Biliary strictures: endoscopic assessment and management

Abstract

The diagnosis of biliary strictures can be challenging. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to improve the diagnostic performance of endoscopy and expand its therapeutic role. Recent studies have enabled greater clarity about the role of preoperative biliary drainage and the choice of stents in this setting as well as the utility of metal stents in benign and malignant disease.

Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video)

“…1,2 In the absence of apparent extrinsic compression, accurate characterization of strictures caused by biliary ductal disease can be challenging. 3,4 Because of the major differences in treatment comprising endoscopic intervention, medical treatment, extensive surgery, and palliation, a correct diagnosis, preferably at first ERCP, is crucial for patient prognosis and management. For example, although a benign postsurgical biliary stricture can often be treated successfully with an endoscopic approach, a cholangiocarcinoma needs aggressive surgical and oncologic management associated with appreciable morbidity and not insignificant mortality.…”

“…For example, although a benign postsurgical biliary stricture can often be treated successfully with an endoscopic approach, a cholangiocarcinoma needs aggressive surgical and oncologic management associated with appreciable morbidity and not insignificant mortality. 4,5 Because conventional ERCP-based cholangiography has poor sensitivity in distinguishing the cause of stricture, tissue acquisition is necessary. 4,6 The standard evaluation of indeterminate biliary strictures therefore always involves cross-sectional imaging followed by ERCP plus biopsy sampling and/or brushing.…”

The incremental benefit of EUS for the identification of malignancy in indeterminate extrahepatic biliary strictures: A systematic review and meta-analysis

“…With a sensitivity of 45% for ERCP brushings alone, other diagnostic modalities are necessary to increase the detection of cancers early in the investigative process. [21] When paired with ERCP, our results show that EUS facilitates the identification and cytopathological confirmation of malignancy to enable timely therapy. It is interesting to note that ERCP and EUS procedures done in tandem yield a higher pooled estimate of effect than when the procedures are done separately.…”

The interobserver agreement of optical features used to differentiate benign from neoplastic biliary lesions assessed at balloon‐assisted cholangioscopy

“…Endoscopic retrograde cholangiopancreatography (ERCP)‐guided brush cytology and histology are limited by their poor sensitivity . Endoscopic ultrasound‐guided fine needle aspiration has a modest diagnostic sensitivity for malignant biliary lesions ranging from 76% to 83% for proximal and distal lesions, respectively, while concerns about possible tumor seeding limit its role in proximal biliary strictures . More recently, there has been growing interest in the role of cholangioscopy to assess indeterminate biliary lesions.…”

“…[6][7][8][9] Endoscopic ultrasound-guided fine needle aspiration has a modest diagnostic sensitivity for malignant biliary lesions ranging from 76% to 83% for proximal and distal lesions, respectively, while concerns about possible tumor seeding limit its role in proximal biliary strictures. [10][11][12][13][14] More recently, there has been growing interest in the role of cholangioscopy to assess indeterminate biliary lesions. Direct cholangioscopic examination of biliary lesion morphology has been used to predict neoplasia and to target biopsies.…”