False-negative factors of percutaneous transluminal clamp biopsy for biliary stricture: 194 case analyses from a single center

doi:10.21203/rs.3.rs-2071024/v1

Download PDF

Research Article

False-negative factors of percutaneous transluminal clamp biopsy for biliary stricture: 194 case analyses from a single center

https://doi.org/10.21203/rs.3.rs-2071024/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective: To study the predictive factors of false negatives in the diagnosis of biliary stricture (BS) by percutaneous transluminal clamp biopsy (PTCB).

Method: From January 2016 to January 2021, 194 patients with a high suspicion of malignant tumors due to BS underwent PTCB during biliary drainage at our department. The final diagnosis was confirmed by postoperative pathology, other tissue or cell evidence, or medical imaging follow-up. Univariate and multivariate regression analyses were performed on the pathological results, summarizing the independent risk factors for false-negative value (FNV) to help further clinical diagnosis and treatment.

Results: Of the 194 cases, 144 and 18 cases were diagnosed as malignant and benign BS, respectively. The sensitivity, specificity, false-positive value and FNV of PTCB were 81.8%, 100%, 0% and 18.2%, respectively. Multivariate analysis showed that noncholangiocarcinoma PS was an independent risk factor for FNV of PTCB [odds ratio 7.5, (95% CI 1.74-32.6), p<0.01].

Conclusion PTCB is an effective minimally invasive interventional technique for BS diagnosis. Noncholangiocarcinoma BS is an independent risk factor for FNV.

Cholangiography

cholangiocarcinoma

clamp biopsy

interventional angiography

biliary obstruction

Biliary stricture (BS), with the main clinical manifestations of fatty diarrhea, skin yellowing, bleeding tendency, and pancreatitis, is caused by intrahepatic or extrahepatic malignant or benign diseases, which will result in high biliary pressure above the BS^[1–2]. When the bile duct pressure increases to a certain extent, direct bilirubin will reversely flow into the blood system, ultimately resulting in pathophysiological changes in multiple organs, and intestinal bacteria can easily invade the biliary system and develop into bacteremia and toxemia, leading to multiple organ failure^[3]. There are many reasons for mechanical BS, such as malignant tumors, biliary stones, inflammation, and postoperative anastomotic stenosis. In the past few decades, great progress has been made in BS imaging, such as intraluminal ultrasound, MRCP and enhanced CT scanning^[4–5]. These noninvasive imaging systems can quickly obtain the relevant BS anatomical information, but how to complete pathological biopsy of the narrow BS is the most critical information for the final diagnosis.

To obtain intrabiliary sampling, there are currently three methods: percutaneous biopsy/fine needle aspiration under CT/US guidance^[6], endoscopic retrograde cholangiopancreatography (ERCP)-guided intrabiliary clamp biopsy/brush inspection^[7], and percutaneous transluminal clamp biopsy (PTCB)/brush inspection under fluoroscopy guidance^[8]. Percutaneous biopsy has relatively high technical operation requirements and a high risk of puncture-relevant bleeding and bile extravasation, especially for very small tumors. Moreover, the biliary drainage procedure cannot be performed simultaneously. ERCP-guided biopsy is simple and convenient and is suitable for extrahepatic low BS; however, ERCP-guided biopsy for hilar BS has relatively low technical success (35.0-53.4% from previous studies^[9–10]). Moreover, ERCP requiring general procedures is more expensive than other methods. PTCB under local anesthesia is suitable for all positions of the bile duct, and bliliary drainage can be completed simultaneously. Science Elyaderani first reported PTCB in 1980^[11], and increasing clinical data from the US, Europe and China have shown that it is an efficient and safe technology. A 2022 meta-analysis from Jeon TY et al^[12] analyzed 1762 PTCB procedures from 14 studies and found that the sensitivity and specificity were 80% and 100%, respectively. However, few studies have focused on the influencing factors of false-negative value (FNV) in large sample analyses. The purpose of this study was to evaluate the diagnostic accuracy of PTCB among 194 patients with BS and to determine the predictive factors related to FNV.

The Ethics Committee of the First Affiliated Hospital of Zhengzhou University agreed to this retrospective study. From January 2016 to January 2021, 248 patients with BS underwent PTCB combined with biliary drainage at our department. Fifty-four cases were excluded because they did not meet the inclusion criteria, and 194 cases were included. The inclusion criteria for the study were as follows: 1) age range 18–80 years; 2) the direct bilirubin (DB) was significantly higher than the normal value by more than 3 times; 3) the clinical manifestations were typical BS, such as yellow staining of skin and mucosa, cholangitis and fever; 4) Eastern Cooperative Oncology Group (ECOG) score of 0–2; 5) complete clinical data and more than 6 months follow-up time span; 6) platelet count > 50×10⁹/L and prothrombin time (PT) ≤ 25 s. The exclusion criteria were as follows: 1) uncontrollable ascites; 2) severe coagulation dysfunction; 3) ECOG score of 3–4; 4) severe cardiopulmonary dysfunction; and 5) incomplete data and follow-up time less than 6 months. All patients [male:female = 101:93, mean age (61.0 ± 9.3) years old] presented with clinical symptoms of BS, and preoperative enhanced CT/MR showed slight to severe intrahepatic bile duct dilatation. Preoperative total bilirubin (TB), direct bilirubin (DB) and alanine aminotransferase (ALT) were 169.4 ± 58.5 µmol/L (range: 93.6-342.1), 135.0 ± 50.4 µmol/L (range: 76.4-277.9), and 91.9 ± 40.6 U/L (range: 24.4-198.6), respectively. All procedures were performed by the three interventional radiologists at our center (Jiao D, Ren J and Han X, who had PTCB experience of 11, 15 and 25 years). The following information was recorded from the patient electronic records: age, sex, operator, PTCB approach (left or right approach), BS site, BS length, imaging findings (eccentricity, rat tail, truncation and filling defect sign), maximum lesion diameter at the BS area, and final pathological results.

Procedures

Blood routine, liver function, kidney function, electrolyte, coagulation function, electrocardiogram and tumor markers were examined before operation, and plain scan plus enhanced upper abdomen CT or MR were performed to understand the dilatation of bile duct, the location of BS, tumor size, and the planned puncture path.

The patient laid supine on the DSA (artis zeego, Siemens, Germany) examination bed, and a mixed solution of dizosin (10 mg) and dexmedetomidine hydrochloride (400 µg) was injected intravenously to obtain a sastifactory analgesic state. After routine disinfection and towel laying at the right costal area, local anesthesia was performed with 2% lidocaine (5 ml) at the skin puncture point, which was determined by preoperative enhanced CT/MR or introoperative US. A 21G Chiba needle (Cook, United States) was used to puncture the dilated bile duct, a platinum micro wire (0.018 inch×30 cm) was introduced to the biliary system after cholangiography (320 mg iodine/100 mL, Hengrui, Jiangsu, China, diluted 50% for use), a 6F dialator was introduced along the micro hydrophilic membrane wire, and another cholangiography was performed to confirm the BS length and extent. A 0.035-inch wire and 5F KMP catheter were exchanged with a 6F dialator, the BS part was opened with the cooperation of the guide wire and catheter, and the catheter finally entered the duodenum. Another 0.035 inch strength guide wire (145 cm in length, Radiofocus M, Terumo, Tokyo, Japan) was introduced to establish the skin-bile duct-duodenum approach. Along the guide wire, a 9F short sheath (23 cm long, cordis, USA) was introduced, whose end was located above the BS segment. After confirmation by angiography, the biopsy forceps (6.0 mm in diameter, Nanjing microport, China) were introduced to the BS part through a 9F sheath, the biopsy forceps were opened and pushed forward for 5–10 mm, and the biopsy forceps were then tightened to clamp the tissue. The biopsy forceps were withdrawn, and the tissue was fixed in 4% formaldehyde solution. PTCB was repeated 3–6 times until the sample size met the needs of clinical diagnosis (assessed by Shenglei Li pathologists, who had more than 15 years of experience). 8.5 F internal and external drainage tubes (Cook, USA) were introduced after biopsy, and the lateral drainage holes were allowed to cross the BS area. Liver protective and anti-infective drugs were given after the operation for 3–7 days.

Definition

Technical success was defined as successfully obtaining enough biliary tissue to complete the pathology examination. The final diagnosis was confirmed by surgery, other histology or cytology (i.e., percutaneous fine needle aspiration biopsy and bile cytology). If there was no histology or cytology, the patient was followed up for at least 6 months, and the patient was diagnosed as malignant if the size of the lesions was significantly increased and/or metastasis was found by imaging examination. If there was no obvious disease progression in clinical manifestations or imaging findings, it was diagnosed as benign. Diagnostic indicators included sensitivity, specificity, FNV and false-positive value (FPV). PTCB-related complications were defined according to the international Society of Interventional Radiology (SIR) operating guidelines^[13]. In view of multifactorial analysis, malignant tumors are divided into two groups according to their origin: cholangiocarcinoma (malignant tumors originating from the bile duct epithelium) and noncholangiocarcinoma tumors (malignant tumors other than cholangiocarcinoma, such as pancreatic cancer, gallbladder cancer, hepatocellular carcinoma, duodenal cancer, and hilar metastatic lymph nodes).

Statistical analysis

Continuous data are expressed as the means ± standard deviation, and a t test was used to compare the indices of alanine aminotransferase, total bilirubin and direct bilirubin before and 1 week after drainage. Univariate and multivariate logistic regression analyses were used to identify independent prognostic factors associated with FNV. Statistical analysis was performed using SPSS software version 21.0 (IBM, Chicago, IL). A p value < 0.05 was considered to indicate a significant difference.

All patients obtained a sufficient sample for diagnosis, and the technical success rate was 100%. The right and left puncture approaches were performed in 164 and 30 cases, respectively. There were 12, 54, 89 and 39 cases of BS involving the intrahepatobiliary duct (IHD), hilar duct, middle extrahepatic bile duct and distal extrahepatic bile duct, respectively. The average number of biopsies was 4.0 ± 1.3 times/case. The final diagnoses were 172 cases of malignant tumors, including 119 cases of cholangiocarcinoma and 53 cases of noncholangiocarcinoma tumors [24 cases of pancreatic cancer, 9 cases of gallbladder cancer and 20 cases of metastatic cancers (gastric cancer, liver cancer, lymphoma, intestinal cancer metastasis)]. The final diagnosis standards of malignant diseases were made by surgical pathological examination (n = 29), fine needle aspiration biopsy (n = 23), and cytological evidence of bile and ascites (n = 11). The imaging indices of regular follow-up showed that the local lesions were enlarged or metastasized (n = 109). Eighteen cases were diagnosed as benign stenosis, of which 5 were confirmed by surgical pathology. In the absence of surgical pathology results, 13 benign diseases were based on a medical follow-up of at least 6 months, and neither the clinical course nor imaging examination showed evidence of disease progression (Table 1).

Table 1

Results of PTCB and final diagnosis
PTCB	Final diagnosis		Total
PTCB	Positive result	Negative result	Total
Positive result	144	0	144
Negative result	32	18	50
Total	176	18	194

Thirty-two cases were identified as false-negative results, including chronic inflammation (n = 21) and fibrous connective tissue (n = 11). Among them, 8 cases obtained malignant pathological evidence due to secondary PTCB, and the remaining 24 were diagnosed as false-negative by medical imaging follow-up. The results of this study showed that the sensitivity, specificity, false-positive value and FNV of PTCB were 81.8%, 100%, 0% and 18.2%, respectively. The overall diagnostic accuracy of PTCB for all biliary strictures was 83.5% (162 of 194 cases were confirmed) (Table 2). TB decreased from 169.4 ± 58.5 µmol/L before drainage to 82.4 ± 32.2 µmol/L at 1 week, which was a significant difference (t = 9.3, p = 0.00). DB decreased from 135.0 ± 50.4 µmol/L before drainage to 61.3 ± 22.5 µmol/L at 1 week, which was a significant difference (t = 9.5, p = 0.00). Alanine aminotransferase decreased from 91.9 ± 40.6 U/L before drainage to 55.3 ± 17.8 U/L at 1 week, which was a significant difference (t = 5.1, P = 0.00).

Table 2

Baseline characteristics and univariate risk factor analysis of 194 patients with false-negative results
Influence factor	All patients (n = 194)	False-negative (n = 32)	Univariate analysis	P value
Influence factor	All patients (n = 194)	False-negative (n = 32)	OR(95% CI)	P value
Age(year)	61 ± 9.29	63 ± 9.09	1.02 (0.98–1.06)	0.36
Male(female)	101(93)	16 (16)	1.10 (0.52–2.36)	0.80
Operator
Operator 1	83	12	1
Operator 2	80	5	1.37 (0.60–3.13)	0.46
Operator 3	31	15	1.14 (0.37–3.54)	0.82
Puncture approach
Right side	164	26	1
Left side	30	6	1.33 (0.50–3.56)	0.58
Forcep times	4.0 ± 1.28	4.0 ± 1.10	1.12 (0.84–1.50)	0.45
BS part
Intrahepatic BS	12	8	1
Hilar BS	54	2	0.87 (0.16–4.73)	0.87
MEBS	89	15	1.01(0.20–5.10)	0.99
DEBS	39	7	1.09(0.20–6.14)	0.92
The length of BS	2.9 ± 0.72	2.7 ± 0.80	1.30(0.77–2.18)	0.33
Imaging features
Eccentricity sigh	69	5	1
Truncation sign	48	7	0.42 (0.14–1.24)	0.12
Rat tail sign	55	15	0.53 (0.20–1.40)	0.20
Filling defect sign	22	5	1.06 (0.34–3.34)	0.92
Max.Diameter at BS part	2.5 ± 1.38	3.3 ± 1.28	1.56(1.21–2.01)	0.00*
Tumor type
Cholangiocarcinoma	119	0	1
Noncholangiocarcinoma tumors	53	13	4.56 (2.04–10.19)	0.00*
Benign BS	22	19	0.00	1.0
OR: Odds ratio; BS: Biliary stricture; MEBS: Middle extrahepatic biliary stricture; DEBS: Distal extrahepatic biliary stricture; * p < 0.05

Thirteen cases (6.7%) experienced early complications, including 9 cases of minor biliary bleeding (total volume ≤ 10 ml), all of which were transient biliary bleeding, which gradually decreased and disappeared within 2–72 hours. Four patients experienced acute pancreatitis (abdominal pain with continuous elevation of blood amylase), and those patients recovered after 3–7 days of symptomatic treatment, such as fasting, acid inhibition, and reduction of pancreatic enzyme secretion. No bile duct perforation, hepatic artery pseudoaneurysm, or severe bleeding was found in the study.

Univariate logistic analysis was used to determine the predictive factors related to FPN, including age, sex, operator, biopsy approach (right or left approach), number of biopsies, location of obstruction, length of obstruction, imaging findings, maximum diameter of tumor, and primary tumor type (cholangiocarcinoma and noncholangiocarcinoma tumor). Univariate logistic analysis showed that FPV was related to the maximum diameter of the bile duct tumor and the type of primary tumor (Table 2). Multivariate logistic regression analysis showed that only noncholangiocarcinoma tumors [odds ratio 7.5, 95% CI (1.7–32.6), P = 0.007] were independent prognostic factors for FPN (Table 3).

Table 3

Multivariate analysis of false-negative results
Influence factor	Multivariate analysis	P value
Influence factor	OR(95% CI)	P value
Max.Diameter at BS part	0.835 (0.510–1.367)	0.47
Imaging features
Eccentricity sigh	1
Truncation sign	0.347 (0.109–1.104)	0.07
Rat tail sign	0.503 (0.178–1.421)	0.20
Filling defect sign	1.086 (0.309–3.817)	0.90
Tumor type
Cholangiocarcinoma	1
Noncholangiocarcinoma tumors	7.501 (1.724–32.630)	0.01*
Benign	0	1.00
OR: Odds ratio; BS: Biliary stricture; * p < 0.05

BS caused by malignant tumors in and around the bile duct has no specific clinical manifestation at an early stage, and more than 70% of cases have lost the opportunity for surgery at diagnosis^[14]. A recent meta-analysis showed that the overall survival for cholangiocarcinoma was less than 15% with extremely poor outcomes^[15]. Cholangiocarcinomas are small when BS occurs, and US, CT or MR can only indirectly infer the nature of the lesions and cannot determine the histopathological diagnosis. Since 2000, our center has developed such technology: the biliary obstruction was opened by a catheter and guidewire during PTCD; then, the skin-bile duct-duodenal approach was established by a strengthen guidewire, and a 9F short sheath instead of endoscopy was advanced to establish a PTCB channel to complete the forceps biopsy^[16]. This retrospective study showed that the sensitivity and specificity were 81.8% and 100%, respectively, which was equivalent to the diagnosis and treatment efficiency reported by other centers (70–93%)^[17–20] and higher than the results of simple cell brush examination (35%- 60%)^[21–23]. The reason may be that PTCB can obtain more deep-level tissue structure than surface tissue from brush examination(Fig. 1). Moreover, the internal environment of cholangiocarcinoma is rich in fibrous connective tissue, and it is difficult to obtain enough cytological evidence by brush examination. ERCP-guided biopsy of intrahepatic obstruction is more suitable for low-level obstruction of the bile duct, and the diagnostic efficiency is 54%-82%^[24–26]. Furthermore, hilar and introhepatic BS is still technologically difficult for inexperienced doctors. More importantly, ERCP requires general anesthesia, which increases the surgical cost, while PTCB can be performed under local anesthesia, which is more suitable for elderly patients with cardiopulmonary dysfunction. It has been reported that intraductal ultrasound (IDU)-assisted ERCP-guided biopsy can improve the diagnostic efficiency^[27], but IDU is expensive, and the majority of hospitals do not have such equipment in China. Therefore, regardless of the requirements for subjectivity and objectivity, PTCB has a wider range of indications and a higher cost-effective diagnosis. Theoretically, the risk of intraluminal biopsy of the bile duct wall includes damage to the blood vessels in the adjacent Gleason system or bile leakage. Our study found no such serious complications, which further explained the safety of this technology.

In this study, imaging features under fluoroscopy were included in the analysis of the FNV of PTCB for the first time, which is a major characteristic of this study(Fig. 2). The rat tail, truncation, filling defect, and eccentricity sign were 28.4%, 24.7%, 11.3% and 35.6%, respectively, but there was no significant difference using univariate and multivariate multifactor analyses. It is considered that: (1) One sign, such as truncation sign, can have multiple causes, including cholangiocarcinoma, metastatic cancer, pancreatic cancer or benign lesions, and so can other signs. (2) The same disease can have multiple signs. For example, cholangiocarcinoma can show centripetal or eccentric stenosis and can also show truncation signs or mouse tail signs. (3) The same BS part can have multiple diseases, the hilar part can be cholangiocarcinoma, liver cancer or metastatic cancer, and so can other sites. (4) The signs are not typical. Metastatic and pancreatic cancers can directly compress and invade the bile duct to cause BS; gallbladder cancer can have direct invasion, lymph node metastasis and intraluminal dissemination of the bile duct to cause BS; and gastrointestinal tumors can metastasize to the hilar or hepatoduodenal ligament to cause lymph node enlargement and compression or infiltration of the bile duct to cause BS. Theoretically, there should be obvious signs of pushing and displacement of the bile duct wall. However, in practice, this sign is very rare, mainly because these noncholangiocarcinoma tumors still have the characteristics of infiltrative growth. Most of them directly invade the surrounding tissue space, lymphatic or blood vessels, infiltrating and destroying the bile duct wall and its surrounding tissue structure.

Univariate analysis showed that the FNV was related to tumor size, but multivariate analysis showed no significant difference. It is not difficult to understand that PTCB is different from percutaneous puncture and cutting biopsy. The sampling site of the intraluminal PTCB is the most serious site of the BS lumen, which indicates abundant tumor-infiltrating tissue. Sato et al. ^[28] demonstrated that the biopsy specimen was only taken from the superficial part of the mucosa and fibromuscular layer of the bile duct. The space of the bile duct was small, and the malignant proliferation of the bile duct epithelium led to local cancer cell aggregation. Therefore, more cancerous tissues could be obtained by clamping the BS area. As a result, PTCB is less helpful in detecting exogenous tumors or deep tumors in the bile duct wall. A study from Terasaki et al. demonstrated that the results of PTCB for bile duct obstruction caused by metastatic disease compression largely depend on the depth and degree of invasion of the external tumor to the bile duct wall ^[29].

Park et al.^[30] analyzed the data of 271 cases of bile duct PTCB and showed that, in addition to the tumor type, the lesions in the periampullary segment of the common bile duct were also independent risk factors for FNV. They further explained that the clamp is always clamped to the sidewall of the common bile duct rather than the BS because the bile duct in the ampullary region was angled. However, our study showed that tumor location was not a significant factor. This may be related to the use of instruments and biopsy methods: (1) The 9F sheath was bent by 60% with external force before PTCB to adapt to the hilar curvature. (2) The sheath used in this center is thicker than that used in other centers and can therefore accommodate large biopsy forceps and take sufficient samples. Wu Z et al.^[31] showed that large biopsy forceps can obtain more samples (6.0 mm vs. 4.5 mm) to improve the accuracy rate. (3) Our center requires that the sheath be placed above the BS to touch the lesion as closely as possible. A recent large-scale study including 241 patients with BS showed that stenosis length ≥ 30 mm was an important indicator for positive diagnosis of PTCB ^[32]. However, in our study, stenosis length was not associated with FNV. This may be related to the sampling method. It is recommended to adopt segmental sampling (sampling at the low-middle and upper parts to obtain more representative samples) for long BS. Theoretically, the number of biopsies should be of great significance for FPV, but univariate and multivariate analyses showed that the number of biopsies was not related. Considering that most of the specimens in the bile duct are adenocarcinoma, as long as the most serious part of BS, i.e., the most serious part of tumor invasion, can be obtained, the materials should be representative, and the average number of clamps at our center was 4, while other studies reported 3 ^[30]. A sufficient sample size can be obtained by increasing the number of biopsies.

This retrospective study has certain limitations. Only 14.9% of the cases were confirmed by final surgery and pathology, while up to 62.9% of the patients were only confirmed by imaging follow-up. The follow-up time was at least 12 months, which is still short because some bile duct tumors show inertia. This study is only a single center study, which limited its statistical power to a certain extent.

In conclusion, PTCB is safe and reliable in the diagnosis of malignant biliary obstruction with fewer complications, and noncholangiocarcinoma tumors are an independent risk factor for FNV.

Acknowledgements

Not applicable.

Author contributions

Zhang CZ and Jiao DC wrote the main manuscript text. Zhang CZ carried out statistical analysis; Sun ZG and Ren JZ carried out the collection of clinical data; Song MY prepared Table 1-3, and Han XW prepared Figure 1-2.All authors reviewed the manuscript.

Funding

None.

Availability of data and materials

In addition to the raw data in the manuscript, the datasets used are available from the corresponding author on request.

Ethics approval and consent to participate

This retrospective study was performed in accordance with the Declaration of Helsinki and was approved by the Clinical Ethics Committees of the First Affiliated Hospital of Zhengzhou University (Ethical review number: 2021-KY-376). The requirement for informed consent was waived by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University because of the retrospective nature of the study.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Bonnel D, André T, Mader B, et al. Malignant biliary obstruction, general review and clinical practice. Bull Cancer. 2013;100(5):443–52.
O'Brien S, Bhutiani N, Egger ME, et al. Comparing the efficacy of initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography with stenting for relief of biliary obstruction in unresectable cholangiocarcinoma. Surg Endosc. 2020;34(3):1186–90.
Yang E, Lee J, Seo H, et al. Clinical characteristics and outcomes of Staphylococcus aureus bacteremia from a biliary source. Eur J Clin Microbiol Infect Dis. 2020;39(10):1951–7.
Wang GX, Ge XD, Zhang D, et al. MRCP Combined With CT Promotes the Differentiation of Benign and Malignant Distal Bile Duct Strictures. Front Oncol. 2021;11:683869.
Aslam A, Wasnik AP, Shi J, et al. Intraductal papillary neoplasm of the bile duct (IPNB): CT and MRI appearance with radiology-pathology correlation. Clin Imaging. 2020;66:10–7.
Augustin AM, Steingrüber M, Fluck F, et al. Percutaneous endobiliary forceps biopsy of biliary strictures for histopathologic examination. Diagn Interv Radiol. 2020;26(4):339–44.
Stella SF, Van Borsel M, Markose G, Nair SB. Image Guided Percutaneous Biopsy for Pancreatic Lesions: 10-Year Experience in a Tertiary Cancer Center.Can Assoc. Radiol J. 2019;70(2):199–203.
Jiao D, Zhou X, Li Z, Bi Y, Zhang Q, Li J, et al. A newly designed biliary brachytherapy drainage catheter for patients with malignant biliary obstruction: A pilot study. J Cancer Res Ther. 2020;16(2):286–91.
Weber A, von Weyhern C, Fend F, Schneider J, Neu B, Meining A, et al. Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma. World J Gastroenterol. 2008;14(7):1097–101.
Kobayashi M, Ryozawa S, Araki R, Nagata K, Tanisaka Y, Fujita A, et al. Investigation of Factors Affecting the Sensitivity of Bile Duct Brush Cytology. Intern Med. 2019;58(3):329–35.
Elyaderani MK, Gabriele OF.Brush and forceps biopsy of biliary ducts via percutaneous transhepatic catheterization.Radiology. 1980;135(3):777–8.
Jeon TY, Choi MH, Yoon SB, Soh JS, Moon SH. Systematic review and meta-analysis of percutaneous transluminal forceps biopsy for diagnosing malignant biliary strictures. Eur Radiol. 2022;32(3):1747–56.
SCardella JF, Kundu S, Miller DL, Millward SF, Sacks D. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol. 2009;20(7 Suppl):189-91.
Kapoor BS, Mauri G, Lorenz JM. Management of Biliary Strictures: State-of-the. -Art Rev Radiol. 2018;289(3):590–603.
Razumilava N, Gores GJ. Cholangiocarcinoma Lancet. 2014;383(9935):2168–79.
Li TF, Ren KW, Han XW, Li WC, Ren JL, Jiao DC, et al. Percutaneous transhepatic cholangiobiopsy to determine the pathological cause of anastomotic stenosis after cholangiojejunostomy for malignant obstructive jaundice. Clin Radiol. 2014;69(1):13–7.
Fohlen A, Bazille C, Menahem B, Jegonday MA, DuPont B, Le Pennec V, et al. Transhepatic forceps biopsy combined with biliary drainage in obstructive jaundice: safety and accuracy.Eur Radiol. 2019;29(5):2426–2435.
Augustin AM, Steingrüber M, Fluck F, Goetze O, Bley TA. Kickuth R.Percutaneous endobiliary forceps biopsy of biliary strictures for histopathologic examination. Diagn Interv Radiol. 2020;26(4):339–44.
Lutz HH, Trautwein C, Tischendorf JJW. Diagnostic quality of transluminal biopsy in undetermined biliary duct stenosis by primary PTCD with "cross and push" technique - a prospective monocentric pilot study. Z Gastroenterol. 2020;58(10):939–44.
Inchingolo R, Spiliopoulos S, Nestola M, Nardella M. Outcomes of percutaneous transluminal biopsy of biliary lesions using a dedicated forceps system. Acta Radiol. 2019;60(5):602–7.
Navaneethan U, Njei B, Lourdusamy V, Konjeti R, Vargo JJ, Parsi MA. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015;81(1):168–76.
Boos J, Yoo RJ, Steinkeler J, Ayata G, Ahmed M, Sarwar A, et al. Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction. Eur Radiol. 2018;28(2):522–9.
Weber A, von Weyhern C, Fend F, Schneider J, Neu B, Meining A. Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma. World J Gastroenterol 14:1097–1101.
Lee YN, Moon JH, Choi HJ, Kim HK, Choi SY, Choi MH, et al. Diagnostic approach using ERCP-guided transpapillary forceps biopsy or EUS-guided fine-needle aspiration biopsy according to the nature of stricture segment for patients with suspected malignant biliary stricture. Cancer Med. 2017;6(3):582–90.
Hormati A, Jafari S, Jabbari A, Pezeshki Modares M, Afifian M, et al. Comparison between Brush Cytology and Forceps Biopsy under Fluoroscopic Guidance for the Diagnosis of Proximal Cholangiocarcinoma. Middle East J Dig Dis. 2020;12(4):246–51.
Chen WM, Wei KL, Chen YS, Chang PJ, Tung SY, Chang TS, et al. Transpapillary biliary biopsy for malignant biliary strictures: comparison between cholangiocarcinoma and pancreatic cancer.World. J Surg Oncol. 2016;14:140.
Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T, Khor CJ, Ponnudurai R, Moon JH, et al. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol. 2013;28(4):593–607.
Sato M, Inoue H, Ogawa S, et al. Limitations of percutaneous transhepatic cholangioscopy for the diagnosis of the intramural extension of bile duct carcinoma. Endoscopy. 1988;30:281–8.
Terasaki K, Wittich GR, Lycke G, et al. Percutaneous transluminal biopsy of biliary strictures with a bioptome. AJR Am J Roentgenol. 1991;156:77–8.
Park JG, Jung GS, Yun JH, Yun BC, Lee SU, Han BH, et al. Percutaneous transluminal forceps biopsy in patients suspected of having malignant biliary obstruction: factors influencing the outcomes of 271 patients. Eur Radiol. 2017;27(10):4291–7.
Wu ZY, Jiao DC, Guo FF, Zhang DD, Ren JZ, Han XW. Treatment of biliary stenosis using percutaneous transhepatic cholangiobiopsy with biopsy forceps of varying diameter. Quant Imaging Med Surg. 2022;12(1):207–14.
Naitoh I, Nakazawa T, Kato A, Hayashi K, Miyabe K, Shimizu S, et al. Predictive factors for positive diagnosis of malignant biliary strictures by transpapillary brush cytology and forceps biopsy. J Dig Dis. 2016;17(1):44–51.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

False-negative factors of percutaneous transluminal clamp biopsy for biliary stricture: 194 case analyses from a single center

Status:

Version 1

Abstract

Figures

Introduction

Materials And Methods

Procedures

Definition

Statistical analysis

Results

Discussion

Declarations

References

Additional Declarations

Status:

Version 1