Post written by Patrick T. Magahis, BA, from the Joan & Sanford I. Weill Medical College of Cornell University, and SriHari Mahadev, MD, MS, from the Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.

We present a novel EUS-guided liver biopsy (EUS-LB) approach, the hydrostatic stylet technique, resulting in a high-quality core sample with minimal fragmentation or blood contamination for the evaluation of hepatic tissue.

Although EUS-LB is a promising and increasingly used alternative to percutaneous and transjugular approaches, several limitations have prevented its widespread adoption beyond tertiary care centers. Among these, a major reason is the lack of procedural standardization that has contributed in part to concerns about poor histological specimen adequacy and risks of bleeding.

Therefore, we wanted to showcase a new and accessible protocol capable of routinely and safely acquiring high-quality liver biopsy specimens with one pass.

We give a step-by-step demonstration of a novel EUS-LB hydrostatic stylet technique shown to increase biopsy sample yield in which: (1) a needle is pre-flushed with saline prior to reinsertion to provide lubrication and a hydrostatic column of fluid, (2) a stylet is partially reinserted to minimize friction with the endoscope, (3) the stylet is held motionless while the needle is synchronously advanced, (4) the needle is advanced with a sharp thrust to near (but not through) the contralateral liver edge, and (5) multiple actuations can be performed while avoiding passage through the viscus wall and liver capsule more than once.

We also share data showing high-quality specimens can be reliably and safely acquired using this method, which achieves not only high diagnostic adequacy via only a single needle pass through the liver capsule but also overcomes previously described limitations of conventional methods such as specimen fragmentation, blood contamination, and risks of multiple needle passes.

We report a diagnostic adequacy rate of 100% when using the hydrostatic stylet technique in 44 liver parenchymal biopsies and 97% in 180 procedures, including both liver parenchymal and solid lesion biopsies, over the past 2 years. Rates of procedure-related adverse events also were noted to be similar to those in published prospective studies.

With minimal passes needed to obtain high sample adequacy, the hydrostatic stylet technique offers a novel approach for the procurement of high-quality liver biopsy samples.

EUS-guided liver biopsy hydrostatic stylet sampling technique. A, Assistant’s arm in bracing position and motionless stylet grip. B, Assistant releases stylet as actuation motion is completed and needle is withdrawn. C, EUS view of needle puncture within liver (arrow).

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