Endoscopic ultrasound-guided through-the-needle microforceps biopsy improves diagnostic yield for pancreatic cystic lesions: a systematic review and meta-analysis

Abstract

Background and study aims Given variable diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for pancreatic cystic lesions (PCLs), a through-the-needle (TTN) microforceps biopsy device passed through a 19-gauge FNA needle has been devised to improve tissue sampling. This was a systematic review and meta-analysis to evaluate the feasibility, diagnostic yield, and safety of EUS-guided TTN microforceps biopsy for diagnosis of PCLs. Methods Individualized searches were developed in accordance with PRISMA and MOOSE guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, diagnostic yield, accuracy, and procedure-associated adverse events (AEs) as well as comparison to conventional FNA. Results Eleven studies (n = 518 patients; mean age 64.13 ± 5.83 years; 58.19 % female) were included. Mean PCL size was 33.39 ± 3.72 mm with the pancreatic head/uncinate (35.50 %) being the most common location. A mean of 2.47 ± 0.92 forceps passes were performed with a mean of 2.79 ± 0.81 microbiopsies obtained per lesion. Pooled technical success was 97.12 % (95 % CI, 93.73–98.71; I2 = 34.49) with a diagnostic yield of 79.60 % (95 % CI, 72.62–85.16; I2 = 56.00), and accuracy of 82.76 % [(95 % CI, 77.80–86.80; I2 = 0.00). The pooled serious adverse event rate was 1.08 % (95 % CI, 0.43–2.69; I2 = 0.00). Compared to conventional FNA, TTN microforceps biopsy resulted in significant improvement in diagnostic yield [OR 4.79 (95 % CI: 1.52–15.06; P = 0.007)] and diagnostic accuracy [OR 8.69 (95 % CI, 1.12–67.12; P = 0.038)], respectively. Conclusions EUS-guided TTN microforceps biopsy appears to be safe and effective for diagnosis of PCLs with improvement in diagnostic yield and accuracy when compared to FNA alone.

The evolving role of EUS‐guided tissue acquisition

“…A through‐the‐needle (TTN) microforceps inserted through a 19‐G FNA needle was designed to acquire tissue from the wall of pancreatic cystic lesions, given the limited sensitivity using FNA needles (Figure 8). McCarty and Rustagi 31 performed a meta‐analysis of studies that used this microforceps for evaluation of pancreatic cystic lesions. They reported that the technical success was 97.12% (95% CI 93.73%–98.71%), diagnostic yield was 79.60% (95% CI 72.62%–85.16%), and accuracy was 82.76% (95% CI 77.80%–86.80%).…”

Risk Stratification of Pancreatic Cysts With Confocal Laser Endomicroscopy

“…32,41 A systematic review (mostly including retrospective studies) comprising a pooled analysis of over 500 patients showed improvement in diagnostic yield (odds ratio 4.79, P ¼ .007) compared with FNA cytology. 42 In a retrospective analysis comparing the addition of MFB to FNA and nCLE, the use of MFB and nCLE led to discontinuation of surveillance (in 11%) and avoidance of surgery (in 25%). 32 The diagnostic yield of nCLE was the highest (84%) and improved (93%) in combination with MFB and cytology; however, the improvement in the diagnostic yield was statistically insignificant raising questions on the value of adding MFB in setting of nCLE and FNA.…”

“…32 Adverse events were reported in 8%-9% of patients undergoing MFB. 41,42 Most common adverse events were mild acute pancreatitis and intracystic bleeding which were managed conservatively. The serious adverse event was rare, with approximately 1% of patients reporting severe acute pancreatitis.…”

“…The serious adverse event was rare, with approximately 1% of patients reporting severe acute pancreatitis. 42 Although MFB has the potential to be a candidate to complement nCLE in the diagnosis of PC, the advantage of the procedure over nCLE alone is yet to be confirmed in prospective studies.…”

Comments on: “Fine-needle aspiration of pancreatic cystic lesions: a randomized study with long-term follow-up comparing standard and flexible needles”

“…In the two largest prospective studies evaluating EUS-nCLE, the risk of acute pancreatitis ranged from 1.5 % to 3.5 % [3,4]. During TTNB, the risk of post-procedure acute pancreatitis was 3.9 % in a large meta-analysis [5]; however, a more recent single-center large prospective study revealed a rate of 8.9 %, including one patient with acute pancreatitisrelated mortality [6]. In the study of Al-Haddad et al, the authors report acute pancreatitis as being a serious adverse event in 1 % of patients (n = 3).…”