Introduction

Endoscopic or percutaneous bile duct brushing is often performed as first step to differentiate between benign and malignant biliary strictures. Although brush cytology has a high specificity (95-100%), the sensitivity for detection of malignancy has been reported to be poor (41-67%).(1-4) This results in repeated diagnostic procedures with potential treatment delay, adverse events, and additional costs.

Aims & Methods

Aim of this study was to evaluate a change in protocol for brush cytology with optimization of handling and rating, Next Generation Sequencing (NGS), and the use of two brushes plus intraductal biopsies in patients with suspected perihilar or intrahepatic cholangiocarcinoma (pCCA/iCCA). Patients with suspicion of pCCA or iCCA were prospectively included between June 2021 and December 2023. Preferably two brushes and 2-4 intraductal fluoroscopy guided biopsies were taken during the initial procedure. Cells were dislodged in a Cytolyt container within 30 seconds of which two ''thin prep'' slides were prepared. Double reading was routinely performed by at least two expert cytopathologists. NGS was performed in samples with an uncertain diagnosis of atypia. A historical cohort (January 2017-June 2021) was used as control. In this cohort a single brush was performed without intraductal biopsies. The obtained cells were preserved in a Roswell Park Memorial Institute (RPMI) 1640 medium of which four cytospins were done. Double reading and NGS were not routinely performed. In both cohorts morphological diagnosis was assessed according to the Papanicolau society of cytopathology system for reporting pancreatobiliary cytology. Both the diagnostic category ‘suspicious for malignancy’ and ‘malignant’ were classified as results compatible with malignant disease. Final diagnosis was confirmed by either histological proof of malignancy or in case unavailable, follow-up compatible with malignant disease. Primary endpoint was the sensitivity before and after implementation of the protocol; secondary endpoints were the sensitivity of the individual steps of the modified protocol in the prospective cohort e.g. the sensitivity of only the first brush and additional value of NGS, the second brush, and intraductal biopsies.

Results

In this study, a total of 167 patients were evaluated (51 prospectively and 116 historical controls). The final diagnosis was malignant disease in 153 patients (91.6%). After implementation of the protocol, the sensitivity rose to 86% (95%CI, 72.6-93.7%) versus 48.5% (95%CI, 38.7-58.5%) prior to implementation (difference 37.5%; 95%CI, 22.3-52.6%). Specificity was 100% in both groups (1/1 vs 13/13). Sensitivity of the first brush in the prospective cohort was 76% (95%CI, 61.5-86.5%). NGS was of additional diagnostic value in 3 patients with uncertain brush cytology results, increasing the sensitivity to 82% (95%CI, 68.1-91%). A second brush was performed in 37 patients; in one of these patients, the second brush had additional diagnostic value over the first brush. Intraductal biopsies were performed in 26 patients (4 benign, 9 suspicious of malignancy, 13 malignant), leading to a malignant diagnosis in 2 out of 12 patients with false-negative brush cytology.

Conclusion

A modification in the handling of cytopathology, led to a significant improvement in the sensitivity of bile duct brushes to 76% for patients with suspected pCCA or iCCA. Furthermore, adding NGS, use of two brushes, and intraductal biopsies in the initial procedure could further increase sensitivity to 86%.

References

1. Mehmood S, Loya A, Yusuf MA. Biliary Brush Cytology Revisited. Acta Cytol. 2016;60(2):167-72.
2. 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. Internal Medicine. 2019;58(3):329-35.
3. Volmar KE, Vollmer RT, Routbort MJ, Creager AJ. Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods. Cancer. 2006;108(4):231-8.
4. 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.

Disclosure

Jeska A. Fritzsche, Esmée Smit, Otto M. van Delden, Frederike Dijk, Arantza Farina Sarasqueta, Sybren L. Meijer, Anne M. Uyterlinde, Mattheus C.B. Wielenga, IJsbrand A.J. Zijlstra, and Joanne Verheij have no conflicts of interest or financial ties to disclose.
Paul Fockens performed as a consultant for Olympus and Cook Endoscopy.
Geert Kazemier reports research support and travel fees from SAS Analytics and research grants from KWF, ZonMw, Cancer Center Amsterdam Foundation, and Bennink Foundation outside the submitted research.
Heinz-Josef Klümpen performed in advisory board for Janssen, Astra-Zeneca and IPSEN, and received Speaker’s fees from CCO and MedTalks.
Cyriel Y. Ponsioen reports research grants from Gilead and Perspectum, performed as a consultant for Pliant, Takeda and Shire, and received speaker’s fees from Tillotts.
Roy L.J. van Wanrooij performed as a consultant for Boston Scientific.
Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fee from Mylan and Zambon.
All outside the submitted work.

Introduction

Evaluate the predictive factors of failure rate of clearing the biliary system from stones at the initial ERCP.

Aims & Methods

This is a retrospective descriptive and analytical study from September 2004 to September 2023.
All patients with bile duct stones, who underwent ERCP with endoscopic sphincterotomy and stone extraction by standard techniques (extraction balloon or Dormia basket) were included in this study.

Results

A total of 1080 ERCPs were performed to extract biliary duct stones .

The mean age was 58.9 +/- 14.4 years and 59.5% were females.
The mean diameter ofthe Bile duct was 13.4+/- 4.31 mm. The presence of a biliary stricture in 6.3%.
The primary vacuity rate was 75.1%. Supplementary techniques were used in 22.7% of cases.
On univariate analysis, the predictive factors for failure after use of standard techniques were: age(OR: 0.9;CI95%:-0.03- -0.01;p<0.001); gender(OR:0.7;CI95%:-0.5--0.02;p=0.036); previous cholecystectomy (OR:1.3,CI95%:0.02-0.6;p=0.035);presence of angiocholitis(OR: 0.4; CI95%:-1.1- -0.4;p<0.001); dilatation of the CBD >15mm (OR:0,8,CI95%:-0.2-0.1;p<0.001), biliary stricture (OR:0.3;CI95%:-1.7--0.7;p<0.001) and the presence of impacted and/or large stone (OR:0.1;CI95%:-2--1;p<0.001).
On multivariateanalysis, only the presence of angiocholitis (OR:1.9;CI95%: 0.2-1;p=0.001),impacted and/or large stone (OR:2.5;CI95%:0.5-1.3;p<0.001), dilatation ofthe CBD >15mm (OR:0.88;CI95%:-0.17- -0.07;p<0.001), and biliary stricture(OR:2.9;CI95%:0.4-1.7;p=0.002) were significantly associated with failure ofthe primary CBD vacuity rate.
The overall vacuity rate after using the supplementary techniques was 92.4%.

Conclusion

In our study, predictivefactors for failure of the primary CBD vacuity rate were the presence ofangiocholitis, impacted and/or large stone, dilatation of the CBD (>15mm)and biliary stricture.

Introduction

There are few studies evaluating the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 90 years and above (nonagenarian). This study's main goal was to compare the technical success and complications of ERCP in patients over 90 years or younger patient group.

Aims & Methods

929 naive patients who underwent ERCP at the tertiary referral center between January 2021 and December 2023 were retrospectively analyzed. The patient's medical records were reviewed for comorbidities, periampullary diverticulum, cannulation time, cannulation method, technical success, procedure duration, and ERCP-related complications.

Results

A total of 929 naive patients underwent ERCP; 895 (96.3%) patients were < 90 years old and 34 (3.7%) patients were≥ 90 years old. The median ERCP procedure time (18.5 min vs. 18 min, P=0.660), and cannulation time (8 min vs. 7 min, P=0.824) did not differ in patients with two groups respectively. The successful cannulation rate in the nonagenarian group was 34 (100%), and in the younger group was 891 (99.6%), there was no significant difference between the two groups (P=1). The main indication of the ERCP procedure was choledocholithiasis in both groups. There was no significant difference in the ERCP-related complications between the two groups. The main cannulation technique was selective sphincterotomy in both groups.

There was no significant difference in cannulation techniques between the two groups. Patients belonging to the nonagenarian group had a higher frequency of periampullary diverticulum (20.6%) compared to the younger group (14.3%). Type 2B diverticula was the most seen in both groups (11.8% vs. 4.9%). However, there was no significant difference in the presence of periampullary diverticulum between the two groups. The number of chronic concomitant diseases (cardiovascular diseases, chronic lung diseases, chronic renal diseases) was significantly higher in the nonagenarian group [13 (38.2%) vs. 114 (12.7%), P<0.001].

Conclusion

In this study, we showed that ERCP was a safe and successful procedure in patients with nonagenarians. Although comorbidities were substantially higher, ERCP was a successful procedure for nonagenarian patients because the rates of complications are similar to those of younger adult patients.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure. There are multiple clinical guidelines yet practice varies. As part of an on-going BSG Endoscopy Quality Improvement Programme, we aim to describe current ERCP practice in the UK and benchmark this against published guidelines.

Aims & Methods

An anonymised survey link was emailed to all independent ERCP practitioners in the UK and a further survey was sent to all organisations in the UK in which ERCP is carried out. Multiple reminders and individual contacts were used to maximise response rate. Clinical questions covering a range of scenarios were aligned with published guidelines and quality standards including the UK National Institute for Health and Care Excellence (NICE).

Results

171 organisations providing ERCP were identified with a 100% response rate. 491 ERCP practitioners were identified with 78% (n= 386) response rate. In patients with an intermediate likelihood of common bile duct stones (CBDS), 9% of responders would proceed directly to ERCP, 76% would request MRCP or EUS first and 11% would arrange same session EUS +/- ERCP. In patients with normal anatomy and large or difficult to extract stones, 68% would perform sphincterotomy followed by sphincteroplasty and further attempts at duct clearance at the index procedure. After two or more inadvertent guidewire into the pancreatic duct (PD), 25% of individual practitioners always and 51% usually place a PD stent, whereas 19% rarely and 5% never do. In 10% of organisations standard practice is usually not to insert a PD stent.
NICE quality standard in the management of gallstone disease (QS104) stipulate that adults with CBDS causing jaundice have ERCP within 72 hours of diagnosis; 86% of organisations are compliant with this all or most of the time. In patients who need emergency ERCP for CBDS, 66% of organisations are compliant all or most of the time with having an ERCP within 24 hours (QS104).
In 29% of organisations, access to same-day ERCP 5 days a week was not available all/ most of the time. Out of hours ERCP (1800-0800) was not available all or most of the time in 63%, and over weekends it was not available all or most of the time in 59%.ERCP was available out of hours within the hospital in 33% of organisations during weekdays and 36% over the weekends as an unpaid, ad-hoc or goodwill arrangement.
In 26% of organisations there is regular weekly access to a deep sedation / general anaesthetic (DS/GA) list and 60% have access to a DS/GA list on an ad hoc basis or through referral to a different hospital. 55% of ERCPists were aware of the quality of therapeutic intent of any ERCP procedure being affected by suboptimal patient tolerance with endoscopist administered conscious sedation in the past month and 62% would prefer to perform all ERCPs under DS/ GA.

Conclusion

Despite clear guidance, variation in the management of CBDS and placement of pancreatic stents persists. Access to out-of-hours and weekend ERCP is sparse in the UK, and there is a reliance on goodwill to facilitate these cases. The availability of DS/GA is limited and there is a clear desire for improved access to optimise patient tolerance and ERCP outcomes.

Disclosure

Nothing to disclose