Diagnostic quality of biopsy specimens: comparison between a conventional biopsy forceps and multibite forceps

One bite or two? A comparison of single bite and double bite biopsy techniques in gastrointestinal endoscopy (BITES)

BACKGROUND AND AIM

Endoscopic biopsies can be taken using either single or double bite technique. In the single bite method, intubation time may be proportionately prolonged depending upon the number of biopsies taken. In contrast to this, double bite, though a greater number of biopsies may be taken per unit time, it may influence the quality of the biopsy specimen. The aim of the study was to compare these methods and to see if taking double bite has significant effect on the histological quality of the endoscopic biopsies.

METHODS

A prospective, randomised and partly blind study (n = 135, M: 54%, age 21-91 years) divided into two equal arms to compare 144 procedures was conducted. Specimen were compared for time taken to size, depth, crush artefacts, necrosis, fragmentation, distortion, and epithelial stripping. Time taken to collect specimens was also recorded in the upper GI procedures.

RESULTS

No significant difference was observed in the histological quality of single and double bite specimens (p < 0.05). However, DB took significantly less time (M = 88.5, SD ± 28.5) as compared to SB (M = 180, SD ± 55.9) (p < 0.05).

CONCLUSIONS

There is no difference between the histological quality of DB and SB and the former technique takes less time, hence reducing intubation time.

Single-bite versus double-bite technique for mapping biopsies during endoscopic surveillance for hereditary diffuse gastric cancer: a single-center, randomized trial

BACKGROUND : Endoscopic surveillance is recommended in patients with hereditary diffuse gastric cancer (HDGC) who refuse or want to delay surgery. Because early signet-ring cell carcinoma (SRCC) can be inconspicuous, the current surveillance endoscopy protocol entails 30 random biopsies, which are time-consuming. This study aimed to compare single-bite and double-bite techniques in HDGC surveillance. METHODS : Between October 2017 and December 2018, consecutive patients referred for HDGC surveillance were prospectively randomized to the single- or double-bite arm. The primary outcome was the diagnostic yield for SRCC foci. Secondary outcomes were: procedural time for random biopsies; comfort score; biopsy size; and quality of specimens, the latter assessed by the presence of muscularis mucosa, crush artifact, and proportion usable for diagnostic assessment. RESULTS : 25 patients were randomized to the single-bite arm and 23 to the double-bite arm. SRCC foci were detected in three and four patients in the single- and double-bite arms, respectively (P = 0.70). The procedural time for the double-bite arm (12 minutes, interquartile range [IQR] 4) was significantly shorter than for the single-bite arm (15 minute, IQR 6; P = 0.01), but comfort scores were similar. The size of the biopsies in the double-bite arm was significantly smaller than in single-bite arm (2.5 mm vs. 3.0 mm; P < 0.001) but this did not affect the presence of muscularis mucosa (P = 0.73), artifact level (P = 0.11), and diagnostic utility (P = 0.051). CONCLUSION : For patients undergoing HDGC surveillance, the double-bite technique is significantly faster than the single-bite technique. The diagnostic yield for SRCC and the biopsy quality were similar across both groups.

Comparison of 2 differently sized endoscopic biopsy forceps in the evaluation of intestinal disease in cats

BACKGROUND

In clinical practice, histopathological diagnosis of chronic intestinal disease is challenging because of difficulty in obtaining adequate duodenal samples. At present, no studies have investigated the influence of biopsy forceps size on sample quality in cats.

OBJECTIVES

Duodenal biopsy using larger biopsy forceps (2.4 mm) will provide higher quality samples.

ANIMALS

Fifty client-owned cats underwent endoscopy of the upper gastrointestinal tract for evaluation of chronic gastrointestinal signs, with inflammatory bowel disease (IBD) or intestinal lymphoma as differential diagnoses.

METHODS

For each cat, duodenal biopsy specimens were obtained using both small (1.8 mm) and large (2.4 mm) forceps and evaluated for adequacy, orientation, the presence of artifacts, villi morphology, the presence of inflammation, and neoplastic infiltration.

RESULTS

The percentage of adequate and evaluable biopsy specimens obtained using the larger forceps was significantly higher than that collected using the smaller forceps. Agreement between the forceps was variable for histological features and substantial in the case of lymphoma. However, in case of disagreement, the proper diagnosis usually was achieved only with the larger biopsy forceps.

CONCLUSIONS AND CLINICAL IMPORTANCE

Use of a larger biopsy forceps allows collection of a higher percentage of adequate and evaluable biopsy specimens compared to the commonly used smaller forceps and indirectly decreases the percentage of artifacts and increases the percentage of samples with evaluable villi. The use of a larger forceps could be helpful to obtain high-quality samples and improve diagnostic accuracy.

Comparison of standard single-bite with multiple-bite biopsy forceps for collection of gastrointestinal biopsies in dogs: a prospective study

Various types of endoscopic biopsy forceps have been investigated in dogs. The Multibite (MB) are multiple-bite forceps that collect up to four tissue specimens in a single pass through the endoscope, reducing procedure time. The authors prospectively investigated its clinical utility by comparing procedure times and diagnostic quality of samples obtained with the MB to that of biopsies performed with a single-bite forceps (SB), in 21 dogs with gastrointestinal disorders. When comparing the depth, crush artefacts and diagnostic adequacy of the gastric and duodenal biopsies, there was no significant difference between the MB and SB forceps. The procedure time was significantly longer with the MB. There was no learning curve effect, and there were no reported adverse events. This study failed to demonstrate any significant clinical advantage associated with the use of the Multibite forceps over that of conventional disposable SB forceps.

Endoscopic multiple biopsy and rapid diagnosis by in situ fixation and histopathologic processing

BACKGROUND AND AIMS

Endoscopic forceps biopsy and fixation are laborious and prolong the procedure and anesthesia. Multiple biopsy overcomes these shortcomings with a single endoscope pass that cuts, like a needle biopsy, up to 25 biopsy samples of uniform size and depth during endoscope withdrawal. Biopsy specimens are collected in acquisition order and stored in a perforated plastic storage chamber within the perforated metal tip. The tip is cut off, immersed in fixative, and sent to pathology. A formatted log identifies each biopsy specimen by site and position. In pathology, the plastic storage cylinder, designed for processing and microtomy with biopsy specimens in situ, supports rapid diagnosis by frozen section and microwave or routine paraffin processing.

METHODS

After a 10-patient Institutional Review Board safety study and US Food and Drug Administration registration, biopsies were performed in 57 patients during colonoscopy, upper GI endoscopy, and ERCP. A blinded retrospective study compared colon surveillance biopsies in 15 patients who underwent multiple biopsy with 15 patients who underwent forceps biopsies performed by anonymous physicians on the same day. Patient information was removed from slides, and forceps biopsies were oriented manually for blinding.

RESULTS

Multiple biopsy specimens fixed and processed in situ were not significantly different from batched processed forceps biopsy specimens for depth, orientation, fixation, artifacts, and diagnostic information. Multiple biopsy colonic specimens were significantly (26%) smaller with better epithelial preservation than forceps specimens. Each biopsy saves 61 seconds during withdrawal.

CONCLUSIONS

Single-pass multiple biopsy reduces biopsy time with less specimen damage, work, workplace risk, and soiling. Diagnostic quality is equal to forceps biopsy with better epithelial preservation, although 26% smaller. In pathology, in situ processing and microtomy reduce work and workplace risk. Grossing and manual orientation are unnecessary. Rapid diagnosis by frozen section and microwave or paraffin processing are facilitated. Multiple biopsy speeds diagnosis and improves productivity in endoscopic biopsy and histopathologic processing.

Comparison of 3 Handling Techniques for Endoscopically Obtained Gastric and Duodenal Biopsy Specimens: A Prospective Study in Dogs and Cats

Background

Limited evidence exists in the literature regarding whether a specific mount is preferable to use for processing endoscopically obtained gastrointestinal biopsy specimens.

Hypothesis/Objectives

To compare 3 methods of handling endoscopically obtained gastrointestinal biopsy specimens from collection to laboratory processing and to determine if any technique produced superior results.

Animals

Twenty‐three dogs and cats presented for gastrointestinal signs.

Methods

Prospective study of dogs and cats presented with gastrointestinal signs to a veterinary teaching referral hospital which underwent upper gastrointestinal endoscopy. Biopsy specimens were taken from the stomach and duodenum and submitted to the laboratory using 3 techniques: mounted on a cucumber slice, mounted on a moisturized synthetic foam sponge, and floating free in formalin. The techniques were compared with regard to the specimens' width, orientation, presence of artifacts, and pathologist's confidence in diagnosis.

Results

Twenty‐three patients were included, with a total of 528 biopsies collected. Specimens on cucumber slice and on sponge were significantly wider (P < .001 and P = .001, respectively) compared to those floating free in formalin (mean width of 3.81 versus 3.31 and 2.52 mm, respectively). However, specimens on synthetic sponge had significantly fewer artifacts compared to those on cucumber slice (P = .05) and those floating free in formalin (P = .02). Confidence in the diagnosis also was superior with the sponge technique over floating free specimens (P = .002).

Conclusions and Clinical Importance

The use of mounted gastrointestinal biopsy specimens was superior over the use of specimens floating free in formalin. This technique improved the quality of the specimens and the pathologist's confidence in their histopathologic interpretation.

Comparison of two types of biopsy forceps in gastroscopic biopsy for chronic gastritis

AIM: To compare the sampling effect and pathological results of two biopsy forceps in the endoscopic biopsy for chronic gastritis.

METHODS: One hundred and thirty chronic gastritis patients hospitalized at the First Hospital of Zibo City from July of 2013 to July of 2014 were included and divided into groups A and B, with 65 cases in each. Group A underwent gastroscopy and biopsy with needle-free stomach forceps, and group B underwent gastroscopy and biopsy with needle forceps. The sampling effect and pathological results were compared between the two groups.

RESULTS: With regard to the sampling effect, the rates of satisfaction to sampling effect at the greater curvature of the stomach and gastric antrum were 80% and 76.9%, respectively, in group A, which were significantly lower than those (92.3% and 90.7%) in group B (P < 0.05). A comparison of the pathological results of the tissues collected from groups A and B with the final pathological results revealed that the pathological diagnostic accuracy and final pathological diagnostic accuracy were 61.5% and 72.3%, respectively, for superficial gastritis and 30.7% and 46.2% for atrophic gastritis in group A (P > 0.05). The corresponding percentages in group B were 69.2% and 72.3% for superficial gastritis and 43.1% and 46.2% for atrophic gastritis (P > 0.05). There were no significant differences between groups A and B (P > 0.05).

CONCLUSION: For endoscopic biopsy in patients with chronic gastritis, the type of biopsy forceps is related to sampling effect, but not to pathological results. Needle biopsy forceps are better needle-free stomach biopsy forceps.

Endoscopic biopsy technique in the diagnosis of celiac disease: one bite or two?

BACKGROUND

The diagnosis of celiac disease is dependent on the quality of biopsy specimens obtained at EGD. Endoscopists may obtain a single- or double-biopsy specimen with each pass of the forceps.

OBJECTIVE

To compare the quality of biopsy specimens obtained with the single-biopsy and double-biopsy techniques.

DESIGN

Prospective cohort study.

SETTING

U.S. tertiary-care university hospital.

PATIENTS

Patients undergoing upper endoscopy with confirmed, suspected, or unknown celiac disease status.

INTERVENTIONS

Four biopsy specimens from the second portion of the duodenum: 2 by using the single-biopsy technique (1 bite per pass of the forceps) and an additional 2 by using the double-biopsy technique (2 bites per pass of the forceps). Specimens were blindly reviewed to determine orientation, consecutive crypt-to-villous units, and Marsh score.

MAIN OUTCOME MEASUREMENTS

Proportion of well-oriented biopsy specimens.

RESULTS

Patients (N = 86) were enrolled, 47% with known celiac disease, 36% with suspected celiac disease, and 17% with an unknown celiac disease status. Well-oriented biopsy specimens were noted in 66% of patients with the single-biopsy technique and 42% of patients with the double-biopsy technique (P < .01). Analysis of matched pairs showed improved orientation with the single-biopsy technique (odds ratio 3.1; 95% confidence interval, 1.5-7.1; P < .01). This persisted in subgroup analysis of patients with known celiac disease (P = .02), villous atrophy (P = .02), and a final diagnosis of celiac disease (P < .01).

LIMITATIONS

A single-center trial.

CONCLUSION

The single-biopsy technique improves the yield of well-oriented duodenal biopsy specimens. Endoscopists should consider taking only 1 biopsy specimen per pass of the forceps in patients undergoing biopsies of the duodenal mucosa.

The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps

BACKGROUND

Polypectomy with jumbo forceps (JF) and polypectomy with hot biopsy forceps (HBF) are still widely used techniques for removal of diminutive colorectal polyps (DCPs). JF may be more effective for the removal of DCPs because of their larger size.

AIM

To evaluate the histological quality and adequacy of DCPs resected using JF compared with HBF.

METHODS

One hundred and seventy-nine patients with 237 DCPs were included in this study. DCPs were removed using either JP or HBF.

RESULTS

The tissue architecture was good in 29.9 % of the HBF group, in comparison with 90 % of the JF group (p < 0.001). No cautery damage or crash artifact was observed in 93.3 % of JF group and in 8.5 % of HBF group (p < 0.001). Moreover, there were statistically significant differences between the groups with regard to the high level of cautery damage or crush artifact (p < 0.001). The overall diagnostic quality of the specimens removed using JF was significantly better than that of the specimens removed by HBF (96 vs. 80 %, respectively, p < 0.001). There were statistically significant inverse associations between cautery damage or crush artifact and overall diagnostic quality of HBF and JF (r = -0.373, p < 0.001; r = -0.382, p < 0.001, respectively). Surgical margins were determined as negative in 87.5 % of the JF group and in 76.1 % of the HBF group (p = 0.022). A total of 80.8 % of the JF specimens and 30.8 % of the HBF specimens were well evaluated for two lateral and deep surgical margins (p < 0.001).

CONCLUSION

JF was superior to HBF for histopathological interpretation and eradication of DCPs.

The submucosal cushion does not improve the histologic evaluation of adenomatous colon polyps resected by snare polypectomy

BACKGROUND & AIMS

Although the "submucosal cushion" technique or injection-assisted polypectomy (IAP) is often used to resect colon polyps, little is known on the influence of this technique on histologic interpretation. We aimed to evaluate whether the use of a submucosal cushion improves the histologic and margin evaluation of colon polyps.

METHODS

Consecutive patients undergoing polypectomy with and without IAP were included. An experienced blinded gastrointestinal pathologist evaluated the specimens using standardized criteria.

RESULTS

One hundred eleven sessile colon adenomas were analyzed (IAP, n = 65, standard, n = 46). Two-thirds of polyps ranged in size from 10 to 20 mm; the average polyp size was 13.2 mm for IAP and 9.9 mm for standard snare polypectomy (P = .001). The cautery degree, cautery amount, and margin evaluability, did not differ substantially with regard to the resection technique. For polyps ≥10-20 mm, the overall architecture quality was better in polyps resected with standard technique as compared with IAP.

CONCLUSIONS

The utilization of IAP did not result in a better margin evaluability of the resected polyp. Overall, IAP does not result in a better histologic polyp evaluability.

Prospective, randomized, pathologist-blinded study of disposable alligator-jaw biopsy forceps for gastric mucosal biopsy

BACKGROUND

Endoscopic biopsy forceps differ in the size and shape of the biopsy cup and the presence or absence of a needle.

METHODS

We compared four different "large cup" forceps (three with needles) designed for 2.8mm biopsy channels. A gastric antral and corpus biopsy were obtained with each. Parameters examined included: weight (mg), length (mm), orientation (poor, good), intactness (1, 2, or 3 pieces), depth (superficial, above muscularis mucosae, included muscularis mucosae), crush artefact (yes, no), and overall adequacy (inadequate, suboptimal, adequate).

RESULTS

Twenty-four patients were enrolled (191 biopsies). The median length was approximately 5mm (range 1.1-8.2mm). Histologically inadequate specimens were present in 4% with the forceps without needle compared to 16% of those with needles (P=0.061) and there were significantly fewer specimens in three or more pieces than did the forceps with needles 2.1% vs. 12.6% (P<0.05).

CONCLUSIONS

Current alligator style forceps provide a high proportion of acceptable specimens with only minor differences between brands. Forceps from one source were least preferred by endoscopy assistants and had the highest rates of inadequate biopsies and biopsies with crush artefact. Forceps without needles provide histologically acceptable samples slightly more frequently than those with needles.

Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens

BACKGROUND

In inflammatory bowel disease (IBD) surveillance colonoscopy, an increased number of biopsy specimens correlates with a higher dysplasia detection rate. Larger biopsy specimens may also increase the diagnostic yield.

OBJECTIVE

To compare a new jumbo forceps with a standard large-capacity forceps in obtaining diagnostically adequate IBD surveillance biopsy specimens.

DESIGN

Prospective single-center study.

PATIENTS AND METHODS

Twenty-four patients who were undergoing an IBD surveillance colonoscopy were enrolled. As part of standard IBD surveillance, 8 paired biopsy specimens were obtained from the rectosigmoid by using the jumbo forceps and a standard large-capacity forceps.

OUTCOME MEASUREMENTS

Biopsy specimens were deemed adequate if they met all 3 of the following criteria: (1) length > or =3 mm, (2) penetration into the muscularis mucosa, and (3) < 20% crush artifact.

RESULTS

The proportion of adequate biopsy specimens obtained with the jumbo forceps was significantly higher than that obtained with the large-capacity control forceps (67% vs 48%, P < .0001). The average length of the biopsy specimen obtained with the jumbo forceps was 4.00 mm (95% CI, 3.81-4.20 mm) compared with 3.19 mm (95% CI, 2.99-3.38 mm) with the large-capacity (control) forceps.

LIMITATIONS

(1) No validated outcome measurement for the quality of GI biopsy specimens exists and (2) in this study, interobserver variability between pathologists was high.

CONCLUSIONS

The jumbo forceps was superior to a standard large-capacity forceps in obtaining diagnostically adequate IBD surveillance biopsy specimens. Because biopsy specimens obtained with the jumbo forceps were larger, the use of this forceps for IBD surveillance will allow the endoscopist to sample a larger colonic mucosal surface area, potentially resulting in an increased dysplasia detection rate.

One bite or two? A prospective trial comparing colonoscopy biopsy technique in patients with chronic ulcerative colitis

BACKGROUND AND STUDY AIMS

Surveillance for mucosal dysplasia in patients with chronic ulcerative colitis requires numerous biopsies (often over 40). The aim of the present study was to determine if two biopsies could be obtained with jumbo forceps before removing them from the instrument (double biopsy technique), as opposed to one biopsy per pass, without sacrificing the histological quality of the biopsy material.

METHODS

Twelve patients with chronic ulcerative colitis underwent colonoscopy, and four-quadrant biopsies were obtained at 10 cm intervals. For biopsies at each interval, two quadrants were obtained using the double biopsy technique and the other two quadrants were obtained individually. Two pathologists blinded to the biopsy technique examined each biopsy for technical and diagnostic qualities. The primary outcome was the histological adequacy in the evaluation of dysplasia.

RESULTS

A total of 468 biopsies were obtained. A higher proportion of double-biopsy specimens were inadequate for dysplasia assessment compared with single-biopsy specimens (OR=2.78, 95% CI 1.37 to 5.59; P=0.005). In the double biopsy technique group, 14 samples were deemed inadequate due to actual tissue specimen loss, compared with eight samples in the single biopsy technique. However, when analysis was repeated using only the retrieved specimens, the double biopsy technique continued to be at higher risk of obtaining inadequate specimens (OR=14.5, 95% CI 2.1 to 98.7; P=0.006).

CONCLUSIONS

The results of the present study suggest that the double biopsy technique is vulnerable to specimen loss and reduced histological quality, and the adoption of this technique as an equivalent method for tissue sampling may be premature.

Comparison of Pelican single-use multibite biopsy forceps and traditional double-bite forceps: evaluation in a porcine model

BACKGROUND

The multibite biopsy forceps is intended for consecutive acquisition of numerous tissue specimens with a single pass. The Pelican multibite forceps is equipped with a sleeve for tissue retention that allows up to 6 specimens to be obtained with each pass of the device through the accessory channel. Reducing the need for device exchange could decrease the total procedure time for colon cancer surveillance in patients with longstanding inflammatory bowel disease (IBD).

OBJECTIVE

The aim of this study was to evaluate a new multibite biopsy forceps in comparison with a standard double-bite forceps.

DESIGN

Prospective randomized animal model trial.

SETTING

Multicenter university and community hospitals.

INTERVENTIONS

By using a live porcine model, multiple colonoscopic biopsy specimens were obtained with both the Pelican multibite forceps and the Radial Jaw 3 (RJ3) double-bite forceps to mimic colorectal cancer surveillance in patients with IBD. Six biopsy specimens were obtained with each of 6 passes when using the Pelican forceps, and 2 biopsy specimens were obtained with each of 18 passes when using the RJ3 forceps.

MAIN OUTCOME MEASUREMENTS

All trials were timed. Two independent pathologists blinded to the forceps used evaluated the specimens.

RESULTS

Tissue acquisition when using the Pelican multibite forceps was significantly faster than with a standard double-bite forceps. The devices compared equivalently for specimen retention and quality.

LIMITATIONS

The operator could not be blinded to the devices used. This study uses an animal model to extrapolate how the devices might perform in human use.

CONCLUSIONS

These findings support the evaluation of the Pelican forceps for colon cancer surveillance in patients with longstanding IBD.

Diagnostic quality of: polyps resected by snare polypectomy: does the type of electrosurgical current used matter?

BACKGROUND

Traditionally, snare polypectomy is performed using blended, coagulation, or pure cutting electrical current (EC). The aim of this study was to assess and compare the diagnostic quality of polyps obtained by snare polypectomy using two different electrosurgical currents.

METHODS

Consecutive patients undergoing colonoscopy underwent polypectomy using either blended EC with a conventional electrosurgical generator (ESG) or using an ESG with a microprocessor that automatically controls cutting and coagulation (Endocut). An experienced blinded gastrointestinal (GI) pathologist evaluated the specimens for diameter, cautery damage (amount and degree), margin evaluability, architecture, and general histologic diagnostic quality.

RESULTS

One hundred sixteen patients (69% men, mean age 63.8 +/- 15 yr) underwent 148 polypectomies (78 using blended current and 70 using Endocut). We found that the cautery degree was less with the Endocut than with the blended current (p < 0.02). Cautery amount was also higher in polyps resected using blended current (56%) than Endocut (51%) but this difference did not reach statistical significance (p= 0.1). Polyps resected using Endocut had better margin evaluability (75.7% to 60.3%, p= 0.046). The overall tissue architecture was similar in both groups. Polyps removed with blended current had less overall quality as compared to polyps removed by Endocut (p= 0.024).

CONCLUSIONS

More extensive tissue damage occurred using blended EC with the conventional ESG than when using Endocut. The quality of the polypectomy specimens was overall better using Endocut. Finally, the ability to evaluate resected polyp margins and overall tissue histology was better with the microprocessor-controlled ESG than with the conventional ESG.

The impact of tissue sampling on endoscopy efficiency

Much of the time spent in gastrointestinal endoscopy is devoted to tissue sampling. For this reason, efforts to facilitate tissue diagnosis can greatly influence the overall efficiency of endoscopy. This overview reviews the steps involved in tissue sampling and highlights potential ways to achieve increased efficiency in tissue sampling. Both potential improvements in process and innovations in technology are considered.

Intraprocedural steps to enhance efficiency

This section focuses on intraprocedural steps that can improve endoscopic efficiency. Contributors to procedural efficiency and inefficiency are considered. The limitations to enhancing efficiency are presented. Strategies for incorporating contributors to efficiency including techniques, technologies, accessories, and attitudes are presented.

Biopsy of the gastrointestinal tract

Gastrointestinal biopsy is a potentially powerful tool, but it is easy to do it incorrectly. If clinicians are careless in performing or submitting biopsies, or if they blindly believe whatever the histopathology report says, they are abdicating their responsibility to the client and patient. Two comments seem most appropriate. First, the goal of endoscopy is not to be able to place the tip of an endoscope in a particular location; rather, the goal of endoscopy is to be able to access a particular location and then take a diagnostic specimen well enough that surgery can be avoided. Second, attention to detail is worth at least as much if not more than technology.