How many biopsies should be performed during percutaneous transhepatic cholangioscopy to diagnose biliary tract cancer?

Acceptable number of cholangioscopy-guided biopsies for diagnosing perihilar cholangiocarcinoma

INTRODUCTION

diagnosing perihilar cholangiocarcinoma can be challenging. Previous studies suggest that the sensitivity of taking three cholangioscopy-guided biopsies is approximately 70 %. We hypothesized that obtaining four or more biopsies might improve the sensitivity for diagnosing perihilar cholangiocarcinoma.

OBJECTIVE

to determine the acceptable number of cholangioscopy-guided biopsies to improve sensitivity for diagnosing perihilar cholangiocarcinoma.

METHODS

this retrospective study analyzed clinical records of adults with perihilar stenosis who underwent cholangioscopy-guided biopsies. Patients with gallbladder cancer or metastatic bile duct obstruction were excluded. Data were grouped based on the number of biopsies taken: group A (one to three biopsies), group B (four to six biopsies), and group C (seven to ten biopsies). Results from each group were compared against a composite standard, including clinical follow-up and/or biopsies performed by alternative methods.

RESULTS

the group that underwent 4-6 biopsies had a sensitivity of 77.4 %, while the group with 7-10 biopsies had a sensitivity of 70.8 %. The group with 1-3 biopsies had a sensitivity of 34.5 %. Statistically significant differences were observed between the groups, with comparisons showing improved sensitivity in the 4-6 biopsy group versus the 1-3 biopsy group (χ² = 14.42, p = 0.0001), and the 7-10 biopsy group versus the 1-3 biopsy group (χ² = 6.56, p = 0.010).

CONCLUSIONS

performing four to six cholangioscopy-guided biopsies significantly improves sensitivity for diagnosing perihilar cholangiocarcinoma compared to one to three biopsies. Further studies are needed to validate these findings.

Efficacy and safety of a single-use cholangioscope for percutaneous transhepatic cholangioscopy

Background and study aims Percutaneous transhepatic cholangioscopy (PTCS) is a management option for patients in whom peroral cholangioscopy or endoscopic retrograde cholangiopancreatography (ERCP) fail. We conducted a case series on the efficacy and safety of PTCS using a cholangiopancreatoscope cleared by the US Food and Drug Administration in 2020. Patients and methods Fifty adult patients scheduled for PTCS or other cholangioscopic procedure were enrolled at seven academic medical centers and followed for 30 days after the index procedure. The primary efficacy endpoint was achievement of clinical intent by 30 days after the index PTCS procedure. Secondary endpoints included technical success, procedure time, endoscopist ratings of device attributes on a scale of 1 to 10 (best), and serious adverse events (SAEs) related to the device or procedure. Results Patients had a mean age of 64.7±15.9 years, and 60.0% (30/50) were male. Forty-four patients (88.0%) achieved clinical intent by 30 days post-procedure. The most common reasons for the percutaneous approach were past (38.0%) or anticipated (30.0%) failed ERCP. The technical success rate was 96.0% (48/50), with a mean procedure time of 37.6 minutes (SD, 25.1; range 5.0-125.0). The endoscopist rated the overall ability of the cholangioscope to complete the procedure as a mean 9.2 (SD, 1.6; range 1.0-10.0). Two patients (4.0%) experienced related SAEs, one of whom had a fatal periprocedure aspiration. Conclusions PTCS is an important endoscopic option for selected patients with impossible retrograde access or in whom ERCP fails. Because of the associated risk, this technique should be practiced by highly trained endoscopists at high-volume centers. (ClinicalTrials.gov number, NCT04580940).

MicroRNAs as Indicators of Malignancy in Pancreatic Ductal Adenocarcinoma (PDAC) and Cystic Pancreatic Lesions

The dysregulation of microRNAs has recently been associated with cancer development and progression in pancreatic ductal adenocarcinoma (PDAC) and cystic pancreatic lesions. In solid pancreatic tumor tissue, the dysregulation of miR-146, miR-196a/b, miR-198, miR-217, miR-409, and miR-490, as well as miR-1290 has been investigated in tumor biopsies of patients with PDAC and was reported to predict cancer presence. However, the value of the predictive biomarkers may further be increased during clinical conditions suggesting cancer development such as hyperinsulinemia or onset of diabetes. In this specific context, the dysregulation of miR-486 and miR-196 in tumors has been observed in the tumor tissue of PDAC patients with newly diagnosed diabetes mellitus. Moreover, miR-1256 is dysregulated in pancreatic cancer, possibly due to the interaction with long non-coding RNA molecules that seem to affect cell-cycle control and diabetes manifestation in PDAC patients, and, thus, these three markers may be of special or “sentinel value”. In blood samples, Next-generation sequencing (NGS) has also identified a set of microRNAs (miR-20a, miR-31-5p, miR-24, miR-25, miR-99a, miR-185, and miR-191) that seem to differentiate patients with pancreatic cancer remarkably from healthy controls, but limited data exist in this context regarding the prediction of cancer presences and outcomes. In contrast to solid pancreatic tumors, in cystic pancreatic cancer lesions, as well as premalignant lesions (such as intraductal papillary neoplasia (IPMN) or mucinous-cystic adenomatous cysts (MCAC)), the dysregulation of a completely different expression panel of miR-31-5p, miR-483-5p, miR-99a-5p, and miR-375 has been found to be of high clinical value in differentiating benign from malignant lesions. Interestingly, signal transduction pathways associated with miR-dysregulation seem to be entirely different in patients with pancreatic cysts when compared to PDAC. Overall, the determination of these different dysregulation “panels” in solid tumors, pancreatic cysts, obtained via fine-needle aspirate biopsies and/or in blood samples at the onset or during the treatment of pancreatic diseases, seems to be a reasonable candidate approach for predicting cancer presence, cancer development, and even therapy responses.

Future of Cholangioscopy

This article highlights the current status of cholangioscopy. In addition, the authors present their view on the future directions of cholangioscopy, including novel clinical applications, the need for technologic developments, and the expansion on the use of cholangioscopy in clinical practice. The authors envision that cholangioscopy will eventually become a conventional tool in the shelf of any biliary endoscopist. Future technologic improvements including optics, maneuverability, and full device accessories, plus the introduction of real-time artificial intelligence algorithms, will optimize the outcomes of cholangioscopy, but baseline proficiency in therapeutic endoscopic retrograde cholangiopancreatography will remain necessary for its successful utilization.

Comparison of the Diagnostic Performance of Novel Slim Biopsy Forceps with Conventional Biopsy Forceps for Biliary Stricture: A Multicenter Retrospective Study

Novel slim biopsy forceps provide some technical advantages to facilitate a more accurate diagnosis, although we are not aware of any comparative studies. Therefore, we compared tissue acquisition and diagnostic accuracy between novel slim biopsy forceps and conventional biopsy forceps in cases with a biliary stricture. We reviewed 341 patients who underwent endoscopic retrograde cholangiopancreatography for the histological confirmation of biliary stricture at two tertiary hospitals between 2013 and 2020. The primary endpoint was the forceps’ diagnostic accuracies. We included 276 patients who underwent biopsy using the novel forceps (n = 130) or conventional forceps (n = 146). The novel forceps provided 81.7% sensitivity, 100.0% specificity, positive-predictive value (PPV) of 100.0%, and negative-predictive value (NPV) of 57.8%, with an accuracy of 85.4% when the diagnosis by endobiliary biopsy included suspected or positive malignancy. The conventional forceps provided 61.7% sensitivity, 100.0% specificity, PPV of 100.0%, and NPV of 36.1%, with an accuracy of 68.5%. Only novel forceps use was significantly associated with an accurate diagnosis (odds ratio: 2.70, 95% confidence interval: 1.52–5.00). There were no significant inter-group differences in the procedure-related rates of adverse events. Endobiliary biopsy using novel forceps offered better diagnostic performance and more acceptable procedure-related adverse events than conventional forceps.

Clinical impact of digital cholangioscopy in management of indeterminate biliary strictures and complex biliary stones: a single-center study

Aims:

Endoscopic management of indeterminate strictures and complex stones remains a challenge, for which the latest generation single-operator digital cholangioscope (SpyGlass DS) has shown promising results. We aimed to study the clinical impact of single-operator digital cholangioscope at our tertiary academic center.

Methods:

We retrospectively reviewed all digital cholangioscopies performed from June 2015 to May 2018. Patient characteristics, procedure characteristics, and post-procedural patient outcomes were recorded.

Results:

A total of 50 patients (26 men, average age 61.4 years) underwent 67 procedures. Indications were biliary stones (21/50, 42%), strictures and primary sclerosing cholangitis surveillance (22/50, 46%), and miscellaneous (7/50, 14%). The average procedure time was 82 ± 29 min (99.5 min for stones and 74.2 min for strictures). Stone clearance was achieved in 19/21 (90.47%) cases, with electrohydraulic lithotripsy employed in 16/21 and repeat cholangioscopy necessary in 9/21. Malignant strictures (10) were differentiated from benign (12) in all cases both in patients with primary sclerosing cholangitis (9) and in those without (13), based on visual cholangioscopic features (sensitivity and specificity 100%), single-operator digital cholangioscope–directed biopsies (sensitivity 60% and specificity 100%), and brush cytology (sensitivity 37.5% and specificity 100%). Complications included one post-sphincterotomy bleeding and one post-procedural cholangitis despite antibiotic prophylaxis, but no procedure-related mortality.

Conclusion:

Single-operator digital cholangioscope had a high success rate and a low rate of complications for management of indeterminate strictures and difficult biliary stones. Visual cholangioscopic features of biliary strictures had excellent diagnostic accuracy, and targeted biopsies outperformed brush cytology. Early implementation of cholangioscopy for select indications leads to successful patient outcomes and reduces diagnostic delays, cost, and risks of repeat endoscopic retrograde cholangiopancreatographies.

Peroral cholangioscopy by SpyGlass DS versus CHF-B260 for evaluation of the lateral spread of extrahepatic cholangiocarcinoma

Background and study aims  A newly developed peroral cholangioscopy (POCS) system, SpyGlassDS has high maneuverability. This study aimed to evaluate acceptability of the accuracy of SpyGlassDS accompanied by simultaneous POCS-guided biopsy compared with that of a traditional POCS scope, CHF-B260, to diagnose the lateral extent of extrahepatic cholangiocarcinoma (LEC). Patients and methods  Patients who underwent surgical resection after preoperative examinations to diagnose LEC were evaluated. POCS by CHF-B260 was performed if there was discrepancy between preceding fluoroscopy-guided biopsy findings and other examinations between January 2004 and September 2015 (group A, n = 56); and POCS plus POCS-guided mapping biopsy by SpyGlassDS was performed in all surgical candidates between October 2015 and December 2017 (group B, n = 20). The main outcome measure was the accuracy of overall preoperative diagnosis (OPD) of LEC defined based on all examinations, including POCS. Results  Accuracy of OPD for the liver side and the ampullary side was 93 % and 100 %, respectively, in group A, and 84 % and 100 %, respectively, in group B ( P  = 0.37 for the liver side; P , not available for the ampullary side). Diagnostic accuracy of simple optical evaluation by POCS for the liver side and the ampullary side was 83 % and 100 %, respectively, in group A, and 58 % and 88 %, respectively, in group B ( P  = 0.29 for the liver side; P  = 0.40 for the ampullary side). Conclusions  POCS by SpyGlassDS was found to be acceptable and could be a standard approach for diagnosis of LEC.

Cholangioscopy in the digital era

Cholangioscopy allows direct visualization and subsequent therapeutic maneuvers of the biliary ductal system. With advances in endoscopic and imaging technology, cholangioscopy has become an important modality for the diagnosis of indeterminate biliary strictures and an essential therapeutic tool for difficult to remove biliary stones. Enhanced imaging and operability of the latest generation cholangioscopes have further expanded their clinical applications to include ductal tumor ablation, gallbladder drainage, access to difficult to reach branches of the biliary tree, and biliary foreign body manipulation. In this review, we discuss the technical evolution of cholangioscopy into the digital era and review the clinical evidence supporting its use in the diagnosis and therapy of biliary tract disease.

Factors affecting the accuracy of endoscopic transpapillary sampling methods for bile duct cancer

BACKGROUND AND AIM

Various methods for endoscopic transpapillary sampling have been developed. However, the factors affecting the accuracy of these methods for bile duct cancer are unknown. The aim of the present study was to determine the factors affecting the accuracy of endoscopic transpapillary sampling methods.

METHODS

We reviewed the results from 101 patients with bile duct cancer who underwent transpapillary sampling by aspiration bile cytology, brushing cytology, and fluoroscopic forceps biopsy. The final diagnosis of bile duct cancer was made on the basis of pathological evaluation of specimens obtained at surgery and the clinical course over at least 1 year in patients not operated on. We carried out subgroup analyses for the factors affecting the accuracy of each transpapillary sampling method.

RESULTS

Aspiration bile cytology was carried out 238 times in 77 patients, brushing cytology was carried out 67 times in 60patients, and fluoroscopic forceps biopsy was carried out 64 times in 53 patients. Accuracies of aspiration bile cytology were significantly higher for longer (≥15 mm) biliary cancerous lesions than for shorter (<15 mm) lesions (30% vs 18%, respectively, P = 0.049). Accuracies of brushing cytology and fluoroscopic forceps biopsy were significantly higher for non-flat than for flat-type biliary cancerous lesions (brushing: 58% vs 38%, respectively, P = 0.032; forceps biopsy: 60% vs 33%, respectively, P = 0.043).

CONCLUSION

Endoscopic transpapillary sampling methods are more accurate for longer or elevated (non-flat) biliary cancerous lesions than for shorter or flat lesions.

Choledochoscopy/cholangioscopy

Miniature endoscopes that can be introduced into the bile duct through the duodenoscope during endoscopic retrograde cholangiopancreatography were developed to allow nonsurgical management of difficult biliary stones. The direct visualization enabled by these cholangioscopes of the biliary epithelium provides additional data in the assessment of biliary strictures. Cholangioscopy allows assessment of the biliary lumen, biliary epithelium, targeted tissue acquisition, targeted therapy, and wire guidance.

Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study

BACKGROUND

Currently available techniques to diagnose indeterminate biliary lesions have many limitations.

OBJECTIVE

To assess the accuracy of single-operator peroral cholangioscopy by using the SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions.

DESIGN

Prospective, single-arm, single-center study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling.

INTERVENTIONS

SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies.

MAIN OUTCOME MEASUREMENTS

Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions.

RESULTS

Thirty-six patients (22 men, mean age 48.3 years [range 27-68 years]) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis.

LIMITATIONS

No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures.

CONCLUSIONS

SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.

Per-oral cholangioscopy

Direct endoscopic views of bile duct have been described in literature since the 1970s. Since then rapid strides have been made with the advent of technologically advanced systems with better image quality and maneuverability. The single operator semi-disposable per-oral cholangioscope and other novel methods such as the cholangioscopy access balloon are likely to revolutionize this field. Even though cholangioscopy is currently used primarily for characterization of indeterminate strictures and management of large bile duct stones, the diagnostic and therapeutic indications are likely to expand in future. The following is an overview of the currently available per-oral cholangioscopy equipments, indications for use and future directions.

New options of cholangioscopy

In the evaluation of biliary diseases, cholangioscopy is considered as complementary procedure to radiographic imaging. Direct visualization of the bile duct is the premier advantage of cholangioscopy over indirect imaging techniques. However, cholangioscopy has not gained wide acceptance because of several technical limitations such as scope fragility, impaired steerability, limited irrigation, and suction capabilities, as well as the need for two experienced endoscopists. Recent innovations such as the implementation of electronic video cholangioscopes and the development of single-operator systems facilitate the procedure, and promise to increase the diagnostic and therapeutic yield of cholangioscopy.

The successful use of peroral cholangioscopy for the diagnosis and treatment of the biliary tract lesions and giant bile duct stones in a 76-year-old man

We encountered a case in whom peroral cholangioscopy was useful for the diagnosis and treatment of irregular biliary tract mucosa and giant bile duct stones. Peroral cholangioscopy seems to improve the diagnosis of biliary tract diseases and allow internal treatment. The proper diagnosis of biliary tract diseases may be further confirmed by the concomitant use of narrow band imaging and this endoscopic technology.

Cholangiopancreatoscopy: a comprehensive review

Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.

Application of per oral cholangiopancreatoscopy in pancreatobiliary diseases

Pancreaticobiliary ductal diseases are largely investigated by indirect imaging techniques. Therefore, the pathology of up to 30% of cases remains undetermined. Cholangiopancreatoscopy allows direct visualization of ductal abnormalities with the ability to sample tissue and deliver a number of endotherapies. The technique can be broadly categorized into either two-operator or single-operator systems. Both systems provide important diagnostic information in the investigation of undetermined biliary or pancreatic strictures, intraductal papillary mucinous neoplasia, occult ductal malignant changes in patients with primary sclerosing cholangitis and occult intraductal stones in patients with complex biliary stone diseases. Therapeutically, cholangiopancreatoscopy-guided endotherapies provide a highly effective and safe alternative to surgery for patients with difficult extrahepatic and intrahepatic ductal stones that are not amenable to conventional endoscopic extraction by endoscopic retrograde cholangiopancreatography. The clinical application of cholangiopancreatoscopy, however, will be limited unless the technology is further refined to improve its durability, image quality, therapeutic capability and technical feasibility.

How many cytological examinations should be performed for the diagnosis of malignant biliary stricture via an endoscopic nasobiliary drainage tube?

BACKGROUND AND AIM

The sensitivity of bile cytology is recognized as being low. Repeating cytological sampling is likely to improve the sensitivity. The aim of this study is to determine the optimal number of repeated cytological sampling of bile obtained via an endoscopic nasobiliary drainage (ENBD) tube for the diagnosis of malignant biliary stricture.

METHODS

Ninety-eight patients with malignant biliary stricture who underwent ENBD were enrolled. Diagnoses included bile duct carcinoma (n = 53), pancreatic carcinoma (n = 28), carcinoma of the major papilla (n = 8), gallbladder carcinoma (n = 6), and hepatocellular carcinoma (n = 3). Bile was aspirated via an ENBD tube once a day and immediately evaluated cytologically.

RESULTS

The median number of cytological samplings via an ENBD tube was 2.8 times (range, 1-10). In 40 of 98 patients with malignant biliary stricture, cytology was positive at the first cytological sampling (sensitivity 40.8%). Cytology was cumulatively positive in 71 of 98 patients (sensitivity 72.4%) from which repeated samples were taken. In 71 patients with positive cytology, correlation of the positive rate and the number of cytological samplings performed was investigated. In 68 of 71 (95.8%) patients with positive cytology, positive results were obtained by or at the sixth examination.

CONCLUSIONS

Bile cytology via an ENBD tube is an easy method, and has been shown to have relatively high sensitivity. The optimal number of repeated cytological samplings using bile obtained via an ENBD tube for the diagnosis of malignant biliary stricture was concluded to be six.

Management of hilar biliary strictures

Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40-60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.

Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy

BACKGROUND

Current cholangioscopes are restricted to 2 deflection angles and require more than 1 operator. The newly developed Spyglass peroral cholangiopancreatoscopy system provides 4-way deflected steering by a single operator.

OBJECTIVE

To evaluate access and biopsy in all simulated biliary-duct quadrants with the Spyglass system, high-level disinfection of the reusable Spyglass optical probe, and feasibility of in vivo biopsy.

DESIGN

Laboratory simulations comparing biliary-duct access and biopsy with the Spyglass versus a conventional system, laboratory determination of high-level disinfection effectiveness, and observational investigation of biopsies in a porcine model.

SETTING

Research laboratories.

MAIN OUTCOME MEASUREMENTS

Rate ratios (RR) and 95% confidence intervals (CI) for successful access to all quadrants and simulated biopsy.

RESULTS

Success rates for access in all quadrants were significantly higher with the Spyglass system than with the control system, both without (RR 1.71, 95% CI 1.39-2.29) and with (RR 2.00, 95% CI 1.56-2.78) biopsy forceps loaded. Higher success rates were also attained by using the Spyglass system to access biopsy targets (RR 2.09, 95% CI 1.60-2.91) and to perform simulated biopsies (RR 2.94, 95% CI 2.05-4.52). Microbial species log reductions of 6.0 to 7.0 were achieved by high-level disinfection of Spyglass optical probes. In 31 in vivo porcine biopsies yielding adequate gross specimens, the quality for histologic examination was excellent to adequate for 90% of specimens.

LIMITATIONS

Study procedures were performed by a single nonblinded operator. All data were collected ex vivo or in animals, and clinical applicability remains to be determined.

CONCLUSIONS

The Spyglass system allows access and biopsy in all quadrants and merits clinical investigation.

Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy

Two hundred and five preoperative intraductal samplings (brushing and biopsy) were evaluated from 113 patients with biliary or Wirsung duct strictures. One hundred and three strictures could be specified by histology of the operative specimens, autopsy, or by the patients' clinical course. Preoperative diagnostic efficacy depended on the tumor location (it was the best for ampullary and para-papillary tumors), but the average quantitative indices for sensitivity, absolute sensitivity, specificity, positive and negative predictive values, diagnostic accuracy of cytology were 53%, 20%, 100%, 100%, 25%, 59%, respectively. The same values for biopsy were 43%, 34%, 100%, 100%, 36% and 56%. These figures improved after simultaneous cytology and biopsy. Close cooperation with the endoscopist was necessary in cases of negative, inconclusive and dysplastic (27%) samples. Repetition of sampling improved the results by 8%. Among the 26 preoperative false negative cases, sampling-, technical- and interpretative errors occurred in 84%, 4% and 12%, respectively. Revision of samples revealed 4 malignant cases among the false negative cytologic brushings. Reclassification of specimens considering the latest criteria - primary and secondary malignant features, pancreatic intraepithelial neoplasia (PanINs), etc. - resulted in improvement of the diagnostic efficiency.

Diagnostic utility of peroral cholangioscopy for various bile-duct lesions

BACKGROUND

We evaluated the utility of peroral cholangioscopy (POCS) for distinguishing malignant from benign biliary disease to cover low sensitivity of tissue sampling.

METHODS

From February 1992 to April 2004, all consecutive patients who underwent POCS to confirm the etiology of biliary disorders were included in this study. Brushing cytology or endobiliary forceps biopsy also was performed. We analyzed the diagnostic accuracy of tissue sampling with or without POCS diagnosis.

RESULTS

A total of 97 patients (66 men, 31 women; mean age 64.2 years) were included. The final diagnosis was confirmed by surgical resection in 44, clinical follow-up in 52, and cytologic study of ascitic fluid in one. On the basis of ERCP findings, there were 76 strictures and 21 filling defects. Forceps biopsy was performed in 25 patients, and brush cytology was performed in 68 patients. In the remaining 4 patients (4 filling defects, which were identified as stones by POCS), tissue samplings were not carried out. ERCP/tissue sampling correctly identified 22 of 38 malignant strictures and all 35 benign lesions except in 3 patients with inadequate samples (accuracy, 78.0%; sensitivity, 57.9%; specificity, 100%). The addition of POCS correctly identified all 38 malignant strictures and 33 of 38 benign lesions (accuracy, 93.4%; sensitivity, 100%; specificity, 86.8%). For the 21 filling defects observed by ERCP, POCS correctly diagnosed all 8 malignant diseases and 13 benign lesions.

CONCLUSIONS

The addition of POCS to tissue sampling improves the diagnostic ability and covers for insufficient sensitivity. POCS is especially useful for diagnosing a filling defect.

Histologic assessment of biliary obstruction with different percutaneous endoluminal techniques

Background

Despite the sophisticated cross sectional image techniques currently available, a number of biliary stenosis or obstructions remain of an uncertain nature. In these pathological conditions, an "intrinsic" parietal alteration is the cause of biliary obstruction and it is very difficult to differentiate benign from malignant lesions using cross-sectional imaging procedures alone. We evaluated the efficacy of different endoluminal techniques to achieve a definitive pathological diagnosis in these situations.

Methods

Eighty patients underwent brushing, and or biopsy of the biliary tree through an existing transhepatic biliary drainage route. A subcoort of 12 patients needed balloon-dilatation of the bile duct and the material covering the balloon surface was also sent for pathological examination (balloon surface sampling). Pathological results were compared with surgical findings or with long-term clinical and instrumental follow-ups. Success rates, sensitivity, specificity, accuracy, confidential intervals, positive predictive value and negative predictive value of the three percutaneous techniques in differentiating benign from malignant disease were assessed.

The agreement coefficient of biopsy and brushing with final diagnosis was calculated using the Cohen's "K" value.

Results

Fifty-six patients had malignant strictures confirmed by surgery, histology, and by clinical follow-ups. Success rates of brushing, balloon surface sampling, and biopsy were 90.7, 100, and 100%, respectively. The comparative efficacy of brushing, balloon-surface sampling, and biopsy resulted as follows: sensitivity of 47.8, 87.5, and 92.1%, respectively; specificity of 100% for all the techniques; accuracy of 69.2, 91.7 and 93.6%, Positive Predictive Value of 100% for all the procedures and Negative Predictive Value of 55, 80, and 75%, respectively.

Conclusions

Percutaneous endoluminal biopsy is more accurate and sensitive than percutaneous bile duct brushing in the detection of malignant diseases (p < 0.01).

Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty

BACKGROUND AND AIM

Endoscopic balloon sphincteroplasty (EBS) is an alternative to sphincterotomy for the treatment of bile duct stones. The purpose of this study was to determine if epinephrine irrigation of the papilla can prevent the pancreatic damage associated with EBS.

METHODS

A total of 173 patients with bile duct stones were treated by EBS. After conventional endoscopic retrograde cholangiography, EBS was performed by using a biliary dilatation catheter (balloon diameter: 8 mm). The duct was then cleared by using Dormia baskets or retrieval balloon catheters. Mechanical lithotripsy was performed before extraction when the stones were greater than 8 mm in diameter. In 81 patients, the dilated orifice was irrigated with 40-120 mL (50 +/- 37 mL) of 1:1,000,000 epinephrine (epinephrine group). In the remaining 92 patients, epinephrine irrigation was not performed (control group). Acute pancreatitis was defined by a serum amylase concentration fivefold greater than the upper limits of normal in association with abdominal pain.

RESULTS

After EBS, serum amylase concentrations were significantly increased in both groups. However, the degree of hyperamylasemia was less in the epinephrine group than in the control group (617 +/- 611 vs 1037 +/- 1491 IU/L, P < 0.05). The incidence of pancreatitis was lower in the epinephrine group than in the control group (1.2 vs 7.6%, P < 0.05).

CONCLUSIONS

Epinephrine irrigation is a simple and useful method to prevent post-EBS pancreatic damage and pancreatitis.

Multiple bile duct biopsies using a sheath with a side port: usefulness of intraductal sonography

OBJECTIVE

We clarified the number of biopsies required to determine malignancy of the biliary tract on the basis of the type of bile duct tumor.

SUBJECTS AND METHODS

Patients with a biliary tract malignancy (n = 33) and a benign biliary stenosis (n = 3) underwent biopsy via the percutaneous transhepatic route. We performed intraductal sonography using a 20-MHz probe with a 2.0-mm diameter. The sonographic findings were prospectively classified as polypoid, circular, or semicircular. The tip of a long 9-French sheath with a side port was wedged into the stenosis, and six specimens were obtained with a 1.8-mm-diameter forceps with serrated cups.

RESULTS

When cholangiography or intraductal sonography showed a polypoid lesion, the sensitivity of two biopsies was 100% (6/6). When cholangiography showed a stenotic lesion, the sensitivity of nine biopsies (96%, 26/27) was superior to that of two biopsies (74%, 20/27; p < 0.05). When intraductal sonography showed a circular lesion, the sensitivity of three biopsies (100%, 14/14) was superior to that of a single biopsy (64%, 9/14; p < 0.05). When it showed a semicircular lesion, the sensitivity of nine biopsies (92%, 12/13) was superior to that of two biopsies (54%, 7/13; p < 0.05).

CONCLUSION

Bile duct biopsy using a sheath with a side port has a high sensitivity. However, the number of biopsies required depends on the cholangioscopic and intraductal sonographic appearance of the tumor.

Transpapillary intraductal US prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma

BACKGROUND

The utility of intraductal US via the transpapillary route prior to biliary drainage in the assessment of longitudinal extension of extrahepatic bile duct carcinoma was investigated.

METHODS

In 19 patients with extrahepatic bile duct carcinoma who underwent surgical resection, an ultrasonic probe (diameter, 2.0 mm; frequency, 20 MHz) was inserted into the bile duct via the transpapillary route prior to biliary drainage. Longitudinal cancer extension along the bile duct was prospectively determined and compared with the histologic findings in the resected specimens.

RESULTS

Results on the hepatic side were as follows: Intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 9 of 19 patients with one instance of overdiagnosis. The accuracy of intraductal US in assessing the extent of spread (84%) was superior to that of cholangiography (47%) (p < 0.05). Results on the duodenal side were as follows: In patients with suprapancreatic bile duct cancer (n = 14), intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 8 of 14 patients. The accuracy of intraductal US in assessing the extent of the spread (86%) was superior to that of cholangiography (43%) (p < 0.05).

CONCLUSIONS

Transpapillary intraductal US prior to biliary drainage is useful in demonstrating longitudinal extension of bile duct cancer. However, the surgical margins were inaccurate in some patients.

Ropeway-type bile duct biopsy forceps with a side slit for a guidewire

BACKGROUND

Transpapillary procurement of bile duct biopsy specimens is an effective diagnostic technique in cases of biliary structure. The utility of new ropeway-type bile duct biopsy forceps with a side slit for a guidewire was investigated in this study.

METHODS

The 12 patients in this study had bile duct cancer (n = 3), cancer of the head of the pancreas (n = 4), gallbladder cancer (n = 1), and benign bile duct stenosis (n = 4). After endoscopic retrograde cholangiography, a guidewire was placed in the bile duct across the stenosis. The new forceps (1.8-mm diameter clamshell-type biopsy forceps without needle) was then introduced through the intact papilla along the guidewire.

RESULTS

In all patients, sufficient tissue for histopathologic evaluation was obtained without complication. In one patient, biopsy specimens were selectively obtained of the left hepatic duct, which was impossible with conventional forceps. In another patient, histologic examination of specimens obtained by using this new forceps showed adenocarcinoma, whereas specimens obtained with a conventional forceps did not contain adenocarcinoma. However, in another patient, biopsy specimens obtained with a conventional forceps contained adenocarcinoma that was not evident in specimens obtained with the new forceps. Dislodgement of the guidewire during procurement of biopsy specimens occurred in 1 patient. In the other 11 patients, an endoscopic biliary drain was inserted over the guidewire.

CONCLUSION

The new ropeway-type biopsy forceps is useful for selectively obtaining biopsy specimens of the bile duct. With this system, access for subsequent endoscopic biliary drainage is maintained.

Access for percutaneous transhepatic cholangioscopy in patients with nondilated bile ducts using nasobiliary catheter cholangiography and oblique fluoroscopy

BACKGROUND

Percutaneous transhepatic biliary drainage is required for percutaneous transhepatic cholangioscopy. However, puncture of nondilated bile ducts under ultrasonographic guidance is difficult.

METHODS

In 10 patients with no ultrasonographic evidence of intrahepatic bile duct dilatation, percutaneous transhepatic biliary drainage was performed under fluoroscopic guidance using cholangiography obtained via a nasobiliary drainage catheter. Direct puncture was performed by means of a left ventral approach using oblique C-arm fluoroscopy.

RESULTS

Bile duct puncture was successful in all patients. There were no procedure-related complications. Subsequent cholangioscopy was successful in all patients.

CONCLUSIONS

Direct puncture using nasobiliary drainage cholangiography and oblique fluoroscopy is a useful method when cholangioscopy is necessary in patients with nondilated bile ducts.

EUS-guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma: a case series

BACKGROUND

Improved methods of tissue diagnosis for obstruction at the hilum of the liver (porta hepatis) have contributed substantially to the preoperative diagnosis of cholangiocarcinoma. Endoscopic brushing during endoscopic retrograde cholangiopancreatography (ERCP), with sensitivity of 20% to 100%, is the preferred technique for obtaining accurate pathologic results. Extensive hepatic resection with curative intent as well as modern approaches to palliative treatment are based on definitive diagnosis. This is a study involving endosonography-guided, fine-needle aspiration (EUS-FNA) for cytodiagnosis of potentially operable hilar cholangiocarcinoma when brush cytology was negative or unavailable.

METHODS

Ten consecutive patients (7 men, 3 women; age 47 to 78 years, median 59 years) with bile duct strictures at the hepatic hilum, diagnosed by CT and/or ERCP, underwent EUS-FNA using linear echoendoscopes and 22-gauge needles.

RESULTS

Adequate material was obtained in nine patients. Cytology revealed cholangiocarcinoma in seven and hepatocellular carcinoma in one. One benign inflammatory lesion identified on cytology proved to be a false-negative finding by frozen section. Metastatic locoregional hilar lymph nodes were detected in two patients, and in one patient the celiac and para-aortic lymph nodes were aspirated to obtain tissue proof of distant metastasis. There were no complications.

CONCLUSIONS

When standard methods of tissue diagnosis are inconclusive, EUS-guided FNA may have a potential role in the diagnosis of primary cholangiocarcinoma of the hepatic hilum. As a new, minimally invasive approach, it proved to be technically feasible without significant risks.

Biliary tract cancer

Investigation into the molecular and cellular biology of carcinogenesis continues to elucidate potential mechanisms for the initiation and progression of biliary tract cancer. The potential role of cell cycle regulators, such as Fas ligand, has been examined in the etiology of bile duct carcinoma. In addition, there is evidence for a possible link between chronic inflammation and malignant transformation through the relation between nitric oxide and DNA repair enzymes. Noninvasive imaging modalities, including helical computed tomography scanning, magnetic resonance cholangiopancreatography (MRCP) and positron emission tomography (PET) scanning, are gaining acceptance and may eventually supplant standard methods of evaluation. In addition, innovative tissue-sampling modalities including choledochoscopy are being developed. Several large series, Japanese and Western, continue to report improved 5-year survival rates after aggressive surgical resections of hilar cholangiocarcinoma. Although chemotherapeutic options remain limited in biliary tract carcinoma, radiation therapy may provide a benefit in local control in patients with microscopically positive margins. Photodynamic and multimodality therapy also may become important components of improving palliation for patients with advanced disease.

Double-catheter method to prevent dislodgement during percutaneous transhepatic cholangioscopy

BACKGROUND

We evaluated the utility of the double-catheter method to establish the track for percutaneous transhepatic cholangioscopy (PTCS).

METHODS

Dilatation of the percutaneous transhepatic track to 16F for PTCS was attempted in 105 patients. The results were prospectively analyzed. Using the single-catheter method (n = 22), a 16F PTCS catheter was replaced without the inner catheter. Using the double-catheter method (n = 83), a 7F catheter with a balloon tip was inserted through a 16F PTCS catheter. The balloon was located distal to the major duodenal papilla. The double-catheter method was further subclassified as follows: Method 2A (n = 62), the tip of the outer catheter (16F) was not advanced through biliary stenoses; Method 2B (n = 21), the catheter was advanced through biliary stenoses.

RESULTS

In the patients treated by the double-catheter method, dislodgement of the catheter did not occur, whereas the single-catheter became dislodged in 18% (p < 0.0005). The morbidity of method 2A (0%) was less than that of method 2B (14%) (p < 0.005).

CONCLUSION

The double-catheter method prevents dislodgement of the PTCS catheter. The outer catheter should not be advanced to the biliary stenosis.