Biliary guidewire facilitates bile duct biopsy and endoscopic drainage

Observation for the feasibility of a bile duct biopsy technique using a loop-tip guidewire during endoscopic retrograde cholangiopancreatography

Endoscopists frequently have difficulty approaching biliary lesions using biopsy forceps. The aim of this study was not only to describe an easy technique for biliary biopsy assisted by a looped guidewire but also to present preliminary results regarding its safety and feasibility. A preliminary proof-of-concept study was performed at a single tertiary medical center. Between August 2019 and January 2020, 13 patients with bile duct strictures underwent endoscopic retrograde cholangiopancreatography (ERCP) with a new loop guidewire-assisted forceps approach technique. The efficacy and safety were evaluated using the success rate as the primary outcome and diagnostic yield and complication rates as secondary outcomes. The tissue sampling success rate was 100% (13/13). All samples were acceptable for histopathological analysis. Eleven specimens were confirmed to be adenocarcinomas. After reexamination of the remaining 2 patients, all cases were eventually diagnosed as being malignant. The sensitivity of the single procedure was 84.6% (11/13). There were 2 patients with mild hyperamylasemia, but there were no severe complications with respect to safety. This new technique could enhance the success rate and diagnostic yield and reduce the risk of failure when using the biopsy forceps approach during ERCP.

Impact of trimodality sampling on detection of malignant biliary strictures compared with patients with primary sclerosing cholangitis

BACKGROUND AND AIMS

Malignant biliary strictures can be difficult to diagnose, with up to 20% considered indeterminate after initial tissue sampling. This study aimed to determine the performance characteristics of transpapillary biopsy sampling (TPB) and fluorescence in situ hybridization (FISH) in isolation or in combination with standard brush cytology (BC) in patients who received trimodality sampling for biliary strictures.

METHODS

This single-center retrospective cohort study included patients with biliary strictures undergoing ERCP with trimodality sampling between September 2014 and April 2019. Performance characteristics for each diagnostic test alone and in combination were calculated.

RESULTS

Two hundred four patients underwent trimodality biliary sampling, including 104 (51.0%) with malignancy. The diagnostic sensitivity for malignancy with BC (17.3%) significantly improved with dual modality (BC+FISH, 58.7%; BC+TPB, 40.4%) or trimodality sampling (68.3%; P < .001 for all comparisons). Trimodality sampling improved diagnostic sensitivity for malignancy compared with BC+FISH (P = .002) and BC+TPB (P < .001). There was no statistically significant difference in the sensitivity of trimodality sampling in detecting cholangiocarcinoma (79.7%) compared with pancreatic cancer (62.5%; P = .1). Among 57 patients with primary sclerosing cholangitis (PSC), the sensitivity of detecting biliary malignancy (n = 20) was 20% for BC and significantly improved with the addition of FISH (80%; P < .001) but not with TPB (35.0%; P = .25). Trimodality sampling did not further improve diagnostic sensitivity (85%) over BC+FISH (80%) for malignancy in the setting of PSC (P = 1).

CONCLUSIONS

Trimodality sampling improves the diagnostic sensitivity for the detection of malignant biliary strictures with no significant difference in sensitivity for cholangiocarcinoma compared with pancreatic cancer. However, in patients with PSC, trimodality sampling was not superior to BC+FISH.

Efficacy of endoscopic samplings during initial biliary drainage for cases of pancreatic head cancer: United diagnostic yields of multiple pathological samplings

BACKGROUND/OBJECTIVES

The diagnostic ability of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been fully studied; however, the efficacy of other endoscopic samplings (OESs) is less clear. The aim of this study was to examine the diagnostic efficacies of OESs for pancreatic head cancer (PHC).

METHODS

The diagnostic efficacies of endoscopic samplings were retrospectively analyzed in 448 PHC cases and 63 cases of mass-forming pancreatitis (MFP) during initial transpapillary biliary drainage. The OESs included duodenal biopsy (118 PHCs and 50 MFPs), biliary biopsy (218 and 51) with cytology (368 and 53), and pancreatic duct biopsy (23 and 13) with cytology (56 and 43). EUS-FNA was conducted in a different session (149 and 62). Factors associated with OES sensitivity were analyzed. The sensitivity of biliary biopsy was compared between 1.95 mm and 1.8 mm forceps.

RESULTS

Cancer cells were confirmed in 87.9% of the EUS-FNA samplings and in 64.1% (268/418) obtained by combined OESs (average 1.7 OES types per case): 68.6% by duodenal biopsy, 59.6% by biliary biopsy, 32.6% by biliary cytology, 73.9% by pancreatic duct biopsy, and 33.9% by pancreatic duct cytology. No MFP cases revealed cancer by any sampling. OESs did not increase adverse events. Duodenal stenosis, serum bilirubin, tumor size, and pancreatic juice amounts were associated with OES sensitivity. Biliary biopsy had the same sensitivity with different forceps.

CONCLUSION

EUS-FNA was the most diagnostic protocol; however, OESs can be safely applied during the initial biliary drainage to reduce the demand for EUS-FNA while providing good diagnostic yields.

The Wire-Grasping Method as a New Technique for Forceps Biopsy of Biliary Strictures: A Prospective Randomized Controlled Study of Effectiveness

Background/Aims

Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy.

Methods

Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wire-grasping method, forceps in the duodenum grasps a guide-wire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination.

Results

In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively).

Conclusions

The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall.

Diagnostic approach using ERCP-guided transpapillary forceps biopsy or EUS-guided fine-needle aspiration biopsy according to the nature of stricture segment for patients with suspected malignant biliary stricture

In malignant biliary stricture (MBS), the diagnostic accuracy of ERCP‐based tissue sampling is insufficient. EUS‐guided fine needle aspiration biopsy (EUS‐FNAB) is emerging as a reliable diagnostic procedure. This study aimed to evaluate the usefulness of a diagnostic approach using ERCP‐guided transpapillary forceps biopsy (TPB) or EUS‐FNAB according to the characteristics of suspected MBS. Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with intraductal ultrasonography (IDUS) and TPB were performed as initial diagnostic procedures. Based on the results of imaging studies and IDUS, all MBS were classified as extrinsic or intrinsic type. If the malignancy was not confirmed by TPB, EUS‐FNAB for extrinsic type or second TPB for intrinsic type was performed. Among a total of 178 patients, intrinsic and extrinsic types were detected in 88 and 90 patients, respectively. The diagnostic accuracy of first TPB was significantly higher in the intrinsic than in the extrinsic type (81.8% vs. 67.8, P = 0.023). In 33 patients with extrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of EUS‐FNAB was 90.9%. In 19 patients with intrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of second TPB was 84.2%. The diagnostic accuracies of the combination of initial TPB with EUS‐FNAB and second TPB were 96.7% and 96.6%, respectively. A diagnostic approach using EUS‐FNAB or TPB according to the origin of MBS is considered effective to improve the diagnostic accuracy of MBS with negative for malignancy on first TPB. (Clinical trial registration number: UMIN000016886).

Immunoglobulin G4-related sclerosing cholangitis mimicking hilar cholangiocarcinoma diagnosed with following bile duct resection: report of a case

We report a rare case of immunoglobulin G4 (IgG4)-related sclerosing cholangitis without other organ involvement. A 69-year-old-man was referred for the evaluation of jaundice. Computed tomography revealed thickening of the bile duct wall, compressing the right portal vein. Endoscopic retrograde cholangiopancreatography showed a lesion extending from the proximal confluence of the common bile duct to the left and right hepatic ducts. Intraductal ultrasonography showed a bile duct mass invading the portal vein. Hilar bile duct cancer was initially diagnosed and percutaneous transhepatic portal vein embolization was performed, preceding a planned right hepatectomy. Strictures persisted despite steroid therapy. Therefore, partial resection of the common bile duct following choledochojejunostomy was performed. Histologic examination showed diffuse and severe lymphoplasmacytic infiltration, and abundant plasma cells, which stained positive for anti-IgG4 antibody. The final diagnosis was IgG4 sclerosing cholangitis. Types 3 and 4 IgG4 sclerosing cholangitis remains a challenge to differentiate from cholangiocarcinoma. A histopathologic diagnosis obtained with a less invasive approach avoided unnecessary hepatectomy.

Intraductal biopsies in indeterminate biliary stricture: Evaluation of histopathological criteria in fluoroscopy- vs. cholangioscopy guided technique

BACKGROUND

Differentiating malignancy from benign disease in indeterminate biliary stricture by imaging modalities is limited. Definite diagnosis relies on histopathological diagnosis.

AIMS

To assess accuracy of histopathological diagnosis of fluoroscopy-guided vs. cholangioscopy-directed intraductal biopsies in indeterminate biliary stricture.

METHODS

All patients with indeterminate biliary stricture and fluoroscopically (n=68) or cholangioscopy-directed (working channel 2mm, n=38) biopsies were included. Histopathological results of biopsies were classified into inflammatory lesion (class 1), dysplasia/intraepithelial neoplasia (class 2) and malignancy (class 3) and results as well as macroscopic diagnosis were compared with final diagnosis.

RESULTS

Sensitivity and specificity of fluoroscopy-guided vs. cholangioscopy-directed biopsies were 22.9% and 100% vs. 25.0% and 100% for class 1+2 vs. class 3 lesions, respectively. Sensitivity for class 1 vs. class 2+3 lesions was 45.7% (p=0.044) vs. 58.3% (p=0.214) for fluoroscopy-guided vs. cholangioscopy-directed biopsies, respectively, while specificity was 100% in both. There was no difference in size of the obtained sample (p=0.992). True positive diagnosis rate increased with the number of biopsies taken (p=0.028).

CONCLUSION

Fluoroscopy-guided and cholangioscopy-directed intraductal biopsies are equally limited in establishing the diagnosis of malignancy in indeterminate biliary stricture. Categorizing dysplasia or intraepithelial neoplasia as malignancy increases sensitivity without decrease in specificity. By taking more biopsies, diagnostic yield is increased.

Transpapillary biliary biopsy for malignant biliary strictures: comparison between cholangiocarcinoma and pancreatic cancer

BACKGROUND

Tissue sampling for biliary stricture is important for differential diagnosis and further treatment. This study aims to assess the differences of transpapillary biliary biopsy for malignant biliary strictures between cholangiocarcinoma and pancreatic cancer.

METHODS

From January 2010 to December 2013, we retrospectively studied 79 patients who suffered from biliary strictures and received transpapillary forceps biopsy after sphincterotomy for tissue sampling. The diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of forceps biopsy were calculated in all cases for both cholangiocarcinoma and pancreatic cancer patients. Possible factors that distinguish malignant strictures from benign strictures and which could affect the accuracy of tissue sampling were analyzed.

RESULTS

There are 65 malignant and 14 benign biliary stricture patients enrolled. The malignant group has a significantly higher serum bilirubin level than the benign group, but age, clinical presentation, level of serum carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and alkaline phosphatase are not. The sensitivity, specificity, PPV, and NPV of forceps biopsy for biliary stricture are 53.85, 100, 100, and 31.82%, respectively. The cholangiocarcinoma group has a higher sensitivity (73.53 versus 29.17%, p < 0.001), older age, lower CA 19-9 level, and more common hepatic duct strictures than the pancreatic group. The age, serum CEA, CA 19-9 and the alkaline phosphatase level, serum bilirubin level >10 mg/dL, tissue sampling ≧3 are not significant factors affecting diagnostic accuracy in forceps biopsy for pancreatobiliary strictures. There is neither major bleeding nor perforation in our study.

CONCLUSIONS

Transpapillary forceps biopsy of biliary strictures after sphincterotomy for tissue sampling is safe and a significantly higher sensitive method in cholangiocarcinoma but not in pancreatic cancer.

Diagnosing Biliary Malignancy

The most common malignant causes of biliary strictures are pancreatic cancer and cholangiocarcinoma. Differentiating between malignant and benign causes of biliary strictures has remained a clinical challenge. Endoscopic retrograde cholangiopancreatography (ERCP) remains the mainstay and first-line method of tissue diagnosis but has a poor diagnostic yield. This article reviews the causes of biliary strictures, the initial clinical evaluation of biliary obstruction, the diagnostic yield of ERCP-based sampling methods, the role of newer tools in the armamentarium for evaluating strictures, and ways to address the ongoing challenge of stricture evaluation in patients with primary sclerosing cholangitis.

Triple modality testing by endoscopic retrograde cholangiopancreatography for the diagnosis of cholangiocarcinoma

OBJECTIVES

Brush cytology has a low sensitivity for the diagnosis of cholangiocarcinoma. This study aimed to compare the standard approach (brush cytology) with a triple modality approach utilizing brush cytology, forceps biopsy and fluorescence in situ hybridization in terms of sensitivity and specificity for the diagnosis of cholangiocarcinoma.

METHODS

In a retrospective study at a single academic center, 50 patients underwent triple modality testing. Additionally, 61 patients underwent brush cytology alone. Intervention was endoscopic retrograde cholangiopancreatography with brush cytology, fluorescence in situ hybridization, and forceps biopsy. The main outcome measures included sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

Overall, 50 patients underwent triple tissue sampling, and 61 patients underwent brush cytology alone. Twenty-two patients were eventually diagnosed with cholangiocarcinoma. Brush cytology had a sensitivity of 42%, specificity of 100%, positive predictive value of 100% and negative predictive value of 88%. Triple tissue sampling had an overall sensitivity of 82%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 87%. Within the triple test group, brush cytology had a sensitivity of 27%, forceps biopsy had a sensitivity of 50%, and fluorescence in situ hybridization analysis had a sensitivity of 59%.

CONCLUSIONS

A triple modality approach results in a marked increase in sensitivity for the diagnosis of cholangiocarcinoma compared with single modality testing such as brush cytology and should be considered in the evaluation of indeterminate or suspicious biliary strictures.

Bile analysis using high-throughput FTIR spectroscopy for the diagnosis of malignant biliary strictures: a pilot study in 57 patients

This study aimed at determining whether FTIR spectroscopy is able to distinguish bile samples from patients with and without malignant biliary strictures. Bile samples were collected in 19 patients with malignant biliary strictures and 38 with benign biliary diseases during endoscopic procedures. FTIR spectra were acquired on dried drops of whole bile, aqueous and organic phases obtained after lipid extraction. Data were analyzed by principal component analysis and by the support vector machine classification using a leave-n-out cross validation procedure. This was applied to the whole set of spectra and the mean and median spectra of each patient. By leaving one patient out, the classifier allowed discriminating patients with and without malignant biliary strictures with a sensitivity between 82% and 95% and a specificity between 85% and 100%. Using a randomized leave-n -out cross-validation with n = 2, 5 and 10 patients, the sensitivity decreased slightly by about 5 to 10% while the specificity remained stable, suggesting the robustness of the classifier. FTIR spectroscopy combined with chemometrics therefore shows potential to differentiate bile from patients with and without malignant biliary strictures. Although promising, the results of this pilot study cannot be generalized and needs to be confirmed in a larger population.

Factors affecting the yield of endoscopic transpapillary bile duct biopsy for the diagnosis of pancreatic head cancer

BACKGROUND

Transpapillary biliary biopsy (TBB) is a simple endoscopic technique that can be performed during an initial biliary drainage session. This procedure has the potential to reduce the load of another tissue sampling in cases of pancreatic head cancer (PHC) with biliary stricture. The aim of this study is to identify factors associated with a positive outcome using TBB for PHC.

METHODS

In total, 130 cases that underwent TBB for investigation of distal biliary stricture were included [62 cases of PHC, 36 cases of distal biliary cancer (DBC), and 32 cases of benign biliary stricture (BBS)]. Factors affecting the diagnostic efficiency of TBB were determined using univariate and multivariate logistic analyses.

RESULTS

Cancer tissue was obtained in 31 cases (50%) of PHC and 33 cases (91.7%) of DBC. Multivariable analysis showed that ≧10 mg/dl of serum bilirubin level (odds ratio [OR]: 5.58; 95% confidence interval [CI]: 1.29-28.20; P = 0.021) and ≧3 tissue samplings (OR: 3.59; 95% CI: 1.02-14.27, P = 0.046) were independent factors affecting cancer-positive rate in cases of PHC. In >90% of resected cases of PHC, cancer involved the left side of the biliary mucosa and the range of cancer invasion (≧2/3 of circumference of biliary mucosa) was also a significant factor (P = 0.001).

CONCLUSIONS

PHC showing high level of serum bilirubin (>10 mg/dl) and high circumferential proportion of bile duct invasion (>2/3 judging from MDCT) is a good indication for biliary biopsy. Targeting the left-side wall and ≧3 tissue samplings will lead to the higher sensitivity.

Endoscopic evaluation of bile duct strictures

Differentiating between malignant and benign bile duct strictures is often challenging. Endoscopic retrograde cholangiopancreatography with brush cytology and/or endobiliary forceps biopsy is routinely performed. Advanced cytologic methods such as fluorescence in situ hybridization or digital image analysis increases the sensitivity of cytology. Endoscopic ultrasonography enables detailed examination of tissues surrounding the bile duct stricture and offers the advantage of fine-needle aspiration. Intraductal ultrasonography enables detailed evaluation of bile duct wall layers, and cholangioscopy offers direct visualization of the bile duct lesions. Novel techniques of probe-based confocal laser endomicroscopy and optical coherence tomography have introduced the era of in vivo histology.

Current endoscopic approach to indeterminate biliary strictures

Biliary strictures are considered indeterminate when basic work-up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are non-diagnostic. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patient’s outcome. Early and accurate diagnosis of malignancy impacts not only a patient’s candidacy for surgery, but also potential timely targeted chemotherapies. A significant portion of patients with indeterminate biliary strictures have benign disease and accurate diagnosis is, thus, paramount to avoid unnecessary surgery. Current sampling strategies have suboptimal accuracy for the diagnosis of malignancy. Emerging data on other diagnostic modalities, such as ancillary cytology techniques, single operator cholangioscopy, and endoscopic ultrasonography-guided fine needle aspiration, revealed promising results with much improved sensitivity.

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.

Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol)

OBJECTIVES

Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues.

METHODS

A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38-95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol).

RESULTS

Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1-17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers.

CONCLUSIONS

Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.

How many cytological examinations should be performed for the diagnosis of malignant biliary stricture via an endoscopic nasobiliary drainage tube?

BACKGROUND AND AIM

The sensitivity of bile cytology is recognized as being low. Repeating cytological sampling is likely to improve the sensitivity. The aim of this study is to determine the optimal number of repeated cytological sampling of bile obtained via an endoscopic nasobiliary drainage (ENBD) tube for the diagnosis of malignant biliary stricture.

METHODS

Ninety-eight patients with malignant biliary stricture who underwent ENBD were enrolled. Diagnoses included bile duct carcinoma (n = 53), pancreatic carcinoma (n = 28), carcinoma of the major papilla (n = 8), gallbladder carcinoma (n = 6), and hepatocellular carcinoma (n = 3). Bile was aspirated via an ENBD tube once a day and immediately evaluated cytologically.

RESULTS

The median number of cytological samplings via an ENBD tube was 2.8 times (range, 1-10). In 40 of 98 patients with malignant biliary stricture, cytology was positive at the first cytological sampling (sensitivity 40.8%). Cytology was cumulatively positive in 71 of 98 patients (sensitivity 72.4%) from which repeated samples were taken. In 71 patients with positive cytology, correlation of the positive rate and the number of cytological samplings performed was investigated. In 68 of 71 (95.8%) patients with positive cytology, positive results were obtained by or at the sixth examination.

CONCLUSIONS

Bile cytology via an ENBD tube is an easy method, and has been shown to have relatively high sensitivity. The optimal number of repeated cytological samplings using bile obtained via an ENBD tube for the diagnosis of malignant biliary stricture was concluded to be six.

Is preoperative histological diagnosis necessary for cholangiocarcinoma?

Surgery is currently the only curative treatment for patients with cholangiocarcinoma (CCA). Whether histological diagnosis of CCA is necessary before surgery is controversial. Fifteen percent of patients with suspected biliary malignancy who undergo surgery are found to have benign disease. Surgery is a major procedure with significant morbidity and mortality and alternative treatment is available for those known to have benign stenoses. The aim of this review was to determine whether any of the current diagnostic tests have sufficient sensitivity and specificity to identify patients with benign and malignant bile duct stenoses. A literature search was performed until July 2007 to obtain information from studies published in the previous 10 years. Only studies reporting an appropriate reference test (confirmation of malignancy by biopsy, confirmation of benign nature by histology following surgical excision, or at least 6 months of follow-up for all patients) were included for review. The diagnostic odds ratio was used to measure diagnostic performance. Forty-one references of 34 studies were included in this review. None of the studies used differential verification. Six studies used blinding of assessor. None of the diagnostic tests had sufficient diagnostic accuracy to reliably separate patients with benign from malignant biliary strictures. Differentiating benign from malignant bile strictures is an important aim. There is no trial evidence demonstrating benefit in obtaining a preoperative histological diagnosis of CCA. New methods are required for stricture assessment.