Endoscopy 2020; 52(02): 157
DOI: 10.1055/a-1031-9504
Letter to the editor
© Georg Thieme Verlag KG Stuttgart · New York

The 22-gauge core needle is not optimal for endoscopic ultrasound-guided liver biopsy

Shaffer R. S. Mok
1  Case Western Reserve School of Medicine, Cleveland, Ohio, United States
David L. Diehl
2  Geisinger Medical Center, Danville, Pennsylvania, United States
Bradley D. Confer
2  Geisinger Medical Center, Danville, Pennsylvania, United States
Amitpal S. Johal
2  Geisinger Medical Center, Danville, Pennsylvania, United States
Harshit S. Khara
2  Geisinger Medical Center, Danville, Pennsylvania, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
28 January 2020 (online)

We read with interest the study on endoscopic ultrasound-guided liver biopsy (EUS-LB) with a 22-G core biopsy needle [1], and the accompanying editorial [2]. This is not the first prospective study of a 22-G fine-needle biopsy (FNB) needle for liver biopsy as the authors suggest; we published a prospective randomized study [3] comparing the 22-G FNB needle (fork tip) with a regular 19-G fine-needle aspiration (FNA) needle, as cited in both the article and the editorial. We found adequate cores in 68 % of EUS-LBs done with the 22-G FNB compared with 90 % with the 19-G FNA needle. There was increased fragmentation during standard tissue processing of 22-G FNB specimens, probably because of the smaller diameter of the cores (about half the diameter on average vs. the 19-G needle).

An experienced pathologist can deal with fragmented cores, but this may not be the case in general pathology practice. The 100 % “adequate diagnostic yield” in the Hasan et al. study can only occur with interpretation by experienced liver pathologists. Every effort should be made to deliver the best possible specimens to the pathologist. The 19-G needle, particularly the 19-G core needle [4] is the most reliable way to do this.

An additional benefit of the larger needle is that special needle maneuvers as described in the article (limited elevator use, straightening the needle, slow stylet insertion) are not necessary, decreasing the chances of user error. We agree with Larghi to limit the number of needle throws; we currently use 1 – 3 to-and-fro movements with fanning and full wet suction with heparin [5].

Many different techniques for EUS-LB work well. The 22-G needle may be less daunting for inexperienced endosonographers. However, the safety of 19-G needles is outstanding, and the larger size is more likely to obtain histologically adequate specimens in general use.