Cholangioscopy for Indeterminate Strictures: Is the Juice Worth the Squeeze? Probably
Bret T. Petersen, MD, FASGE reviewing Gerges C, et al. Gastrointest Endosc 2019 Nov 25.
Biliary strictures are often hard to characterize using standard brush cytology and fluoroscopically directed biopsies. Visually targeted biopsy during cholangioscopy might be superior to these standard sampling techniques.
This prospective, international, multicenter study, initiated by investigators, randomized 57 patients with indeterminate, intrinsic, mid-to-proximal bile duct strictures, which had been identified by MRCP, to initial assessment with one of two techniques: a SpyGlass single-operator cholangioscopy exam and directed biopsies (SOC) without use of prior cholangiography versus standard fluoroscopic imaging and brush cytology (STD). Reviewing pathologists were blinded to the procedure details. Initial SOC yielded significantly higher sensitivity than initial STD for both visual characterization (SOC, 95.5% vs STD, 66.7%; P=0.02) and biopsy identification of malignancy (SOC, 68.2% vs STD, 21.4; P<0.01). Overall accuracy (SOC, 87.1% vs STD, 65.5; P=0.05) was significantly higher with SOC, but specificity and positive and negative predictive values were not significantly different. Adverse events were equivalent in both arms.
COMMENT
A number of studies have now shown the utility of SOC visual exam and guided biopsies for assessment of indeterminate biliary strictures. In this study, fluoroscopically directed biopsies were not used in the standard exam, despite their demonstrated significant yield beyond brush cytology alone. Surprisingly, the mean number of procedures to reach a concluding diagnosis was not different between arms, perhaps suggesting loss to follow-up or lack of concluding diagnoses prior to patient demise. Studies are needed to assess both relative costs for SOC-enhanced accuracy and characterization of stricture subtypes for which SOC exam might be most useful.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Bret T. Petersen, MD, FASGE
CITATION(S)
Gerges C, Beyna T, Tang RSY, et al. Digital single-operator peroral cholangioscopy-guided biopsy versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized multicenter trial (with video). Gastrointest Endosc 2019 Nov 25. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2019.11.025)
