EUS guided liver biopsy

Transcription

1 EUS guided liver biopsy Abdul El Chafic, MD Ochsner Medical Center Department of Gastroenterology Section of Advanced endoscopy Disclosure/ Disclaimer I have a financial interest/arrangement of affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this program and/or presentation. Medtronic: Consultant Some of the presented information, results and recommendations are based on my personal experience and may not reflect those of Medtronic. 1

2 Outline What is a good quality liver biopsy sample What is the yield of different approaches; PC, TJ, EUS EUS-LB compared to PC-LB and TJ-LB Liver disease heterogeneity and sampling variability; is this a problem and how to overcome it Technique modification Advantages of EUS-LB Different liver biopsy techniques Percutaneous liver biopsy 1920s Transjugular liver biopsy 1970s EUS guided liver biopsy 2

3 What is a good quality liver biopsy? Adequate specimen Adequacy is a qualitative assessment 20 mm long and 11 complete portal triads (CPTs) needed to overcome interobserver variability and disease heterogeniety Minimal or no fragmentation Liver disease can be heterogenous Two biopsies; one from each lobe is preferred Cholongitas, E., et al., A systematic review of the quality of liver biopsy specimens. Am J Clin Pathol, PC-LB and TJ-LB Systematic review Studies Specimens Mean length CPT PC-LB 32 10, PC-LB (US) 13 5, TJ-LB 5 1, TJ-LB (3 passes) Cholongitas, E., et al., A systematic review of the quality of liver biopsy specimens. Am J Clin Pathol,

4 Endoscopic ultrasound-guided liver biopsy: a multicenter experience 19-gauge EUS-FNA needle, fanning technique, 2-3 passes 108 (98 %) of 110 patients yielded specimens sufficient for definitive pathological diagnosis The overall complication rate was 1/110 (0.9 %). Diehl, D.L., et al., Endoscopic ultrasound-guided liver biopsy: a multicenter experience. Endosc Int Open, 2015 EUS/PC/TJ EUS: 19 G FNA; 2-3 passes // PC: G; 1 pass // TJ: G; 2-3 passes Pineda, J.J., et al. Gastrointest Endosc,

5 Fragmentation is a Disadvantage of EUS-LB Pineda, J.J., et al. Gastrointest Endosc, 2016 Sampling variability in NAFLD Histologic lesions of NASH are unevenly distributed throughout the liver parenchyma; therefore, sampling error of liver biopsy can result in substantial misdiagnosis and staging inaccuracies Needle biopsy sample usually represents around 1/50,000 of the total mass of the liver 5

6 Sampling variability in NAFLD Prospective study Two percutaneous liver samples from 51 patients were extracted using a 16-gauge needle from right lobe No significant intra-observer variability. 60.0% 58.8% 56.8% 51 patients 50.0% 40.0% 30.0% 20.0% 10.0% 41.2% 43.1% 11.7% 11.7% 0.0% 0.0% Same score 1 stage difference 2 stage difference Cirrhosis on one sample but not the other Fibrosis staging k= 0.47 Necroinflammatory staging k = 0.18 Ratziu, V., et al., Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology, 2005 Technique modification Needle 19 G core needle One pass instead of fanning Right and left lobe sampling Modified wet suction technique 6

7 Technique modification Wet suction Prospective, single-blind, randomized, controlled trial Wet Vs Dry for the first pass and then alternating Attam, R., et al., "Wet suction technique (WEST), Gastrointest Endosc, 2015 EUS-guided fine-needle core liver biopsy sampling using a novel 19-gauge needle with modified 1- pass, 1 actuation wet suction technique TSL LLP CPT AE FNA, fanning (110) 4 cm 0.75 cm % Modified technique (165) 6 cm 2.4 cm % Nieto, J., et al., EUS-guided fine-needle core liver biopsy using a novel 19G needle with modified one pass, one actuation wet suction technique. Gastrointest Endosc,

8 Right lobe Left lobe 8

9 Advantages of EUS-LB Safety High resolution image guidance with doppler capability of the linear echoendoscope allows intrahepatic vessels and major bile ducts to be avoided during FNA reducing potential complications. A 19-gauge needle is used, which is smaller than the 16-gauge needles that have traditionally been used for PC-LB reducing potential complications. Quality and Quantity Easily and safely allows biopsy of both left and right lobes of the liver, achieving more accurate representation of liver histology, potentially addressing concerns about sampling error. Patient satisfaction Patients are sedated for the EUS procedure, thus the LB is less uncomfortable than a percutaneous approach. Likely less pain associated with EUS-LB compared to PC-LB Recovery time is much shorter than that of PC-LB (about 4 hours). One stop shop In a patent who is already undergoing an esophagogastroduodenoscopy or EUS for their respective indication, EUS-LB can be performed with little additional time and risk.? More cost effective. Thank You 9