Review Article

Tissue sampling at ERCP in suspected malignant biliary strictures (Part 2)☆

Brush cytology

Several studies have evaluated the cancer detection rate of brush cytology since the first description by Osnes et al.¹ in 1975. Brushing is the most frequently used tissue sampling technique and can be performed for most biliary strictures detected at ERCP. It is technically easy, requires little time, and is generally safe.2, 3, 4, 5, 6, 7, 8

Endobiliary forceps biopsy

The endobiliary forceps biopsy provides a sample of bile duct tissue deep to the epithelium, theoretically obviating the problem of inadequate sampling that may occur with brushing. This technique is more time consuming than brushing and is less widely used.

Biopsy specimens can be obtained from biliary strictures at ERCP by using forceps made for use with standard and pediatric upper endoscopes, or malleable forceps.9, 29 After performing a sphincterotomy, the forceps is passed through the

Multimodal tissue sampling

Several studies have shown that combining several techniques for obtaining tissue samples from biliary strictures at ERCP enhances the detection of cancer (Table 3).9, 21, 28, 34, 38

Improving the diagnostic yield of tissue sampling at ERCP

Currently, the cancer detection rate when sampling biliary stricture is clearly less than that for endoscopic sampling of lesions in the esophagus, stomach, and colon. Thus, new and better techniques are needed.

Conclusions

Ideally, the initial steps in the approach to malignant obstructive jaundice should establish whether the patient is a candidate for surgery and whether the tumor is potentially resectable. The former is determined by clinical evaluation of the patient and the latter by staging US and CT. If the patient is considered a surgical candidate and the tumor potentially resectable based on CT findings, there is little or no role for ERCP and concurrent tissue sampling.⁶³ The patient should undergo EUS