Shrestha UK. Preventive strategies for complications after endoscopic ultrasound-guided fine-needle biopsy. World J Gastrointest Endosc 2026; 18(7): 119987 [DOI: 10.4253/wjge.119987]
Corresponding Author of This Article
Umid K Shrestha, MD, PhD, Professor, Department of Gastroenterology and Hepatology, Nepal Mediciti Hospital, Bhaisepati, Ward No. 18, Lalitpur 44700, Bagmati, Nepal. umidshrestha@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
editorial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Shrestha UK contributed to the conceptualization and design, wrote the original draft, and reviewed and edited.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Umid K Shrestha, MD, PhD, Professor, Department of Gastroenterology and Hepatology, Nepal Mediciti Hospital, Bhaisepati, Ward No. 18, Lalitpur 44700, Bagmati, Nepal. umidshrestha@gmail.com
Received: February 12, 2026 Revised: March 4, 2026 Accepted: April 3, 2026 Published online: July 16, 2026 Processing time: 154 Days and 17.8 Hours
Abstract
In this editorial, we comment on the paper from Peruhova et al on this issue of World Journal of Gastointestinal Endoscopy. The major complications of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) include perforation, bleeding, infection, acute pancreatitis when sampling pancreatic lesions, bile peritonitis, needle tract seeding, and device-related malfunctions. The preventive strategies for complications following EUS-FNB include careful pre-procedural planning, technical efficiency during the procedure, and appropriate post-procedure care. In order to prevent the inadvertent perforation, one has to be careful about the presence of any esophageal stricture, diverticula, or anatomical abnormalities. The complication of bleeding can be minimized by the use of color Doppler to avoid puncturing intervening blood vessels, by limiting the number of passes, and by adhering to the guidelines to stop the anticoagulants and antiplatelets prior to the procedure. The risk of infection can be prevented by maintaining strict aseptic precautions, aspirating the cyst completely when present, and using antibiotic prophylaxis in patients with a high risk of infection, such as those with a pancreatic cyst. Acute pancreatitis can be prevented by minimizing the puncture of the main pancreatic duct and minimizing the number of needle passes. Bile peritonitis can be prevented by avoiding inadvertent puncture of the common bile duct or intrahepatic ducts when the target lesion is in close proximity to the bile duct. The needle tract seeding can be prevented by selecting the proper needle route in the possible resection field and by limiting the needle passes. EUS-FNB needs specific ethical considerations, which involve the balancing of the need for accurate histological diagnosis with patient safety, procedural risks, and informed consent. The proper use of suitable strategies to avoid complications will help the endosonographer to perform EUS-FNB safely and effectively.
Core Tip: The major complications of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) include perforation, bleeding, infection, acute pancreatitis when sampling pancreatic lesions, bile peritonitis, needle tract seeding where tumor cells are deposited along the needle track, and device-related malfunctions. The preventive strategies for complications following EUS-FNB include careful pre-procedural planning, technical efficiency during the procedure, and appropriate post-procedure care. EUS-FNB needs specific ethical considerations, which involve the balancing of the need for accurate histological diagnosis with patient safety, procedural risks, and informed consent. The proper use of suitable strategies to avoid complications will help the endosonographer to perform EUS-FNB safely and effectively.
Citation: Shrestha UK. Preventive strategies for complications after endoscopic ultrasound-guided fine-needle biopsy. World J Gastrointest Endosc 2026; 18(7): 119987
This editorial refers to “Complication incidence after endoscopic ultrasound-guided fine needle biopsy - a single-center experience” by Peruhova et al, 2026; https://doi.org/10.4253/wjge.v18.i4.111687.
INTRODUCTION
In this editorial, we comment on the paper from Peruhova et al on this issue of World Journal of Gastointestinal Endoscopy. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an effective procedure for tissue acquisition from lesions in the gastrointestinal tract and adjacent organs. Fine-needle biopsy (FNB) needles are advanced, minimally invasive tools designed to acquire larger “core” specimens that preserve tissue architecture and permit histologic evaluation and immunohistologic staining. FNB needles differ from fine-needle aspiration (FNA) needles through their geometric shape of specialized cutting tip designs (e.g., Franseen-type needle, fork-tip needle) or a side slot (core trap) at the needle tip (Figure 1)[1-4].
Figure 1 Fine-needle biopsy needles for endoscopic ultrasound-guided tissue acquisition.
The procedural techniques for FNB are generally similar to those used for FNA and involve to-and-fro movement within the target lesion and the use of suction or slow-pull, with FNB often requiring fewer passes[5]. Studies confirm that while newer, more aggressive, and larger FNB needles like Franseen (e.g., Acquire) and fork-tip (e.g., SharkCore) provide superior histological specimens and higher diagnostic accuracy, they exhibit complication rates similar to traditional FNA[6]. The currently available newer generation FNB needles are significantly changing the diagnosis of pancreatic, liver, and gastrointestinal tract diseases. EUS-FNB is considered an ideal sampling technique because it combines high cellular yield with the preservation of tissue structure, allowing for both detailed histological examination and advanced molecular testing[7].
Under direct endoscopic ultrasound guidance, the FNB needle punctures the gastrointestinal wall, typically at the point closest to the lesion. Regarding the needle selection, a 19-G needle is suitable for core biopsies in non-angulated positions (e.g., lymph nodes, liver), a 22-G needle is versatile and commonly used for pancreatic masses, and a 25-G needle is ideal for hard, fibrotic lesions (e.g., chronic pancreatitis). The biopsy technique involves different aspiration methods, which include slow pull, suction, and wet suction, and is based on the lesion characteristics. The tissue acquisition is maximized by the fanning technique, which involves sampling different regions of a target lesion without completely removing the needle from it; two to three needle passes are usually sufficient for core tissue sampling. Transgastric and transduodenal EUS-FNB of a pancreatic mass with the use of to-and-fro motion of the FNB needle, along with the fanning technique, are shown in Figures 2 and 3. The clinical indications and applications of EUS-FNB are shown in Table 1.
Figure 2 Endoscopic ultrasound-guided fine-needle biopsy of a mass.
A: Transgastric endoscopic ultrasound-guided fine-needle biopsy of a mass in the body of the pancreas; B: To-and-fro movement of the Fine-needle biopsy needle; C: Oscillations of the Fine-needle biopsy needle inside the lesion (“fanning technique”). EUS-FNB: Endoscopic ultrasound-guided fine-needle biopsy; FNB: Fine-needle biopsy.
Figure 3 Transgastric endoscopic ultrasound-guided.
A: Transduodenal endoscopic ultrasound-guided fine-needle biopsy of a mass in the head of the pancreas; B: To-and-fro movement of the fine-needle biopsy needle; C: Oscillations of the fine-needle biopsy needle inside the lesion (“fanning technique”). EUS-FNB: Endoscopic ultrasound-guided fine-needle biopsy; FNB: Fine-needle biopsy.
Table 1 Clinical indications and applications of endoscopic ultrasound-guided fine-needle biopsy.
Despite being considered a generally safe procedure, EUS-FNB is associated with some potential complications; some complications are due to the effect of procedural sedation, while others are due to the echoendoscope itself or the sampling procedure. Most complications are associated with inexperience or trainee involvement, and hence, supervision is the key. Training in EUS-FNB is a progressive journey that requires theoretical knowledge, including a solid foundation in EUS imaging, anatomy, and biopsy techniques, simulation-based practice, and supervised live experience. The preventive strategies for complications following EUS-FNB include careful pre-procedural planning, technical efficiency during the procedure, and appropriate post-procedure care. The incidence and risk factors of complications after EUS-guided procedures[8] are given in Table 2. After a thorough evaluation of indications, advantages, limitations, and risk factors of EUS-FNB, the proper preventive measures should be followed to use it safely and effectively.
Table 2 Incidence and risk factors of complications after endoscopic ultrasound-guided procedure[8].
Complications
Incidence (%)
Risk factors
Perforation
0.02-0.08
Trainee involvement, operator inexperience, older patient, history of difficult esophageal intubation, presence of esophageal malignancy, cervical spine osteophytes
COMPLICATIONS OF EUS-FNB AND THEIR PREVENTIVE MEASURES
Perforation
Luminal perforation during routine endoscopic ultrasound is a rare but potentially serious adverse event that most often results from the echoendoscope itself. The incidence of upper endoscopic ultrasound associated cervical esophageal perforation is generally higher than that associated with standard upper gastrointestinal endoscopy[9]; this is due to the fact that the linear-array echoendoscope possesses a distal tip that is both longer (roughly 4 cm) and more rigid than upper endoscope and provides an oblique view of the lumen during insertion, making intubation a partially blind, high-risk maneuver. The following factors have been clinically identified as increasing the risk of perforation during EUS[10-13]: Trainee involvement, lack of experience, poor visualization, or excessive force during instrumentation, older patients, history of difficult esophageal intubation, Zenker’s diverticulum, cervical spine osteophytes, or esophageal stricture. Lower esophageal perforation may occur due to the luminal obstruction secondary to the esophageal stricture. The risk of perforation of the duodenum can be due to the sharp bend or stricture between the first and second parts of the duodenum, anatomical deformities of the duodenum caused by the benign or malignant pancreatobiliary masses, and duodenal diverticulum. Excessive torque on the scope can bend the FNB needle inside the instrument channel, leading to poor visualization and risk of damaging surrounding tissue during puncture. It is important to be familiar with the echoendoscope equipment and handle it with meticulous care in patients with these risk factors. Scope lubrication and use of a partially inflated balloon can facilitate the initial intubation and help to navigate in angled areas[14]. Excessive torque, maneuverability, and angulation of the echoendoscope should be avoided to prevent damage to the gastrointestinal wall. It is highly advisable to use carbon dioxide instead of air for insufflation, as it is absorbed rapidly, which reduces the risks and discomfort associated with a perforation or retained gas.
Bleeding
Bleeding after EUS-FNB can occur in the puncture site due to the intervening blood vessel in the lumen wall or in the structure being targeted, such as a cyst wall or visceral organ, and can present immediately or in a delayed fashion. Bleeding in the cyst cavity can be identified during EUS by hyperechoic flow or turbulence within the cyst cavity against the background of hypoechoic fluid. Clinically significant bleeding, defined as a hemoglobin drop > 2 g/dL and/or evidence of hematemesis, melena, or hematochezia[15], is rare after EUS-FNB. Most bleeding episodes after FNB stop spontaneously without requiring any endoscopic or other intervention.
The increased risk of bleeding is well documented after FNB in patients on antiplatelet and anticoagulant medications[16-18], prophylactic doses of low molecular weight heparin[19], procedures performed in the lower gastrointestinal tract compared with the upper gastrointestinal tract[20], and placement of fiducial markers for guiding radiation therapy (especially SBRT) in pancreatic cancer[21,22]. Moreover, FNB of the liver carries a risk of bleeding and or subcapsular hematoma in 0.6% to 0.9% of patients[23,24].
Since EUS-FNB is considered a high-risk procedure for bleeding in patients on anticoagulation or antithrombotic agents, it is essential to have a thorough knowledge about the indication for the procedure and the medical indication for the anticoagulation medication[25]. The decision to interrupt any antiplatelet and/or anticoagulant agents should carefully incorporate the subsequent risk of thrombotic events and may benefit from a multidisciplinary review. The decision to interrupt antiplatelet and anticoagulant agents before procedures requires a careful balance between the risk of bleeding associated with EUS-FNB and the risk of thrombotic events (such as stroke, myocardial infarction, or stent thrombosis) associated with stopping the medication.
The technique used during EUS-FNB can influence the risk of bleeding. Color Doppler should be used to avoid blood vessels during needle insertion. If bleeding occurs, mechanical pressure is applied with the echoendoscope to stop the bleeding. Other strategies to prevent bleeding after EUS-FNB include limiting needle passes by the use of the fanning technique and avoiding the torquing of the echoendoscope when the needle is inserted. During the procedure of EUS-FNB of solid lesions, aspirin may be continued, but anticoagulants such as warfarin, unfractionated heparin/low molecular weight heparin, thienopyridines (clopidogrel), fondoparinux and others should be stopped prior to the procedure as per the recommended guideline[26,27]. Moreover, the laboratory value of platelet count > 50000/mm3 and international normalized ratio < 1.5 is advisable prior to the procedure[28].
Infection
The incidence of bacteremia after EUS-guided tissue acquisition of solid lesions is low, similar to that of routine upper gastrointestinal endoscopy[29-31]. This low risk of bacteremia in average-risk patients supports the recommendation of not using routine antibiotic prophylaxis for EUS-guided tissue acquisition of lymph nodes and solid lesions[32]. Bacteremia associated with EUS is transient and rarely leads to symptomatic infections. However, prophylactic antibiotics are reserved for EUS-guided tissue acquisition of mediastinal or pancreatic cystic lesions. When draining cysts, it is advisable to ensure complete aspiration wherever feasible to reduce infection risk. When sampling the partly cystic lesions, it is important to evaluate the necessity of prophylactic antibiotics against the risks associated with their use. The precautionary strategy of administering prophylactic antibiotics can be applied to mitigate the risk of infection when the needle traverses the bile duct, pancreatic duct, or major vascular structure, even though there are limited data to fully verify this necessity.
Pancreatitis
EUS-FNB has emerged as an important tool for getting the sample in the pancreatic lesions. Pancreatitis is a recognized complication after EUS-FNB of pancreatic ducts, cysts, or masses. Some studies suggest a risk of pancreatitis, with rates reported up to 3.1% in some cohorts undergoing EUS-guided fiducial placement for pancreatic cancer[33]. Because of the very low event rate of complications of pancreatitis, the use of nonsteroidal anti-inflammatory drugs to prevent post-EUS-FNB pancreatitis has not been formally studied in large, randomized controlled trials. Despite the lack of specific, large-scale evidence for FNB, the inflammatory mechanism for post-EUS pancreatitis seems to be similar to that of post-ERCP pancreatitis. Moreover, the risk of post-EUS pancreatitis is higher when sampling occurs through normal pancreatic parenchyma (e.g., in the uncinate process or head) or the pancreatic duct. While data is scarce, 100 mg rectal suppository of diclofenac or indomethacin may be given prior to the procedure to reduce the risk of pancreatitis, based on its safety, low cost, and proven efficacy in reducing post-ERCP pancreatitis.
Since a recent history of acute pancreatitis is a known, statistically significant risk factor for developing post-EUS-pancreatitis, it is advisable to wait for a significant period after an acute pancreatitis episode (often 4-8 weeks) to ensure complete resolution of pancreatic edema and reduce the risk of further, potentially severe, inflammatory reactions. EUS-FNB for small pancreatic lesions (≤ 2 cm) suspected to be pancreatic neuroendocrine tumors has been identified as a risk factor for adverse events, such as bleeding or acute pancreatitis; hence, caution is advised while approaching such lesions. EUS-FNB needle path and trajectory that minimizes traversal of healthy pancreatic parenchyma is a critical technique to reduce the risk of post-procedure pancreatitis. The needle should take the shortest possible route through healthy, non-tumorous pancreatic tissue to reach the target lesion. Choosing a transgastric or transduodenal route depends on the location of the mass, with the goal of avoiding uninvolved pancreatic parenchyma whenever possible.
Sampling benign, inflammatory lesions (e.g., chronic pancreatitis) carries a higher risk of pancreatitis than malignant lesions because the surrounding parenchyma is often more reactive, and the needle must traverse more normal-appearing, yet sensitive, tissue. It is important to avoid the puncture of not only the main pancreatic duct, but also its larger side branches, particularly in a situation where a pancreatic mass causes an obstruction with a dilated upstream duct, which, when get punctured, the leakage of pancreatic fluid into the surrounding tissue can trigger severe inflammation and acute pancreatitis.
Bile peritonitis
During EUS-FNB, inadvertent, accidental puncture of the common bile duct or intrahepatic ducts may lead to bile peritonitis and biloma (a well-circumscribed, extra-biliary collection of bile), or secondary infection (infected biloma). The risk increases with multiple needle passes, prolonged examination time, and when the target lesion is in close proximity to the bile duct. To prevent the complications related to the biliary system, it is critical to ensure that the FNB needle does not completely transect the bile duct, particularly when aiming for tissue acquisition in neighboring structures. Extreme caution should be exercised when performing EUS-FNB around an obstructed bile duct in patients with inadequate drainage of bile.
MISCELLANEOUS COMPLICATIONS AND THEIR PREVENTIVE MEASURES
Complications related to EUS-guided liver biopsy
EUS-guided liver biopsy (EUS-LB) has recently emerged as an effective method for tissue acquisition from the liver (Figure 4). The most common complications are generally mild, including abdominal pain and minor bleeding. About 30% to 40% of patients experience abdominal pain after EUS-LB[34]. A systematic review and meta-analysis showed that the pooled rate of adverse events with EUS-LB is 2.3%, with minor bleeding being the most common complication[35]. Other rare complications of EUS-LB include bile leak, acute pancreatitis, or infection. As in other routine EUS-FNB, color Doppler is used in EUS-LB to select a safe needle path to avoid intervening blood vessels. The fanning technique reduces the need for multiple, high-risk, separate needle punctures in EUS-LB. The “blood patch” technique has been used in post-EUS-LB bleeding; if color Doppler reveals persistent flow (bleeding) in the tract after 2 minutes to 3 minutes of observation, the FNB stylet is used to push 25% to 50% of the distal needle contents back into the track, creating a mechanical tamponade[36,37]. If this technique does not work, then injection of a gelatin sponge slurry can be used for further hemostasis[37].
Figure 4 Endoscopic ultrasound-guided fine-needle biopsy of liver mass.
Needle tract seeding
Needle tract seeding (NTS) is a rare complication of EUS-FNB for malignant or premalignant lesions. It is primarily associated with transgastric EUS-FNB of pancreatic mass in the body or tail[6]. The development of NTS can occur several months to years after the biopsy and can lead to inoperability or the need for aggressive surgical resection of the seeded nodules to improve survival. Hence, while performing EUS-FNB of pancreatic body or tail cancer, it is important to minimize the number of punctures and, if possible, select a route that will be included in the subsequent surgical resection. Needle cleansing protocol is followed before each subsequent puncture in order to avoid the risk of NTS, and involves the wiping of the needle with alcohol cotton and flushing of the inside of the needle with sterile saline; this method is presumed to remove residual tumor cells that could otherwise be implanted along the puncture tract[38]. After transgastric EUS-FNB of pancreatic body or tail cancer, most NTS are located in the gastric wall and are presented as submucosal tumor-like lesions; hence, if the puncture route is not included in the surgical resection site, periodic follow-up with surveillance endoscopy should be done for the early detection of potential seeding in the gastric wall[39]. Transduodenal EUS-FNB of pancreatic head lesions is considered safe and generally does not cause clinically significant NTS because the potential tumor-contaminated tract in the duodenum is resected en bloc during a subsequent pancreaticoduodenectomy (Whipple procedure). EUS-FNB of hilar cholangiocarcinoma is associated with a higher rate of peritoneal metastasis, and hence, this approach should be avoided if curative surgery, such as liver transplantation, is planned.
Device-related malfunctions
The real-world experience of using EUS-FNB devices was evaluated by analyzing postmarketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database and found 344 device-related issues: 53.7% were due to detachment or breakage of the device, 40.8% of the breakages occurred during the procedure and 47.8% cases occurred during the removal of the needle from the endoscope[40]. The most frequent patient-related adverse event reported was a retained foreign body (14.5%), followed by bleeding (4.6%), out of a total of 50 cases[40]. The retained foreign body caused by the needle breakage during EUS-FNB may sometimes require further intervention, including surgery. Hence, FNB needles should indeed be inspected before the initiation of the procedure and after withdrawal to prevent, identify, and manage potential device malfunctions. The endosonographer, patient, and device manufacturer should be aware of these potential risks[40].
PRE-PROCEDURAL PLANNING
Keeping in mind the complications after EUS-FNB, the proper assessment and preparation of the patient should be done before the procedure. While screening for coagulation disorders and stopping anticoagulants or thienopyridines prior to the procedure are important to mitigate the bleeding risks, considering prophylactic antibiotics prior to EUS-FNB of cystic lesions is reasonable to prevent cyst infection. Since the procedure of EUS-FNB is done under sedation, the patient should be on a fast for at least 2 hours for clear liquids and 6 hours for a light meal in order to reduce the risk of aspiration.
POST-PROCEDURE CARE
The post-procedure care includes the careful monitoring of the patient for 24 hours for the signs and symptoms of complications. Immediate post-procedure complications, such as mild abdominal pain and minor bleeding within the gastrointestinal tract, can occur within 1-2 hours after EUS-FNB, but are self-limiting. Routine imaging is not typically required for asymptomatic patients. However, when the patients develop severe, persistent abdominal pain, fever, or signs of bleeding, imaging becomes crucial for detecting the delayed post-procedure complications after EUS-FNB. Though less sensitive to detect post-procedure complications, abdominal ultrasound can be useful in finding complications, such as fluid collection. Computed tomography scan is the preferred imaging modality to evaluate for suspected pancreatic, retroperitoneal, or intraperitoneal bleeding, perforation, acute pancreatitis, and fluid collection. If severe abdominal pain, hypotension, or a drop in hemoglobin occurs, computed tomography imaging should be done to detect delayed hemorrhage, splenic hematomas, retroperitoneal hematomas, or pseudoaneurysms. Recent studies suggest that early feeding within 4 hours after successful EUS-FNB is safe and can reduce hospital stay without increasing the risk of complications[41].
ETHICAL ISSUE
EUS-FNB needs specific ethical considerations, which involve the balancing of the need for accurate histological diagnosis with patient safety, procedural risks, and proper informed consent. EUS-FNB device-related issues due to detachment or breakage of the needle, with a foreign body being left in the patient raises ethical questions about manufacturer liability and the necessity of improved safety[40]. Bleeding risks are elevated in patients on anticoagulants, requiring careful risk-benefit analysis. Despite being designed to obtain more tissue than FNA, EUS-FNB can still suffer from poor yield in certain situations (e.g., chronic pancreatitis), making the risk-benefit analysis of performing the procedure ethically complex. Because EUS-FNB is often used to diagnose severe, life-threatening conditions (e.g., pancreatic cancer), ensuring the patient fully understands the risks is a critical ethical duty. The safety and accuracy of the procedure are heavily dependent on the skill of the endosonographer, implying an ethical obligation to ensure competent and experienced staff perform the procedure. While EUS-FNB is increasingly preferred for its ability to provide larger tissue samples for molecular analysis compared to FNA, these ethical considerations highlight the need for careful patient selection and procedural expertise.
CONCLUSION
The preventive strategies for complications following EUS-FNB include careful pre-procedural planning, technical efficiency during the procedure, and appropriate post-procedure care. A multi-faceted approach centered on training, technique, and adherence to established protocols is critical to avoid complications and will help the endosonographer to perform EUS-FNB safely and effectively.
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