Abstract
Introduction: Tissue diagnosis of pancreatobiliary malignancies has always been a challenging task. Various methods, which have been used for pre-operative diagnosis like endoscopic brush cytology, EUS FNA, have shown poor yield.Moreover imaging and tumour markers have also not been precise. Methods: We conducted a retrospective analysis of consecutive cases of malignant obstructive jaundice which were referred to us for ERCP and biliary stenting from april 2013 to march 2015. ERCP and appropriate tissue sampling followed by biliary stenting was done.CA19-9 assays were also done in majority.Last 10 cases were subjected to cholangioscopy.Cytology data was compared to clinical, radiological and surgical diagnosis. Results: 102 cases were referred for ERCP out of which 15 had hilar block involving the confluence hence were taken up for PTBD,4 had operable lesion hence taken up for surgery and 5 had CBD stones masquerading as malignant stricture where CBD clearance was done. Rest 78 where ERCP was done formed the study group.This included 35 cases of CholangioCA,19 Ca GB and 24 pancreatic tumours.in 48 brush smear in 28 bile and in 2 spy bite was taken.Cytology was positive for malignancy in 34,negative in 20 & indeterminate in 24.On further analysing the indeterminate,14 finally confirmed as malignancy & 6 were benign. The diagnostic yield was 61.5%(48/78), It was more for Brush smear 70%(34/48) vs bile 50%(14/28). Cholangioscopy was suggestive of malignancy in 8/10.spybite was taken in 2,both were positive. But we switched over to brush cytology as we found cholangioscopic forceps difficult to use.CA19.9 levels were available in 30 of 48 confirmed cases and were >500 in 20, 100-500 in 2, 35-100 in 6 and normal in 2,but were also raised to >500 in 4/5 cases with CBD stones. Conclusion: It is known that yield of biliary cytology during ERCP is around 30-50% in various studies. Factors which favour a positive result are older age,longer stricture and presence of a mass. our study showed a higher yield of brushings probably because we take brush after dilatation of stricture, without injecting contrast (air cholagiogram guided) and that we have an onsite pathologist. We conclude that brush cytology is a good tool and diagnostic yield is 70%.Very high levels of CA19.9 are suggestive but can not be relied upon as sole evidence of malignancy.Cholangioscopic images strengthen the diagnosis but cholangioscopic biopsy is not a practical tool as passage through scope is dificult and time consuming
Published Version
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