Su1541 DIAGNOSIS OF BILIARY STRICTURES USING SPYGLASS DIRECTED BIOPSIES – INTENTION TO TREAT ANALYSIS AT A TERTIARY CARE CENTER

Abstract

Diagnosis of biliary strictures remains clinically arduous and challenging. We aimed to evaluate the utility of single-operator cholangioscopy (SOC)-system SpyGlass with and without cytology versus cold biopsies performed during endoscopic retrograde cholangiopancreatography (ERCP) in a single tertiary care center to diagnose biliary strictures. We conducted a retrospective analysis of all biliary strictures that underwent biopsies for diagnosis in an intention to treat analysis. A total of 42 patients (51% males) are included over a period of 3 years. Follow up was complete in 37 patients. The patients were divided into 4 groups – bile duct biopsies only using the SpyGlass system (n=19), bile duct biopsies using the SpyGlass system with cytology brushings (n=8), bile duct biopsies using cold biopsy forceps alone (n=6) and only cytology brushings (n=4). The objective was to obtain the diagnostic accuracy of each method for malignant, and for all lesions combined. Biliary stricture was located in the common bile duct in 55% patients and the common hepatic duct in 32% patients. The median length was 14.5±8 mm with a mean bilirubin of 10+8 mg/dl. The biopsy site corroborated with the site of the stricture except in patients with right or left hepatic duct strictures (n=5) where right hepatic duct biopsies could be obtained only in 1 patient. Spyglass was successful in all patients except 1. Twenty-five (68%) patients were found to have malignant and 12 (32%) patients had benign lesions. SpyGlass with cytology accurately detected malignancies in 67% of patients with total diagnostic accuracy for all lesions was 75%. SpyGlass biopsies alone accurately diagnosed 64% malignancies, and 79 % all lesions. When both these groups were combined, diagnostic accuracy for malignant lesions was 65% and for all lesions was 78%. Diagnostic accuracy for cold biopsy forceps was 75% for malignant lesions and 83% for all lesions. Cytology accurately diagnosed 50% of malignant lesions and 50% of all lesions. One patient diagnosed initially with benign stricture on SpyGlass was later diagnosed as having malignancy when biopsied again using SpyGlass. The outcomes are provided in table 2. There were no episodes of post-ERCP pancreatitis. Retrospective analysis at a single center. The number of biopsies using SpyGlass was variable (3-6) and not uniformly reported. Performing SpyGlass biopsies has a high rate of technical success. SpyGlass directed biopsies accurately predict diagnosis in 79% of patients. The addition of cytology does not add much incremental yield in the diagnosis of bile duct strictures. Cold biopsy forceps are not always technically feasible, but when possible offers excellent diagnostic yield, although our sample size is limited. Future prospective randomized studies with a larger dataset are recommended.View Large Image Figure ViewerDownload Hi-res image Download (PPT)