Postoperative biopsy of the common bile duct via the T-tube tract

Percutaneous transhepatic use of rigid bronchial forceps as bailout in difficult biliary stent retrieval

Endoscopic retrieval of embedded, proximally migrated, or fractured plastic biliary stents may be technically challenging and sometimes unsuccessful. Percutaneous transhepatic techniques have previously been described to assist in such challenging cases. Here in, we describe a difficult case in which all commonly described endoscopic and percutaneous techniques failed to retrieve a proximally migrated, fractured, and looped plastic biliary stent. We finally successfully retrieved the plastic forceps after off-label utilization of rigid bronchial forceps via a percutaneous transhepatic approach. We describe the technique utilized in detail and this appears to be the first description of this off-label use in this challenging scenario.

Cholangiopancreatoscopy: a comprehensive review

Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.

Biliary ductal shave biopsy with use of the Simpson atherectomy catheter

PURPOSE

The authors performed percutaneous biliary ductal shave biopsy through an existing transhepatic biliary drainage tract with use of the Simpson atherectomy catheter. The technical feasibility, sensitivity, and complications of this endoluminal biopsy method were studied when used for diagnosis of biliary ductal and pancreatic neoplasm.

PATIENTS AND METHODS

Nineteen bile duct shave biopsies were performed in 18 patients with symptomatic biliary obstruction by using a 9-F Simpson directional atherectomy catheter. Seven of the 18 patients underwent nine negative percutaneous needle biopsies prior to undergoing percutaneous biliary drainage. Results of previous transcatheter brush biopsies performed through the transhepatic tract were negative in all patients.

RESULTS

A histologic diagnosis was obtained in 15 of the 19 procedures (sensitivity, 0.79) and included cholangiocarcinoma (n = 7), pancreatic carcinoma (n = 5), metastatic carcinoma (n = 2), and primary sclerosing cholangitis (n = 1). Two complications occurred in the 19 procedures (10.5%), both transient but significant hemorrhage, one of which necessitated transfusion.

CONCLUSIONS

Percutaneous biliary ductal shave biopsy with the Simpson atherectomy catheter can be performed successfully through the transhepatic approach and is a sensitive endoluminal biopsy technique, particularly in patients with tumors of the biliary tree that are not diagnosed by means of percutaneous needle biopsy or endoscopic methods. Disadvantages of this method include the high cost of the device and risk of hemorrhage. Atherectomy shave biopsy should be used cautiously and only after more conventional biopsy methods have been employed.

Diagnostic value of cytology for biliary stricture

Over the past 20 years, bile aspiration at endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography has been developed for cytological diagnosis of biliary tract stricture. This safe and specific test has allowed a diagnosis to be reached before or without operation in about one-third of malignancies of the pancreas or biliary tree. The recent development of biliary brush cytology has produced better results. An endobiliary biopsy forceps is now available that may allow safe sampling of lesions causing extrinsic compression of the biliary tract. An endobiliary aspiration cytology needle has been produced that may permit non-ulcerating lesions to be diagnosed. A safe alternative to endobiliary methods is percutaneous fine-needle aspiration cytology; this yields a diagnosis in about half of patients presenting with obstructive jaundice and an imaged mass lesion.

Fine needle aspiration biopsy in malignant obstructive jaundice

Percutaneous cytodiagnosis of malignancy in patients with biliary tract obstruction is often useful in planning subsequent therapy. Of 121 patients presenting for percutaneous transhepatic cholangiography and biliary drainage, 45 had fine needle aspiration biopsies. Forty-one patients had malignant obstruction of the biliary tree, while benign disease was present in 4 patients. Neoplasia was diagnosed in 12 of 13 patients with bile duct carcinoma, 16 of 22 patients with pancreatic cancer, and 3 of 6 patients with other malignancies. Radiologic biopsy sensitivity was only slightly inferior to surgical biopsy sensitivity in the same patient population. A scheme for biliary cytodiagnosis is presented, which uses a percutaneous approach for patients with suspected pancreatic carcinoma and a transcatheter approach for patients with suspected bile duct carcinoma. The utility of this procedure and the low complication rate are stressed.