Article Text

Radiology-guided percutaneous approach is superior to EUS for performing liver biopsies
1. Ji Young Bang1,
2. Thomas J Ward2,
5. Francisco Contreras2,
6. Nirag Jhala4,
7. Udayakumar Navaneethan5,
8. Robert H Hawes5,
1. 1 Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
3. 3 Hepatology, AdventHealth Orlando, Orlando, Florida, USA
4. 4 Pathology, Temple University Hospital, Philadelphia, Pennsylvania, USA
5. 5 Digestive Health Insitute, Orlando Health, Orlando, Florida, USA
1. Correspondence to Dr Ji Young Bang, AdventHealth Orlando, Orlando, Florida 32803, USA; jybang213{at}gmail.com

## Message

Although liver biopsies (LBs) are being increasingly performed under endoscopic ultrasound (EUS) guidance, there are limited data comparing outcomes with current standard-of-care, transabdominal ultrasound (US)-guided percutaneous (PC) methods. In a randomised trial, we observed that the PC, US-guided method yielded significantly more optimal specimens, defined as specimen length of 25 mm or greater and presence of at least 11 complete portal tracts, compared with the EUS-guided method (57.9% vs 23.8%, p=0.028). Also, the PC method resulted in worse initial postprocedural pain but was less costly (US$1824 vs US$3240, p<0.001).

## In more detail

Despite significant advances in non-invasive assessment, LB still remains the gold standard for evaluation of subacute and chronic liver diseases, whose clinical presentation can oftentimes be both confusing and challenging.1 LB is usually performed percutaneously under the guidance of real-time imaging using transabdominal US or CT, or via the transjugular approach in patients with underlying coagulopathy. More recently, endoscopists have been performing the procedure via the transgastric or transduodenal route under EUS guidance. Perceived advantages include the ability to simultaneously exclude diseases in the pancreas or bile duct, access to both the left and right lobes of the liver, and avoidance of intraprocedural pain as EUS is performed under sedation.2 While prospective single-arm and retrospective comparative studies suggest that EUS-guided LB can establish the diagnosis in more than 90% of patients and is equally successful,3 4 there are no randomised trials comparing outcomes with PC methods. Additionally, in the present era of cost containment, financial analysis is critical in healthcare decision-making, particularly for commonly indicated procedures such as LB. Therefore, we conducted a randomised trial comparing specimen quality and financial costs between PC and EUS-guided LB methods.

Eligible consecutive patients from outpatient clinics or inpatient wards were referred by hepatologists to undergo LB and were randomised to either EUS-guided …

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## Footnotes

• Contributors JYB: Study design, endoscopist performing procedures in the study, statistical analysis, interpretation of data, drafting of manuscript and critical revision of manuscript. SV: Study concept and design, endoscopist performing procedures in the study, interpretation of data, drafting of manuscript and critical revision of manuscript. RH and UN: Interpretation of data, endoscopist performing procedures in the study and critical revision of manuscript. TJW: Study design, radiologist performing procedures in the study and critical revision of manuscript. FC: Radiologist performing procedures in the study and critical revision of manuscript. SG: Hepatologist participating in the study and critical revision of manuscript. NJ: Study design and critical revision of manuscript. KK: Cytopathology technician collecting data for the study and critical revision of manuscript

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests JYB: Consultant for Olympus America and Boston Scientific Corporation. SV: Consultant for Boston Scientific Corp., Olympus America, Covidien and Creo Medical. RH: Consultant for Boston Scientific Corp., Olympus America, Covidien, Creo Medical, Nine Points Medical and Cook Medical. TJW, SG, KK, FC, NJ and UN have no disclosure to declare.

• Provenance and peer review Not commissioned; internally peer reviewed.

• Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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