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Endoscopic ultrasound–guided liver biopsy: needle types and suction methods

Open AccessPublished:August 24, 2021DOI:https://doi.org/10.1016/j.vgie.2021.06.007

      Video

      (mp4, (162.15 MB)

      Tools and techniques: understanding EUS-guided liver biopsy needle types and tissue acquisition techniques.

      Abbreviations:

      EUS-LB (EUS-guided liver biopsy), FNB (fine-needle biopsy)

      Introduction

      Endoscopic ultrasound−guided liver biopsy (EUS-LB) is gaining traction among hepatologists and endosonographers. It is safe and effective at delivering excellent liver biopsy cores and can be time saving if another endoscopic procedure is required at the same time.
      • Mok S.R.S.
      • Diehl D.L.
      The role of EUS in liver biopsy.
      Although the first EUS-guided biopsy of a liver lesion was described in 1997, EUS-LB for routine assessment of elevated liver biochemistries or evidence of cirrhosis was later reported in 2008.
      • Bentz J.S.
      • Kochman M.L.
      • Faigel D.O.
      • et al.
      Endoscopic ultrasound-guided real-time fine-needle aspiration: clinicopathologic features of 60 patients.
      ,
      • Mathew A.
      EUS-guided routine liver biopsy in selected patients.
      There is no clear consensus on the optimal tools and techniques used in EUS-LB. Herein, we describe the various types of needles used in this procedure and suction techniques available.

      EUS-LB

      Before initiating the procedure, it is important to review the indications and contraindications. Indications are similar to those for percutaneous or transjugular liver biopsy and include identifying the etiology of complex liver disease, staging of liver disease (nonalcoholic steatohepatitis or cirrhosis), and tissue acquisition of focal hepatic lesions.
      • Sbeit W.
      • Kadah A.
      • Mahamid M.
      • et al.
      A state-of-the-art review on the evolving utility of endoscopic ultrasound in liver diseases diagnosis.
      Contraindications can be extrapolated from EUS-guided FNA in GI tract lesions and may include inability to tolerate sedation, gastric outlet obstruction, no clear biopsy path without collaterals, abnormal coagulation factors, or hemodynamic instability.
      Both EUS-FNA and fine-needle biopsy (FNB) can be used in EUS-LB (Fig. 1). Three different EUS-FNB needle types are commercially available: ProCore, SharkCore, and Acquire. Each has a different needle type consisting of a reverse-bevel core, Fork tip (SharkCore; Medtronic, Minneapolis, Minn), and Franseen tip (Acquire; Boston Scientific, Natick, Mass), respectively (Fig. 1). A discrepancy in the literature exists regarding the superiority of FNA versus FNB needles based on the most recent meta-analyses available.
      • Mohan B.P.
      • Shakhatreh M.
      • Garg R.
      • et al.
      Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis.
      • Bang J.Y.
      • Hawes R.
      • Varadarajulu S.
      A meta-analysis comparing ProCore and standard fine-needle aspiration needles for endoscopic ultrasound-guided tissue acquisition.
      • Khan M.A.
      • Grimm I.S.
      • Ali B.
      • et al.
      A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment.

      Baran B, Kale S, Patil P, et al. Endoscopic ultrasound-guided parenchymal liver biopsy: a systematic review and meta-analysis. Surg Endosc. Epub 2020 Oct 14.

      However, data may favor FNB needles in terms of diagnostic yield. In a meta-analysis by Khan et al,
      • Khan M.A.
      • Grimm I.S.
      • Ali B.
      • et al.
      A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment.
      diagnostic yield was similar between FNA and FNB needles only when FNA was accompanied by rapid onsite evaluation of the specimen. In addition, a 2020 meta-analysis by Baran et al

      Baran B, Kale S, Patil P, et al. Endoscopic ultrasound-guided parenchymal liver biopsy: a systematic review and meta-analysis. Surg Endosc. Epub 2020 Oct 14.

      found that FNB needles yielded a higher number of complete portal tracts.
      Figure thumbnail gr1
      Figure 1Needle types. From left to right: ProCore FNB Needle, SharkCore FNB Needle, Acquire FNB Needle, and Expect FNA Needle.
      There are 6 reported tissue acquisition techniques that can be used in EUS-LB (Fig. 2).
      • Attam R.
      • Arain M.A.
      • Bloechl S.J.
      • et al.
      “Wet suction technique (WEST)”: a novel way to enhance the quality of EUS-FNA aspirate. Results of a prospective, single-blind, randomized, controlled trial using a 22-gauge needle for EUS-FNA of solid lesions.
      • Mok S.R.S.
      • Diehl D.L.
      • Johal A.S.
      • et al.
      A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos).
      • Tong T.
      • Tian L.
      • Deng M.
      • et al.
      Comparison between modified wet suction and dry suction technique for endoscopic ultrasound-guided fine-needle biopsy in pancreatic solid lesions.
      The wet suction technique may improve diagnostic yield compared with dry suction when using FNA.
      • Attam R.
      • Arain M.A.
      • Bloechl S.J.
      • et al.
      “Wet suction technique (WEST)”: a novel way to enhance the quality of EUS-FNA aspirate. Results of a prospective, single-blind, randomized, controlled trial using a 22-gauge needle for EUS-FNA of solid lesions.
      Another useful FNA technique is wet heparin, which reportedly has less tissue fragmentation, more complete portal tracts, and increased aggregate specimen length compared with dry techniques.
      • Mok S.R.S.
      • Diehl D.L.
      • Johal A.S.
      • et al.
      A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos).
      Heparin priming of the needle may decrease blood clots within the specimen, leading to less blood contamination, and enhance tissue processing and interpretation.
      • Mok S.R.S.
      • Diehl D.L.
      • Johal A.S.
      • et al.
      A prospective pilot comparison of wet and dry heparinized suction for EUS-guided liver biopsy (with videos).
      Video 1 outlines the EUS-LB tools and techniques, a brief ex vivo cadaveric EUS-LB, and an in vivo real-world example of EUS-LB (Video 1, available online at www.giejournal.org; Fig. 2).
      Figure thumbnail gr2
      Figure 2Suction techniques. Ex vivo cadaveric liver.
      Adverse events may be related to sedation, may be well-recognized endoscopic adverse events, or may be biopsy-related, including bleeding, abdominal pain, infection, or needle tract seeding of malignant cells. Although FNB needles in 1 study conferred a higher likelihood of pain postprocedure compared with FNA, no studies to date have shown a higher bleeding risk in EUS-LB based on needle type or size.
      • Mok S.R.S.
      • Diehl D.L.
      The role of EUS in liver biopsy.

      Summary

      EUS-LB is now more routinely used for diagnostic purposes in liver pathology. Several suction techniques using different needle options have been described over the past decade. Outcomes are comparable, and there is currently no consensus regarding the optimal approach to EUS-LB.

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

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