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

BackgroundBiliary tract malignancies can be assessed with either EUS or SpyGlass cholangioscopy (SGC).ObjectiveTo evaluate the impact of EUS and guided biopsy before considering SGC in patients who had biliary strictures with negative ductal brushing.DesignProspective, observational study.SettingTertiary level referral hospital.PatientsForty consecutive patients with biliary strictures.InterventionEUS 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 MeasurementsTissue diagnosis, technical success, adverse events, and clinical outcomes.ResultsOn 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.LimitationsRelatively small sample size.ConclusionsEUS 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.