Les mesures de SWE sont sujettes à un biais subjectif potentiel de l’opérateur qui pourrait entraîner un certain degré de variabilité. En début de travail et sur la première année notamment, l’échographiste a pu manquer d’expérience en particulier en ce qui concerne la mesure de l’élasticité et de la détection des nodules.
Dans certaines situations, il n’était pas possible de faire la différence entre une valeur d’élasticité élevée et un artéfact.
L’étude parenchymateuse était nettement sous optimale en échographie sur 31 cas en raison du morphotype des patients et de l'atténuation liée à la stéatose, en particulier pour le segment I qui est également situé profondément.
Quelques autres difficultés ont été rencontrées lors de la mesure de SWE des segments: la mesure de SWE des quelques segments est plus difficile que celle des autres (segment II en raison de l’artéfact cinétique cardiaque, segment IV en raison de sa position et de son atrophie, segment VII en raison du cul de sac pleural); la mesure SWE du segment III est parfois réalisée en position debout en raison de la position haute du foie gauche; l'étroitesse de l'espace
intercostal; l'impossibilité pour le patient de maintenir une apnée par le patient (patient fatigué, âgé, dyspnéique). Le morphotype du patient et les gaz digestifs sont également une difficulté.
En plus, le changement de la version de logiciel d’élastométrie de l’appareil pendant l’étude a pu induire une variabilité de la mesure d'élasticité.
Par ailleurs, cette étude ne comprend pas un assez grand échantillon de patients atteints de CHC pour permettre une étude quantitative.
En plus, il présente également une erreur d'échantillonnage, on a pu mal classer les patients F3 ou F4, notamment ceux avec Fibroscan seul. Comme SWE, la mesure de la dureté du foie par Fibroscan a des artéfacts liés au morphotype des patients (obèses), patient dyspnéique, ascite abdominale, l'étroitesse de l'espace intercostal.
Enfin, pour les segments VI et VII le taux d’échec de 12.3 et 25.1 % nous a paru très élevé, sauf en cas d’obésité associée, et aurait pu être amélioré si le mode avec pénétration avait été utilisé au lieu du mode standard.
CONCLUSION
Malgré les limitations méthodologiques d’une comparaison cas-contrôle rétrospective pour estimer l’amélioration de la survie sans carcinome hépatocellulaire, et d’effectifs relativement modestes pour comparer l’efficacité du FibroTest à celle de l’élastométrie, ces résultats suggèrent fortement la pertinence d’associer une recherche de nodule dès la découverte d’un stade F3 ou F4 par un examen sanguin comme le FibroTest. Dans notre population une stratégie n’utilisant que la TE au seuil de 9.5 kpa aurait retardé le diagnostic de 6 cancers sur 13.
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