Effectiveness of intraoperative cholangiography using indocyanine green (versus contrast fluid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy

INTRODUCTION

During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the "gold standard" for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy.

MATERIALS AND METHODS

Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the "analyzability rate" (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis.

RESULTS

The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p = 0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure.

CONCLUSION

IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy

BACKGROUND

Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC.

METHODS

Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected.

RESULTS

Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C.

CONCLUSIONS

NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Ultrasound scanning in infants with biliary atresia: the different implications of biliary tract features and liver echostructure

OBJECTIVE

To evaluate ultrasonographic features of the liver and biliary tree, including the presence of the triangular cord, in infants with biliary atresia and to analyze the correspondence between hepatic echostructure and histological aspects of the liver.

MATERIALS AND METHODS

35 consecutive infants (19 males) with documented diagnosis of biliary atresia were included. Ultrasonography evaluation, performed at a mean age of 63.1 ± 34.9 days, was focused on the extrahepatic bile ducts, characteristics of the gallbladder and liver, and the presence of the triangular cord. Liver biopsies were examined with particular regard to the presence and severity of fibrosis.

RESULTS

On ultrasound, the gallbladder was not seen in 11 (31 %) cases, while in the remaining 24 patients the gallbladder was regular in 6 patients and irregular in 18 cases. The triangular cord was identified in 9 (26 %) of 35 patients. In 21 patients the liver echostructure appeared normal, while in 14 infants the liver parenchyma was more echogenic and coarse than normal. Liver biopsy showed signs of cirrhosis or fibrosis in all cases, including patients with a normal hepatic echostructure.

CONCLUSION

Although the triangular cord was visualized in one-fourth of the infants with biliary atresia, abnormalities of the gallbladder on ultrasound (absence or abnormalities of length/shape) were detected in 83 % of the patients. Therefore, ultrasound evaluation of the liver and biliary tree plays an important role in suspecting biliary atresia. On the other hand, a low correspondence between liver echostructure aspects and the presence and severity of fibrosis at liver biopsy was identified. Therefore, severe liver disease in infants with biliary atresia cannot be excluded only on the basis of ultrasound findings.

Hyaline vascular Castleman's disease involving the biliary tract

We report a case of Castleman's Disease (CD), hyaline vascular subtype involving the biliary tract with obstruction. A 43 year old man presented with a 5 week history of abdominal and back pain with biliary obstructive symptoms. He was jaundiced with persistently high LFTs. Radiological investigation revealed a stricture in the extrahepatic biliary tract. The clinical impression at the time was of sclerosing cholangitis with bile duct cholangiocarcinoma. A Whipple's procedure was performed. Histology and immunohistochemistry supported the histologic diagnosis of CD of hyaline vascular subtype. There was no evidence of disease elsewhere and the patient was disease free after a 6 year follow-up. Our case describes the hyaline vascular subtype of CD, a relatively rare disease occurring in a previously undescribed location.

[Application of digitalized minimally invasive technique in treatment of hepatolithiasis based on MI-3DVS]

OBJECTIVE

To assess the clinical value of digitalized minimally invasive technique in the treatment of the hepatolithiasis.

METHODS

The 64-slice spiral CT data were acquired from 4 hepatolithiasis patients for three-dimensional reconstruction and simulation operation using abdominal medical image-3D visualization system (MI-3DVS). Three-dimensional reconstruction was performed for the liver, hepatic arteries, hepatic veins, portal veins, intrahepatic bile ducts and calculi. Based on the size and position of the calculi and the distribution of the dilated or stenotic biliary ducts, several simulation operations such as partial hepatectomy and hepaticojejunstomy were performed. With guidance by the findings in the simulation operation, the actual minimally invasive operation was performed.

RESULTS

The three-dimensional models of the liver, hepatic arteries, hepatic veins, portal veins, intrahepatic bile ducts and calculi were reconstructed successfully, which clearly visualized the site and the number of calculi and the condition of the involved intrahepatic bile ducts. Guided by the three-dimensional models and the simulation operations, partial hepatectomy and hepaticojejunstomy were performed and the calculi were removed completely in all the 4 cases with maximum preservation of the residual liver volume.

CONCLUSION

Three-dimensional reconstruction and simulation operation allows digital minimally invasive treatment of hepatolithiasis, which can be a new approach to hepatobiliary surgery.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients

PURPOSE

To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients.

MATERIALS AND METHODS

During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated.

RESULTS

Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed.

CONCLUSIONS

Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Intrahepatic duct dilatation in type 4 choledochal malformation: pressure-related, postoperative resolution

BACKGROUND

Type 4 choledochal malformations (CMs) may be defined as those with both intrahepatic and extrahepatic bile duct dilatation. The aims of this study were to investigate possible causes of intrahepatic duct (IHD) dilatation in CM and to define the effect of surgery over time.

METHODS

This study was a single-center retrospective review of a database of all children with CM undergoing surgery (excision of extrahepatic bile duct dilatation and hepaticojejunostomy) and identified as type 4 (on imaging and at surgery). Data included intraoperative choledochal pressure measurements and biliary amylase content and were expressed as median (interquartile range [IQR]). All comparisons used nonparametric statistical tests. P ≤.05 was regarded as significant.

RESULTS

Twenty children were identified as type 4 CM (age, 4.3 years; range, 2.7-10.4 years) with preoperative IHD dilatation (right duct: diameter [range], 8.5 [4.5-14] mm; left: 8 [4-14.5] mm). Median intraoperative choledochal pressure was 17 (8-27) mm Hg (normal, <5 mm Hg), and intraoperative bile amylase was 3647 (range, 500-58,000) IU/L (normal, <100 IU/L). Preoperative IHD diameter correlated with choledochal pressure (right: r(s)=0.46, P = .03; left: r(s)=0.34, P = .07) but not with biliary amylase (P = .28 and P = .39, respectively). At 1 year postsurgery, median (range) IHD diameter had decreased to 1 (1-2.5) mm for right duct (P = .0002) and 1.5 (1-3) mm for left duct (P = .0006) and remained stable for up to a 10-year follow-up.

CONCLUSION

Our data suggest that IHD dilatation is related to sustained increased intrabiliary pressure rather than any intrinsic intrahepatic CM. Effective surgery invariably reduces measured IHD toward normal values.

Intraoperative ultrasonography for reducing bile duct injury during laparoscopic cholecystectomy

BACKGROUND/AIMS

Laparoscopic cholecystectomy has become a standard procedure for gallstone disease. Bile duct injury during laparoscopic cholecystectomy is one of the most serious complications. The cause of such injury is usually the erroneous interpretation of bile duct anatomy, especially mistaking common bile duct for the cystic duct. A method for the prevention of this injury has not been established. The objective of this study was to test the usefulness of intraoperative ultrasonography for preventing bile duct injury.

METHODOLOGY

We performed intraoperative ultrasonography to visualize the junction of the cystic duct and common bile duct before cannulation for intraoperative cholangiography. A total of 200 patients were enrolled in this study from May 2004 to November 2005.

RESULTS

In 188 out of 200 cases (94%), the junction was identified by intraoperative ultrasonography before the cholangiography.

CONCLUSION

Identification of the junction of the cystic duct and common bile duct before intraoperative cholangiography may reduce bile duct injury in laparoscopic cholecystectomy.

[Management of perforations as adverse events of ERCP plus ES. Personal experience]

INTRODUCTION. ERCP has brought real progress in the study and treatment of pancreatic and biliary diseases, because of its ambivalence as diagnostic and therapeutic procedure. Among its complications, perforations occur in fewer than 1% of patients, but are associated with a mortality rate of 16% -18%.

CASE REPORTS

CASE 1- F, 89 years old with obstructive jaundice by choledocholithiasis submitted to ERCP plus ES, during which occurs type II lesion; the partial removing of stones from choledochus during the procedure allow us to opt for a conservative treatment, with resolution on post-ERCP day 12. CASE 2- F, 53 years old with recurring cholangitis and post-cholecystectomy stenosis of choledochus already treated by stenting; for the occurrence of type I lesion during ERCP, the patient undergoes surgery in emergency with healing in postoperative day 23. CASE 3- M, 84 years old with lithiasic cholecystitis, obstructive jaundice, lung emphysema and ischemic heart disease; after percutaneous cholecystostomy in emergency, we attempt to ERCP with evidence of type I lesion. Because of comorbility, we opt for a conservative treatment, not resolving, and then proceed to surgery. Exitus for cardio-respiratory complications. CASE 4- M, 89 years old with obstructive jaundice; ERCP is suspended for respiratory complications and then a PTC is perform; during it we note a type IV lesion, which is treated conservatively with resignation in day 12. CASE 5- F, 68 years old with cholecystitis and choledocholithiasis; during ERCP plus SE a type II lesion occurs with worsening signs of acute abdomen. Because of clinical conditions and the impossibility of carrying out stones from choledochus by endoscopy, we opt for a surgical treatment in emergency. Exitus for respiratory complications.

DISCUSSION

Because of the controversy exists on what should be the management of perforations as adverse events of ERCP plus ES (immediate surgery or conservative therapy), we can only hope an eclectic approach based on the anatomical and clinical peculiarity of each case.

[A case of autoimmune pancreatitis combined with extensive involvement of biliary tract]

Autoimmune pancreatitis is a distinct disease characterized by the presence of autoantibodies and hypergammaglobulinemia, inflammation of the pancreatic parenchyma, and irregular stricture of the pancreatic duct. The involvement of distal common bile duct is frequently observed, but intrahepatic bile duct involvement is very rare, which seem to have similar feature to primary sclerosing cholangitis. We report a case of the patient with autoimmune pancreatitis combined with extensive involvement of extrahepatic and intrahepatic bile duct, which had a favorable response to steroid therapy.

Staging of extrahepatic cholangiocarcinoma

Preoperative staging of extrahepatic cholangiocarcinoma is important in determining the best treatment plan. Several classification systems have been suggested to determine the operability and extent of surgery. Longitudinal tumor extent is especially important in extrahepatic cholangiocarcinoma because operative methods differ depending on the tumor extent. The Bismuth-Corlette classification system provides useful information when planning for surgery. However, this classification system is not adequate for selecting surgical candidates. Anatomic variation of the bile duct and gross morphology of the tumor must be considered simultaneously. Lateral spread of the tumor can be evaluated based on the TNM staging provided by American Joint Committee on Cancer (AJCC). However, there is a potential for ambiguity in the distinction of T1 and T2 cancer from one another. In addition, T stage does not necessarily mean invasiveness. Blumgart T staging is helpful for the assessment of resectability with the consideration of nodal status and distant metastasis as suggested by the AJCC cancer staging system. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary tools used in the assessment of longitudinal and lateral spread of a tumor when determining respectability. Diagnostic laparoscopy and positron emission tomography (PET) may play additional roles in this regard.

[Clinical value of three-dimensional reconstruction of the biliary calculi based on 64-slice spiral CT scanning data]

OBJECTIVE

To study the clinical value of 3-dimensional (3D) reconstruction of the liver and its ductal structures using 64-slice spiral CT data in hepatobiliary surgery.

METHODS

The image data of 64-slice spiral CT scanning was obtained from patients with biliary calculi. Image segmentation was performed both using computer programs and manually, and 3D reconstruction of the liver was carried out using Mimics software. The reconstructed model of the liver and the ductal system was exported in STL format, and then into the FreeForm Modeling System for modification and smoothing, followed by image registration of the liver with the ductal system and the calculi.

RESULTS

The reconstructed liver model accurately represented the actual size of the liver and its anatomic landmarks, and by adjusting the transparency of the liver, the hepatic and intrahepatic arteries, veins, the portal vein, some abdominal vessels and the biliary system with the calculi were clearly visualized. The calculi in the intrahepatic and extrahepatic bile ducts were distinct in terms of the location and number, and dilation and stenosis of the intrahepatic and extrahepatic bile ducts were also clearly observed. The model presented with realistic profile of the liver that allowed vivid 3D observation. The model also allowed zooming and rotation for observation in full views.

CONCLUSIONS

The reconstructed model of the liver and its ductal system can be useful for preoperative planning and intraoperative complete removal of the calculi from the bile duct, and for the bile duct dilation and stenosis detected in the model, appropriate measures should be taken to reduce the residual calculi and prevent reoccurrence.

Villous adenoma of extrahepatic bile duct: contrast-enhanced sonography findings

We report a case of villous adenoma in the extrahepatic bile duct that was successfully diagnosed with contrast-enhanced sonography (CEUS) before surgical resection. On baseline sonography, the mass appeared as a homogeneously isoechoic mass filling the bile duct from the confluence of the right and left hepatic ducts to the distal common bile duct. No intralesional flow signal was found on color Doppler imaging and power Doppler imaging. On CEUS, the mass showed homogeneous enhancement during arterial phase, thus confirming the neoplastic nature of the lesion. The enhancement decreased gradually so that the mass became hypoenhanced during portal and late phases. Surgical resection was performed, and pathologic examination confirmed a villous adenoma of the bile duct epithelium with mild dysplasia.

Duplication of the extrahepatic bile duct with anomalous union of the pancreaticobiliary ductal system revealed by MR cholangiopancreatography

MR cholangiopancreatography (MRCP) is a valuable, non-invasive tool for accurate examination of the biliary system. We report a case in which MRCP played a critical role in the diagnosis of a duplication of the extrahepatic bile duct with anomalous union of the pancreaticobiliary ductal system in a patient with hilar cholangiocarcinoma. This variant of a duplication of the extrahepatic biliary system has not been described previously in the literature.

ULTRASONOGRAPHIC FEATURES OF EXTRAHEPATIC BILIARY OBSTRUCTION IN 30 CATS

The goals of our study were to review the ultrasonographic features of spontaneous extrahepatic biliary obstruction in cats and to determine whether these features can assist in differentiating tumor, inflammation, and choleliths as the cause of obstruction. Thirty cats with a presurgical ultrasound examination an dconfirmed extrahepatic biliary obstruction were studied. A common bile duct diameter over 5 mm was present in 97% of the cats with extrahepatic biliary obstruction. Gallbladder dilation was seen in < 50% of the cats. Ultrasound identified all obstructive choleliths (calculus or plugs) in the common bile duct. However, neither common bile duct diameter nor appearance or any other ultrasonographic feature allowed differentiation between tumor and inflammation as the cause of obstruction. A short duration of clinical signs (10 days or less) seemed to be associated with obstructive cholelithiasis.

Papillomatosis of intra- and extrahepatic biliary tree: Successful treatment with liver transplantation

Approximately 60 cases of biliary papillomatosis have been reported in the world literature, while only 6 cases have been reported to be treated with liver transplantation. This rare disease, which is characterized by relapsing episodes of obstructive jaundice and cholangitis that lead to secondary cirrhosis and death from sepsis or liver failure, it is also considered premalignant because of its frequent malignant transformation (25-50%). We present a case of a 43-year-old white man with papillomatosis of intra- and extrahepatic biliary tree who sought care for repeated episodes of obstructive jaundice and cholangitis. The diagnosis was suspected after endoscopic retrograde cholangiopancreatography and confirmed by liver and common bile duct biopsies. The patient underwent orthotopic liver transplantation with Roux-en-Y hepatico-jejunostomy to treat end-stage liver cirrhosis. Fifteen months' follow-up revealed a patient with normal graft function and with no clinically or laboratory findings of disease recurrence or cancer development.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Spontaneous perforation of the extrahepatic bile duct in infancy: report of two cases and literature review

BACKGROUND

Spontaneous perforation of the bile duct (SPBD) is a rare disease in infancy. The pathogenesis, diagnostic modalities and treatment options for this condition are reviewed and discussed.

METHODS

The authors report 2 new observations of SPBD in 2 male newborns aged respectively 27 and 21 days.

RESULTS

The 2 newborns presented with cholestatic jaundice. Abdominal sonography showed an extrahepatic mass. Exploratory laparotomy revealed that the perforation was located in the cystic duct in the first case and in the common bile duct (CBD) in the second. The site of perforation was repaired and both patients underwent simple external biliary drainage. The postoperative course was uneventful for both patients with follow-up ranging from 2 to 4 years.

CONCLUSIONS

SPBD is a rare, but important cause of surgical jaundice in infants. The pathogenesis of SPBD is unknown and multifactorial and diagnosis is often problematic. Surgical management is always required and a conservative approach is usually recommended. The prognosis is good with early surgical management.

[Intraductal ultrasonography for the selection of self expandable metal stent in extrahepatic bile duct carcinoma]

BACKGROUND/AIMS

Endoscopic stent insertion with self expandable metal stent (SEMS) is one of the standard palliative treatments for the patients with unresectable bile duct carcinoma. The aim of this study was to determine whether detection of longitudinal spread of extrahepatic bile duct carcinoma by intraductal US (IDUS) would be helpful in the selection of metal stent for the palliative drainage in bile duct carcinoma.

METHODS

Seventeen patients with histologically proven unresectable extrahepatic bile duct carcinoma who underwent endoscopic retrograde cholangiography with IDUS were included. Longitudinal cancer extension along the bile duct was determined and, then, compared with the cholangiographic image. The type and length of SEMS was selected based on IDUS findings.

RESULTS

IDUS demonstrated more extensive tumor spread than ERC in 7 of 17 (41.2%) patients with the hepatic side of strictures and in 7 of 16 (43.8%) patients with the duodenal side of strictures. Five of 17 (29.4%) patients have changed the plan of endoscopic biliary drainage with SEMS after IDUS. There was no early dysfunction associated with endoscopic biliary drainage.

CONCLUSIONS

IDUS prior to biliary drainage would be useful in demonstrating longitudinal extension of extrahepatic bile duct carcinoma. It has a potential role in helping stent selection and identifying factors which predict early stent dysfunction.

EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results

BACKGROUND

Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult.

OBJECTIVE

To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP.

DESIGN

Retrospective cohort study.

SETTING

Single, tertiary referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP.

INTERVENTIONS

EUS-FNA of PBS.

MAIN OUTCOME MEASURES

Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up.

RESULTS

A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively.

LIMITATIONS

Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery.

CONCLUSIONS

EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.