Endoscopic ultrasound‐guided versus percutaneous liver biopsy: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background Percutaneous liver biopsy (PC-LB) has long been the usual method for acquisition of liver tissue. Recently, endoscopic ultrasound-guided liver biopsy (EUS-LB) has gained popularity as an alternative modality. We aimed to compare the efficacy and safety of EUS-LB versus PC-LB.

Methods We systematically searched PubMed, Embase, and the Cochrane Library databases for randomized controlled trials (RCTs) comparing EUS-LB with PC-LB published until October 20, 2023. The primary outcome was diagnostic adequacy. Secondary outcomes were: the number of complete portal tracts (CPTs), longest sample length (LSL), total sample length (TSL), post-procedure pain scores, and adverse events (AEs), including overall AEs and AEs excluding minor post-procedure symptoms. We compared binary outcomes using risk ratios (RRs) and continuous outcomes using the mean difference (MD) or standardized mean difference (SMD), with 95%CIs.

Results Four RCTs (258 patients) were included. The EUS-LB group presented lower post-procedure pain scores (SMD −0.58, 95%CI −0.95 to −0.22) than the PC-LB group. Both groups performed similarly in terms of diagnostic adequacy (RR 1.0, 95%CI 0.96 to 1.04), number of CPTs (MD 2.57, 95%CI −4.09 to 9.22), LSL (MD −2.91 mm, 95%CI −5.86 to 0.03), TSL (MD 4.16 mm, 95%CI −10.12 to 18.45), overall AEs (RR 0.54, 95%CI 0.20 to 1.46), and AEs excluding minor post-procedure symptoms (RR 1.65, 95%CI 0.21 to 13.02).

Conclusions This meta-analysis suggests that EUS-LB is as safe and effective as PC-LB and is associated with lower post-procedure pain scores.

Registration on PROSPERO: CRD42023469469.

Introduction

Liver biopsy remains the gold standard for evaluating the nature and severity of liver disease, although there have been significant advances in noninvasive assessment [1]. Ultrasound-guided percutaneous liver biopsy (PC-LB) is currently the method of choice, despite its association with a noteworthy variability in the histologic yield and a non-negligible rate of adverse events (AEs), such as abdominal pain (13%), major bleeding (0.5%), and death (0.01%) [2] [3] [4].

Recently, interventional endoscopic ultrasound (EUS) has emerged with promising results for the diagnosis and management of liver disease, and the concept of “endohepatology” has been created to describe its applications [5] [6]. As part of this, endoscopic ultrasound-guided liver biopsy (EUS-LB) has been proposed as an attractive alternative technique for liver sampling, given its high rate of successful histologic diagnoses and low incidence of AEs [7] [8].

Two recent meta-analyses, both based mainly on observational studies, have compared EUS-LB versus PC-LB. Facciorusso et al. [9] found that both procedures presented similar results in terms of total sample length (TSL), number of complete portal tracts (CPTs), and the rate of severe AEs; however, Chandan et al. [10] demonstrated that PC-LB gave longer sample sizes and a higher number of CPTs. In terms of diagnostic adequacy, Chandan et al. found no significant difference between EUS-LB and PC‑LB (94.9% vs. 96.6%), while Facciorusso et al. described sample adequacy (defined as the proportion of samples defined as adequate for histologic diagnosis) as being similar between both groups (96.4% for EUS-LB and 99% for PC-LB) [9].

In view of the discrepancies mentioned above and recognizing that both of the previous studies were based on mainly observational data, we aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the diagnostic adequacy, number of CPTs, longest sample length (LSL), TSL, AEs, and post-procedure pain scores between EUS-LB and PC-LB.

Methods

This systematic review and meta-analysis was designed and reported according to the Cochrane Collaboration Handbook for Systematic Review of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [11] [12].

Search strategy and eligibility criteria

We selected trials according to the following inclusion criteria: RCTs published in English, comparing EUS-LB with PC-LB in adult patients undergoing liver biopsy, and reporting at least one of the outcomes of interest. Editorials, letters, reviews, systematic reviews, and meta-analyses were excluded.

Two authors (P.A.E.S. and A.L.N.) systematically searched PubMed, Embase, and the Cochrane Library to identify studies from inception to October 20, 2023. The search strategy is described in detail in Appendix 1s, see online-only Supplementary Material. After excluding duplicates, and titles and/or abstracts clearly unrelated to the clinical question, we assessed the eligibility of each remaining study based on full-text review of the articles. Additionally, we conducted a backward snowballing search for additional studies from the references of the included RCTs and previous systematic reviews and meta-analyses. Disagreements were resolved by a third author (G.C.M.).

Data extraction

Two authors (P.A.E.S. and A.L.N.) performed the data extraction independently. We extracted the following information from the included studies: study characteristics (first author, year of publication, design, and country); study population (number of patients, age, and sex); procedure specifications (type of needle used, technique, and route); indications for liver biopsy; and outcomes of interest. Missing standard deviations were estimated by applying the method of Wan and Luo, as per Cochrane recommendations [13] [14].

Outcomes

The primary outcome was diagnostic adequacy. Additional outcomes were: the number of CPTs, LSL, TSL, AEs (stratified as overall AEs, AEs excluding minor post-procedure symptoms, and post-procedure symptoms), and post-procedure pain scores.

Outcome definitions

We established the definition of each evaluated outcome using the criteria most employed by the studies included in the analysis (i.e. we determined the definitions after completing the data extraction). For all studies, diagnostic adequacy was defined as the ability to render a histopathologic diagnosis, regardless of the number of needle passes, length of biopsy cores, or number of portal tracts present in the specimen. The presence of all three portal structures (portal vein, hepatic artery, and bile duct) constituted one CPT. TSL was defined by all authors as the total core length achieved by liver biopsy; LSL was the maximum core length achieved.

Overall AEs were a composite of minor bleeding, intra-abdominal/perihepatic hematoma, pneumothorax, hemobilia, infection, death, and minor post-procedure symptoms (nausea, bloating, headache, or abdominal pain). The post-procedure pain score was evaluated 1 hour after EUS-LB or PC-LB through the Numeric Rating Scale – Pain Intensity (NRS-PI) for one study and with a Visual Analog Scale (VAS) for two other included studies [15] [16] [17].

Risk of bias and evidence quality assessment

We performed quality assessment using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) [18]. Two reviewers (P.A.E.S. and A.L.N.) independently assessed each study included in the analysis for the potential risk of bias across five domains, assigning a rating of high, low, or some concerns for each specific trial outcome. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of the evidence from the systematic review and meta-analysis, classifying it as high, moderate, low, or very low quality [19].

Data analysis and reporting

We used pooled risk ratios (RRs), and mean differences (MDs) or standardized mean differences (SMDs), with 95%CIs, for binary and continuous outcomes, respectively. We applied a Mantel–Haenszel random-effects model for all binary outcomes and inverse-variance method for continuous outcomes; the DerSimonian–Laird method was used to estimate between-study variance. P values <0.05 were considered statistically significant for all analyses.

We assessed between-study heterogeneity using Cochran’s Q test and I ² statistics; P values <0.10 and an I ² ≥25% were considered significant for between-study heterogeneity. We further performed leave-one-out sensitivity analyses to assess potential study dominance where there was substantial heterogeneity (I ² ≥50%). Statistical analysis was performed using Review Manager 5.4 (Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) and OpenMeta [Analyst] Software.

Results

Characteristics of the included studies

Our initial search yielded 257 results. As shown in [Fig. 1], after study triage, we included four studies (258 patients) [15] [16] [17] [20].

Fig. 1 PRISMA flow diagram of study identification, screening, and selection.

Three studies used 19G fine-needle biopsy (FNB) needles for the EUS-LB procedure [15] [17] [20], while the study by Samanta et al. [16] used 19G fine-needle aspiration (FNA) needles. Ali et al. [15] and Lariño-Noia et al. [20] used the heparin wet-suction technique during EUS-LB, whereas Bang et al. [17] employed a no-suction technique.

Lariño-Noia et al. [20] and Bang et al. [17] performed PC-LB with a 16G biopsy needle, Samanta et al. [16] used an 18G biopsy needle, and Ali et al. [15] used the latter needle for most procedures. PC-LB was performed in two studies by interventional radiologists [15] [17] and in a third one by expert hepatologists [20]; in all studies, the procedure was conducted under ultrasound guidance.

The main indications for liver biopsy were metabolic dysfunction-associated steatotic liver disease (MASLD) and abnormal liver enzymes. [Table 1] summarizes the study characteristics.

Table 1 Characteristics of the four included randomized controlled trials.

First author, year		Ali, 2023 [15]	Bang, 2021 [17]	Lariño-Noia, 2023 [20]	Samanta, 2022 [16] (abstract)
EUS-LB, endoscopic ultrasound-guided liver biopsy; FNA, fine-needle aspiration; FNB, fine-needle biopsy; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, MASLD and alcohol-related liver disease; N/A, not available; PC-LB, percutaneous liver biopsy. 1 For most procedures.
Location, centers		USA, single center	USA, single center	Spain, single center	India, two centers
Patients, n	EUS-LB	40	21	44	24
	PC-LB	40	19	46	24
Sex, female, n (%)	EUS-LB	27 (67.5%)	13 (61.9%)	22 (50.0%)	N/A
	PC-LB	27 (67.5%)	13 (68.4%)	25 (54.3%)	N/A
Age, median	EUS-LB	52.5	55	60.8	N/A
	PC-LB	53	55	58.1	N/A
Procedure specifications	EUS-LB	19G FNB needle; transduodenal route; wet suction; minimum 1 pass	19G FNB needle; transduodenal or transgastric route; no suction; minimum 2 passes	19G FNB needle; transduodenal and transgastric route; wet suction; minimum 2 passes	19G FNA needle
	PC-LB	18G needle1	16G needle	16G needle	18G needle
Indications for liver biopsy		Abnormal liver enzymes (65%); suspected MASLD (20%); fibrosis staging (15%)	N/A	MASLD (42%); MetALD (11%); alcohol-related liver disease (2%); autoimmune liver disease (30%); liver transplant (7%)	N/A

Quality assessment of the included studies

As depicted in Fig. 1s, one study was considered to have some concerns owing to incomplete reporting because it was a conference abstract and lacked information about the methods used for randomization and concealment, along with patient demographic data [16]. Sources of bias in the measurement of the outcomes were identified in the evaluation of the results of all studies, because of outcome assessors being aware of the intervention received by the study participants, which were therefore considered to have an unclear risk of bias. Publication bias was not assessed using funnel plots because the power of this test is insufficient to discriminate between chance and true funnel plot asymmetry when analyzing fewer than 10 studies [21].

Primary outcome

All studies reported the diagnostic adequacy rate. The pooled estimated diagnostic adequacy rate with EUS-LB was 97.8% (95%CI 95.3% to 100%) and with PC-LB was 97.4% (95%CI 94.6% to 100%) Therefore, the risk of diagnostic adequacy was similar between the two groups (RR 1.0, 95%CI 0.96 to 1.04; I ² = 0%) ([Fig. 2]).

Fig. 2 Comparison of diagnostic adequacy between endoscopic ultrasound-guided liver biopsy (EUS-LB) and percutaneous liver biopsy (PC-LB).

Secondary outcomes

Number of CPTs

Three studies [15] [16] [20], encompassing 218 patients, reported the number of CPTs in the sample. The pooled mean number of CPTs in the EUS-LB group was 14.4 (95%CI 11.3 to 17.5) and in the PC-LB group was 11.9 (95%CI 7.2 to 16.6). There was no significant difference in the number of CPTs between the two groups (MD 2.57, 95%CI −4.09 to 9.22; I ² = 93%) ([Fig. 3] a). After sensitivity analysis, no single study excessively influenced the effect estimate or drove heterogeneity (Table 1s).

Fig. 3 Comparison between endoscopic ultrasound-guided liver biopsy (EUS-LB) and percutaneous liver biopsy (PC-LB) in terms of: a number of complete portal tracts; b longest sample length; c total sample length.

Longest sample length

The LSL was reported in all studies. The EUS-LB and PC-LB groups had similar LSLs (MD −2.91 mm, 95%CI −5.86 to 0.03; I ² = 87%) ([Fig. 3] b). No single RCT was found to excessively drive between-study heterogeneity, but exclusion of the study by Ali et al. [15] resulted in a significantly shorter LSL in the EUS-LB group (MD −4.36 mm, 95%CI −6.43 to −2.29; I ² = 71%) (Table 1s).

Total sample length

Three studies [15] [16] [20], including 218 patients, reported the TSL. There was no significant difference in the TSL between the groups (MD 4.16 mm, 95%CI −10.12 to 18.45; I ² = 92%) ([Fig. 3] c). In the sensitivity analysis, no single RCT was found to excessively drive between-study heterogeneity but, after exclusion of the study by Ali et al. [15], the EUS-LB group had a significantly higher TSL compared with the PC-LB group (MD 12.13 mm, 95%CI 0.41 to 23.84; I ² = 88%) (Table 1s).

Adverse events and post-procedure symptoms

Most AEs were mild post-procedure symptoms and their prevalence varied greatly among the studies. The overall AE rate was reported in three studies [15] [16] [20]. EUS-LB had a pooled rate of 14.8% (95%CI 6.7% to 22.9%) and PC-LB of 42.1% (95%CI −9.4% to 93.6%), therefore the risk for overall AEs was similar between the two techniques (RR 0.54, 95%CI 0.20 to 1.46; I ² = 68%) (Fig. 2s, part A). In the sensitivity analysis, exclusion of the study by Lariño-Noia et al. [20] favored the EUS-LB group but maintained high heterogeneity (RR 0.37, 95%CI 0.16 to 0.88; I ² = 60%) (Table 1s).

All studies reported AEs excluding minor post-procedure symptoms and the risk was similar between the groups (RR 1.65, 95%CI 0.21 to 13.02; I ² = 0%) (Fig. 2s, part B). Three studies [15] [16] [20] reported post-procedure symptoms (RR 0.51, 95%CI 0.16 to 1.64; I ² = 70%) (Fig. 2s, part C), and there were similar risks for both outcomes between the groups. After sensitivity analysis, no single study excessively influenced the effect estimate or drove heterogeneity.

Post-procedure pain scores

Post-procedure pain scores were reported in three studies [15] [16] [17] and were significantly lower in the EUS-LB group compared with the PC-LB group (SMD −0.58, 95%CI −0.95 to −0.22; I ² = 0%) ([Fig. 4]).

Fig. 4 Comparison of pain scores 1 hour after the procedure between the endoscopic ultrasound-guided liver biopsy (EUS-LB) and percutaneous liver biopsy (PC-LB) groups.

Evidence quality assessment

[Table 2] summarizes the main results and overall certainty of evidence according to the GRADE tool for RCTs.

Table 2 The outcomes of endoscopic ultrasound-guided liver biopsy (EUS-LB) compared with percutaneous liver biopsy (PC-LB).

	Anticipated absolute effects (95%CI)1		Relative effect (95%CI)	Participants (studies), n	Certainty of the evidence (GRADE)2	Comments
	Risk with PC-LB	Risk with EUS-LB
AE, adverse event; MD, mean difference; RCT, randomized controlled trial; RR, risk ratio; SMD, standardized mean difference. 1 The risk in the intervention group (and its 95%CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95%CI). 2 GRADE Working Group grades of evidence are as follows: high certainty, we are very confident that the true effect lies close to that of the estimate of the effect; moderate certainty, we are moderately confident in the effect estimate – the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different; low certainty, our confidence in the effect estimate is limited – the true effect may be substantially different from the estimate of the effect; very low certainty, we have very little confidence in the effect estimate – the true effect is likely to be substantially different from the estimate of effect.
Diagnostic adequacy	97.4 per 100 (94.6 to 100)	97.8 per 100 (95.3 to 100)	RR 1.00 (0.96 to 1.04)	258 (4 RCTs)	⊕⊕⊕⊕ High
Number of complete portal tracts (CPTs)	Mean CPTs ranged from 7.2 to 16.6	MD 2.57 more (4.09 fewer to 9.22 more)	–	218 (3 RCTs)	⊕⊕⊕○ Moderate	Substantial heterogeneity between studies.
Total specimen length (TSL)	Mean TSL ranged from 15.0 to 58.9 mm	MD 4.16 mm higher (10.12 lower to 18.45 higher)	–	218 (3 RCTs)	⊕⊕⊕○ Moderate	Substantial heterogeneity between studies.
Longest specimen length (LSL)	Mean LSL ranged from 10.5 to 25.9 mm	MD 2.91 mm lower (5.86 lower to 0.03 higher)	–	258 (4 RCTs)	⊕⊕⊕○ Moderate	Substantial heterogeneity between studies.
AEs (excluding minor symptoms)	2.5 per 100 (0.8 to 7.5)	2 per 100 (0.6 to 6.5)	RR 1.65 (0.21 to 13.02)	258 (4 RCTs)	⊕⊕⊕⊕ High
Post-procedure pain score	–	SMD 0.58 lower (0.95 lower to 0.22 lower)	–	168 (3 RCTs)	⊕⊕⊕⊕ High

Discussion

In this systematic review and meta-analysis of four RCTs, we compared EUS-LB with PC-LB for obtaining liver biopsy samples. There were nonsignificant differences between both methods regarding diagnostic adequacy, number of CPTs, LSL, TSL, and AEs excluding minor post-procedure symptoms; however, EUS-LB was associated with lower post-procedure pain scores compared with PC-LB.

Some valuable advantages of EUS-LB are that patient comfort can be enhanced through sedation, multiple needle passes can be performed with a single hepatic capsule puncture, and liver biopsy can be conducted in patients with ascites, a scenario where PC-LB is usually considered to be contraindicated [22] [23] [24]. Furthermore, EUS-LB enables easy sampling of multiple liver segments, a task that is difficult to achieve through PC-LB. Under EUS guidance, the hepatic left lobe can be reached from the proximal stomach, while the right lobe can be accessed through the duodenal bulb [25].

The potential disadvantages of EUS-LB are the longer procedure time, limited accessibility, and higher cost compared with PC-LB [10]. Only Bang et al. [17] provided mean procedural cost information, showing that PC-LB was less expensive than EUS-LB (US$1824 vs. US$3240; P < 0.001), with the cost difference partly associated with the additional sedation cost for the endoscopic procedure.

Despite being more invasive and expensive, EUS-LB could be considered as an alternative to PC-LB for those patients who require additional procedures that may be provided by upper gastrointestinal endoscopy or EUS, such as upper gastrointestinal evaluation, endoscopic shear wave elastography, portal pressure gradient measurement, EUS-guided vascular therapy for portal hypertension management, and EUS-guided radiofrequency ablation of liver tumors [5] [6] [26] [27] [28]. Integrating endoscopic procedures may reduce the total cost and provide a comprehensive single-session evaluation and treatment of the patient with liver disease [22] [26] [29] [30].

Although not within the scope of this review, the transjugular approach represents another option for obtaining liver tissue. This method may be more appropriate for patients with ascites who cannot tolerate the sedation typically required during EUS procedures. In addition, this procedure may be a good alternative when portal venous pressure measurements are required and are not available through EUS guidance [31].

Sampling variability in liver biopsy is almost unavoidable as the parenchymal abnormalities are irregularly distributed in almost all liver diseases. For instance, in a single pass, even with over 15 mm of tissue collected, there is a 14% chance of confusing steatohepatitis with simple steatosis [32]. Therefore, the American Association for the Study of Liver Diseases (AASLD) recommends that a satisfactory biopsy specimen must be at least 20 mm in length and present an adequate number of CPTs (>11) [32].

Only two of the included RCTs provided data on the rate of optimal specimen acquisition according to the AASLD guidelines, with conflicting results. Bang et al. [17] found higher rates of optimal specimen acquisition with PC-LB than with EUS-LB (57.8% of patients vs. 23.8%), while Lariño-Noia et al. [20] found better results with EUS-LB (95.4% of patients vs. 32.6%). The EUS-LB groups in both of these studies employed 19G FNB needles and a minimum of two passes were performed for all patients, but there were variations in the EUS-LB technique. Bang et al. [17] used the no-suction EUS-LB technique and generally the biopsies were taken from the right lobe of the liver. Lariño-Noia et al. [20] used the wet-suction EUS-LB technique and biopsies were taken from both the right and left lobes of the liver. The PC-LB groups of both studies used 16G needles and a second pass was only made if the first pass yielded no specimen.

In the present meta-analysis, although the mean number of CPTs, TSL, and LSL were similar for EUS-LB and PC-LB, these outcomes exhibited high heterogeneity. Notably, one study by Ali et al. [15] reported divergent results for all three outcomes. In the RCT by Ali et al. [15], the EUS-LB procedures used a 19G FNB needle, with a minimum of one pass performed for all patients, generally targeting the right lobe of the liver and using the wet-suction technique. The sensitivity analysis revealed that excluding the study by Ali et al. [15] resulted in a shorter LSL and larger TSL in the EUS-LB group compared with the PC-LB group. These findings suggest that, while the LSL may be shorter with EUS-LB, this may be compensated for by a larger TSL, possibly owing to the performance of a minimum of two passes during the EUS-LB procedure in most studies, ultimately yielding similar diagnostic adequacy.

The incidence of AEs excluding minor post-procedure symptoms was very low and the risks were similar between the groups. EUS-LB and PC-LB also had a similar risk of overall AEs, but this outcome exhibited high heterogeneity, probably due to the large variability observed in the incidence of minor post-procedure symptoms, which constituted most of the overall AEs and were subject to nonobjective measurement.

Our study has some strengths, particularly the inclusion of RCTs, which minimizes the potential confounding factors frequently present in observational data. The included studies were conducted on different continents, thereby enhancing the generalizability of the results obtained in this meta-analysis. Additionally, we used rigorous methods that were predetermined in the meta-analysis protocol.

This study also has several limitations. First, the included studies had relatively small sample sizes, which can result in over- or underestimation of the underlying treatment effect; however, this underscores the importance of pooling data in a meta-analysis. Second, some outcomes had significant between-study heterogeneity, as discussed previously. Possible sources of this heterogeneity may include the variations in needle size used in PC-LB, the diverse EUS-LB techniques, and nonobjective measurement of “minor post-procedure symptoms” across the included trials. Finally, the limitations of insufficient patient-level data, small sample size, and high heterogeneity prevented us performing a detailed subgroup analysis.

In conclusion, this meta-analysis indicates that EUS-LB and PC-LB are equally effective in terms of diagnostic adequacy, number of CPTs, TSL, LSL, and risk of AEs; however, EUS-LB is associated with lower post-procedure pain scores.

Conflict of Interest

F. Maluf-Filho has served on the advisory boards of Boston Scientific, Olympus, Medtronic, and Cook in the past 3 years. P.A. do Espirito Santo, G.C. Meine, A.L. Nau, E.C. Barbosa, S. Baraldo, and L. Lenz declare that they have no conflict of interest.

• References

• 1 Bravo AA, Sheth SG, Chopra S. Liver biopsy. NEJM 2001; 344: 495-500
• 2 Regev A, Berho M, Jeffers LJ. et al. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection. Am J Gastroenterol 2002; 97: 2614-2618
• 3 Neuberger J, Patel J, Caldwell H. et al. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut 2020; 69: 1382-1403
• 4 Thomaides-Brears HB, Alkhouri N, Allende D. et al. Incidence of complications from percutaneous biopsy in chronic liver disease: a systematic review and meta-analysis. Dig Dis Sci 2022; 67: 3366-3394
• 5 Lesmana CRA, Paramitha MS, Gani RA. The role of interventional endoscopic ultrasound in liver diseases: what have we learnt?. Can J Gastroenterol Hepatol 2021; 2021: 9948979
• 6 Rudnick SR, Conway JD, Russo MW. Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound. World J Hepatol 2021; 13: 887-895
• 7 Dewitt J, McGreevy K, Cummings O. et al. Initial experience with EUS-guided Tru-cut biopsy of benign liver disease. Gastrointest Endosc 2009; 69: 535-542
• 8 Mohan BP, Shakhatreh M, Garg R. et al. Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis. Gastrointest Endosc 2019; 89: 238-246.e3
• 9 Facciorusso A, Crinò SF, Ramai D. et al. Diagnostic yield of endoscopic ultrasound-guided liver biopsy in comparison to percutaneous liver biopsy: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16: 51-57
• 10 Chandan S, Deliwala S, Khan SR. et al. EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes. Endosc Ultrasound 2023; 12: 171-180
• 11 Higgins J, Thomas J, Chandler J. et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane. 2022 Accessed July 08, 2024 at: www.training.cochrane.org/handbook
• 12 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
• 13 Luo D, Wan X, Liu J. et al. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res 2018; 27: 1785-1805
• 14 Wan X, Wang W, Liu J. et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014; 14: 135
• 15 Ali AH, Nallapeta NS, Yousaf MN. et al. EUS-guided versus percutaneous liver biopsy: A prospective randomized clinical trial. Endosc Ultrasound 2023; 12: 334-341
• 16 Samanta J, Chavan R, Gupta P. et al. EUS-guided liver biopsy scores over radiology guided percutaneous liver biopsy: a multicenter randomised controlled trial. Gastrointest Endosc 2022; 95: AB485-AB486
• 17 Bang JY, Ward TJ, Guirguis S. et al. Radiology-guided percutaneous approach is superior to EUS for performing liver biopsies. Gut 2021; 70: 2224-2226
• 18 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
• 19 Schünemann HJ, Oxman AD, Brozek J. et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008; 336: 1106-1110
• 20 Lariño-Noia J, Fernández-Castroagudín J, de la Iglesia-García D. et al. Quality of tissue samples obtained by endoscopic ultrasound-guided liver biopsy: a randomized, controlled clinical trial. Am J Gastroenterol 2023; 118: 1821-1828
• 21 Lau J, Ioannidis JPA, Terrin N. et al. The case of the misleading funnel plot. BMJ 2006; 333: 597-600
• 22 Téllez-Ávila FI, García-Saenz-de-Sicilia M. Endohepatology: current status and perspectives. Ann Hepatol 2022; 27: 100730
• 23 Pineda JJ, Diehl DL, Miao CL. et al. EUS-guided liver biopsy provides diagnostic samples comparable with those via the percutaneous or transjugular route. Gastrointest Endosc 2016; 83: 360-365
• 24 Sundaram S, Shah B, Jagtap N. et al. Diagnostic efficacy of endoscopic ultrasound-guided liver biopsy for diffuse liver diseases and its predictors – a multicentric retrospective analysis. Clin Exp Hepatol 2023; 9: 243-250
• 25 Ramai D, Pannu V, Facciorusso A. et al. Advances in endoscopic ultrasound (EUS)-guided liver biopsy. Diagn Basel Switz 2023; 13: 784
• 26 Diehl DL. Top tips regarding EUS-guided liver biopsy. Gastrointest Endosc 2022; 95: 368-371
• 27 Choi AY, Chang KJ, Samarasena JB. et al. Endoscopic ultrasound-guided porto-systemic pressure gradient measurement correlates with histological hepatic fibrosis. Dig Dis Sci 2022; 67: 5685-5692
• 28 Rangwani S, Ardeshna DR, Mumtaz K. et al. Update on endoscopic ultrasound-guided liver biopsy. World J Gastroenterol 2022; 28: 3586-3594
• 29 DeWitt JM, Arain M, Chang KJ. et al. Interventional endoscopic ultrasound: current status and future directions. Clin Gastroenterol Hepatol 2021; 19: 24-40
• 30 Diehl DL, Confer B, Adler DG. et al. EUS-guided versus percutaneous liver biopsy: Do we have a winner?. Endosc Ultrasound 2022; 11: 339-341
• 31 Shuja A, Alkhasawneh A, Fialho A. et al. Comparison of EUS-guided versus percutaneous and transjugular approaches for the performance of liver biopsies. Dig Liver Dis 2019; 51: 826-830
• 32 Rockey DC, Caldwell SH, Goodman ZD. et al. Liver biopsy. Hepatology 2009; 49: 1017-1044

Publication History

Received: 13 December 2023

Accepted after revision: 07 June 2024

Article published online:
28 August 2024