Simplified brush biopsy of the bile ducts

Improved Accuracy of Percutaneous Biopsy Using "Cross and Push" Technique for Patients Suspected with Malignant Biliary Strictures

PURPOSE

Various methods have been used to sample biliary strictures, including percutaneous fine-needle aspiration biopsy, intraluminal biliary washings, and cytological analysis of drained bile. However, none of these methods has proven to be particularly sensitive in the diagnosis of biliary tract malignancy. We report improved diagnostic accuracy using a modified technique for percutaneous transluminal biopsy in patients with this disease.

MATERIALS AND METHODS

Fifty-two patients with obstructive jaundice due to a biliary stricture underwent transluminal forceps biopsy with a modified "cross and push" technique with the use of a flexible biopsy forceps kit commonly used for cardiac biopsies. The modification entailed crossing the stricture with a 0.038-in. wire leading all the way down into the duodenum. A standard or long sheath was subsequently advanced up to the stricture over the wire. A Cook 5.2-Fr biopsy forceps was introduced alongside the wire and the cup was opened upon exiting the sheath. With the biopsy forceps open, within the stricture the sheath was used to push and advance the biopsy cup into the stricture before the cup was closed and the sample obtained. The data were analysed retrospectively.

RESULTS

We report the outcomes of this modified technique used on 52 consecutive patients with obstructive jaundice secondary to a biliary stricture. The sensitivity and accuracy were 93.3 and 94.2%, respectively. There was one procedure-related late complication.

CONCLUSION

We propose that the modified "cross and push" technique is a feasible, safe, and more accurate option over the standard technique for sampling strictures of the biliary tree.

Cytological sampling versus forceps biopsy during percutaneous transhepatic biliary drainage and analysis of factors predicting success

PURPOSE

To assess the accuracy of cytological sampling and forceps biopsy in obstructing biliary lesions and to identify factors predictive of success.

METHODS

Consecutive patients (n = 119) with suspected malignant inoperable obstructive jaundice treated with percutaneous transhepatic biliary drainage during 7 years were included (60 male; mean age 72.5 years). All patients underwent forceps biopsy plus cytological sampling by washing the forceps device in cytological solution. Patient history, procedural and pathological records, and clinical follow-up were reviewed. Statistical analysis included chi-square test and multivariate regression analysis.

RESULTS

Histological diagnosis after forceps biopsy was more successful than cytology: Sensitivity was 78 versus 61%, and negative predictive value was 30 versus 19%. Cytology results were never positive when the forceps biopsy was negative. The cytological sample was negative and forceps sample positive in 2 cases of cholangiocarcinoma, 16 cases of pancreatic carcinoma, and 1 case of benign disease. Diagnostic accuracy was predicted by low bilirubin (p < 0.001), aspartate transaminase (p < 0.05), and white cell count (p ≤ 0.05).

CONCLUSIONS

This technique is safe and effective and is recommended for histological diagnosis during PTBD in patients with inoperable malignant biliary strictures. Diagnostic yield is greater when bilirubin levels are low and there is no sepsis; histological diagnosis by way of forceps biopsy renders cytological sampling unnecessary.

Bile duct: analysis of percutaneous transluminal forceps biopsy in 130 patients suspected of having malignant biliary obstruction

PURPOSE

To evaluate percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction.

MATERIALS AND METHODS

One hundred thirty consecutive patients (82 men and 48 women; mean age, 59 years) with obstructive jaundice underwent transluminal forceps biopsy during or after percutaneous transhepatic biliary drainage. The lesions involved the common bile duct (n = 58), common hepatic duct (n = 39), hilum (n = 14), ampullary segment of the common bile duct (n = 11), right or left intrahepatic bile duct (n = 5), or the entire extrahepatic bile duct (n = 3). In each patient, three to five specimens (mean, 4.1 specimens) were taken from the lesion with 5.4-F biopsy forceps. The final diagnosis for each patient was confirmed with pathologic findings at surgery, additional histocytologic data, or clinical and radiologic follow-up. Statistical analysis was performed with the chi(2) test; a P value < or =.05 was considered to indicate a significant difference.

RESULTS

Ninety-eight of 130 biopsies resulted in correct diagnoses of malignancy. Five biopsy diagnoses proved to be true-negative. There were 27 false-negative diagnoses and no false-positive diagnoses. The diagnostic performance of transluminal forceps biopsy in malignant biliary obstructions was as follows: sensitivity, 78.4%; specificity, 100%; and accuracy, 79.2%. Sensitivity of biopsy in the 82 patients with cholangiocarcinoma was higher than in the 43 patients with malignant tumors other than cholangiocarcinoma (86.6% vs 62.8%, P <.005). Sensitivity was significantly lower in the ampullary segment of the common bile duct than in other sites (P <.01). No major complications related to the biopsy procedures occurred.

CONCLUSION

Percutaneous transluminal forceps biopsy is a safe procedure that is easy to perform through a transhepatic biliary drainage tract. It provides relatively high accuracy in the diagnosis of malignant biliary obstructions.

Intraductal biliary biopsy: comparison of three techniques

PURPOSE

To compare the results obtained with three different techniques for percutaneous transhepatic intraductal biopsy.

MATERIALS AND METHODS

Eighty-eight patients with obstructive jaundice underwent placement of percutaneous biliary drainage catheters for biliary decompression. As part of the initial procedure or at a subsequent date, intraductal biliary biopsy (n = 109) was performed with use of one or more of three techniques including cytologic brush (n = 53), clamshell forceps under choledochoscopic guidance (n = 31), and clamshell forceps under fluoroscopic guidance (n = 25).

RESULTS

Forty-eight patients (55%) had a final diagnosis of malignant disease, and 40 (45%) had a diagnosis of benign disease. One hundred six (97%) biopsy procedures yielded technically adequate specimens. No complications directly related to the biopsy procedures occurred. Overall sensitivity and specificity for each biopsy technique were 26% and 96% for the cytologic brush technique, 30% and 88% for the clamshell forceps under fluoroscopic guidance technique, and 44% and 100% for the clamshell forceps under choledochoscopic guidance technique, respectively. The sensitivities of the biopsy techniques for pancreatic carcinoma and cholangiocarcinoma, respectively, were 47% and 0% for brush; 75% and 0% for fluoroscopic clamshell; and 100% and 27% for choledochoscopic clamshell.

CONCLUSION

The choledochoscope-directed biopsy technique had the greatest sensitivity and specificity of the three techniques evaluated, but this difference was not statistically significant versus the brush or fluoroscopic clamshell technique (P > .10). The sensitivity of all three techniques for pancreatic carcinoma was significantly greater than that for cholangiocarcinoma. Multiple biopsies did not increase the overall sensitivity of intraductal biliary biopsy as a diagnostic technique. All three techniques proved to be safe and easy to perform.

Biliary ductal shave biopsy with use of the Simpson atherectomy catheter

PURPOSE

The authors performed percutaneous biliary ductal shave biopsy through an existing transhepatic biliary drainage tract with use of the Simpson atherectomy catheter. The technical feasibility, sensitivity, and complications of this endoluminal biopsy method were studied when used for diagnosis of biliary ductal and pancreatic neoplasm.

PATIENTS AND METHODS

Nineteen bile duct shave biopsies were performed in 18 patients with symptomatic biliary obstruction by using a 9-F Simpson directional atherectomy catheter. Seven of the 18 patients underwent nine negative percutaneous needle biopsies prior to undergoing percutaneous biliary drainage. Results of previous transcatheter brush biopsies performed through the transhepatic tract were negative in all patients.

RESULTS

A histologic diagnosis was obtained in 15 of the 19 procedures (sensitivity, 0.79) and included cholangiocarcinoma (n = 7), pancreatic carcinoma (n = 5), metastatic carcinoma (n = 2), and primary sclerosing cholangitis (n = 1). Two complications occurred in the 19 procedures (10.5%), both transient but significant hemorrhage, one of which necessitated transfusion.

CONCLUSIONS

Percutaneous biliary ductal shave biopsy with the Simpson atherectomy catheter can be performed successfully through the transhepatic approach and is a sensitive endoluminal biopsy technique, particularly in patients with tumors of the biliary tree that are not diagnosed by means of percutaneous needle biopsy or endoscopic methods. Disadvantages of this method include the high cost of the device and risk of hemorrhage. Atherectomy shave biopsy should be used cautiously and only after more conventional biopsy methods have been employed.

The management of problematic biliary calculi

Recent advances in modern medical technology have significantly reduced the number of patients with 'problematic calculi'. When a patient does present with a difficult bile duct stone, various non-surgical treatment options are now available. In experienced hands, with healthy or high-risk patients, percutaneous treatment is as safe and as efficacious as endoscopy or surgery. Since it does not require general anaesthesia, and patients recover much more quickly than after surgery, the percutaneous approach is preferred when endoscopy fails to achieve ductal clearance. Surgery is indicated for patients with lesions requiring surgical removal or correction, but seldom for removal of biliary calculi alone.

Tissue sampling from the common bile duct through endoscopic retrograde cholangiopancreatography, endoscopic papillo(sphinctero)tomy and drainage in juxtapapillary malignancies

In 22 patients with radiological evidence of a malignant stricture or an obstruction of the common bile duct, endobiliary tissue specimens were obtained through endoscopic retrograde cholangiopancreatography. An endoscopic papillo(sphinctero)tomy was necessary in 9 of the 22 patients. The following techniques were employed: (1) forceps biopsy of the papillary infundibulum and/or of the common bile duct; (2) brush cytology in the same sites as above; (3) biliary juice cytology obtained by a nasobiliary drainage tube. In 8 patients, two different sampling techniques were used. The final diagnosis was established by means of pathological evaluation of surgical or necroscopic material. The diagnostic adequacy was 100% for biopsy, 88% for brush cytology, and 62% for bile cytology. The sensitivity was 100%, 66%, and 25%, respectively, for the above techniques. From 6 cases without biliary cancer, the specificity was 100%. These data show that biopsy specimens alone provide a definitive preoperative diagnosis in most cases, provided adequate samples are obtained.

Fine needle aspiration biopsy in malignant obstructive jaundice

Percutaneous cytodiagnosis of malignancy in patients with biliary tract obstruction is often useful in planning subsequent therapy. Of 121 patients presenting for percutaneous transhepatic cholangiography and biliary drainage, 45 had fine needle aspiration biopsies. Forty-one patients had malignant obstruction of the biliary tree, while benign disease was present in 4 patients. Neoplasia was diagnosed in 12 of 13 patients with bile duct carcinoma, 16 of 22 patients with pancreatic cancer, and 3 of 6 patients with other malignancies. Radiologic biopsy sensitivity was only slightly inferior to surgical biopsy sensitivity in the same patient population. A scheme for biliary cytodiagnosis is presented, which uses a percutaneous approach for patients with suspected pancreatic carcinoma and a transcatheter approach for patients with suspected bile duct carcinoma. The utility of this procedure and the low complication rate are stressed.