Multidisciplinary Approach to Indeterminate Biliary Strictures

Effect of brush rinse on the diagnostic accuracy of biliary stricture evaluation: A multicenter trial

BACKGROUND

Brush cytology is the most commonly used technique for tissue acquisition during endoscopic retrograde cholangiopancreatography for the evaluation of biliary strictures. Nonetheless, brush cytology is limited by its low sensitivity due to insufficient cellular yield.

AIM

To evaluate the impact of the sheath-rinse technique on improving the cellularity yield.

METHODS

A total of 112 patients with suspected malignant biliary strictures were enrolled at two tertiary centers in South Korea. The sample cellularity and diagnostic accuracy of brush-wash and sheath-rinse specimens were compared.

RESULTS

A significantly increased number of total cell clusters per representative 20 × field was recorded in the sheath-rinse compared with the brush-wash specimens (median: 12 vs 3, P < 0.001). This trend persisted when large (> 50 cells) clusters (median: 8 vs 3, P < 0.001), medium (6-49 cells) (median: 7 vs 3, P < 0.001), and small (2-5 cells) clusters (median: 9 vs 3, P < 0.001) were evaluated. Diagnostic accuracy and sensitivity for differentiating malignancy were superior with sheath-rinsing than with the brush-wash method (72.3% vs 62.5%, P < 0.001 and 69.9% vs 59.2%, P < 0.001, respectively).

CONCLUSION

Incorporating sheath-rinse specimens significantly improved the yield and diagnostic accuracy of biliary brush cytology. Sheath-rinsing should be integrated into routine clinical practice to improve diagnostic performance for biliary strictures.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

Case report: The diagnostic dilemma of indeterminate biliary strictures: report on two cases with a literature review

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.

A Case of Foreign Body in the Biliary Tree and the Challenge of Hypereosinophilia

In all reported cases of foreign body migration or impaction in the biliary tree, there is no mention of the presence of hypereosinophilia among the laboratory findings. This could possibly be attributed to the local tissue reaction caused by the impacted foreign body. Here, we present our experience with the removal of a screw from a surgical retractor that became lodged in the common bile duct (CBD) and migrated in a patient who had previously undergone a left lateral hepatectomy for hepatic hydatidosis. The imaging was not sufficient to make a diagnosis, and the interpretation of hypereosinophilia in such a case could pose a challenge.