399 ENDOSCOPIC ULTRASOUND GUIDED LIVER BIOPSY USING A 22 GUAGE FINE NEEDLE BIOPSY NEEDLE: A PROSPECTIVE STUDY.

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Endoscopic ultrasound guided liver biopsy (EUS-LB), is gaining traction as a safe and effective alternative to percutaneous and trans-jugular liver biopsy. EUS guided true-cut and 19-gauge needles can be technically difficult to maneuver, particularly when sampling the right lobe. Other factors that have curtailed the wide spread use of EUS guided liver biopsy are, fear and anxiety about the potential complications with the use of larger bore needles and tissue fragmentation of the histological specimen. We prospectively aimed at evaluating the diagnostic adequacy and safety of EUS-LB using a smaller (22-gauge) fine needle biopsy (FNB) needle while using proper technique of tissue expression from the needle to prevent fragmentation of the specimen. Patients referred for endosonographic evaluation of elevated liver enzymes, in whom no obstructive etiology was identified on EUS and did not require ERCP, were included in this prospective, non-randomized study at a single tertiary hospital. EUS-LB was performed using a 22-guage EUS-FNB needle. A total of three passes were made from both lobes. With each pass, 3-4 back and forth slow movements were made in a fanning fashion without the use of suction. The needle was kept straight while disengaging from the scope and during tissue expression. Tissue was slowly expressed from the needle over 3-4 minutes using only the stylet. This technique was used to prevent tissue fragmentation. The presence of visible core tissue from each pass was evaluated, formalin-fixed and sent for histopathological evaluation in separate containers. Core length (CL) from each pass was measured and complete portal triads (CPT’s) counted by a pathologist. Patients were followed for post procedure (2-4 hours), early (24 hours) and late (30 days) complications. 17 patients (median age, 57 years; 10 women) underwent EUS-LB. Adequate core tissue for histopathological evaluation was obtained in all 17 patients (100%) without the use of suction. 16 patients (94%) required the use of a single 22-gauge FNB needle. One patient required an additional similar needle due to needle dysfunction. 1 sample (5.8%) was described as bloody, but contained adequate core tissue. The overall tissue yield per pass was a median CL (longest fragment per pass) of 5 mm (range 2mm-33mm) and median CPT of 17 (range 8-65). Tissue procurement from right liver lobe was described as technically easier by the endosonographers. The most common minor complication was mild abdominal pain in 3 patients (17.6 %) at 24 hours. There were no major complications, and no immediate or delayed bleeding. EUS-LB using a 22-gauge FNB needle is safe and has an adequate diagnostic yield. Using proper technique for tissue procurement and expression from the needle can prevent tissue fragmentation.