With the increasing application of nonsurgical therapy for patients with pancreaticobiliary strictures, a definitive histologic diagnosis is crucial in the diagnosis and management of these patients. The growing literature advocating tissue sampling at ERCP has demonstrated that single techniques produce yields in the 37% to 71% range 1 Sherman S Esher EJ Pezzi JS et al. Yield of ERCP tissue sampling of biliary strictures by brush, forceps, and needle aspiration methods. Gastrointest Endosc. 1995; 42 ([Abstract]): 415 Google Scholar , 2 Kubota Y Takaoka M Tuni K et al. Endoscopic transpapillary biopsy for diagnosis of patients with pancreaticobiliary strictures. Am J Surg. 1993; 88: 1700-1704 Google Scholar , 3 Howell DA Beveridge RP Bosco JJ et al. Endoscopic needle aspiration biopsy at ERCP in the diagnosis of biliary strictures. Gastrointest Endosc. 1992; 38: 531-535 Abstract Full Text PDF PubMed Scopus (101) Google Scholar , 4 Ferrari AP Lichtenstein DR Slivka A et al. Brush cytology during ERCP for the diagnosis of biliary and pancreatic malignancies. Gastrointest Endosc. 1994; 40: 140-145 Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar , 5 Kurzawinski TR Deery JS Dick R et al. A prospective study of biliary cytology in 100 patients with bile duct strictures. Hepatology. 1993; 18: 1399-1403 Crossref PubMed Scopus (119) Google Scholar , 6 Scudera PL Koizumi J Jacobson IM. Brush cytology examination of lesions encountered during ERCP. Gastrointest Endosc. 1990; 36: 281-284 Abstract Full Text PDF PubMed Scopus (80) Google Scholar for detecting pancreaticobiliary malignancies. These lower yields in comparison to tissue biopsy at upper and lower endoscopy are likely due to the extrinsic nature of malignancies involving the pancreaticobiliary tree, often with intact ductal epithelium. Despite the availability of sampling techniques for more than 20 years, tissue diagnosis at ERCP is pursued aggressively in only a few tertiary medical centers. This is probably due to the technical difficulties of achieving deep cannulation of the bile and pancreatic ducts, to the potential risks of sphincterotomy, and to the technical expertise necessary to obtain adequate tissue from strictures. In addition, the availability of CT-guided percutaneous biopsy has provided an alternative to endoscopic collection of specimens. Recently, concerns regarding the potential seeding of needle tracks or spillage of malignant cells into the peritoneal cavity have been raised, 7 Warshaw AL. Implications of peritoneal cytology for staging of early pancreatic cancer. Am J Surg. 1991; 161: 26-29 Abstract Full Text PDF PubMed Scopus (279) Google Scholar producing caution in the widespread use of percutaneous biopsy techniques. The yield of exfoliative cytology has been disappointing and is rarely used, leaving three endoscopic techniques available to the clinician. Brush cytology is the most commonly utilized technique, but its yields are disappointing, particularly in pancreatic adenocarcinoma. Transpapillary forceps biopsies generally require sphincterotomy but have an improved yield. 2 Kubota Y Takaoka M Tuni K et al. Endoscopic transpapillary biopsy for diagnosis of patients with pancreaticobiliary strictures. Am J Surg. 1993; 88: 1700-1704 Google Scholar Finally, fine-needle aspiration biopsy using a ball tipped needle placed across the papilla may sample from beneath the epithelium improving yields, but is also technically challenging and requires sphincterotomy.
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Dec 1, 2015
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