The role of endoscopic ultrasound in biliary strictures

An Approach to and Treatment of Indeterminate Biliary Strictures: A Comprehensive Review of the Literature

This review aims to focus on what we know about the management of biliary strictures of unknown etiology, especially exploring our diagnostic armamentarium in the setting of indeterminate biliary strictures. Presently, this is a current issue that has a relevant impact both on patient prognosis, often delaying diagnosis, and on overall costs associated with repeating diagnostic procedures, sometimes performed with very expensive devices. We also focus on current biliary drainage approaches, providing an overview of therapeutic options, endoscopic or not.

Standards for providing emergency care at the prehospital and early hospital stages for patients with mechanical jaundice

Mechanical jaundice is a condition characterized by obstructive disorders in the biliary system, posing a diagnostic challenge that requires advanced visualization techniques and laboratory tests for accurate diagnosis. This article explores the role of biochemical markers, presents an analysis of the algorithm for laboratory diagnosis and visualization techniques in order to stratify patients with jaundice syndrome, and conduct timely and effective conservative treatment with further surgical interventions. A comprehensive diagnostic and therapeutic algorithm has been developed whose use by emergency physicians at the prehospital and early hospital stages will lead to a rapid and qualitative elimination of biliary obstruction, a reduction in the level of complications, and the achievement of optimal treatment outcomes for patients.

Comparison of EUS and ERCP-guided tissue sampling in suspected biliary stricture

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are commonly used diagnostic modalities in biliary strictures. We compared the diagnostic yield of EUS and ERCP-based tissue sampling in intrinsic biliary strictures without extrinsic mass outside the bile duct.

METHODS

A total of 85 patients who underwent ERCP and EUS for diagnosis of suspected biliary strictures confined to the bile duct were analyzed retrospectively at Samsung Medical Center, Seoul, Korea, between 2010 and 2018.

RESULTS

Seventy-one patients were diagnosed with malignancy and 14 patients were diagnosed with benign strictures. EUS-based tissue sampling was more sensitive and accurate than ERCP-based tissue sampling (p = 0.038). The overall sensitivity and accuracy were 67.6% (95% confidence interval (CI) 56.1-77.3) and 72.9% (95% CI 62.7-81.2) for ERCP-based sampling, and 80.3% (95% CI 69.6-87.9) and 83.5% (95% CI 74.2-89.9) for EUS-based sampling, respectively. EUS-based sampling was superior to ERCP-based sampling in distal bile duct strictures (accuracy: 87.0% vs. 72.5%, p = 0.007), but not in perihilar strictures. In cases without intraductal mass, EUS-based tissue sampling was also superior to ERCP-based sampling (accuracy: 83.3% vs. 69.7%, p = 0.029), but not in cases with mass.

CONCLUSION

EUS-based tissue sampling was superior to ERCP-based method in intrinsic biliary stricture with no mass outside the bile duct, particularly in those without intraductal mass or those with strictures located in distal bile duct. Therefore, EUS-based sampling should be considered for making a pathological diagnosis of suspected distal bile duct strictures even in lesions without definite mass.

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

Endoscopic management of benign biliary strictures

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

Cholangiocarcinoma: Aggressive Surgical Intervention Remains Justified

Cholangiocarcinoma (CCA) continues to be a difficult disease to both diagnose and treat. Optimal treatment includes resection to histologically negative margins. In recent years, advanced imaging, including magnetic resonance cholangiography and endoscopic ultrasound, has presumably improved the accuracy of determining resectability. From 2004 to 2009, a total of 61 patients with cholangiocarcinoma were evaluated for resection. The majority were men (37) and ages ranged from 29 to 87 years (mean, 67 years). Only 31 per cent were found to be obviously unresectable based on imaging alone. The remaining 69 per cent underwent exploration, at which time resection was found unfeasible in an additional 25 per cent (overall 56% unresectable). Although all resection specimens had grossly negative margins, 37 per cent were ultimately found to be microscopically positive. The overall 5-year actuarial survival for patients undergoing resection was 39.2 per cent with no survival difference between those with positive and negative margins. Despite advances in diagnostic imaging, more than half of patients with CCA presenting for surgical evaluation are ultimately found to be unresectable. However, the final determination can still only be made at the time of exploration. Even in the presence of microscopic residual disease, surgical intervention results in improved survival. An aggressive stance toward surgical intervention in patients with CCA remains justified.

Endoscopic ultrasound in the evaluation of radiologic abnormalities of the liver and biliary tree

Gastroenterologists increasingly find themselves in the un-enviable position of having to choose the optimal radiographic test to visualize the biliary tree and the liver. This dilemma is compounded by the rapid evolution of the available technologies and their ever-increasing resolution capabilities. Endoscopic ultrasound (EUS) has shown itself to be equally capable of providing detailed imaging of the biliary tree and of surrounding structures; its potential for evaluating liver lesions is just now being realized. EUS-fine needle aspiration (FNA) may supplant some of the existing technologies as it offers a way to sample masses, strictures, lymph nodes, and now certain segments of the liver and periportal regions. This review takes an in-depth look at the role of EUS in evaluating bile duct dilatation, suspected choledocholithiasis, biliary strictures, and polyps and masses of the gallbladder. It also reviews the literature on the exciting and rapidly evolving role of EUS-FNA evaluation of occult, metastatic, and primary hepato-cellular malignancies, as well as periportal lesions. Technologies such as EUS elastography may completely obviate FNA of liver lesions.