Endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement and liver biopsy have become alternatives to the traditional transjugular methods, providing combined hemodynamic and histological assessment in patients with liver disease in a single session. However, data on the procedural learning curve remain limited. This study evaluates learning curves for combined EUS-guided PPG and LB during a single procedure, focusing on proficiency, milestones, and safety as these techniques are integrated into clinical practice.

A learning curve analysis of a prospectively maintained EUS-guided PPG and LB database was conducted, which involved 29 consecutive outpatients who underwent combined EUS-guided procedures performed by a single operator at a tertiary center. The procedures were performed by an endoscopist with 4 years of independent practice (approximately 2000 EUS procedures and 1000 non-liver fine needle aspirations/biopsies). Before learning curve analysis, the operator had only carried out three EUS-guided PPG measurements and no prior LB. PPG reliability was defined as duplicate or triplicate measurements within 1mmHg of difference, LB adequacy was based on AASLD criteria (≥25 mm length and ≥11 complete portal tracts), and procedure duration was defined as duration between scope insertion and scope withdrawal. Learning curves were assessed using case-sequence–based logistic regression for binary outcomes (technical success, LB and PPG outcomes) and linear regression for procedure time.

Technical success was achieved in 90% of cases (n=26), adequate LB were obtained in 93.1% (n=27), and reliable PPG measurements were obtained in 82.8% (n=24). A learning curve analysis of EUS-guided LB showed no significant improvement in obtaining adequate biopsy specimens over consecutive cases. For the primary endpoint—adequate liver tissue the odds ratio (OR) per case was 0.98 (95% CI: 0.82–1.61), indicating a slight non-significant 2.3% decrease in odds of adequacy per additional case. When both adequate LB and reliable PPG were considered, the OR was 1.00 (95% CI: 0.89–1.12), showing negligible change with experience. For secondary outcomes, technical success increased marginally with experience (OR 1.02, 95% CI: 0.89–1.18), representing a 2% improvement per additional case. The mean procedure time for combined EUS-guided LB and PPG was 20.7 ±4.8 minutes and procedural time showed a non-significant negligible trend toward increase (slope = 0.08 min/case, p = 0.46, R² = 0.02), suggesting time efficiency was achieved early, with case number explaining only 2% of time variability. There was only 1 (3.4%) mild adverse event related to the intervention (abdominal pain).

In the hands of an endosonographer with 4 years of independent practice, the learning curve for EUS-guided PPG and LB was minimal, with consistent high performance observed across cases with technical success above 90%, rates of adequate LB above 90% and 80% reliable PPG. These findings suggest that combined EUS-guided LB and PPG measurement in the same session can be performed effectively with high success rates and very short learning curve.