Debate: ‘Safety, adequacy, cost’ still favor percutaneous vs. endoscopic ultrasound biopsy
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SAN DIEGO — Although percutaneous liver biopsy is still the “gold standard,” advances in techniques and increased use of endoscopic ultrasound-guided biopsy may soon change that dynamic, according to a debate at Digestive Disease Week 2022.
“There are several advantages to [endoscopic ultrasound (EUS)-guided liver biopsy], not the least of which is patient comfort,” David L. Diehl, MD, FASGE, of Geisinger Medical Center in Danville, Pennsylvania, told attendees. “It provides outstanding sample yields with the current techniques, and it’s possible to do bilobar sampling in a very simple manner, which can decrease sampling error.”
He added, “Let’s face it: It’s an improved patient experience with much less anxiety. Patients who have had it both ways — sedated and unsedated liver biopsy — have been very pleased with the results. Additionally, if you need to do an [esophagogastroduodenoscopy (EGD)] or even a colonoscopy at the same time, it can be done, which is cost-saving and stress-saving for the patient.”
Regarding specimen adequacy, Diehl noted that AASLD recommends a specimen of greater than 20 mm and more than 11 complete portal triads, criterion which EUS-guided biopsy “routinely meets.”
“Clearly, the need for liver biopsy is not soon going away; in fact, it’s likely to increase in the near future,” Diehl noted. “EUS-guided liver biopsy has tissue yields equivalent or higher than percutaneous or transvenous approaches, which has been proven many times. The safety record for EUS-guided liver biopsy is excellent and inadvertent splenic puncture is a unique adverse event, which should be completely avoidable with proper technique.”
While Stanley Martin Cohen, MD, medical director of hepatology at University Hospitals Cleveland Medical Center, agreed that liver biopsy is still needed for diagnosis, therapeutic guidance and occasionally prognosis, he believes that “percutaneous is still the way to go” due to safety of the procedure, adequacy of biopsy specimen and cost.
“Safety is really well established for percutaneous biopsy,” Cohen said, citing data from Mohan and colleagues published in Gastrointestinal Endoscopy, which, in an analysis of 437 EUS-guided biopsies, the rate of adverse events was 2.3% and rate of bleeding was 1.2%.
“Not overly high,” Cohen said. “I’m going to argue that safety-wise, it’s kind of a wash. ... Adequacy is where I think percutaneous biopsy is still going to win, at least for now.”
Citing the 2014 Royal College of Pathologists guidelines, Cohen noted that “you want a 20-to-25-millimeter biopsy, you want 11-plus portal tracts and you’ll see from the 2020 guidelines, they recommended a 16-gauge needle.”
However, according to the findings from Mohan and colleagues, “what they found here was that 10% of the EUS-guided biopsies did not hit those criteria,” Cohen said. “But more importantly, 6% did not even hit a criterion where they could make a diagnosis.”
In terms of cost, Cohen noted that percutaneous biopsy can be done without sedation, using only local anesthetic, whereas EUS-guided biopsy requires either conscious sedation or anesthesia-assisted sedation. Moreover, he noted that the cost for EUS-guided biopsy can be almost twice as high as percutaneous biopsy: $7,000 to $12,000 for EUS vs. $4,000 to $5,000 for percutaneous biopsy from billing in 2022.
“I would say that percutaneous still remains the gold standard,” Cohen said. “Better tissue yield, one pass, more cost effective, could be done with local anesthesia and more readily available, as many centers lack EUS biopsy capability. For now, safety, adequacy and cost favor percutaneous biopsy.”
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Diehl DL. Sp585: Liver Biopsy: EUS is the way to go. Presented at: Digestive Disease Week; May 21-24, 2022; San Diego (hybrid meeting).
Cohen SM. Sp586: Liver Biopsy: Percutaneous is still the gold standard. Presented at: Digestive Disease Week; May 21-24, 2022; San Diego (hybrid meeting).
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