Diagnosis Of Bile Duct Strictures Research Articles

Clinical Outcomes of Digital Cholangioscopy-Guided Procedures for the Diagnosis of Biliary Strictures and Treatment of Difficult Bile Duct Stones: A Single-Center Large Cohort Study

Although Spy DS (SpyGlass DS Direct Visualization System) is considered to be useful for the diagnosis of bile duct strictures and the treatment of bile duct stones, there is limited data to date validating its efficacy. We hence retrospectively evaluated the clinical outcomes of the use of Spy DS in a large number of patients. A total of 183 patients who underwent Spy DS-guided procedures for indeterminate bile duct strictures (n = 93) and bile duct stones (n = 90) were analyzed retrospectively. All patients (93/93) with bile duct strictures successfully underwent visual observation, and 95.7% (89/93) of these patients successfully underwent direct biopsy. The sensitivity, specificity, and overall accuracy were 94.7%, 83.3%, and 90.3%, respectively, for visual impression; 80.9%, 100%, and 89.2%, respectively, for histopathological analysis of a direct biopsy; and 96.5%, 91.7%, and 94.6%, respectively, for visual impression combined with biopsy. Successful visualization of the stones was achieved in 98.9% (89/90) of the patients, and complete stone removal was achieved in 92.2% (83/90) of the patients, with an average of 3.3 procedures. The adverse events rate was 17.5% (32/183; cholangitis in 15 patients, fever the following day in 25, pancreatitis in 1, hemorrhage in 1, and gastrointestinal perforation in 1). No administration of antibiotics before the procedure was found to be a statistically significant risk factor for the development of fever after the procedure (p < 0.01). Spy DS-guided procedures are effective for the diagnosis and treatment of bile duct lesions and can be performed with a low risk of serious adverse events.

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

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)

Possibilities of per-oral transpapillary cholangioscopy in oncological practice

Relevance. Diagnosis of malignant diseases causing bile duct strictures is a big challenge. At admission, patients with suspected biliary tract stricture, initially undergo endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic and treatment method. The morphological diagnosis of bile duct stricture based on ERCP with brush biopsy or intraductal forceps biopsy is limited by their low sensitivity. Consequently, a significant proportion of strictures remains undiagnosed, which led to the development of methods based on cholangioscopy.&#x0D; Aim. To determine the role of per-oral transpapillary cholangioscopy (TCS) in a specialized cancer clinic.&#x0D; Materials and methods. SpyGlass direct visualization system for per-oral intraductal examination from Boston Scientific was clinically tasted in Blokhin National Medical Research Center of Oncology of the Ministry of Health of Russia. Using this electronic system, TCS was performed in 4 patients with various malignant diseases.&#x0D; Results. In all cases, TCS was successful. In all patients, the diagnosis was confirmed with a forceps intraductal biopsy using Spybite forceps.&#x0D; Conclusion. Single-use electronic direct visualization system for per-oral intraductal examination and interventions like SpyGlass can be recommended for use in specialized cancer centers.

Endoscopic methods for cytopathologic diagnosis of bile duct strictures

Endoscopic methods for cytopathologic diagnosis of bile duct strictures

The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures.

Conventional endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy and radiography to diagnose and treat pathological conditions of the bile duct. The aim of the present analysis was to evaluate the clinical and economic impact of the use of single-operator intraductal cholangioscopy (IDC), which allows for direct visualization of the bile duct, as an alternative to ERCP for the treatment of difficult bile duct stones and the diagnosis of bile duct strictures. The clinical and economic consequences of single-operator IDC use were evaluated using two decision-tree models, one for management of difficult-to-remove stones and one for stricture diagnosis. A hospital perspective was adopted. Data to populate the models were derived from two Belgian hospitals that specialize in endoscopic procedures of the bile duct. Overall, the examined population consisted of 62 patients with difficult stones and 49 patients with indeterminate strictures. In the model for difficult stone management, the use of IDC determined a decrease in the number of procedures (- 27 % relative reduction) and costs (- €73 000; - 11 % relative reduction) when compared with ERCP. In the model for stricture diagnosis, the use of IDC determined a decrease in the number of procedures (- 31 % relative reduction) and costs (- €13 000; - 5 % relative variation) when compared with ERCP. The single-operator IDC system performed better than ERCP for the treatment of difficult bile duct stones and the diagnosis of bile duct strictures, and reduced the overall expenditure in hospitals in Belgium.

Comparison of brush and basket cytology in differential diagnosis of bile duct stricture at endoscopic retrograde cholangiopancreatography

A previous report has identified a significantly higher sensitivity of cancer detection for dedicated grasping basket than brushing at endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to compare the diagnostic accuracy of Geenen brush and Dormia basket cytology in the differential diagnosis of bile duct stricture. The current study enrolled one hundred and fourteen patients who underwent ERCP with both Geenen brush and Dormia basket cytology for the differential diagnosis of bile duct stricture at our institution between January 2008 and December 2012. We adopted sequential performances of cytologic samplings by using initial Geenen brush and subsequent Dormia basket cytology in 59 patients and initial Dormia basket and subsequent Geenen brush cytology in 55 patients. Presampling balloon dilatations and biliary stentings for the stricture were performed in 17 (14.9%) and 107 patients (93.9%), respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Geenen brush cytology for the diagnosis of malignant bile duct stricture were 75.0%, 100.0%, 100.0%, 66.7% and 83.3%, respectively, and those of Dormia basket cytology were 64.5%, 100.0%, 100.0%, 58.5% and 76.3%, respectively (P=0.347 and 0.827 for sensitivity and accuracy, respectively). The good and excellent cellular yields (≥grade 2) were obtained by Geenen brush and Dormia basket cytology in 88 (77.2%) and 79 (69.3%) patients, respectively. The sensitivity, specificity and accuracy of biliary sampling with a Dormia basket are comparable to those with conventional Geenen brush cytology in the detection of malignant bile duct stricture.

PTH-033 A Systematic Approach to Standard Endoscopic Sampling of Bile Duct Strictures is Highly Accurate in the Diagnosis of Biliary Strictures

IntroductionAccurate diagnosis of bile duct strictures as malignant or benign is imperative for optimal patient management, but is frequently difficult. Histological and cytological samples can be obtained at ERCP. Various...

Mo1356 Intraductal Ultrasound (IDUS) Substantiates the Diagnosis of Bile Duct Strictures of Unknown Etiology: Results of a Histopathologically Controlled Retrospective Study Including 402 Patients

All procedures were performed under general anesthesia with endotracheal intubations. Trans-gastric NOTES approach was achieved by puncturing the gastric wall using a needle knife followed by a 8mm-balloon (CRETMESO/ PYL5839, Boston Scientific, USA) dilation for small sized endoscope and a 18mm-balloon (CRETMESO/PYL5841, Boston Scientific, USA) dilation for big sized endoscope. Carbon dioxide was used for laparoscopy and NOTES pneumoperitoneum. Following the peritoneoscopy, the endoscope was withdrawn into the stomach and gastric wall incision was closed with EndoClips. The animals were survived for 2 weeks and then sacrificed for post-mortem examination. Blood was drawn at 1h preoperatively and 1h, 12h, 2d, 7d postoperatively. WBC was tested and Inflammatory markers (TNF-a, IL-6) were analyzed by ELISA. Results: The peritoneoscopy was successfully finished by both NOTES route and laparoscopic route. There were no intra-operative and post-operative complications. No significant differences were found between SG, BG and LG in terms of TNF-a levels at 1h pre-operatively (P 0.414) and at 1h (P 0.9173), 12h(P 0.3352), 2d(p 0.6208), 7d(p 0.4109) post-operatively. There was no significant difference in IL-6 levels at the same time points as above among the 3 groups (p 0.05). There was no significant difference of WBC counts among the 3 groups at 2d (p 0.2879) and 7d (p 0.0690) post-operatively. Conclusions: Transgastric NOTES peritoneoscopy is not less invasive than laparoscopy and a small sized endoscope is not superior to a big sized one for NOTES procedure in terms of inflammatory response.

Multidetector computed tomography cholangiography with multiplanar reformation for the assessment of patients with biliary obstruction

We sought to evaluate the diagnostic use of multidetector computed tomography (MDCT) cholangiography with multiplanar reformation (MPR) for the assessment of patients with biliary obstruction. MDCT cholangiography with the MPR technique was performed in 58 patients who were thought to have biliary obstruction. No cholangiographic contrast agent was administered. MRCP in 24 patients, Endoscopic retrograde cholangiopancreatography (ERCP) in 46 patients and percutaneous transhepatic cholangiography (PTC) in 24 patients were performed. Eighteen patients underwent biopsy or surgery. The findings on MDCT cholangiography were compared with those of MRCP, ERCP, PTC, biopsy or surgery. The findings of MDCT cholangiography were as follows: choledocholithiasis (n = 34, 56.7%), malignant stricture (n = 14, 23.3%), benign stricture (n = 1, 1.7%), and cholelithiasis (n = 11, 18.3%). A small common bile duct (CBD) stone in one patient could not be detected on MDCT cholangiography. One patient with a small stone in distal CBD detected on MDCT cholangiography had no stone on ERCP. Two patients with initial diagnoses of CBD stones by MDCT cholangiography were disclosed to have malignant bile duct stricture by reference examination. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stones were 96.9% and 96.2%, respectively. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stricture were 85.7% and 100%, respectively. The overall accuracy of MDCT cholangiography for the diagnoses of the causes of biliary obstruction was 89.8%. MDCT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high sensitivity and specificity for the diagnoses of the causes of biliary obstruction.

Intraductal ultrasonography (IDUS) for preoperative diagnosis of bile duct strictures. Prospective study comparing idus with conventional endosonography (EUS)

Intraductal ultrasonography (IDUS) for preoperative diagnosis of bile duct strictures. Prospective study comparing idus with conventional endosonography (EUS)

Benign post-operative bile duct strictures

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The ‘gold standard’ for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.