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Agudo Castillo B, Mascarenhas M, Martins M, Mendes F, de la Iglesia D, Costa AMMPD, Esteban Fernández-Zarza C, González-Haba Ruiz M. Advancements in biliopancreatic endoscopy: a comprehensive review of artificial intelligence in EUS and ERCP. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38832589 DOI: 10.17235/reed.2024.10456/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
The development and implementation of artificial intelligence (AI), particularly deep learning (DL) models, has generated significant interest across various fields of gastroenterology. While research in luminal endoscopy has seen rapid translation to clinical practice with approved AI devices, its potential extends far beyond, offering promising benefits for biliopancreatic endoscopy like optical characterization of strictures during cholangioscopy or detection and classification of pancreatic lesions during diagnostic endoscopic ultrasound (EUS). This narrative review provides an up-to-date of the latest literature and available studies in this field. Serving as a comprehensive guide to the current landscape of AI in biliopancreatic endoscopy, emphasizing technological advancements, main applications, ethical considerations, and future directions for research and clinical implementation.
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Affiliation(s)
| | | | - Miguel Martins
- Gastroenterology, Centro Hospitalar Universitário de São João
| | - Francisco Mendes
- Gastroenterology, Centro Hospitalar Universitário de São João, Portugal
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Milluzzo SM, Landi R, Perri V, Familiari P, Boškoski I, Pafundi PC, Farina A, Ricci R, Spada C, Costamagna G, Tringali A. Diagnostic accuracy and interobserver agreement of cholangioscopy for indeterminate biliary strictures: A single-center experience. Dig Liver Dis 2024; 56:847-852. [PMID: 38016895 DOI: 10.1016/j.dld.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 09/27/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND STUDY AIMS Characterization of indeterminate biliary strictures (IDBS) still represents a major challenge. Digital single-operator cholangioscopy (DSOC) could potentially overcome limits of conventional biopsy and brush sampling. The aim of this study was to compare diagnostic accuracy of visual evaluation and DSOC-guided biopsies to conventional trans-papillary sampling techniques and to evaluate the inter-observer agreement (IOA) on visual diagnosis. PATIENTS AND METHODS All consecutive patients undergoing DSOC-guided biopsy after conventional sampling techniques for IDBS during a six-year period were retrospectively evaluated. Final diagnosis was based on histological evaluation of the surgical specimen if available or a clinical follow-up of at least 6 months. For IOA, 20-second DSOC clips were retrospectively reviewed by 6 experts and 6 trainees and classified according to the Monaco Classification. RESULTS Thirty-five patients underwent DSOC for IDBS in the study period; 14 patients (F = 9) with a median age of 64 years (range 53-76) met the study aim. After DSOC, strictures location was changed in three patients (additional yield of 21.4 %). Intraductal DSOC-guided biopsy were technically successful in all cases, with an adequacy of 92.8 %. No adverse events were recorded. Final diagnosis was benign disease in five cases and cholangiocarcinoma in the others. For IOA, 29 videos were evaluated with almost perfect agreement for final diagnosis (kappa 0.871; agreement 93.1, p <0.001), although overall accuracy of DSOC visual finding was 73.6 % and 64.4 % for experts and trainees, respectively. CONCLUSIONS DSOC could improve diagnostic accuracy for IDBS, since it showed high sensitivity for visual finding and high specificity for DSOC guided-biopsy. Visual diagnosis seems reliable for diagnosis using the Monaco Classification.
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Affiliation(s)
| | - Rosario Landi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy.
| | - Vincenzo Perri
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
| | - Pietro Familiari
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
| | - Ivo Boškoski
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
| | - Pia Clara Pafundi
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annarita Farina
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy
| | - Riccardo Ricci
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC di Anatomia Patologica, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Department of Pathology, Roma, Lazio, Italy
| | - Cristiano Spada
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
| | - Guido Costamagna
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
| | - Andrea Tringali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy
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Robles-Medranda C, Alcivar-Vasquez J, Raijman I, Kahaleh M, Puga-Tejada M, Del Valle R, Alvarado H, Cifuentes-Gordillo C, Binmoeller KF, Baptista AJ, Barreto-Perez J, Rodriguez J, Egas-Izquierdo M, Cunto D, Calle-Loffredo D, Lukashok H, Baquerizo-Burgos J, Tabacelia D. Accurate and safe diagnosis and treatment of neoplastic biliary lesions using a novel 9F and 11F digital single-operator cholangioscope. Endosc Int Open 2024; 12:E498-E506. [PMID: 38585021 PMCID: PMC10997424 DOI: 10.1055/a-2282-6678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/15/2024] [Indexed: 04/09/2024] Open
Abstract
Background and study aims Digital single-operator cholangioscopy (DSOC) allows the diagnosis of biliary duct disorders and treatment for complicated stones. However, these technologies have limitations such as the size of the probe and working channel, excessive cost, and low image resolution. Recently, a novel DSOC system (eyeMAX, Micro-Tech, Nanjing, China) was developed to address these limitations. We aimed to evaluate the usefulness and safety of a novel 9F and 11F DSOC system in terms of neoplastic diagnostic accuracy based on visual examination, ability to evaluate tumor extension and to achieve complete biliary stone clearance, and procedure-related adverse events (AEs). Patients and methods Data from ≥ 18-year-old patients who underwent DSOC from July 2021 to April 2022 were retrospectively recovered and divided into a diagnostic and a therapeutic cohort. Results A total of 80 patients were included. In the diagnostic cohort (n = 49/80), neovascularity was identified in 26 of 49 patients (46.9%). Biopsy was performed in 65.3% patients with adequate tissue sample obtained in 96.8% of cases. Biopsy confirmed neoplasia in 23 of 32 cases. DSOC visual impression achieved 91.6% sensitivity and 87.5% specificity in diagnosing neoplasms. In the therapeutic cohort (n = 43/80), 26 of 43 patients required lithotripsy alone. Total stone removal was achieved in 71% patients in the first session. Neither early nor late AEs were documented in either the diagnostic or therapeutic cohort. Conclusions The novel DSOC device has excellent diagnostic accuracy in distinguishing neoplastic biliary lesions as well as therapeutic benefits in the context of total stone removal, with no documented AEs.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Juan Alcivar-Vasquez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Isaac Raijman
- Gastroenterology, Digestive Associates of Houston, Houston, United States
| | - Michel Kahaleh
- Gastroenterology, Robert Wood Johnson Medical School, New Brunswick, United States
| | - Miguel Puga-Tejada
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Raquel Del Valle
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Haydee Alvarado
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | | | | | | | - Jonathan Barreto-Perez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Jorge Rodriguez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Maria Egas-Izquierdo
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Domenica Cunto
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Daniel Calle-Loffredo
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Hannah Lukashok
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
| | - Daniela Tabacelia
- Gastroenterology, Elias Emergency University Hospital, Bucuresti, Romania
- Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
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Meng C, Wang J, Zhang P, Wang B. Case report: The diagnostic dilemma of indeterminate biliary strictures: report on two cases with a literature review. Front Oncol 2024; 14:1301937. [PMID: 38601754 PMCID: PMC11004331 DOI: 10.3389/fonc.2024.1301937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/18/2024] [Indexed: 04/12/2024] Open
Abstract
Background It is still a challenging problem for clinicians to explore the nature of the indeterminate biliary strictures (IBSs). Approximately 20% of biliary strictures remain undetermined after a thorough preoperative assessment. Case presentation Here, we present two cases of indeterminate biliary strictures patients, whose cross- sectional imaging and endoscopic examination were nondiagnostic. The patients underwent exploratory laparotomy finally and were confirmed as malignancy. We also reviewed the recent reports in literatures regarding the evaluation of IBSs. Conclusions Given the majority of the biliary strictures are malignancy, preoperative differentiation between benign and malignant is critical for choosing the best therapeutic regimen. Thus, close follow-up, multiple multidisciplinary discussion, and prompt surgical exploration are necessary for some difficult diagnostic cases.
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Affiliation(s)
- Chunyan Meng
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Health Management Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peipei Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Wang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gupta P, Kambadakone A, Sirohi B. Editorial: Role of imaging in biliary tract cancer: diagnosis, staging, response prediction and image-guided therapeutics. Front Oncol 2024; 14:1387531. [PMID: 38567157 PMCID: PMC10985351 DOI: 10.3389/fonc.2024.1387531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bhawna Sirohi
- Department of Medical Oncology, BALCO Medical Centre, Raipur, Chhattisgarh, India
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Malik AK, Davidson BR, Manas DM. Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024:108248. [PMID: 38467524 DOI: 10.1016/j.ejso.2024.108248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
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Affiliation(s)
- Abdullah K Malik
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK.
| | - Brian R Davidson
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK; NHS Blood and Transplant, Bristol, UK
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Rey Rubiano AM, González-Teshima LY, Arango L, Blanco-Avellaneda C, Carvajal Gutiérrez JJ, Castaño-Llano R, Gómez Zuleta MA, González C, Peñaloza-Ramírez A, Pinilla Morales R, Pinto Carta R, Polanía Liscano HA, Rincón Sánchez RA, Sepúlveda Copete M, Vargas-Rubio R, Avendaño Capriles CA, García-Sierra AM, Yepes-Nuñez JJ. Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones. Surg Endosc 2024; 38:499-510. [PMID: 38148404 PMCID: PMC10830582 DOI: 10.1007/s00464-023-10569-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/23/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.
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Affiliation(s)
- Adriana Margarita Rey Rubiano
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia
| | | | - Lázaro Arango
- Department of Clinical Surgical Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Department of Endoscopy and Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Union of surgeons, Zentria Group, Manizales, Caldas, Colombia.
| | - Camilo Blanco-Avellaneda
- Department of Gastrointestinal Surgery and Digestive Endoscopy, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia
- Education and Research Group, Faculty of Education, Universidad El Bosque, Bogotá, D.C., Colombia
- Videoendoscopy Unit of Restrepo Ltda, Bogotá, D.C, Colombia
| | - Jhon Jaime Carvajal Gutiérrez
- Department of Gastroenterology, Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Rodrigo Castaño-Llano
- Department of Gastroenterology, Universidad de Antioquia, Medellín, Antioquia, Colombia
- Institute of Cancerology, Clínica las Américas Auna, Medellín, Antioquia, Colombia
| | - Martin Alonso Gómez Zuleta
- Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
- Department of Internal Medicine, Gastroenterology Section, Hospital Universitario Nacional de Colombia, Bogotá, D.C., Colombia
| | - Carlos González
- Department of Gastroenterology and Digestive Endoscopy, Clínica Reina Sofia, Bogotá, D.C., Colombia
- Department of Gastroenterology and Digestive Endoscopy, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
- Department of Gastroenterology, Clínica Colombia, Bogotá, D.C., Colombia
| | - Arecio Peñaloza-Ramírez
- Department of Gastroenterology, Fundación Universitaria de Ciencias de la Salud, Bogotá, D.C., Colombia
- Department of Gastroenterology, Hospital de San José, Bogotá, D.C., Colombia
| | - Raúl Pinilla Morales
- Department of Gastroenterology and Oncological Digestive Endoscopy, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
| | - Renzo Pinto Carta
- Colombian Association of Digestive Endoscopy, Bogotá, D.C., Colombia
- American Society for Gastrointestinal Endoscopy, Rochester, USA
| | - Héctor Adolfo Polanía Liscano
- Department of Gastroenterology, Universidad Surcolombiana, Neiva, Huila, Colombia
- Endotek Ltda, Hospital Universitario Neiva, Neiva, Huila, Colombia
| | - Reinaldo Andrés Rincón Sánchez
- Department of Internal Medicine and Gastroenterology, Pontificia Universidad Javeriana - Hospital Universitario San Ignacio, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Clínica Shaio, Bogotá, D.C., Colombia
| | | | - Rómulo Vargas-Rubio
- Department of Gastroenterology, Hospital Universitario de San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Camilo Andrés Avendaño Capriles
- School of Medicine, Universidad del Norte, Barranquilla, Colombia
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrés Mauricio García-Sierra
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- School of Global Health Management and Informatics, University of Central Florida, Orlando, USA
| | - Juan José Yepes-Nuñez
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia.
- Pulmonology Service, Internal Medicine Section, Fundación Santa Fe de Bogotá University Hospital, Bogotá, D.C., Colombia.
- Colombia GRADE Network, Bogotá, D.C., Colombia.
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Mauro A, Mazza S, Scalvini D, Lusetti F, Bardone M, Quaretti P, Cobianchi L, Anderloni A. The Role of Cholangioscopy in Biliary Diseases. Diagnostics (Basel) 2023; 13:2933. [PMID: 37761300 PMCID: PMC10528268 DOI: 10.3390/diagnostics13182933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Pietro Quaretti
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
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9
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Robles-Medranda C, Baquerizo-Burgos J, Alcivar-Vasquez J, Kahaleh M, Raijman I, Kunda R, Puga-Tejada M, Egas-Izquierdo M, Arevalo-Mora M, Mendez JC, Tyberg A, Sarkar A, Shahid H, del Valle-Zavala R, Rodriguez J, Merfea RC, Barreto-Perez J, Saldaña-Pazmiño G, Calle-Loffredo D, Alvarado H, Lukashok HP. Artificial intelligence for diagnosing neoplasia on digital cholangioscopy: development and multicenter validation of a convolutional neural network model. Endoscopy 2023; 55:719-727. [PMID: 36781156 PMCID: PMC10374349 DOI: 10.1055/a-2034-3803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/13/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND We aimed to develop a convolutional neural network (CNN) model for detecting neoplastic lesions during real-time digital single-operator cholangioscopy (DSOC) and to clinically validate the model through comparisons with DSOC expert and nonexpert endoscopists. METHODS In this two-stage study, we first developed and validated CNN1. Then, we performed a multicenter diagnostic trial to compare four DSOC experts and nonexperts against an improved model (CNN2). Lesions were classified into neoplastic and non-neoplastic in accordance with Carlos Robles-Medranda (CRM) and Mendoza disaggregated criteria. The final diagnosis of neoplasia was based on histopathology and 12-month follow-up outcomes. RESULTS In stage I, CNN2 achieved a mean average precision of 0.88, an intersection over the union value of 83.24 %, and a total loss of 0.0975. For clinical validation, a total of 170 videos from newly included patients were analyzed with the CNN2. Half of cases (50 %) had neoplastic lesions. This model achieved significant accuracy values for neoplastic diagnosis, with a 90.5 % sensitivity, 68.2 % specificity, and 74.0 % and 87.8 % positive and negative predictive values, respectively. The CNN2 model outperformed nonexpert #2 (area under the receiver operating characteristic curve [AUC]-CRM 0.657 vs. AUC-CNN2 0.794, P < 0.05; AUC-Mendoza 0.582 vs. AUC-CNN2 0.794, P < 0.05), nonexpert #4 (AUC-CRM 0.683 vs. AUC-CNN2 0.791, P < 0.05), and expert #4 (AUC-CRM 0.755 vs. AUC-CNN2 0.848, P < 0.05; AUC-Mendoza 0.753 vs. AUC-CNN2 0.848, P < 0.05). CONCLUSIONS The proposed CNN model distinguished neoplastic bile duct lesions with good accuracy and outperformed two nonexpert and one expert endoscopist.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Juan Alcivar-Vasquez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Michel Kahaleh
- Gastroenterology, Robert Wood Johnson Medical School Rutgers University, New Brunswick, New Jersey, United States
| | - Isaac Raijman
- Houston Methodist Hospital, Houston, Texas, United States
- Baylor Saint Luke’s Medical Center, Houston, Texas, United States
| | - Rastislav Kunda
- Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel (UZB)/Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Miguel Puga-Tejada
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Maria Egas-Izquierdo
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Martha Arevalo-Mora
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Juan C. Mendez
- mdconsgroup, Artificial Intelligence Department, Guayaquil, Ecuador
| | - Amy Tyberg
- Gastroenterology, Robert Wood Johnson Medical School Rutgers University, New Brunswick, New Jersey, United States
| | - Avik Sarkar
- Gastroenterology, Robert Wood Johnson Medical School Rutgers University, New Brunswick, New Jersey, United States
| | - Haroon Shahid
- Gastroenterology, Robert Wood Johnson Medical School Rutgers University, New Brunswick, New Jersey, United States
| | - Raquel del Valle-Zavala
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Jorge Rodriguez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Ruxandra C. Merfea
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Jonathan Barreto-Perez
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | - Daniel Calle-Loffredo
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Haydee Alvarado
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Hannah P. Lukashok
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
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Zhu L, Huang ZQ, Wang ZW, Yang XP, Hong JB, Yang ZZ, Yu ZP, Cao RL, He JL, Chen YX. A comparative study on the application of different endoscopic diagnostic methods in the differential diagnosis of benign and malignant bile duct strictures. Front Med (Lausanne) 2023; 10:1143978. [PMID: 37521338 PMCID: PMC10373872 DOI: 10.3389/fmed.2023.1143978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/22/2023] [Indexed: 08/01/2023] Open
Abstract
Objective To compare the diagnostic value of cytobrush, ERCP-guided biopsy, SpyGlass direct visual impression and SpyGlass-guided biospy (SpyBite) in the differential diagnosis of benign and malignant bile duct strictures. Methods The data of 1,008 patients who were clinically diagnosed with indeterminate biliary strictures and underwent ERCP-guided biopsy, cytobrush, SpyGlass direct visual impression or SpyBite at the First Affiliated Hospital of Nanchang University between January 2010 and December 2019 were collected and analyzed retrospectively. The final diagnose was determined by surgical pathological specimen or follow-up (Malignant stricture can be identified if the stricture showed malignant progression during one year of follow-up). The differential diagnostic value of the above endoscopic diagnostic methods was evaluated by means of sensitivity, specificity, accuracy, positive predictive value, negative predictive value, etc. and safety was evaluated by the incidence rate of adverse events. Results In terms of sensitivity, standard biopsy group (48.6%) and SpyBite group (61.5%) were significantly higher than cytobrush group (32.0%), and visual impression group (100%) was significantly higher than any other group. As far as specificity was concerned, cytobrush group (99.0%), standard biopsy group (99.3%) and the SpyBite group (100%) were significantly higher than visual impression (55.6%), but there was no statistical difference among the three groups above. As far as accuracy was concerned, standard biopsy group (65.3%), and SpyBite group (80.0%) were significantly higher than cytobrush group (44.4%), and SpyBite group (80.0%) was significantly higher than visual impression group (54.8%). In terms of safety, visual impression group and SpyBite group were significantly higher than cytobrush group and standard biopsy group in post-ERCP cholangitis. Conclusion SpyBite combined with SpyGlass-guided visual impression was better for differential diagnosis of benign and malignant bile duct strictures in terms of sensitivity and accuracy compared with conventional endoscopic diagnostic methods such as cytobrush and standard biopsy. Furthmore, the incidence rates of adverse events after SpyGlass examination was similar to those after conventional endoscopic diagnostic methods except for higher cholangitis, which could be controlled by antibiotics and might be avoided by adequate biliary drainage.
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Affiliation(s)
- Liang Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, China
| | - Zhi-Quan Huang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhen-Wen Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xue-Ping Yang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun-Bo Hong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, China
| | - Zhen-Zhen Yang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, China
| | - Zheng-Ping Yu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Rong-Lai Cao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin-Li He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, China
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11
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Deng X, Wang J, Mou T, Pan L, Du C, Wu Q. Case report: Single-operator peroral cholangioscopy system (SpyGlass) diagnosis of an extrahepatic biliary cystadenoma (video). Front Med (Lausanne) 2023; 10:1175034. [PMID: 37425323 PMCID: PMC10327893 DOI: 10.3389/fmed.2023.1175034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/17/2023] [Indexed: 07/11/2023] Open
Abstract
Biliary cystadenoma is a type of rare liver cystic tumor. Intrahepatic biliary cystadenomas are the most common, while extrahepatic biliary cystadenomas are rarely seen. Biliary cystadenoma tends to occur in middle-aged to older women and there is a lack of specific preoperative diagnostic markers. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. Herein, we report a patient in whom a space-occupying lesion was found in the bile duct by SpyGlass, and who later underwent radical surgery. The pathology report indicated that the final diagnosis was biliary cystadenoma. SpyGlass cholangioscopy may be a novel and effective diagnostic method for biliary cystadenoma.
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Affiliation(s)
- Xin Deng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jingwen Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tong Mou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Long Pan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengyou Du
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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12
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Utility of Digital Single-operator Video Cholangioscopy for the Endoscopic Management of Biliary Complications After Liver Transplantation-A Single-center Experience. Transplantation 2022; 107:925-932. [PMID: 36525550 DOI: 10.1097/tp.0000000000004388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Liver transplant recipients (LTRs) frequently develop biliary complications, and endoscopy is crucial for their subsequent management. Recently, single-operator video cholangioscopy (SOVC) with digital imaging quality was introduced. This study evaluated the utility of digital SOVC for the management of biliary complications in LTRs. METHODS This observational study retrospectively analyzed all LTRs undergoing digital SOVC between 2015 and 2019 at a tertiary referral center. Endpoints included the assessment of biliary strictures, performance of selective guidewire passage across biliary strictures, and diagnosis and treatment of biliary stone disease. RESULTS In total, 79 digital SOVCs performed in 50 LTRs were identified. Fifty-eight percent of the procedures were performed for biliary stricture assessment, and using visual signs or guided biopsies, SOVC excluded malignancy in all cases (100%). Of all the examinations, 29.1% (23/79) were performed solely because of a previous failure of conventional endoscopic methods to pass a guidewire across a biliary stricture. Using SOVC, guidewire passage was successfully performed in 73.9% of these examinations, enabling subsequent endoscopic therapy. Furthermore, biliary stones were found in 16.5% (13/79) of the examinations. In 38.5% of these cases, standard fluoroscopy failed to detect stones, which were only visualized using digital SOVC. Biliary stone treatment was successful in 92% (12/13) of the examinations. Complications occurred in 11.4% of all SOVCs. No procedure-associated mortalities were observed. CONCLUSIONS Digital SOVC is effective and safe for the endoscopic management of biliary complications in LTRs and offers unique diagnostic and therapeutic opportunities that strongly impact the clinical course in selected cases.
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13
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Funari MP, Hirsch BS, Franzini TP, de Moura DTH, Miranda Neto AA, McCarty TR, de Moura EGH. Role of cholangioscopy and therapeutic options in complex anastomotic strictures after liver transplantation. Endoscopy 2022; 54:E581-E582. [PMID: 34933361 DOI: 10.1055/a-1704-7503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Bruno Salomão Hirsch
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Tomazo Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Antonio Afonso Miranda Neto
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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14
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Abstract
Bile duct stenosis continues to present a diagnostic dilemma for clinicians. It is important to establish the benign or malignant nature of the stricture early in order to avoid any unnecessary delay in medical treatment or surgery. Tissue acquisition for histological diagnosis is particularly crucial when the initial diagnostic work up is inconclusive. The diagnostic yield from the conventional endoscopic retrograde cholangiopancreatography (ERCP) with brushing and biopsy is suboptimal. Patients with indeterminate biliary strictures (IDBSs) often require a multi-disciplinary diagnostic approach and additional endoscopic evaluation, including cholangioscopy and endoscopic ultrasound, before a final diagnosis can be reached. In this article, we discuss the recent endoscopic advancements in the diagnosis of biliary stricture with a focus on the roles of cholangioscopy and endoscopic ultrasound (EUS).
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15
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Bokemeyer A, Lenze F, Stoica V, Sensoy TS, Kabar I, Schmidt H, Ullerich H. Digital single-operator video cholangioscopy improves endoscopic management in patients with primary sclerosing cholangitis-a retrospective observational study. World J Gastroenterol 2022; 28:2201-2213. [PMID: 35721887 PMCID: PMC9157616 DOI: 10.3748/wjg.v28.i20.2201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) are at a high risk of developing cholestatic liver disease and biliary cancer, and endoscopy is crucial for the complex management of these patients.
AIM To clarify the utility of recently introduced digital single-operator video cholangioscopy (SOVC) for the endoscopic management of PSC patients.
METHODS In this observational study, all patients with a history of PSC and in whom digital SOVC (using the SpyGlass DS System) was performed between 2015 and 2019 were included and retrospectively analysed. Examinations were performed at a tertiary referral centre in Germany. In total, 46 SOVCs performed in 38 patients with a history of PSC were identified. The primary endpoint was the evaluation of dominant biliary strictures using digital SOVC, and the secondary endpoints were the performance of selective guidewire passage across biliary strictures and the diagnosis and treatment of biliary stone disease in PSC patients.
RESULTS The 22 of 38 patients had a dominant biliary stricture (57.9%). In 4 of these 22 patients, a cholangiocellular carcinoma was diagnosed within the stricture (18.2%). Diagnostic evaluation of dominant biliary strictures using optical signs showed a sensitivity of 75% and a specificity of 94.4% to detect malignant strictures, whereas SOVC-guided biopsies to gain tissue for histopathological analysis showed a sensitivity of 50% and a specificity of 100%. In 13% of examinations, SOVC was helpful for guidewire passage across biliary strictures that could not be passed by conventional methods (technical success rate 100%). Biliary stone disease was observed in 17.4% of examinations; of these, in 37.5% of examinations, biliary stones could only be visualized by SOVC and not by standard fluoroscopy. Biliary stone treatment was successful in all cases (100%); 25% required SOVC-assisted electrohydraulic lithotripsy. Complications, such as postinterventional cholangitis and pancreatitis, occurred in 13% of examinations; however, no procedure-associated mortality occurred.
CONCLUSION Digital SOVC is effective and safe for the endoscopic management of PSC patients and may be regularly considered an additive tool for the complex endoscopic management of these patients.
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Affiliation(s)
- Arne Bokemeyer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Frank Lenze
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Viorelia Stoica
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Timur Selcuk Sensoy
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Iyad Kabar
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Hansjoerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
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Wang J, Xia M, Jin Y, Zheng H, Shen Z, Dai W, Li X, Kang M, Wan R, Lu L, Hu B, Wan X, Cai X. More Endoscopy-Based Brushing Passes Improve the Detection of Malignant Biliary Strictures: A Multicenter Randomized Controlled Trial. Am J Gastroenterol 2022; 117:733-739. [PMID: 35108222 DOI: 10.14309/ajg.0000000000001666] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic biliary brushing is the most common method used for sampling in patients with malignant biliary strictures (MBSs); however, its sensitivity is relatively low. There is still no consensus on endoscopy-based biliary brushing, although brushing 10 times in 1 specimen is routinely performed. This study was designed to compare the sensitivity of brush cytology for 10, 20, or 30 brushing times of a pass in 1 specimen in patients with MBSs. METHODS In this multicenter, prospective, randomized controlled study, patients who underwent endoscopic retrograde cholangiopancreatography for suspected MBSs were enrolled. Patients were randomly assigned to receive 10, 20, and 30 brushing times of a pass. The primary outcome was to compare the sensitivity of brush cytology among the 3 groups. Patients were prospectively followed up for 6 months after endoscopic brushing for malignancy diagnosis. RESULTS A total of 443 patients were enrolled for intention-to-treat analysis (147, 148, and 148 patients in the 10-times, 20-times, and 30-time groups, respectively). The 3 groups were similar in baseline characteristics. The sensitivity of brush cytology was 38%, 47%, and 57% in the 10-times, 20-times, and 30-times groups, respectively, and the 30-times group showed significantly higher sensitivity than the 10-times group (P = 0.001). The multivariate analysis revealed that stricture length and the number of brushing passes were significant factors for the detection of biliary malignancy. No significant differences were observed in procedure-related complications among the 3 groups. DISCUSSION Brushing 30 times could increase the diagnostic sensitivity without increasing complications and seems to be preferred for the endoscopic sampling and diagnosis of MBSs (chictr.org.cn, identifier: ChiCTR1800015978).
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Affiliation(s)
- Junjun Wang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingxing Xia
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Yubiao Jin
- Department of Pathology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiming Zheng
- Department of Gastroenterology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenyang Shen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiming Dai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoman Li
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei Kang
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Wan
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lungen Lu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Xinjian Wan
- Department of Gastroenterology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobo Cai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Correia FP, Lourenço LC. Artificial intelligence in the endoscopic approach of biliary tract diseases: A current review. Artif Intell Gastrointest Endosc 2022; 3:9-15. [DOI: 10.37126/aige.v3.i2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/22/2022] [Accepted: 04/19/2022] [Indexed: 02/06/2023] Open
Abstract
In recent years there have been major developments in the field of artificial intelligence. The different areas of medicine have taken advantage of this tool to make various diagnostic and therapeutic methods more effective, safe, and user-friendly. In this way, artificial intelligence has been an increasingly present reality in medicine. In the field of Gastroenterology, the main application has been in the detection and characterization of colonic polyps, but an increasing number of studies have been published on the application of deep learning systems in other pathologies of the gastrointestinal tract. Evidence of the application of artificial intelligence in the assessment of biliary tract is still scarce. Some studies support the usefulness of these systems in the investigation and treatment of choledocholithiasis, demonstrating that they have the potential to be integrated into clinical practice and endoscopic procedures, such as endoscopic retrograde cholangiopancreatography. Its application in cholangioscopy for the investigation of undetermined biliary strictures also seems to be promising. Assessing the bile duct through endoscopic ultrasound can be challenging, especially for less experienced operators, thus becoming an area of potential interest for artificial intelligence. In this review, we summarize the state of the art of artificial intelligence in the endoscopic diagnosis and treatment of biliary diseases.
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Affiliation(s)
- Fábio Pereira Correia
- Department of Gastroenterology, Hospital Prof. Dr Fernando Fonseca, Amadora 2720-276, Portugal
| | - Luís Carvalho Lourenço
- Department of Gastroenterology, Hospital Prof. Dr Fernando Fonseca, Amadora 2720-276, Portugal
- Gastroenterology Center, Hospital Cuf Tejo - Nova Medical School/Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon 1350-352, Portugal
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18
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Dhar Chowdhury S, Jaleel R. Cholangioscopy: Has It Changed Management? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1743183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThe single operator per oral cholangioscope is a catheter-based system that allows for direct visualization of the bile duct and pancreatic duct. The instrument with its improved imaging technique and larger accessory channel allows for high-quality image acquisition and performance of therapeutic and diagnostic procedures within the bile duct and pancreatic duct. There has been an increase in the range of indications for the use of the cholangioscope. The current indications include management of difficult biliary stones, pancreatic calculi, assessment of indeterminate biliary stricture, pancreatic stricture, intra-ductal papillary mucinous neoplasms, and extractions of proximally migrated stents. The use of laser lithotripsy and electro-hydraulic lithotripsy has improved the management of difficult bile duct stones. Direct visualization of biliary and pancreatic duct strictures is helpful in the diagnosis of indeterminate strictures. In this review, we explore how cholangioscopy has changed management.
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Affiliation(s)
| | - Rajeeb Jaleel
- Department of Gastroenterology, Christian Medical College, Vellore, India
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19
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Improving Diagnostic Yield in Indeterminate Biliary Strictures. Clin Liver Dis 2022; 26:69-80. [PMID: 34802664 DOI: 10.1016/j.cld.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Indeterminate biliary strictures are defined as a narrowing of the bile duct that cannot be differentiated as malignant or benign after performing cross-sectional imaging and an ERCP. Identifying the etiology of a bile duct stricture is the single most important step in determining whether a complex and potentially morbid surgical resection is warranted. Due to this diagnostic and therapeutic dilemma, new technologies, laboratory tests, and procedures are emerging to solve this problem.
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Saraiva MM, Ribeiro T, Ferreira JPS, Boas FV, Afonso J, Santos AL, Parente MPL, Jorge RN, Pereira P, Macedo G. Artificial intelligence for automatic diagnosis of biliary stricture malignancy status in single-operator cholangioscopy: a pilot study. Gastrointest Endosc 2022; 95:339-348. [PMID: 34508767 DOI: 10.1016/j.gie.2021.08.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The diagnosis and characterization of biliary strictures (BSs) is challenging. The introduction of digital single-operator cholangioscopy (DSOC) that allows direct visual inspection of the lesion and targeted biopsy sampling significantly improved the diagnostic yield in patients with indeterminate BSs. However, the diagnostic efficiency of DSOC remains suboptimal. Convolutional neural networks (CNNs) have shown great potential for the interpretation of medical images. We aimed to develop a CNN-based system for automatic detection of malignant BSs in DSOC images. METHODS We developed, trained, and validated a CNN-based on DSOC images. Each frame was labeled as a normal/benign finding or as a malignant lesion if histopathologic evidence of biliary malignancy was available. The entire dataset was split for 5-fold cross-validation. In addition, the image dataset was split for constitution of training and validation datasets. The performance of the CNN was measured by calculating the area under the receiving operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values. RESULTS A total of 11,855 images from 85 patients were included (9695 malignant strictures and 2160 benign findings). The model had an overall accuracy of 94.9%, sensitivity of 94.7%, specificity of 92.1%, and AUC of .988 in cross-validation analysis. The image processing speed of the CNN was 7 ms per frame. CONCLUSIONS The developed deep learning algorithm accurately detected and differentiated malignant strictures from benign biliary conditions. The introduction of artificial intelligence algorithms to DSOC systems may significantly increase its diagnostic yield for malignant strictures.
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Affiliation(s)
- Miguel Mascarenhas Saraiva
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal; Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tiago Ribeiro
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
| | - João P S Ferreira
- Department of Mechanical Engineering, Faculty of Engineering, University of Porto, Porto, Portugal
| | - Filipe Vilas Boas
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal; Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Afonso
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
| | - Ana Luísa Santos
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal; Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marco P L Parente
- Department of Mechanical Engineering, Faculty of Engineering, University of Porto, Porto, Portugal
| | - Renato N Jorge
- Department of Mechanical Engineering, Faculty of Engineering, University of Porto, Porto, Portugal
| | - Pedro Pereira
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal; Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, São João University Hospital, Porto, Portugal; WGO Gastroenterology and Hepatology Training Center, Porto, Portugal; Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto, Portugal
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21
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Angsuwatcharakon P, Kulpatcharapong S, Moon JH, Ramchandani M, Lau J, Isayama H, Seo DW, Maydeo A, Wang HP, Nakai Y, Ratanachu-Ek T, Bapaye A, Hu B, Devereaux B, Ponnudurai R, Khor C, Kongkam P, Pausawasdi N, Ridtitid W, Piyachaturawat P, Khanh PC, Dy F, Rerknimitr R. Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture. HPB (Oxford) 2022; 24:17-29. [PMID: 34172378 DOI: 10.1016/j.hpb.2021.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures. METHODS The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement. RESULTS Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties. CONCLUSION Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Santi Kulpatcharapong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jong H Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Seoul, South Korea
| | | | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Dong W Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Global Gleneagles Hospital, Mumbai, India
| | - Hsiu-P Wang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yousuke Nakai
- Departments of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
| | | | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital & Research Center, India
| | - Bing Hu
- Department of Gastroenterology, Eastern Hepatobiliary Hospital, Naval Medical University, Shanghai, China
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore
| | - Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pham C Khanh
- Department of Endoscopy, University Medical Center, Ho Chi Minh City, Viet Nam
| | - Federick Dy
- Section of Gastroenterology, Department of Internal Medicine, Faculty of Medicine and Surgery, University of Santo Tomas Hospital, Manila, Philippines
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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22
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Stassen PM, de Jonge PJF, Webster GJ, Ellrichmann M, Dormann AJ, Udd M, Bruno MJ, Cennamo V. Clinical practice patterns in indirect peroral cholangiopancreatoscopy: outcome of a European survey. Endosc Int Open 2021; 9:E1704-E1711. [PMID: 34790534 PMCID: PMC8589539 DOI: 10.1055/a-1535-1458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background and aims Indirect peroral cholangiopancreatoscopy (IPOC) is a relatively new diagnostic and therapeutic tool for biliopancreatic diseases. This international survey aimed to evaluate clinical practice patterns in IPOC among endoscopists in Europe. Methods An online survey was developed comprising 66 questions on the use of IPOC. Questions were grouped into four domains. The survey was sent to 369 endoscopists who perform IPOC. Results 86 respondents (23.3 %) from 21 different countries across Europe completed the survey. The main indications for cholangioscopy were determination of biliary strictures (85 [98.8 %]) and removal of common bile duct or intrahepatic duct stones (79 [91.9 %]), accounting for an estimated use of 40 % (interquartile range [IQR] 25-50) and 40 % (IQR 30-60), respectively, of all cases undergoing cholangioscopy. Pancreatoscopy was mainly used for removal of pancreatic duct stones (68/76 [89.5 %]), accounting for an estimated use of 76.5 % (IQR 50-95) of all cases undergoing pancreatoscopy. Only 13/85 respondents (15.3 %) had an institutional standardized protocol for targeted cholangioscopy-guided biopsy sampling. IPOC with lithotripsy was used as first-line treatment in selected patients with bile duct stones or pancreatic stones by 24/79 (30.4 %) and 53/68 (77.9 %) respondents, respectively. Conclusions This first European survey on the clinical practice of IPOC demonstrated wide variation in experience, indications, and techniques. These results emphasize the need for prospective studies and development of an international consensus guideline to standardize the practice and quality of IPOC.
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Affiliation(s)
- Pauline M.C. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Jan F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - George J.M. Webster
- Department of Gastroenterology, University College London Hospitals, London, United Kingdom
| | - Mark Ellrichmann
- Department of Interdisciplinary Endoscopy, Medical Department 1, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Arno J. Dormann
- Department of Gastroenterology, GI Oncology, GI-ID, Nutritional Medicine, Kliniken der Stadt Köln, Köln, Germany
| | - Marianne Udd
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Vincenzo Cennamo
- Gastroenterology and Interventional Endoscopy Unit, Local Health Authority of Bologna, Bologna, Italy
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23
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Pouw RE, Barret M, Biermann K, Bisschops R, Czakó L, Gecse KB, de Hertogh G, Hucl T, Iacucci M, Jansen M, Rutter M, Savarino E, Spaander MCW, Schmidt PT, Vieth M, Dinis-Ribeiro M, van Hooft JE. Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:1174-1188. [PMID: 34535035 DOI: 10.1055/a-1611-5091] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected Helicobacter pylori infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers location VUmc, Amsterdam, The Netherlands
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location AMC, Amsterdam, The Netherlands
| | - Gert de Hertogh
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marietta Iacucci
- Institute of Translational Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital, London, UK
| | - Matthew Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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24
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Del Vecchio Blanco G, Mossa M, Troncone E, Argirò R, Anderloni A, Repici A, Paoluzi OA, Monteleone G. Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review. World J Gastrointest Endosc 2021; 13:473-490. [PMID: 34733408 PMCID: PMC8546565 DOI: 10.4253/wjge.v13.i10.473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/24/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023] Open
Abstract
Biliary stenosis may represent a diagnostic and therapeutic challenge resulting in a delay in diagnosis and initiation of therapy due to the frequent difficulty in distinguishing a benign from a malignant stricture. In such cases, the diagnostic flowchart includes the sequential execution of imaging techniques, such as magnetic resonance, magnetic resonance cholangiopancreatography, and endoscopic ultrasound, while endoscopic retrograde cholangiopancreatography is performed to collect tissue for histopathological/cytological diagnosis or to treat the stenosis by insertion of stent. The execution of percutaneous transhepatic drainage with subsequent biopsy has been shown to increase the possibility of tissue diagnosis after failure of the above techniques. Although the diagnostic yield of histopathology and imaging has increased with improvements in endoscopic ultrasound and peroral cholangioscopy, differential diagnosis between malignant and benign stenosis may not be easy in some patients, and strictures are classified as indeterminate. In these cases, a multidisciplinary workup including biochemical marker assays and advanced technologies available may speed up a diagnosis of malignancy or avoid unnecessary surgery in the event of a benign stricture. Here, we review recent advancements in the diagnosis and management of biliary strictures and describe tips and tricks to increase diagnostic yields in clinical routine.
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Affiliation(s)
| | - Michelangela Mossa
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Renato Argirò
- Department of Interventional Radiology, University of Rome Tor Vergata, Rome 00133, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Rozzano 20093, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Rozzano 20093, Italy
| | - Omero Alessandro Paoluzi
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
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25
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Ferreira MTGB, Ribeiro IB, de Moura DTH, McCarty TR, da Ponte Neto AM, Farias GFA, de Miranda Neto AA, de Oliveira PVAG, Bernardo WM, de Moura EGH. Stent versus Balloon Dilation for the Treatment of Dominant Strictures in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis. Clin Endosc 2021; 54:833-842. [PMID: 34192839 PMCID: PMC8652153 DOI: 10.5946/ce.2021.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background/Aims The endoscopic management of primary sclerosing cholangitis (PSC)-associated dominant strictures remains challenging. This systematic review and meta-analysis aimed to compare balloon dilation and stent placement in the treatment of dominant strictures among PSC patients.
Methods Literature searches on MEDLINE, EMBASE, Cochrane CENTRAL and Lilacs/Bireme were performed for studies published until December 2020. Measured outcomes included clinical efficacy, stricture recurrence, cumulative recurrencefree rate, transplant rate, 5-year survival rate, and adverse events (i.e., pancreatitis, cholangitis, bleeding, perforation and death).
Results A total of 5 studies (n=467) were included. Based on pooled analyses, there were no differences in clinical efficacy (risk difference [RD], -0.13; 95% confidence interval [CI], -0.58 to 0.33; I2=93%) or transplant rates (RD, -0.09; 95% CI, -0.19 to 0.01; I2=0%); however, the risk of occurrence of adverse events was lower with balloon dilatation than with stent placement (RD,-0.34; 95% CI, -0.45 to -0.23; I2=61%). Among the types of adverse events reported, only the rates of cholangitis/bacteremia were significantly lower in balloon dilation patients (RD, -0.19; 95% CI, -0.25 to -0.13; I2=51%).
Conclusions Compared to balloon dilation, stent placement for dominant strictures in PSC appeared to have higher complication rates without significant differences in efficacy.
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Affiliation(s)
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Thomas R McCarty
- Division of Gasteoenterology, Hepatology and Endoscopy - Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| | - Alberto Machado da Ponte Neto
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Galileu Ferreira Ayala Farias
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Antônio Afonso de Miranda Neto
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Pedro Victor Aniz Gomes de Oliveira
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unity, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil
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26
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Boškoski I, Schepis T, Tringali A, Familiari P, Bove V, Attili F, Landi R, Perri V, Costamagna G. Personalized Endoscopy in Complex Malignant Hilar Biliary Strictures. J Pers Med 2021; 11:jpm11020078. [PMID: 33572913 PMCID: PMC7911877 DOI: 10.3390/jpm11020078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022] Open
Abstract
Malignant hilar biliary obstruction (HBO) represents a complex clinical condition in terms of diagnosis, surgical and medical treatment, endoscopic approach, and palliation. The main etiology of malignant HBO is hilar cholangiocarcinoma that is considered an aggressive biliary tract's cancer and has still today a poor prognosis. Endoscopy plays a crucial role in malignant HBO from the diagnosis to the palliation. This technique allows the collection of cytological or histological samples, direct visualization of the suspect malignant tissue, and an echoendoscopic evaluation of the primary tumor and its locoregional staging. Because obstructive jaundice is the most common clinical presentation of malignant HBO, endoscopic biliary drainage, when indicated, is the preferred treatment over the percutaneous approach. Several endoscopic techniques are today available for both the diagnosis and the treatment of biliary obstruction. The choice among them can differ for each clinical scenario. In fact, a personalized endoscopic approach is mandatory in order to perform the proper procedure in the singular patient.
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Affiliation(s)
- Ivo Boškoski
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Tommaso Schepis
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Andrea Tringali
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Pietro Familiari
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Vincenzo Bove
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Fabia Attili
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Rosario Landi
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Vincenzo Perri
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Guido Costamagna
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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Proença IM, dos Santos MEL, de Moura DTH, Ribeiro IB, Matuguma SE, Cheng S, McCarty TR, do Monte Junior ES, Sakai P, de Moura EGH. Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification. World J Gastroenterol 2020; 26:7104-7117. [PMID: 33362371 PMCID: PMC7723666 DOI: 10.3748/wjg.v26.i45.7104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/08/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions – such as disruptions and strictures – are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.
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Affiliation(s)
- Igor Mendonça Proença
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Spencer Cheng
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Epifanio Silvino do Monte Junior
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
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Martinez NS, Trindade AJ, Sejpal DV. Determining the Indeterminate Biliary Stricture: Cholangioscopy and Beyond. Curr Gastroenterol Rep 2020; 22:58. [PMID: 33141356 DOI: 10.1007/s11894-020-00797-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Indeterminate biliary strictures (IDBS) continue to be an area of frustration for clinicians. Standard endoscopic retrograde cholangiopancreatography (ERCP) with conventional brush cytology and/or forceps biopsy has a low sensitivity for distinguishing benign from malignant biliary strictures. A delay in diagnosis of malignancy has consequences for subsequent therapy or surgery. In this article, we review current and emerging technologies that may aid in this diagnostic dilemma. RECENT FINDINGS Several technologies have been utilized in IDBS to establish a diagnosis which include peroral cholangioscopy, confocal laser endomicroscopy, endoscopic ultrasound with fine needle aspiration, intraductal ultrasound, optical coherence tomography, fluorescence in situ hybridization, next generation sequencing, integrated molecular pathology, and DNA-image cytometry. While cholangioscopy and confocal laser endomicroscopy have become standards of care in expert centers for the evaluation of patients with IDBS, there are several endoscopic and molecular modalities that may also aid in establishing a diagnosis. Further head-to-head prospective diagnostic studies as well as cost-efficacy studies are needed.
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Affiliation(s)
- Nichol S Martinez
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Arvind J Trindade
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Divyesh V Sejpal
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.
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Wen LJ, Chen JH, Xu HJ, Yu Q, Liu K. Efficacy and Safety of Digital Single-Operator Cholangioscopy in the Diagnosis of Indeterminate Biliary Strictures by Targeted Biopsies: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:E666. [PMID: 32887436 PMCID: PMC7555631 DOI: 10.3390/diagnostics10090666] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Biliary strictures are frequently encountered in clinical practice. The determination of their nature is often difficult. This study aims to systematically evaluate the efficacy and safety of the second generation of digital single-operator cholangioscopy (SpyGlass DS, DSOC) in indeterminate biliary strictures (IBDS) through biopsies. METHODS All relative studies published in Medline, the Cochrane Library, Web of Science, and EMBASE were included. The diagnostic tests for IBDS were compared to the surgical histology, autopsy, or long-term clinical follow-up. The methodological quality of the included studies was evaluated by the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS-2). RESULTS A total of 11 studies, which involved 356 patients diagnosed through biopsies, were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.74 (95% CI: 0.67-0.80), 0.98 (95% CI: 0.95-1.00), 10.52 (95% CI: 5.45-20.32), 0.31 (95% CI: 0.23-0.41), and 65.18 (95% CI: 26.79-158.61), respectively. The area under the curve (AUC) was 0.9479, and the pooled adverse event rate was 7%. The sensitivity and specificity in the heterogeneity analysis were I2 = 48.1% and I2 = 25.4%, respectively. CONCLUSION SpyGlass DS is a safe and effective technique for IBDS. However, future randomized trials are needed to determine optimal number of biopsies.
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Affiliation(s)
- Li-Jia Wen
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Jun-Hong Chen
- College of Clinical Medicine, Jilin University, Changchun 130021, China;
| | - Hong-Ji Xu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Qiong Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun 130021, China;
| | - Kai Liu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
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