Aim: this literature review was conducted to evaluate liver biopsy adequacy, including total core length (TCL), number of portal tracts (PT), fragmentation and complication rates, as a function of needle type and gauge. Method: a systematic electronic search was performed in the Web of Science and Google Scholar databases, according to the PRISMA statement. Eligible data, describing in-vivo percutaneous ultrasound-guided human liver biopsy quality outcomes, were compared to adequacy criteria of the American Association for the Study of Liver Diseases (AASLD, TCL=20mm, PT=11). Results: an adequate mean number of portal tracts was found in 83% of biopsy needles assessed between 2012-2019, compared to 0% between 1998-2004. For total core length, this was 44% and 33%, respectively. Increasing the needle diameter enhanced TCL (result in 50% of included studies) and PT count (100%), and reduced fragmentation rates (75%), whereas no effect on pain or complications was found (83%). In total, five needle types achieved adequate PT counts, using 16G (3x), 17G (1x) or 18G (1x) needles. Adequacy was reached using either a core needle biopsy (CNB, 3x) approach with one pass, or a fine needle aspiration (FNA, 2x) approach with two passes. Conclusion: the recommendations for biopsy adequacy can be met using 16/17G FNA or 16/18G CNB needles. Currently, many publications still present substandard liver biopsy quality outcomes. Although minimizing biopsy invasiveness is desirable, a decreased diameter or number of passes is ill-judged when reliability of biopsy outcomes is at stake.

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