needles (Franseen, 16.2 vs. 12.8, p = 0.003, the Fork-tip, 12.8 vs. 7.0, p < 0.0001).

CONCLUSION

EUS-guided liver biopsy using the 19G Franseen-tip needle may provide more CPTs than 19G Fork-tip needle on a single-pass, single-actuation comparison.

Endoscopic Ultrasound-Guided Fine Needle Aspiration Using a 22-G Needle for Hepatic Lesions: Single-Center Experience

BACKGROUND/AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been accepted as a reliable tool in diagnosing and staging intra-abdominal tumors. In this study, we aimed to investigate the performance of EUS-FNA in the evaluation of liver masses and its impact on patient management and procedure-related complications retrospectively.

METHODS

Data of patients who underwent EUS-FNA biopsies due to liver masses between November 2017 and July 2018 were retrieved retrospectively. Biopsies were performed using 22-G needles. The demographics, EUS-FNA results, sensitivity and specificity of the procedure, negative predictive value, positive predictive value, and specimen sufficiency rates were assessed.

RESULTS

A total of 25 patients (10 females) were included in the study. The mean age was 62.73±15.2 years. The mean size of the masses was 34.50±16.04 mm. The technical success rate was 88%. During the EUS-FNA procedure, each patient had only one pass with 94.45% of aspirate sufficiency rate and 86.3% of biopsy sufficiency rate. The diagnostic accuracy rate was 86.3%. There were no complications.

CONCLUSION

For the evaluation of liver masses, EUS-FNA using a 22-G needle with even one pass had high aspiration and biopsy success rates accompanied with high diagnostic accuracy rates.

A Comparative Study of 22G versus 19G Needles for EUS-Guided Biopsies for Parenchymal Liver Disease: Are Thinner Needles Better?

BACKGROUND AND AIMS

Data on comparative efficacy of various available endoscopic ultrasound-guided liver biopsy (EUS-LB) needles are limited. We sought to compare the performance of a novel Franseen-tip 22G fine-needle biopsy (FNB) device to that of 19G needle platforms for liver parenchyma.

METHODS

Consecutive patients referred for EUS and suspected to have hepatic parenchymal disease underwent EUS-LB using different EUS needles and were included in this retrospective study. Two blinded expert liver pathologists independently reviewed and reported on: total number of tissue fragments, length of longest fragment, number of complete and incomplete portal tracts (CPT and IPT), and specimen adequacy.

RESULTS

A 22G Franseen-tip needle (A) was used in 30 patients; 19G Tru-Cut needle (B) in 50 patients; 19G reverse beveled non-Tru-Cut needle (C) in 27 patients; and a 19G flexible non-Tru-Cut needle (D) in 28 patients. In the order of needles, A, B, C and D,  > 10 tissue fragments were obtained in 100%, 6%, 82%, and 96% samples, the mean number of CPTs was 6.9; 3.0; 7.3; and 16.9, length of longest fragment was 3.8, 4. 7, 3.9, and 8.4 mm, and specimen adequacy was 66.7%, 46%, 82.1%, and 81.5%, respectively. A positive correlation was obtained between number of CPTs and length of longest fragment in samples accrued by 19G needles.

CONCLUSION

EUS-LB specimens using 22G Franseen-tip needle appear highly fragmented, leading to inferior specimen adequacy compared to 19G non-Tru-Cut needles. We also report on using length of longest fragment as an additional criterion for specimen adequacy as it positively correlates with number of CPTs standard.

Endoscopic ultrasound guided hepatic interventions

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.

A State-of-the-Art Review on the Evolving Utility of Endoscopic Ultrasound in Liver Diseases Diagnosis

Liver diseases are amongst the most common diseases worldwide and manifest as a parenchymatic and/or biliary injury due to several causes as well as focal liver lesions, ranging from benign to malignant ones. The diagnosis of liver diseases is based mainly on biochemical and advanced imaging studies and, when required, on liver biopsy. Endoscopic ultrasound (EUS), which combines endoscopy and ultrasonography, is one of the main examination techniques used in gastroenterology as it is applied to evaluate abnormalities in the lumen of the upper and lower gastrointestinal tract and to define pancreatic and hepato-biliary features, often in chronic patients. Given its high spatial resolution and its proximity to the liver, EUS is gaining popularity in the diagnostic work up of liver diseases. This is a comprehensive overview of the current literature on the diagnostic indications for EUS use in patients with liver diseases. We performed a MEDLINE\PubMed and Embase search, and all articles that were relevant, after reviewing abstracts, were assessed and the full text was analyzed to extract data regarding technical success, diagnostic yield, bioptic characteristics, and complications rate. EUS-guided imaging and biopsy techniques in liver diseases have shown consistent favorable promising results among the reports through the literature, with an excellent diagnostic yield and safety profile, especially in the context of focal lesions and portal hypertension. The application of EUS in the diagnosis of liver diseases is a promising technique and should be considered as a first-line therapeutic option in selected cases.

Ultrasound-Guided Percutaneous Liver Biopsy: A Review on Obtaining Adequate Specimens

This literature review was conducted to evaluate liver biopsy adequacy, including total core length (TCL), number of portal tracts (PT), fragmentation, and complication rates, as a function of needle type and gauge. A systematic electronic search was performed in the Web of Science and Google Scholar databases, according to the PRISMA statement. Eligible data, describing in vivo percutaneous ultrasound-guided human liver biopsy quality outcomes, were compared to adequacy criteria of the American Association for the Study of Liver Diseases (AASLD, TCL ≥ 20 mm, PT ≥ 11). An adequate mean number of PTs was found in 83% of biopsy needles assessed between 2012 and 2019, compared to 0% between 1998 and 2004. For TCL, this was 44% and 33%, respectively. Increasing the needle diameter enhanced TCL (result in 50% of included studies) and PT count (100%), and reduced fragmentation rates (75%), whereas no effect on pain or complications was found (83%). In total, five needle types achieved adequate PT counts, using 16 G (3×), 17 G (1×), or 18 G (1×) needles. Adequacy was reached using either a core needle biopsy (CNB, 3×) approach with one pass, or a fine needle aspiration (FNA, 2×) approach with two passes. The recommendations for biopsy adequacy can be met using 16/17 G FNA or 16/18 G CNB needles. Currently, many publications still present substandard liver biopsy quality outcomes. Although minimizing biopsy invasiveness is desirable, a decreased diameter or number of passes is ill-judged when reliability of biopsy outcomes is at stake.

Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures

Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.

EUS-guided fine-needle core liver biopsy with a modified one-pass, one-actuation wet suction technique comparing two types of EUS core needles

Background and study aims  We compared the diagnostic yield and specimen adequacy in EUS-guided parenchymal biopsies between two types of EUS 19 G core needles. Patients and methods  This is a retrospective study of 420 patients at two tertiary medical centers in Florida with unexplained abnormal liver associated tests were referred for EUS evaluation of biliary obstruction and pancreatic pathology. EUS-guided liver biopsy (EUS-LB) was performed at the same session after biliary obstruction was excluded. We compared intact specimen length (ISL), total specimen length (TSL), complete portal triads (CPT) and adverse events (AE). Welch's T and Tukey tests were used for ISL, TSL and CPT. Results  A total of 210 patients underwent EUS-LB using a Franseen needle, 210 patients using a fork-tip needle. Median patient age was 52 years (15.63) and 238 (56.7 %) were female. The fork-tip needle had a mean ISL of 2.7 (1.1 SD) cm, TSL of 6 cm (2.1 SD), and mean 19.5 CPT (8.5 SD) Abdominal pain occurred in 35 patients (17 %) post-procedure and was managed with supportive care. Two patients required intravenous (IV) narcotic administration. Subcapsular hematomas occurred in 1 (0.5 %) patients. The Franseen needle had a mean ISL of 3.1 cm (1.3 SD), TSL of 6.5 cm (2.6 SD), and mean of 24 CPT (8.8 SD). Abdominal pain occurred in four patients (2 %) post-procedure, which resolved in all patients after IV narcotic administration. Subcapsular hematomas occurred in 1 (0.5 %) and bile leak in 1(0.4 %) patients. Conclusions  Use of the Franseen needle resulted in better liver core samples than that obtained with a fork-tip needle.

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound (EUS) is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease. Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy, EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events. In this review, we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses, hepatic parenchymal disease, portal hypertension, esophageal and other varices, and indeterminate biliary strictures.

Optimizing small liver biopsy specimens: a combined cytopathology and surgical pathology perspective

Both fine-needle aspiration (FNA) and core needle biopsy (CNB) are widely used to obtain liver biopsy specimens, particularly from mass lesions. However, the advantages and disadvantages of FNA versus CNB in terms of appropriate use, diagnostic yield, complications, and whether or not specimens should be handled by cytopathologists, surgical pathologists, or both remain subjects of controversy. This review addresses the issues of sample adequacy, appropriate use of each technique and complications, and challenges regarding the diagnosis of both hepatic tumors and non-neoplastic liver disease.

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

BACKGROUND AND AIMS

Diagnostic tools for nonalcoholic fatty liver disease (NAFLD) detection and prognostication are limited, with histology remaining the criterion standard. We evaluated the feasibility and safety of EUS-guided liver biopsy (EUS-LB) sampling in NAFLD staging.

METHODS

In a prospective cohort of NAFLD patients with steatohepatitis and early liver fibrosis based on magnetic resonance elastography (MRE), EUS-LB sampling procedures were performed using a 22-gauge fork-tip core biopsy needle. Samples were evaluated by a blinded pathologist. Total aggregate sample length (TASL), number of complete portal triads, ability to calculate NAFLD activity score, ability to stage liver fibrosis, and ability to provide enough core liver tissue for lipidomics analysis were evaluated. Performance of EUS-LB sampling was compared with MRE.

RESULTS

Forty-one EUS-LB samples were obtained. The median TASL was 2.4 cm (interquartile range, 2.00-2.75). The median number of complete portal triads per TASL was 26 (interquartile range, 7-62). Of the samples, 100% were adequate to convey NAFLD activity score and fibrosis stage. All samples provided enough core liver tissue to allow the application of lipidomics testing. A significant positive linear association between EUS-LB sampling-detected fibrosis and MRE-detected fibrosis was observed (r = .469, P < .005). Compared with MRE, EUS-LB sampling established early fibrosis in 13 cases that MRE classified as normal. EUS-LB sampling-related adverse events occurred in 7% and were restricted to postprocedural pain.

CONCLUSIONS

EUS-LB sampling is a viable technique for full NAFLD evaluation and may be superior to MRE in establishing the diagnosis of nonalcoholic steatohepatitis with early fibrosis. (Clinical trial registration number: NCT02880189.).

The role of EUS in diagnosis and treatment of liver disorders

Background and aim  Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.

Comparison of Endoscopic Ultrasound Biopsy Needles for Endoscopic Ultrasound-Guided Liver Biopsy

Background/Aims

To compare the performance of latest commercially available endoscopic ultrasound biopsy needles.

Methods

Six latest commercially available needles were tested on a freshly harvested bovine liver; the tested needles included three 19 G, one 20 G, and two 22 G needles. Five biopsies were performed per needle with 10 mL of wet suction. The primary outcome was the number of complete portal tracts (CPTs) per needle aspirate. The secondary outcomes were the mean specimen length and mean fragment length. Analysis of variance and Tukey’s test were applied.

Results

All 19 G needles and the 20 G needle yielded similar mean CPTs and were superior to the SharkCore 22 G needle (p<0.001 adjusted for multiplicity). There was no statistically significant difference in total specimen length among the three 19 G needles and the 20 G needle tested. The two 22 G needles performed similarly with respect to the number of CPTs, mean fragment length, and mean specimen length (adjusted p=0.07, p=0.59, and p=0.10, respectively).

Conclusions

The specimen adequacy was similar among the 3 latest commercially available 19 G needles. The endoscopist may choose a larger-bore needle based on availability without concerns of specimen adequacy. Further studies are needed to assess the ease of needle use in various anatomical locations and to confirm the optimal needle design.

Endoscopic ultrasound guided liver biopsy for parenchymal liver disease

Liver biopsy plays an essential role in the diagnosis, evaluation and management of a vast proportion of liver diseases. Conventionally, percutaneous and trans-jugular approaches have been used to obtain liver biopsies. Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a safe and effective alternate in the past two decades. EUS-LB carries a role in evaluation of both benign and malignant diseases of the liver. It can offer higher resolution imaging of the liver and can detect smaller lesions than computed tomography scan of the abdomen or ultrasound scans with the option for doppler assistance to reduce complications. Current evidence demonstrates the superiority of EUS-LB for a targeted approach of focal lesion and there is also evidence of less sampling variability in heterogeneous parenchymal pathologies. These advantages combined with an improved safety profile had led to the rapid progress in the development of new techniques, equipment and procedures for EUS-LB. We provide a comprehensive review of EUS-LB for parenchymal liver disease.

Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided liver biopsy (LB) is an emerging technique over conventional percutaneous (PC) or transjugular (TJ) approaches. Recent studies have reported that EUS-guided LB may have a better safety profile than PC LB or TJ LB without compromising diagnostic yield, and the outcomes are varied with respect to the types of biopsy needles. We performed a systematic review and meta-analysis to estimate the diagnostic yield, specimen adequacy, and adverse events associated with EUS-guided LB.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception to June 2018) to identify studies that reported on EUS-guided LB. The primary outcome was to estimate the pooled rates of successful diagnosis made and insufficient specimen obtained. The secondary outcome was to estimate the pooled rate of adverse events. A subgroup analysis compared the outcomes based on the type of biopsy needle.

RESULTS

A total of 9 study arms with 437 patients were included. The pooled rate of successful histologic diagnoses was 93.9% (95% confidence interval [CI], 84.9-97.7), with heterogeneity I² of 75.3%. The pooled rate of insufficient specimen obtained was 10.1% (95% CI, 3.5-25.8), with I² = 71.6%. The pooled rate of adverse events with EUS-guided LB was 2.3% (95% CI; 1.1-4.8, I² = 0). On subgroup analysis, the adverse events rate with a 19-gauge FNA needle (vs other core biopsy needles) was 0.9% (vs 2.7%, P = .28), and the rate of diagnostic yield was 95.8% (vs 92.7%, P = .59). The rate of insufficient specimen was significantly lower with an FNA needle compared with the core needle (4% vs 20%, P = .03).

CONCLUSION

With a histologic diagnosis rate of 93.9% and adverse event rate of 2.3%, EUS-guided LB appears to be both effective and safe. A 19-gauge FNA needle provides significantly better biopsy specimens and seems to have better outcomes compared with other core biopsy needles.

The Role of EUS in Liver Biopsy

PURPOSE OF REVIEW

EUS-guided liver biopsy (EUS-LB) is being used with increased frequency to perform parenchymal liver biopsy. Evolution of the technique can now achieve excellent liver tissue cores. This review covers important developments in this procedure.

RECENT FINDINGS

Clinical studies have recently demonstrated that the 19G EUS core biopsy needle is superior to non-core needles for liver tissue acquisition. In addition, wet suction provides more robust tissue samples than dry suction. Heparin priming of the needle (instead of saline) can prevent blood clogging within the needle lumen. A 1-hour recovery time after the EUS-LB is sufficient in almost all cases. The EUS-LB can deliver bilobar biopsies, which can decrease sampling error. Patients who need a liver biopsy in addition to an endoscopy or EUS are best served by the EUS-LB, as the combination procedure saves time and cost. The EUS-LB is a safe and effective means for procuring good liver core biopsies. Incremental improvements in technique have increased quality of the resulting specimen. Future directions of this technique are discussed.

Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.

Endoscopic Ultrasound-Guided Tissue Acquisition: Techniques and Challenges

Endoscopic ultrasound-guided fine needle aspiration (EUS FNA) has made pathological diagnosis of pancreatic neoplasms, diseases involving lymph nodes at various mediastinal and abdominal sites, gastrointestinal submucosal lesions, perirectal lesions, adrenal lesions, and mediastinal masses easy. EUS-guided FNA is a multistep procedure that involves assessment of proper clinical indication, correct selection of FNA needles, and adoption of evidence-based techniques for tissue sampling. EUS FNA is done by needles that are available in different sizes, mainly 25, 22, and 19-gauge needle. The need of onsite cytopathologist, dependence on histology/core biopsy occasionally to get a diagnosis, and inability to reliably assess for molecular markers are important limitations of EUS FNA. EUS-guided fine needle biopsy (FNB) that samples the core of tissue is an exciting new development in the field of diagnostic EUS. FNB needles are expensive than FNA needles, and although the initial results are encouraging, more studies with robust evidence proving their superiority beyond any doubt are needed before they can be widely used.

Endoscopic ultrasound-guided biopsy in chronic liver disease: a randomized comparison of 19-G FNA and 22-G FNB needles

Background and study aims  Endoscopic ultrasound-guided liver biopsy uses a 19-gauge (G) needle for parenchymal liver biopsies. We evaluated tissue yields with a 22G fine-needle biopsy (FNB) versus 19G FNA fine-needle aspirate (FNA) device. Patients and methods  Biopsies were obtained from 20 patients using the 19G FNA and 22G FNB randomizing each in a cross-over fashion with a blinded outcome assessor. Tissue adequacy for histologic evaluation was the primary outcome, or the proportion of specimens obtaining pathologic diagnosis (portal structures ≥ 5 or length of the longest piece ≥ 15 mm). Additional secondary outcomes included portal and centrilobular inflammation/fibrosis, length of the longest piece, aggregate specimen length, and small (< 5 mm), medium (5 - 8 mm) and large (> 8 mm) fragments. Results were compared in a per needle basis. Patients with cirrhosis were excluded. Results  Eighty biopsies (40 each 19G FNA and 22G FNB) were obtained. Tissue adequacy was greater for the 19G FNA (88 %) versus 22G FNB (68 %), ( P  = 0.03). There was no difference in total portal structures for the 19G FNA (7.4) and 22G FNB (6.1), ( P  = 0.28). There was no difference in pre-processing outcomes. After processing, length of the longest piece was higher for the 19G FNA (9.1 mm) versus 22G FNB (6.6 mm), ( P  = 0.02). More total post-processing small fragments 29.9 versus 20.7, ( P  = 0.01) and fewer large fragments 1.0 versus 0.4 for the 22G FNB ( P  = 0.01) were detected. Conclusions  Tissue adequacy was higher for the 19G FNA versus 22G FNB needle. The 22G FNB needle produced samples more prone to fragmentation during specimen processing.

A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos)

BACKGROUND AND AIMS

As EUS-guided liver biopsy sampling (EUS-LB) becomes more widely used, further studies have investigated ways to improve tissue yields. Use of a heparin-primed needle may lead to less clotting of blood within the needle, improve tissue recovery, and decrease fragmentation. The purpose of this study was to prospectively evaluate wet suction using a heparin-primed needle for EUS-LB.

METHODS

This was a prospective crossover study evaluating wet suction for EUS-LB in parenchymal liver disease. The primary outcome was specimen adequacy, defined by an aggregate specimen length ≥15 mm and ≥5 complete portal tracts (CPTs). Secondary outcomes included number of CPTs, length of the longest piece, aggregate specimen length, and number of small (≤4 mm), medium (5-8 mm), and large (≥9 mm) fragments. Adverse events were tracked at 7 and 30 days.

RESULTS

One hundred twenty biopsy specimens were collected from 40 participants (3 specimens per patient). Specimen adequacy occurred in 39 wet heparin (98%), 37 dry heparin (93%), and 30 dry needle biopsy samples (80%; 95% confidence interval [CI], .14-.18; P = .01). There was no difference between dry needle techniques. Length of the longest piece was 8.9 mm for wet heparin and 5.8 mm for dry techniques (95% CI, .33-1.53; P = .003). Aggregate specimen length was 49.2 mm for wet heparin and 23.9 mm for dry heparin (95% CI, -46.34 to 44.94; P = .003). Mean CPT count was 7.0 for wet heparin versus 4.0 for dry (95% CI, .74-6.26; P = .01). There were more medium (2.0 vs 1.0; 95% CI, .06-1.24; P = .03) and large (1.0 versus 0.0; 95% CI, .33-1.53; P = .003) fragments with wet suction with no difference in small fragments between groups.

CONCLUSIONS

The use of wet suction EUS-LB demonstrated improved tissue adequacy compared with dry needle techniques. (Clinical trial registration number: NCT03103997.).

A quarter century of EUS-FNA: Progress, milestones, and future directions

Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.

New Developments in Endoscopic Ultrasound Tissue Acquisition

Endoscopic ultrasound (EUS)-guided tissue acquisition has greatly evolved since the first EUS-guided fine-needle aspiration was reported nearly 25 years ago. EUS-guided tissue acquisition has become the procedure of choice for sampling of the pancreas, subepithelial lesions, and other structures adjacent to the gastrointestinal tract. This review focuses on recent developments in procedural techniques and needle technologies for EUS-guided tissue acquisition.

Comparison of the Diagnostic Yield of EUS Needles for Liver Biopsy: Ex Vivo Study

BACKGROUND AND AIMS

EUS-guided liver biopsy is an emerging method of liver tissue acquisition which is safe and had been shown to produce excellent histological yield. There is limited data comparing the diagnostic yield of different FNA needles. We aimed to compare the diagnostic performance of four commercially available 19-gauge FNA needles.

METHODS

Four FNA needles and one percutaneous needle were used to perform liver biopsies on two human cadaveric livers: Cook Echotip Procore™, Olympus EZ Shot 2™, Boston Scientific Expect Slimline™, Covidien SharkCore™, and an 18-gauge percutaneous needle (TruCore™, Argon Medical Devices). Each needle obtained biopsies by three, six, and nine complete back-and-forth motions of the needle ("throw") with a fanning technique. The combined lengths of specimen fragments and the total number of complete portal tracts (CPT) were measured by a blinded pathologist. One-way analysis of variance (ANOVA) and Bonferroni correction were used for statistical analysis.

RESULTS

A total of 52 liver biopsies were performed. The Covidien SharkCore needle had significantly greater number of CPT compared to other FNA needles. The number of "throws" did not impact the number of CPT significantly. There was no statistically significant difference in mean total specimen length between each FNA needle type.

CONCLUSION

The Covidien SharkCore needle produced superior histological specimen by capturing more CPT, possibly due to its unique needle design.

Role of endoscopic ultrasound in liver disease: Where do we stand in 2017?

Endoscopic ultrasound (EUS) was first introduced into medical practice in 1980s as a diagnostic imaging modality for pancreatic pathology. EUS has the unique advantage of combining ultrasound and endoscopy to obtain detailed information of the gastrointestinal tract. Over the past decade, the use of EUS in liver diseases has been increasing. EUS, which was initially used as a diagnostic tool, is now having increasing therapeutic role as well. We provide a review of the application of EUS in the diagnostic and therapeutic aspects of liver disease. We also look at the evolving future research on the role of EUS in liver diseases.

Endoscopic ultrasonography - emerging applications in hepatology

The inspection of the liver is a valuable part of the upper endoscopic ultrasonography (EUS) studies, regardless of the primary indication for the examination. The detailed images of the liver segments provided by EUS allows the use of this technique in the study of parenchymal liver disease and even in the diagnosis and classification of focal liver lesions. EUS has also emerged as an important tool in understanding the complex collateral circulation in patients with portal hypertension and their clinical and prognostic value. Recently, EUS-guided portal vein catheterization has been performed for direct portal pressure measurement as an alternative method to evaluate portal hemodynamics. In this review, the authors summarize the available evidence regarding the application of EUS to patients with liver diseases and how we can apply it in our current clinical practice.

Optimizing EUS-guided liver biopsy sampling: comprehensive assessment of needle types and tissue acquisition techniques

BACKGROUND AND AIMS

EUS-guided liver biopsy sampling using FNA and, more recently, fine-needle biopsy (FNB) needles has been reported with discrepant diagnostic accuracy, in part due to differences in methodology. We aimed to compare liver histologic yields of 4 EUS-based needles and 2 percutaneous needles to identify optimal number of needle passes and suction.

METHODS

Six needle types were tested on human cadaveric tissue: one 19G FNA needle, one existing 19G FNB needle, one novel 19G FNB needle, one 22G FNB needle, and two 18G percutaneous needles (18G1 and 18G2). Two needle excursion patterns (1 vs 3 fanning passes) were performed on all EUS needles. Primary outcome was number of portal tracts. Secondary outcomes were degree of fragmentation and specimen adequacy. Pairwise comparisons were performed using t tests, with a 2-sided P < .05 considered to be significant. Multivariable regression analysis was performed.

RESULTS

In total, 288 liver biopsy samplings (48 per needle type) were performed. The novel 19G FNB needle had significantly increased mean portal tracts compared with all needle types. The 22G FNB needle had significantly increased portal tracts compared with the 18G1 needle (3.8 vs 2.5, P < .001) and was not statistically different from the 18G2 needle (3.8 vs 3.5, P = .68). FNB needles (P < .001) and 3 fanning passes (P ≤ .001) were independent predictors of the number of portal tracts.

CONCLUSIONS

A novel 19G EUS-guided liver biopsy needle provides superior histologic yield compared with 18G percutaneous needles and existing 19G FNA and core needles. Moreover, the 22G FNB needle may be adequate for liver biopsy sampling. Investigations are underway to determine whether these results can be replicated in a clinical setting.

Endoscopic ultrasound-guided fine-needle aspiration can target right liver mass

Background and Objectives:

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing and staging intra-abdominal mass. However, few studies investigated its feasibility, efficacy, and safety for targeting liver mass. We evaluated the efficacy and safety of EUS-FNA in patients with liver masses including the right lobe.

Patients and Methods:

The technical feasibility, safety, and diagnostic yield were determined in 47 patients (30 in the left lobe and 17 in the right lobe) presenting with liver masses between September 2010 and February 2016.

Results:

Thirty-eight patients (80.9%) had malignancies whereas nine patients (19.1%) had benign liver masses. Technical success rate was 97.9% (46/47). EUS-FNA was diagnostic in 38 of 42 patients (90.5%). When the outcomes of EUS-FNA between right liver mass and left mass were accessed, the technical success rates were similar in both lobes (100% vs. 94.1%, P = 0.2). The median tumor size on EUS (25.5 mm, interquartile range [IQR] 13.8–30.3 vs. 28 mm, IQR 18.5–43.5, P = 0.24) and number of needle passes (3, IQR 3–4 vs. 3, IQR 3–3, P = 0.24) were not significantly different. Adequate specimen obtained was statistically higher in the left lobe (28/30, 93.3% vs. 14/17, 82.4%, P = 0.04). However, diagnostic accuracy for liver masses was not different (25/28, 89.3% vs. 13/14, 92.9%, P = 0.86). No complications developed after procedure.

Conclusions:

EUS-FNA can be a safe and efficient method for the diagnosis of liver mass and it is technically feasible even for those in the right lobe.

EUS-guided liver biopsy provides diagnostic samples comparable with those via the percutaneous or transjugular route

BACKGROUND AND AIMS

Liver biopsy (LB) traditionally has been performed via a percutaneous (PC), transjugular (TJ), or surgical approach. EUS-guided LB (EUS-LB) is an emerging method that has shown promise in terms of tissue yield and procedural safety. Comparison of histologic yield of EUS-LB with other methods of LB has not been done. This study aimed to compare tissue yield of different LB methods.

METHODS

EUS-LB, TJ-LB, and PC-LB were identified retrospectively. EUS-LB was obtained via transgastric and transduodenal biopsy, or via transgastric (left lobe) biopsy alone using a 19-gauge FNA needle (non-Trucut). TJ-LB specimens were obtained with an 18- or 19-gauge needle, and PC-LB specimens with an 18- or 20-gauge needle. Stained slides were digitized on a whole slide scanner, and the total specimen length (TSL) and the count of complete portal triads (CPTs) were determined. Comparisons of TSL and CPT among the 3 groups were done with Wilcoxon rank sum tests.

RESULTS

Wilcoxon rank sum tests indicated that EUS-LB of both liver regions produced significantly more tissue in terms of both TSL and CPTs compared with a PC-LB (P = .0000 and .0006). EUS-LB produced significantly longer TSL than TJ-LB (P = .01) and similar CPTs (P = .22). Those EUS-LB cases in which the left lobe only was sampled were not statistically different compared with PC-LB and TJ-LB.

CONCLUSION

EUS-guided-LB produces specimens at least comparable to, and in some cases better than, PC-LB or TJ-LB. Widely separated liver regions can be easily sampled, which may have some benefit. The role of EUS-LB is likely to increase in the future.

EUS-guided liver biopsy for parenchymal disease: a comparison of diagnostic yield between two core biopsy needles

BACKGROUND AND AIMS

EUS-guided biopsy of the liver has a variable diagnostic accuracy and specimen adequacy. A new core biopsy needle has been developed that may improve performance. The objective of this study was to compare the diagnostic yield of a new core biopsy needle with the previous standard needle.

METHODS

In this cross-sectional study, consecutive patients who underwent EUS-guided core liver biopsy over a 7-year period for suspected parenchymal disease were prospectively evaluated. Between 2007 and 2011, all biopsies were performed with a 19-gauge Tru-cut biopsy needle (Quick-core [QC]), whereas a novel reverse bevel needle (PC) was used exclusively from 2011 to 2014. All specimens were examined by 1 of 3 experienced, blinded pathologists for the following: presence of visible core, aggregate specimen length, number of complete portal tracts, and specimen adequacy.

RESULTS

A total of 75 patients (mean age 51 years, 51 female) underwent liver biopsy by using the QC (n = 45) or PC (n = 30) needle. The QC and PC groups had similar demographics, indications for EUS, indications for liver biopsy, and liver findings on EUS. Compared with those of the QC, biopsies with the PC required fewer passes (median 2 vs 3; P < .0001) but produced longer aggregate length (median 20 mm vs 9 mm; P < .0001) with more complete portal tracts (median 5 vs 2; P = .0003) and adequate specimens (P < .01). Two patients had abdominal pain after liver biopsy with the QC needle.

CONCLUSIONS

Compared with the QC needle, EUS-guided core liver biopsy with the PC needle produced longer aggregate length, more complete portal tracts, and more adequate specimens despite fewer passes (Clinical trial registration number: NCT00586313.).

Cell-block procedure in endoscopic ultrasound-guided-fine-needle-aspiration of gastrointestinal solid neoplastic lesions

In the present review we have analyzed the clinical applications of endoscopic ultrasound-guided-fine-needle-aspiration (EUS-FNA) and the methodological aspects obtained by cell-block procedure (CBP) in the diagnostic approach to the gastrointestinal neoplastic pathology. CBP showed numerous advantages in comparison to the cytologic routine smears; in particular, better preservation of cell architecture, achievement of routine haematoxylin-eosin staining equivalent to histological slides and possibility to perform immunohistochemistry or molecular analyses represented the most evident reasons to choose this method. Moreover, by this approach, the differential diagnosis of solid gastrointestinal neoplasias may be more easily achieved and the background of contaminant non-neoplastic gastrointestinal avoided. Finally, biological samples collected by EUS-FNA CBP-assisted should be investigated in order to identify and quantify further potential molecular markers.

One hundred thirteen consecutive transgastric liver biopsies for hepatic parenchymal diseases: a single-institution study

The transgastric approach is a novel method for obtaining liver biopsies in patients undergoing upper gastrointestinal endosonography. Avoidance of vascular puncture and ability to acquire tissue in patients with obesity or ascites offers a practice niche for this technique. Although several series have reported on specimen adequacy, biopsy core length, and number of portal tracts, none has addressed the diagnostic challenges presented by the fragmented nature of these specimens. We systematically evaluated 113 transgastric liver biopsies obtained for diagnosis of parenchymal liver disease by 3 needle types and compared them with 100 percutaneous and 100 transjugular liver biopsies, respectively. Parameters recorded were number of tissue cores, sizes of longest and shortest cores, numbers of complete and incomplete portal tracts, morphologic characteristics, and adequacy of specimen for diagnosis and staging. In contrast to percutaneous and transjugular liver biopsies, transgastric biopsies often contained >10 tissue fragments and smaller tissue cores. In addition, 2 of the 3 types of transgastric needles obtained less numbers of complete portal tracts. Transjugular biopsies were also smaller and contained less number of complete portal tracts than percutaneous specimens but, unlike transgastric biopsies, only rarely contained >10 tissue fragments. Specimen adequacy for diagnosis and staging was 80%, 100%, and 98% for transgastric, percutaneous, and transjugular biopsies, respectively. Difference in specimen adequacy is related to tissue fragmentation of transgastric liver biopsies rather than biopsy core length or numbers of complete portal tracts. Tissue fragmentation is particularly challenging for staging chronic liver disease.

Endoscopic ultrasound-guided liver biopsy: a multicenter experience

BACKGROUND AND AIMS

Endoscopic ultrasound-guided (EUS) liver biopsy (LB) is proposed as a newer method that offers several advantages over existing techniques for sampling liver tissue. This study evaluated the diagnostic yield of EUS-LB as the primary outcome measure. In addition, the safety of the technique in a large patient cohort was assessed.

PATIENTS AND METHODS

Patients undergoing EUS for evaluation of elevated liver enzymes or hepatic disease were included in this prospective, non-randomized, multicenter study. EUS-LB was performed with EUS-fine needle aspiration (FNA; 19-gauge needle). Tissue was formalin-fixed and stained with hematoxylin and eosin, and trichrome. Using a microscope micrometer, specimen length was measured and the number of complete portal triads (CPTs) were counted. The main outcome measure was to assess the diagnostic yield of EUS-LB, and to monitor for any procedure-related complications.

RESULTS

Patients (110; median age, 53 years; 62 women) underwent EUS-LB at eight centers. The indication was abnormal liver enzymes in 96 patients. LB specimens sufficient for pathological diagnosis were obtained in 108 of 110 patients (98 %). The overall tissue yield from 110 patients was a median aggregate length of 38 mm (range, 0 - 203), with median of 14 CPTs (range, 0 - 68). There was no statistical difference in the yield between bilobar, left lobe only, or right lobe only biopsies. There was one complication (0.9 %) where self-limited bleeding occurred in a coagulopathic and thrombocytopenic patient. This complication was managed conservatively.

CONCLUSIONS

EUS-guided LB was a safe technique that yields tissue adequate for diagnosis among 98 % of patients evaluated.

Endoscopic ultrasound-guided liver biopsy

Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.

Usefulness of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of hepatic, gallbladder and biliary tract Lesions

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of the liver is a safe procedure in the diagnosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modalities of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the conventional endoscopic brushing and biopsy.