Application of endoscopic ultrasonography in the diagnosis of cholangiocarcinoma / 中华消化外科杂志

Cholangiocarcinoma is the second common tumor in the hepatobiliary system,with clinical features of biliary stricture,difficult early diagnosis and poor prognosis.High-resolution endoscopic ultrasonography can observe closely the bile duct tree and adjacent organs.In this article,authors reviewed the application of endoscopic ultrasonography in the diagnosis of cholangiocarcinoma.

Prospective Comparison of Intraductal Ultrasonography-Guided Transpapillary Biopsy and Conventional Biopsy on Fluoroscopy in Suspected Malignant Biliary Strictures

BACKGROUND/AIMS: In suspected malignant biliary strictures (MBSs), the diagnostic yield of endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling is limited. Transpapillary forceps biopsy (TPB) under intraductal ultrasonography (IDUS) guidance is expected to improve the diagnostic accuracy in patients with indeterminate biliary strictures. We evaluated the usefulness of IDUS-guided TPB in patients with suspected MBS. METHODS: Consecutive patients with suspected MBS were prospectively enrolled in the study. ERCP with IDUS was performed in all patients. Both conventional TPB and IDUS-guided TPB on fluoroscopy were performed in each patient. The primary outcome was the diagnostic accuracy of conventional TPB and IDUS-guided TPB. RESULTS: The technical success rate of IDUS-guided TPB was 97.0% (65/67 patients). Of these 65 patients, the final diagnosis was malignancy in 61 patients (93.8%). On IDUS, the most common finding of IDUS was an intraductal infiltrating lesion in 29 patients (47.5%). The overall diagnostic accuracy was significantly higher using IDUS-guided TPB than that using conventional TPB (90.8% vs 76.9%, p=0.027). According to the subgroup analysis based on the tumor morphology, IDUS-guided TPB had a significantly higher cancer detection rate than conventional TPB for intraductal infiltrating lesions (89.6% vs 65.5%, p=0.028). CONCLUSIONS: IDUS-guided TPB appears to improve the accuracy of histological diagnosis in patients with MBS.

The Role of Endoscopic Biliary Drainage without Sphincterotomy in Gallstone Patients with Cholangitis and Suspected Common Bile Duct Stones Not Detected by Cholangiogram or Intraductal Ultrasonography

BACKGROUND/AIMS: Treatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS). METHODS: EBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events. RESULTS: Among 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days). CONCLUSIONS: EBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS.

Ampullary Adenoma Treated by Endoscopic Double-Snare Retracting Papillectomy

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.

Intraductal Ultrasonography without Radiocontrast Cholangiogram in Patients with Extrahepatic Biliary Disease

BACKGROUND/AIMS: Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases. METHODS: IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively. RESULTS: Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred. CONCLUSIONS: IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.

Role of Balloon-Sheathed Intraductal Ultrasonography for Patients with Extensive Pneumobilia

Intraductal ultrasonography (IDUS) is one of the most useful diagnostic tools for various extrahepatic biliary diseases. However, conventional IDUS has some limitations in providing accurate cross-sectional imaging of the bile duct in patients with extensive pneumobilia. Using a balloon-sheathed catheter, the US system (balloon-sheathed IDUS) can overcome these limitations. Sixteen patients underwent balloon-sheathed IDUS during endoscopic retrograde cholangiography. The balloon-sheathed IDUS was inserted via a transpapillary route when visualization of the bile duct with conventional IDUS was distorted by extensive pneumobilia. The patient group had a mean age of 65.5 years, and 56.3% (9/16) were male. The balloon-sheathed IDUS permitted successful visualization of the bile duct in all patients, regardless of the extent of pneumobilia. Using this system, remnant common bile duct stones were detected in five patients (31.3%), and cholangiocarcinoma was detected in one patient (6.3%). The balloon-sheath IDUS aided in stone sweeping. No significant complications, including bleeding, perforation, or pancreatitis, occurred in any of the patients. The balloon-sheathed catheter US system was useful and safe for biliary IDUS in patients with extensive pneumobilia.

Endoscopic Extraction of Biliary Fascioliasis Diagnosed Using Intraductal Ultrasonography in a Patient with Acute Cholangitis

Fasciola hepatica infection may result in biliary obstruction with or without cholangitis in the chronic biliary phase. Because clinical symptoms and signs of F. hepatica are similar to other biliary diseases that cause bile duct obstruction, such as stones or bile duct malignancies, that are, in fact, more common, this condition may not be suspected and diagnosis may be overlooked and delayed. Patients undergoing endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography for the evaluation of bile duct obstruction may be incidentally detected with the worm, and diagnosis can be confirmed by extraction of the leaf-like trematode from the bile duct. Intraductal ultrasonography (IDUS) can provide high-resolution cross-sectional images of the bile duct, and is useful in evaluating indeterminate biliary diseases. We present a case of biliary fascioliasis that was diagnosed using IDUS and managed endoscopically in a patient with acute cholangitis.

The diagnostic value of ERCP combined with intraductal ultrasonography for bile duct stricture diseases / 中华消化内镜杂志

Objective To study the diagnostic value of endoscopic retrograde cholangiopancreatography (ERCP) combined with intraductal ultrasonography (IDUS) for bile duct stricture diseases.Methods The results of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography,intraductal uhrasonography,bile duct brushing cytology,the liquid-based cytology and the histopathological examination were analyzed retrospectively.The final diagnosis was made based on clinical data,histopathology and follow-up results(≥4 months).Results Twenty-one patients were diagnosed as having malignant biliary diseases,including 9 biliary tract carcinoma,4 duodenal papilla carcinoma,4 pancreatic cancer infiltrated common bile duct,4 cancer of the liver infiltrated common bile duct ; 15 were diagnosed as having benign biliary diseases,including 9 bile duct stones,4 liver fluke disease,lbile duct inflammatory stenosis,1 bile duct stricture caused by external compression.The accuracy rate of the EUS,ERCP,IDUS and ERCP + IDUS in the differential diagnosis of the bile duct stricture disease were 77.8％,88.9％,91.7％ and 94.4％,respectively.The accuracy rates of IDUS,ERCP,ERCP combined with IDUS were significantly higher than that of EUS (P ＜ 0.05).The sensitivity,specificity,positive predictive value and negative predictive value of ERCP combined with IDUS were 95.2％,93.3％,95.2％ and 93.3％ respectively which were higher than those of EUS,ERCP and IDUS.After the bile duct brushing cytology and the liquid-based cytology or histopathological examination,19 patients were diagnosed as having malignant biliary diseases,17 were benign biliary diseases.The sensitivity,specificity and accuracy of the procedures for malignant bile duct stricture disease were 90.5％,100.0％,94.4％ respectively.Conclusion ERCP combined with IDUS can improve the diagnostic accuracy.The diagnostic positive rate will be higher with the help of ERCP,IDUS and targeted brush.

Endosonographic Preoperative Evaluation for Tumors of the Ampulla of Vater Using Endoscopic Ultrasonography and Intraductal Ultrasonography

BACKGROUND/AIMS: In recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy. METHODS: The subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors. RESULTS: The diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging. CONCLUSIONS: EUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

Usefulness of Intraductal Ultrasonography in the Diagnosis of Cholangiocarcinoma and IgG4-Related Sclerosing Cholangitis

The technique of intraductal ultrasonography (IDUS) of the bile duct with a thin-caliber probe and a ropeway system has provided excellent images of the bile duct and periductal structures and is an easy transpapillary approach. In addition, once the guide wire is inserted into the bile duct, IDUS and transpapillary biopsy after endoscopic retrograde cholangiopancreatography can be performed in a single session. Here, we review the usefulness of IDUS in the diagnosis of cholangiocarcinoma and IgG4-related sclerosing cholangitis.

Intraductal ultrasonography in diagnosis of bile duct stones / 中华消化内镜杂志

Objective To investigate the diagnostic value of intraductal ultrasonography (IDUS) for bile duct stones by comparing between magnetic resonance cholangiopancreatography ( MRCP), endoscopic retrograde cholangiography (ERC) and IDUS. Methods ERC was performed in 30 patients with suspected extrahepatic cholelithiotic after MRCP. IDUS was applied through guide wire after ERC, and stones were removed if necessary. Results MRCP detected bile duct stones in 22 cases, misdiagnosed bile duct floc as stones in 2 and missed stones in 2 others. The accuracy, sensitivity and specificity of MRCP in diagnosis of bile duct stone were 86. 7% (26/30), 91. 7% (22/24), and 66. 7% (4/6), respectively. ERC detected bile duct stones in 23 cases, misdiagnosed bile duct air bubble as stones in 2 and missed stones in 1. The accuracy , sensitivity and specificity of MRCP in diagnosis of bile duct stone were 90% (27/30), 92% (23/25) and 66.7% (4/6) , respectively. IDUS detected 24 cases of bile duct stones, 4 bile duct floc and 2 air bubble without any misdiagnosis. The accuracy, sensitivity and specificity of IDUS in diagnosis of bile duct stone were 100%. Conclusion IDUS, safe and reliable, is superior to ERC and MRCP in diagnosis of bile duct stone.

Intraductal ultrasonography for bile duct microlithiasis / 中华消化内镜杂志

Objective To investigate the diagnostic value of intraductal ultrasonography (IDUS) for unconfirmed microlithiasis under endoscopic retrograde cholangiography ( ERC). Methods The data of 22 patients who were definitely diagnosed as having microlithiasis by IDUS and endoscopic sphincterotomy (EST) from July 2007 to September 2009 were retrospectively analyzed. Microlith was defined as choledo-cholith equal to or less than 3 mm in diameter. Using IDUS plus EST findings as golden standard of bile duct microlithiasis, the accuracy of diagnosis and rate of missed diagnosis of transabdominal ultrasonography, magnetic resonance cholangiography (MRC) and ERC were evaluated and compared. Results Diagnosis rates of trans-abdominal ultrasonography, MRC and ERC for extra-hepatic duct microlithiasis were 27. 3% (6/22), 38. 5% (5/13) and 27. 3% (6/22) , respectively. Detection rates of common bile duct dilation by 3 methods were 68. 2% (15/22) , 84. 6% (11/13) and 68. 2% (15/22) , respectively. The microlithiasis in 2 patients, which manifested as repeated acute pancreatitis, were missed by transabdominal ultrasonography , MRC and ERC, and were finally confirmed by IDUS. Conclusion Sensitivity of ERC in diagnosis of extra-hepatic microlithiasis is not superior to that of transabdominal ultrasonography or MRC. IDUS is a technically easy, safe, highly sensitive and accurate procedure, which is helpful in differentiation of etiology of recurrent acute pancreatitis.

Diagnosis value of intraductal ultrasonography for pancreatic diseases / 第二军医大学学报

Objective: To evaluate the value of intraductal ultrasonography (IDUS) in diagnosis of pancreatic diseases. Methods: We retrospectively reviewed the imaging data of 63 patients with pancreatic diseases who underwent IDUS from February 2005 to February 2010. A 20 MHz over-the-guidewire intraductal US catheter probe was used during endoscopic retrograde cholangio- pancreatography(ERCP) for further examination of the pancreas. We also compared the results of CT, magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) and abdominal ultrasonography in diagnosis of pancreatic diseases, so as to further evaluate the value of IDUS in the clinical diagnosis of pancreatic diseases. Results: The accuracies of IDUS in diagnosis of chronic pancreatitis (23 cases), pancreatic cancer (10 cases), intraductal papillary mucinous tumors (IPMT, 25 cases), and pancreatic adenoma (4 cases) were 93. 7% (59/63), 100.0% (63/63), 90.5% (57/63), and 96.8% (61/63), and the Kappa values were 0.854, 1.00, 0.898, and 0.848, respectively. The diagnostic accuracies and Kappa test values of IDUS were better than those of the other four methods. IDUS correctly diagnosed the pancreatic cystadenocarcinoma in one patient before operation. Conclusion: IDUS has a high diagnostic value for pancreatic diseases.

The diagnostic value of intraductal ultrasonography for complex biliary and pancreatic disease / 中华内科杂志

.7%and 88.6%.Conclusion IDUS after ERCP yields higher diagnostic accuracy for complex biliary and pancreatic diseases and it is also more dependable in differentiating benign tissues from malignant ones than ERCP alones

Intraductal ultrasonography in patients with biliary and pancreatic disorders / 中华消化内镜杂志

Objective To evaluate the value of intraduetal ultrasonography (IDUS) in diagnosing biliary and pancreatic disorders. Methods The findings by endoscopic retrograde cholangiopancreatography (ERCP) and IDUS from 19 patients with suspected biliary and pancreatic disorders from July 2006 to August 2007 in our hospital were analyzed retrospectively. Results Of the 19 patients, 17 had obstructive jaundice (including 6 eases of cholangiocarcinoma, 2 pancreatic adenocareinoma, 2 gallbladder carcinoma, 2 chole-docholithiasis with bile duct stricture, 2 autoimmune pancreatitis, 1 papillary adenocarcinoma, 1 papillary adenoma, and 1 sclerosing cholangitis) and 2 intraduetal papillary mueinous tumor (IPMT). The diagnosis was confirmed by surgery and pathological findings in 11 patients. The diagnostic accuracy of ERCP and IDUS was 73. 7% (14/19) and 84. 2% (16/19), respectively, and that of ERCP combined with IDUS was 89. 5% (17/19). The sensitivity and specificity of ERCP to differentiate benign bile duct strictures from ma-lignant ones were 100. 0% (11/11) and 83.3% (5/6), respectively; and those of IDUS were 100. 0%(11/11) and 100. 0% (6/6), respectively. The sensitivity and specificity of ERCP in diagnosing cholan-gioeareinoma were 83.3% (5/6) and 60% (3/5), respectively; and those of IDUS were 100. 0% (6/6) and 40. 0% (2/5), respectively. Conclusion Combination of ERCP with IDUS can improve the diagnostic accuracy of pancreaticobiliary disorders. Additionally, IDUS shows higher sensitivity and specificity in differ-entiation between benign and malignant bile duct strictures, but it is still difficult to identify the etiologic factors of malignant bile duet strictures by IDUS.

Intraductal Papillary Mucinous Neoplasm of the Pancreas: The Role of Intraductal Ultrasonography in Selection of Resection Method of Pancreas / 대한소화기내시경학회지

BACKGROUND/AIMS: The treatment of choice of intraductal papillary mucinous neoplasm (IPMN) is partial pancreatic resection with complete excision of this potentially malignant lesion, thus preserving sufficient pancreatic tissue to ensure endocrine and exocrine functions. This strategy, however, requires a reliable preoperative assessment of the highly variable extension of IPMN. We performed this study to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN and selecting the resection methods of pancreas. METHODS: A preoperative assessment of IPMN by IDUS was performed in 12 patients who underwent a surgical resection of IPMN. According to the preoperative localization of IPMN by IDUS, various types of limited pancreatic resections were planned. The histologic examination of the frozen section of the pancreatic cut surface was performed in all patient. In the cases of tumor involvement as cut surface margin, a modification of the planned pancreatic resection was done. RESULTS: Technical success was achieved in all 12 cases (100%). There were positive tumor margin of cut surfaces in 2 patients. Of 10 cases whose frozen tissue evaluation of the pancreatic cut surface had been negative at first, one patieat has turned out to be margin positive in permanent section examination, finally. Overall accuracy of IDUS in predicting the continuous extension of IPMN was 75%. CONCLUSIONS: IDUS is a reliable diagnostic modality to guide the resection extent of the pancreas in patients with IPMN.

The Role of Intraductal Ultrasonography on the Detection of Small Remnant Stones and Their Differentiation from Air-Bubbles, after Endoscopic Papillary Balloon Dilatation / 대한소화기내시경학회지

BACKGROUND AND AIMS: A cholangiogram, immediately taken after bile duct stone removal, does not always provide adequate information about the presence of fragmented small stones in the bile duct, due to a large amount of bowel gas around the commom bile duct (CBD) or air-bubbles in the bile duct. We performed this study to evaluate the clinical usefulness of intraductal ultrasonography (IDUS) on the detection of small remnant stones after endoscopic papillary balloon dilatation (EPBD). METHODS: Among the 42 patients treated with EPBD for the removal of CBD stones, 19 patients who had undergone ESWL or mechanical lithotripsy with basket, were evaluated by IDUS for the detection of remnant bile duct stones. RESULTS: 17 out of 19 (89.5%) patients were successfully performed IDUS. Among the 17 patients, 13 showed no definite stones on cholangiogram, but CBD stones were detected using IDUS in 4 patients (30.7%). Among the 4 whose cases were difficult to differentiate air-bubbles from stones on a cholangiogram, 3 patients were diagnosed as having air-bubbles and 1 patient was diagnosed as having stones, through IDUS. During the process of conducting IDUS 19 times, one ultrasonic miniature probe was damaged. CONCLUSIONS: IDUS is very effective in detecting remnant small bile duct stones that are occasionally undetected on cholangiogram, and in differentiating stones from air-bubbles just after the removal of stones using EPBD. More efforts, however, are needed to improve the durability of the ultrasonic miniature probe.