Objective assessment of an algorithmic approach to EUS-guided FNA and interventions

Background: Despite an increasing number of procedures being performed, there is no consensus on an optimal approach to EUS-guided FNA (EUS-FNA) or interventions. Objective: Validate an algorithmic approach to EUS-FNA/interventions with the objective of improving technical outcomes and resource use. Design: Prospective study. Setting: Tertiary-care referral center. Patients: Consecutive patients undergoing EUS-FNA and/or interventions. Intervention: Phase I was a retrospective analysis of EUS-FNA/interventions performed in 548 patients. The 19-gauge needle was used for interventions, and the 22- or 25-gauge needle was used interchangeably for performing FNAs. At phase I, the technical failure rate was 11.5%. Based on these observations, an algorithm was proposed by which all transduodenal FNAs were performed by using a 25-gauge needle and other FNAs with a 22-gauge needle. All transduodenal interventions were performed with a Flexible 19-gauge needle and others with a standard 19-gauge needle. This algorithm was tested prospectively in phase II on 500 patients. Main Outcome Measurements: Compare technical failure, diagnostic adequacy, procedural complications, and average needle costs between both phases. Results: The technical failure rate was significantly less in phase II compared with that of phase I (1.6% vs 11.5%; P <.001) for both FNA (1.8% vs 10.9%; P < .001) and therapeutic interventions (0% vs 16.4%; P = .001). Although there was no difference in diagnostic adequacy (97.1% vs 98.4%; P = .191) or complications (0.4% vs 0.2%; P = 1.0) between phases I and II, the average cost per case was significantly less in phase II ($199.59 vs $188.30; P = .008). Limitations: Single-center study. Conclusion: An algorithmic approach to EUS-FNA/interventions yielded better technical outcomes and cost savings without compromising diagnostic adequacy. (Gastrointest Endosc 2013; 77: 739-44.)