New technologies for indeterminate biliary strictures.

Abstract

An early and accurate diagnosis of biliary strictures yields optimal patient outcomes; however, endoscopic retrograde cholangiopancreatography (ERCP) with cytobrush/biopsy forceps has low sensitivity with a high number of false negatives. Various attempts to improve the accuracy of diagnosing indeterminate biliary strictures though ERCP-guided specimen acquisition have been proposed, such as with the use of fluorescence in situ hybridization, an endoscopic scraper, and the wire-grasping method, with modest to large improvements in sensitivity. Direct visualization of the biliary tree during peroral cholangioscopy has shown high sensitivity and specificity for the differentiation of neoplastic and non-neoplastic biliary lesions; however, there is no consensus on the visual characteristics of neoplastic lesions and moderate agreement between observers. Peroral cholangioscopy system (POCS)-guided specimen acquisition using forceps has shown inferior sensitivity compared to the visual characteristics; however, the specificity remains high. Optimal specimen processing with onsite evaluations and touch imprint cytology have been shown to improve the sensitivity and accurately diagnose nearly 90% of patients. In vivo evaluations of biliary strictures with probe-based confocal laser endomicroscopy have demonstrated high sensitivity with modest specificity for malignant biliary strictures. Optical computed tomography described reproductible criteria for malignancy detection in biliary strictures, increasing the sensitivity during ERCP evaluations. Differentiating benign causes from malignant causes of biliary strictures is a challenging task in clinical practice, with various concerns that still need to be addressed. Efforts should be made to define each diagnostic method's role in the evaluation of indeterminate biliary strictures.