Optimizing EUS-guided tissue acquisition: An international, multi-institution expert consensus

Background and Objectives: EUS-guided tissue acquisition (EUS-TA) techniques are evolving rapidly. Although several clinical guidelines exist, key procedural issues remain unresolved. This study aimed to identify these unmet needs and assess global practice patterns. Methods: A questionnaire was designed by the International Society for Endoscopic Ultrasound. We conducted a global, multi-institutional survey of corresponding authors who had published EUS-TA in the last 5 years. The survey was distributed and collected via email using the SurveyMonkey website. We analyzed the results by calculating agreement percentages for specific statements and by summarizing the most frequently selected options. Results: The survey was completed by 27 experts, all with extensive experience in EUS-TA (62.96% performing >200 cases annually). Consensus was achieved across 9 core domains. For subepithelial lesions, solid pancreatic masses, and most abdominal/extraluminal targets, histology was the preferred evaluation method, while cytology and histology were equally favored for biliary strictures and peritoneal carcinomatosis. For cytological assessment, 22G needles were recommended by 77.78% of experts; for histological assessment, 22G fine-needle biopsy (FNB) needles (specifically the Franseen design) were favored by 62.96%. For EUS-guided portal pressure gradient measurement, fine needles (22G/25G) were recommended by 85.18%, whereas for chronic liver fibrosis assessment, a 19G needle was preferred. For tumors requiring next-generation sequencing, the 22G FNB needle was the consensus choice, with most experts agreeing that establishing organoids requires at least one additional pass. The slow-pull technique was favored for most solid lesions (59.26%), and 85.19% agreed that FNB needles significantly reduced the need for rapid on-site evaluation, with macroscopic on-site evaluation preferred for assessing sample adequacy. For pancreatic cystic lesions, EUS-fine-needle aspiration was the most favored initial technique (51.85%), though routine DNA analysis was not recommended by most (63.0%). Antibiotic prophylaxis was supported by 48.15%, particularly when more invasive techniques were used. Most experts (96.03%) endorsed the fanning technique, and 59.26% did not believe needle-tract seeding risk was underestimated, though multiple passes were identified as the greatest contributing factor. Conclusions: Based on the responses, consensus recommendations were established for several fine-needle aspiration and fine-needle biopsy practice patterns. This international consensus guides controversial EUS-TA issues, which may help improve diagnostic efficacy and quality.