The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures

doi:10.1067/mge.2001.118715

Gastrointestinal Endoscopy

Volume 54, Issue 5, November 2001, Pages 587-594

https://doi.org/10.1067/mge.2001.118715 Get rights and content

Abstract

Background: Brush cytology, routinely performed at ERCP to assess malignant-appearing biliary strictures, is limited by relatively low sensitivity and negative predictive value. This study assessed whether the combination of stricture dilation, endoscopic needle aspiration, and biliary brushing improves diagnostic yield. Methods: In a prospective nonrandomized study, 46 consecutive patients were evaluated with malignant-appearing biliary strictures at ERCP. Twenty-four patients (Group A) underwent standard brush cytology alone and 22 patients (Group B) underwent stricture dilatation to 10F, endoscopic needle aspiration, and subsequent biliary brushing by using the Howell biliary system. The diagnostic yields for both techniques were compared. Results: Of the 46 patients, 34 had proven malignant strictures (14 Group A, 20 Group B). Compared with brushing alone, the combination of stricture dilatation, endoscopic needle aspiration, and subsequent biliary brushing significantly increased both the sensitivity (57% vs. 85%, p < 0.02) and specificity (80% vs. 100%, p < 0.02) of cytology with positive brushings in all patients with pancreatic or gallbladder carcinoma. Conclusions: The combination of stricture dilation, endoscopic needle aspiration, and biliary brushing significantly improves diagnostic yield for malignant bile duct strictures and may particularly be of benefit for extrinsic strictures caused by pancreatic or gallbladder carcinoma. (Gastrointest Endosc 2001;54:587-94.)

Section snippets

Patients and methods

Our hypothesis was that a combination of stricture dilation, needle aspiration, and subsequent brushing would increase the diagnostic yield in cases in which the cholangiographic appearance of a stricture suggested malignancy compared with the yield for brushing alone. Power calculations gave an estimate of minimum sample size required of 20 patients in both groups. This sample size would have more than an 80% power to detect a difference between the 2 groups equal to one group standard

Results

Of the 46 consecutive patients with malignant-appearing strictures at ERCP, carcinoma was confirmed in 34 and benign disease in 12 (Table 1).

. Patient and stricture characteristics

Patient characteristics	Group A	Group B
Number of patients	24	22
Gender (M:F)	13:11	11:11
Median age (range), years	72 (36-88)	71 (47-92)
Interquartile age range, years	63-81	62-79
Malignant strictures	14	20
Pancreatic adenocarcinoma	10	8
Cholangiocarcinoma	4	6
Gallbladder carcinoma	0	3
Metastatic colon cancer	0	3
Benign strictures	10	2
Primary

Discussion

Although malignant-appearing bile duct strictures are commonly encountered at ERCP, reliable differentiation of benign from malignant stenoses remains challenging. Because affected patients are commonly evaluated and primarily treated by ERCP, acquisition of specimens from such lesions during ERCP is the most practical approach to tissue diagnosis. Endobiliary brushing over a guidewire was first described by Foutch et al.¹² and has repeatedly been shown to be convenient and safe, lengthening

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Citation Excerpt :
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^☆: Ajay K. Jain was supported by an educational grant from Hargobind Foundation, India.

^☆☆: Reprint requests: Douglas K. Pleskow, MD, Suite 8E, Lowry Bldg., 110 Francis St., Beth Israel Deaconess Medical Center, Boston, MA 02215.

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Original ArticlesThe combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures☆,☆☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

How to improve the accuracy of diagnosis of malignant biliary strictures

Endoscopy

Diagnostic endoscopic retrograde cholangiopancreatography

Endoscopy

Original Articles
The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures☆,☆☆