Fluoroscopy-guided shaped endobiliary biopsy at endoscopic retrograde cholangiography can accurately diagnose biliary neoplasia: Results from a large cohort

Background and study aims The sensitivity of using standard endobiliary forceps biopsy to diagnose neoplastic biliary lesions remains low. We have developed a unique biopsy approach, termed fluoroscopy-guided, shaped endobiliary biopsy (FSEB), in which the biopsy forceps are modified to improve diagnostic yield. In this study, we evaluate the diagnostic characteristics of FSEB for endobiliary lesions at endoscopic retrograde cholangiography (ERC). Patients and methods Consecutive patients undergoing FSEB between 1/2001 and 12/2014 were retrospectively enrolled. The identification of neoplastic lesions with FSEB, was the primary endpoint. The gold standard of neoplasia was histopathology, cytology or surgical histopathology. The benign cases were followed up for one year. Results A total of 204 patients undergoing 250 biopsy sessions by FSEB were analyzed. Per-patient analysis was performed and FSEB showed 81.1 % sensitivity and 88.2 % accuracy. FSEB detection of proximal biliary lesions was more sensitive (91.1 % vs 73.2 %, P < 0.01) and accurate (94.9 % vs 82.2 %, P < 0.01) compared to distal lesions. No complications from FSEB were reported. Conclusions FSEB shows high accuracy for diagnosis of neoplasia in biliary strictures, especially for proximal lesions. Future prospective randomized controlled studies are merited to further validate the role of FSEB as the first-line sampling tool for evaluation of biliary neoplasm.

Efficacy of Pre-Operative Portal Vein Embolization of Biliary Neoplasm before Major Hepatectomy

Background: Malignant biliary neoplasm is relatively common in Southeast Asia. Portal vein embolization (PVE) is a preoperative procedure to induce hypertrophy of future liver remnants. PVE can decrease the rate of post hepatectomy liver failure (PHLF). Objective: To evaluate the efficacy of preoperative PVE of biliary neoplasm patient prior to major hepatic resection. Materials and Methods: The study included 53 patients with biliary neoplasm planned for major hepatic resection and that underwent PVE between July 2013 and August 2019. Liver volumetry before and after PVE was analyzed. Operative procedure and post hepatectomy outcome were evaluated. Results: Peri-hilar type cholangiocarcinoma, Bismuth-Corlette classification IIIA was the most frequent tumor. The technical success rate of PVE is 100%. Future liver remnant (FLR) volume after PVE was significantly increased from 379.1 to 460 mL (p<0.001). Post PVE FLR over total functional liver volume (TFLV) ratio was significantly increased from 27.8% to 34.6%(p<0.001). The mean kinetic growth rate (KGR) per week was 7.1%. Twenty-four patients underwent subsequent hepatectomy, and two patients presented with PHLF. Twenty-nine patients (54.7%) did not undergo subsequent hepatectomy as planned due to advanced disease with 21 (72.4%) because of locally advanced cancer, peritoneal carcinomatosis, and N2 lymph nodes metastasis), four (13.8%) that refused surgical treatment, and three (10.3%) that were loss to follow-up. Conclusion: Preoperative PVE before major hepatic resection in biliary neoplasm patients is an effective procedure to increase FLR, FLR/TFLV ratio, and provide good KGR. However, more than half of post preoperative PVE could not be obtained hepatectomy because of the progression to advanced stage of disease. Keywords: Biliary neoplasm, Portal vein embolization, Future liver remnant, Major hepatic resection, Post hepatectomy liver failure

Association between gallbladder agenesis and choledochal cyst: cause or coincidence?

This case report describes an extremely rare association between gallbladder agenesis and choledochal cyst (CC). A 9-year-old girl presented with recurrent abdominal pain in the right upper quadrant. Radiological studies revealed a CC type IVa and an agenesis of gallbladder and cystic duct. Due to the possibility of biliary neoplasm, the patient underwent cyst resection and hepaticoduodenostomy. Histopathological findings showed inflamed fibrous tissue covered by biliary epithelium with no evidence of malignancy.

Haemostatic radiation therapy for a bleeding intraductal papillary neoplasm of the biliary tree

Haemostatic radiation was effectively used as a novel rescue therapy in a 60-year-old man who presented with recurrent melaena refractory to all conventional medical and surgical measures. He needed multiple transfusions and was diagnosed to be bleeding from an intraductal papillary biliary neoplasm which was not amenable to surgical resection in view of the background liver disease. He received conventional radiation therapy (RT) of a dose of 3 Gy per fraction for 3 consecutive days after which he stabilised. After cessation of the RT, he did not require transfusion for the next 2 months. His quality of life improved and it gave us time to evaluate for other definitive measures.