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Background Ultrasound (US)-guided percutaneous splenic biopsy has been widely used to evaluate focal or diffuse splenic lesions, and has shown promising results in terms of efficacy and safety. However, concerns regarding hemorrhagic complications and difficulty in patients with ascites or obesity have constrained its wider adoption. Endoscopic ultrasound (EUS)-guided has emerged as a promising approach for tissue acquisition of splenic lesions, as it can provide high-resolution imaging and real-time needle guidance. However, its safety and efficacy in relation to US-guided percutaneous splenic biopsy is not fully established. This systematic review and meta-analysis evaluated the efficacy and safety of EUS-guided and US-guided percutaneous biopsy for splenic lesions.Methods PubMed, Scopus, the Cochrane Library, and Web of Science were searched from inception until January 2026. Studies were included if they assessed the diagnostic performance and complication rates of EUS-guided splenic biopsy or US-guided splenic biopsy. Heterogeneity across pooled studies was evaluated using the I 2 statistic, and methodological quality was evaluated using the Newcastle Ottawa Scale (NOS). The protocol was registered at PROSPERO (CRD420261283689).Results Twenty studies involving 1147 patients were included. The pooled analysis revealed that EUS-guided and US-guided percutaneous splenic biopsy had a high diagnostic performance, with EUS-guided splenic biopsy demonstrating a diagnostic accuracy of 95% (95% CI: 90% to 100%), sensitivity of 97% (95% CI: 82% to 100%) and specificity of 95% (95% CI: 75% to 100%), while US-guided percutaneous biopsy demonstrated a diagnostic accuracy of 89% (95% CI: 87% to 92%), sensitivity of 91% (95% CI: 86% to 94%), and specificity of 98% (95% CI: 96% to 99%) ( figure 1). The overall complication rate for EUS-guided splenic biopsy was 7% which was slightly higher than that for US-guided percutaneous splenic biopsy (3%). Major complications were rare and occurred in 4% of EUS-guided biopsy cases and 1% of US-guided percutaneous biopsy cases. No study reported procedure-related mortality.Conclusion EUS-guided and US-guided percutaneous splenic biopsy are safe and effective methods for the diagnosis of splenic lesions. US-guided percutaneous biopsy may be considered a first-line approach, with EUS-guided biopsy serving as a safe alternative for cases where percutaneous biopsy is contraindicated or technically challenging.References Fritscher-Ravens A, Mylonaki M, Pantes A, et al. Endoscopic ultrasound-guided biopsy for the diagnosis of focal lesions of the spleen. Am J Gastroenterol. 2003 May;98(5):1022–7.Civardi G, Vallisa D, Bertè R, et al. Ultrasound-guided fine needle biopsy of the spleen: high clinical efficacy and low risk in a multicenter Italian study. American Journal of Hematology. 2001;67(2):93–9.Abstract P6 Figure 1Forest plot for the pooled diagnostic accuracy of US-guided percutaneous splenic biopsy