Radiology-guided percutaneous approach is superior to EUS for performing liver biopsies

Although liver biopsies (LBs) are being increasingly performed under endoscopic ultrasound (EUS) guidance, there are limited data comparing outcomes with current standard-of-care, transabdominal ultrasound (US)-guided percutaneous (PC) methods. In a randomised trial, we observed that the PC, US-guided method yielded significantly more optimal specimens, defined as specimen length of 25 mm or greater and presence of at least 11 complete portal tracts, compared with the EUS-guided method (57.9% vs 23.8%, p=0.028). Also, the PC method resulted in worse initial postprocedural pain but was less costly (US$1824 vs US$3240, p<0.001). Despite significant advances in non-invasive assessment, LB still remains the gold standard for evaluation of subacute and chronic liver diseases, whose clinical presentation can oftentimes be both confusing and challenging.1 LB is usually performed percutaneously under the guidance of real-time imaging using transabdominal US or CT, or via the transjugular approach in patients with underlying coagulopathy. More recently, endoscopists have been performing the procedure via the transgastric or transduodenal route under EUS guidance. Perceived advantages include the ability to simultaneously exclude diseases in the pancreas or bile duct, access to both the left and right lobes of the liver, and avoidance of intraprocedural pain as EUS is performed under sedation.2 While prospective single-arm and retrospective comparative studies suggest that EUS-guided LB can establish the diagnosis in more than 90% of patients and is equally successful,3 4 there are no randomised trials comparing outcomes with PC methods. Additionally, in the present era of cost containment, financial analysis is critical in healthcare decision-making, particularly for commonly indicated procedures such as LB. Therefore, we conducted a randomised trial comparing specimen quality and financial costs between PC and EUS-guided LB methods. Eligible consecutive patients from outpatient clinics or inpatient wards were referred by hepatologists to undergo LB and were randomised to either EUS-guided …