Clinical utility of EUS before cholangioscopy in the evaluation of difficult biliary strictures.

BACKGROUND: Biliary tract malignancies can be assessed with either EUS or SpyGlass cholangioscopy (SGC).

OBJECTIVE: To evaluate the impact of EUS and guided biopsy before considering SGC in patients who had biliary strictures with negative ductal brushing.

DESIGN: Prospective, observational study.

SETTING: Tertiary level referral hospital.

PATIENTS: Forty consecutive patients with biliary strictures.

INTERVENTION: EUS evaluation and biopsy, where possible, were performed in all patients. If EUS examination failed to provide a definitive diagnosis, SGC and ductal biopsy was performed. Results were compared with surgical specimens or positive histocytology.

MAIN OUTCOME MEASUREMENTS: Tissue diagnosis, technical success, adverse events, and clinical outcomes.

RESULTS: On EUS, abnormalities responsible for the biliary strictures were identified in 39 patients (98%), with FNA achievable in 30 patients (75%). EUS-FNA provided positive histocytology in 23 patients (58%). SGC-guided biopsy was performed to evaluate nondiagnostic EUS-FNA (17 patients) and to clarify autoimmune pancreatitis on FNA (2 patients). The procedure was successful in 18 patients (95%) and provided tissue diagnosis in 16 patients (88%), with 2 false-negative results from extrinsic pathologies. When EUS was used before the SGC approach, the need for SGC was avoided in 24 patients (60%), cholangitis was minimized in 2.5%, and a cost saving of U.S.$110,000 was realized. Tissue diagnosis was achieved in 38 patients (94%) with this approach.

LIMITATIONS: Relatively small sample size.

CONCLUSIONS: EUS evaluation in patients with difficult biliary stricture prevents the need, cost, and adverse events of SGC in 60% of patients. Together, EUS followed by the SGC approach provides correct clinical diagnosis in 94% of patients with minimal adverse events.