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Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture

Angsuwatcharakon P 1 , Kulpatcharapong S 2 , Moon JH 3 , Ramchandani M 4 , Lau J 5 , Isayama H 6 Show all authors , Seo DW 7 , Maydeo A 8 , Wang HP 9 , Nakai Y 10 , Ratanachu-Ek T 11 , Bapaye A 12 , Hu B 13 , Devereaux B 14 , Ponnudurai R 15 , Khor C 16 , Kongkam P 2 , Pausawasdi N 17 , Ridtitid W 2 , Piyachaturawat P 2 , Khanh PC 18 , Dy F 19 , Rerknimitr R 20

Affiliations 

  • 1 Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  • 2 Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  • 3 Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Seoul, South Korea
  • 4 Asian Institute of Gastroenterology, Hyderabad, India
  • 5 Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
  • 6 Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
  • 7 Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
  • 8 Baldota Institute of Digestive Sciences, Global Gleneagles Hospital, Mumbai, India
  • 9 Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
  • 10 Departments of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
  • 11 Department of Surgery, Rajavithi Hospital, Bangkok, Thailand
  • 12 Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital & Research Center, India
  • 13 Department of Gastroenterology, Eastern Hepatobiliary Hospital, Naval Medical University, Shanghai, China
  • 14 University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
  • 15 Prince Court Medical Center, Kuala Lumpur, Malaysia
  • 16 Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore
  • 17 Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 18 Department of Endoscopy, University Medical Center, Ho Chi Minh City, Viet Nam
  • 19 Section of Gastroenterology, Department of Internal Medicine, Faculty of Medicine and Surgery, University of Santo Tomas Hospital, Manila, Philippines
  • 20 Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Electronic address: ercp@live.com
HPB (Oxford), 2022 Jan;24(1):17-29.
PMID: 34172378 DOI: 10.1016/j.hpb.2021.05.005

Abstract

BACKGROUND: Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures.

METHODS: The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement.

RESULTS: Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties.

CONCLUSION: Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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