Comparative Diagnostic Yield of Different Endoscopic Techniques for Tissue Sampling of Upper Gastrointestinal Subepithelial Lesions: A Network Meta-analysis

Background and aims: There is limited evidence on the comparative diagnostic performance of endoscopic tissue sampling techniques of subepithelial lesions (SELs). We performed a systematic review with network meta-analysis to compare these techniques. Methods: A systematic literature review was conducted for randomized-controlled trials (RCTs) comparing the sample adequacy and diagnostic accuracy of bite-on-bite biopsy, mucosal incision-assisted biopsy (MIAB), endoscopic ultrasound fine-needle aspiration (EUS-FNA), or EUS fine-needle biopsy (FNB). Results were expressed as risk ratio (RR) and 95% confidence interval (CI). Results: Overall, 8 RCTs were identified. EUS-FNB resulted significantly superior to EUS-FNA in terms of sample adequacy (RR 1.20, 1.05-1.45), whereas none of the other techniques significantly outperformed EUS-FNA. Additionally, bite-on-bite biopsy was significantly inferior to EUS-FNB (RR 0.55, 0.33-0.98). Overall, EUS-FNB resulted as the best technique (SUCRA 0.90) followed by MIAB (SUCRA 0.83), whereas bite-on-bite biopsy showed the poorest performance. When considering lesions <2 cm, MIAB but not EUS-FNB showed significantly higher accuracy rates as compared to EUS-FNA (RR 1.68, 1.02-2.88). Overall, MIAB ranked as the best intervention for lesions < 2 cm (SUCRA score 0.86 for adequacy and 0.91 for accuracy), with EUS-FNB only slightly superior to EUS-FNA. When rapid on-site cytological evaluation (ROSE) was available, no difference among EUS-FNB, EUS-FNA and MIAB was observed. Conclusion: EUS-FNB and MIAB seem to provide better performance, while bite-on-bite sampling is significantly inferior to the other techniques. MIAB seems to be the best option for smaller lesions, whereas EUS-FNA remains competitive when ROSE is available