Comparative Diagnostic Performance of Different Techniques for Endoscopic Ultrasound-Guided Fine-Needle Biopsy of Solid Pancreatic Masses: A Network Meta-analysis

Background and aims: There is limited evidence on the comparative diagnostic performance of tissue sampling techniques for endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) of pancreatic masses. We performed a systematic review with network meta-analysis to compare these techniques. Methods: Rates of sample adequacy, blood contamination, and tissue integrity using FNB needles were evaluated. Direct and indirect comparisons were performed among slow-pull technique, "dry suction", "modified wet suction", or "no suction". Results were expressed as risk ratio (RR) and 95% confidence interval (CI). Results: Overall, 9 RCTs (756 patients) were identified. On network meta-analysis, "no suction" technique was significantly inferior to the other techniques (RR 0.85, 95% CI 0.78-0.92 vs slow pull; RR 0.85, 0.78-0.92 vs "dry suction"; RR 0.83, 0.76-0.90 vs "modified wet suction") in terms of sample adequacy. Consequently, "modified wet suction" resulted as the best technique (SUCRA 0.90), with "no suction" showing poorer performance in terms of sample adequacy (SUCRA score 0.14). "Dry suction" was associated with significantly higher rates of blood contamination as compared to slow pull (RR 1.44, 1.15-1.80), whereas "no suction" led to less blood contamination of samples in comparison to other techniques (RR 0.71, 0.52-0.97 vs slow pull; RR 0.49, 0.36-0.66 vs "dry suction"; RR 0.57, 0.40-0.81 vs "modified wet suction"). "Modified wet suction" significantly outperformed "dry suction" in terms of tissue integrity of the sample (RR 1.36, 1.06-1.75). Conclusion: "Modified wet suction" seems to provide high rates of integrity and adequate samples, although with high blood contamination. "No suction" technique performs significantly worse than other sampling strategies.