We sincerely appreciate the valuable comments of Papaefthymiou et al
1
on our recent article.2
As they make clear in their commentary, the diagnostic accuracy of peroral cholangioscopy (POC) is less affected by an existing plastic stent than are the accuracies of other diagnostic modalities such as CT, MRI, and EUS because POC permits direct observation of the biliary tract after removal of the stent.Given that the utility of narrow-band imaging (NBI) during bile duct evaluation has received less attention than NBI of the GI tract, we investigated the diagnostic utility of NBI (compared with white-light imaging) during POC in patients with indeterminate biliary strictures. NBI allowed detailed observations of the surface structures, microvessels, and lesional margins, and it usefully predicted malignancies of indeterminate biliary strictures.
2
, 3
, 4
These results are consistent with our previous reports: NBI effectively identified minute, intraductal superficial lesions of the bile duct that were not well detected by conventional imaging modalities.5
We entirely agree with Papaefthymiou et al
1
that any definitive final diagnosis of malignancy should be pathologic, not cholangioscopic, even if NBI is used. In this context, POC may be better than ERCP-guided transpapillary biopsy in that POC allows direct visualization of the bile duct and thus yields targeted biopsy samples.6
In particular, direct POC by use of an ultraslim endoscope affords several advantages in terms of pathologic sampling, ie, high image quality, NBI capability, and adequate tissue sampling with the use of large (5F) biopsy forceps.7
Although the retrospective design of the work may have affected our results (as described in the limitations of the Discussion section), POC with NBI allowed more accurate diagnosis of indeterminate biliary strictures. To validate these results, we are planning a prospective study. As technology advances, we see a more prominent role for POC in terms of the diagnosis of various biliary tract diseases, ranging from indeterminate biliary strictures to intraductal neoplasms of the bile duct.
Disclosure
Both authors disclosed no financial relationships.
References
- The clinical value of narrow-band imaging in biliary strictures.Gastrointest Endosc. 2023; 97: 604-605
- Efficacy of narrow-band imaging during peroral cholangioscopy for predicting malignancy of indeterminate biliary strictures (with videos).Gastrointest Endosc. 2022; 96: 512-521
- Peroral cholangioscopy to evaluate indeterminate bile duct lesions and preoperative mucosal cancerous extension: a prospective multicenter study.Endoscopy. 2013; 45: 635-642
- Per-oral video cholangiopancreatoscopy with narrow-band imaging for the evaluation of indeterminate pancreaticobiliary disease.Gastrointest Endosc. 2017; 85: 509-517
- Use of peroral cholangioscopy to screen for neoplastic bile duct lesions in patients with bile duct stones (with videos).Gastrointest Endosc. 2021; 94: 776-785
- Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video).Gastrointest Endosc. 2020; 91: 1105-1113
- Peroral cholangioscopy: diagnostic and therapeutic applications.Gastroenterology. 2013; 144: 276-282
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