To the Editor:
Shin et al
1
reported the excellent performance of narrow-band imaging (NBI) during peroral cholangioscopy in differentiating biliary strictures, demonstrating 87.5% sensitivity, 91.4% specificity, and 91.3% accuracy, adjusted with biopsy. The presented results are significantly better than those of other studies of white-light (WL) cholangioscopy, in which visual appearances, thought to be strongly associated with malignancy (eg, tortuous mucosal vessels), were seen in both benign and malignant disease.2
These results are particularly impressive because a definitive diagnosis was achieved in none of the 71 patients at prior ERCP with histologic assessment, but high diagnostic accuracy both cholangioscopically and on sampling was achieved at the next procedure. Moreover, the limited impact of previous stent placement (presumably performed at index ERCP) on cholangioscopic interpretation is notable. The retrospective design could affect these results, so further prospective studies may define the value of NBI in clinical practice and clarify whether the apparently improved diagnostic accuracy relates to enhanced definition of known characteristic features or to the identification of lesions not recognized with WL.
The central question, when investigating biliary stenoses, is the presence or absence of malignancy. Early diagnosis of an operable cholangiocarcinoma may be crucial for the opportunity of surgical cure, and misdiagnosis could result in inappropriate stricture management or immunosuppression.
3
Conversely, the misdiagnosis of a benign stricture as cancer may lead to unnecessary surgery, with associated morbidity.4
,5
Despite these encouraging data, it is unlikely in clinical practice that a definitive diagnosis of malignancy (and subsequent management) will be based on cholangioscopic appearances in the specific absence of confirmation by pathologic examination. As in luminal endoscopy,
6
,- Thosani N.
- Abu Dayyeh B.K.
- Sharma P.
- et al.
ASGE Technology Committee
ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds adopting real-time imaging–assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus.
ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds adopting real-time imaging–assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus.
Gastrointest Endosc. 2016; 83: 684-698.e7
7
visual appearance of mucosal abnormality is largely used to target pathologic sampling. In the area of intrabiliary pathology, the marrying of visual appearance and pathologic sampling has unavoidably lagged decades behind luminal disease because of the only recent availability of high-quality cholangioscopy. It is to be hoped that advances in WL and NBI may allow a rapid advance in diagnostic capabilities.Disclosure
All authors disclosed no financial relationships.
References
- Efficacy of narrow-band imaging during peroral cholangioscopy for predicting malignancy of indeterminate biliary strictures (with videos).Gastrointest Endosc. 2022; 96: 512-521
- Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures.Gastrointest Endosc. 2021; 94: 1059-1068
- Autoimmune cholangitis and cholangiocarcinoma.J Gastroenterol Hepatol. 2012; 27: 1783-1789
- Cholangiocarcinoma or IgG4-associated cholangitis.Ann Surg. 2012; 256: 1059-1067
- Preoperative misdiagnosis of pancreatic and periampullary cancer in patients undergoing pancreatoduodenectomy: a multicentre retrospective cohort study.Eur J Surg Oncol. 2021; 47: 2525-2532
- ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds adopting real-time imaging–assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus.Gastrointest Endosc. 2016; 83: 684-698.e7
- An international multicenter real-life prospective study of electronic chromoendoscopy score PICaSSO in ulcerative colitis.Gastroenterology. 2021; 160: 1558-1569.e8
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