Endoscopic transpapillary biopsy using a self-assembled device: the tunnel technique

Endoscopic transpapillary biopsy under fluoroscopic control is a well-established method for tissue sampling in the case of biliary stenosis during endoscopic retrograde cholangiopancreatography (ERCP). Nevertheless, some adverse events and technical challenges, especially in proximal strictures, have been reported [1]. Cholangioscopy-guided biopsy remains an expensive, niche technique with small-sized forceps, making histological analysis difficult [2]. Finding a safe, cost-effective technique for histology remains a challenge. Herein we report a new technique for transpapillary biopsy using a biliary dilation catheter.

A 77-year-old patient was referred to our center in September 2019 for cholangitis. The patient underwent a computed tomography (CT) scan and magnetic resonance imaging (MRI), revealing stenosis of the left intrahepatic duct. ERCP confirmed the left biliary stenosis ([Fig. 1]), but results from brushing the stenosis were inconclusive. Three days later, a second attempt at ERCP was performed. To obtain adequate tissue specimens for histopathological analysis, the tunnel technique was applied.

Fig. 1 Cholangiogram showing a left intrahepatic biliary stenosis.

An 11.5-Fr biliary dilation catheter was used as the tunnel for the biopsy forceps after cutting the tapered tip, leaving the dilator’s radiopaque marker as a reference point. Biliary cannulation was obtained, and the 11.5-Fr tapered catheter was advanced over a guidewire and a 6-Fr catheter, in the left biliary duct, close to the stricture ([Fig. 2]). Following removal of both the guidewire and 6-Fr inner catheter, the 7-Fr biopsy forceps with 7-mm-wide cups were inserted inside the 11.5-Fr catheter ([Fig. 3]). Multiple biopsies were easily performed on the stricture ([Fig. 4]). No adverse events were recorded. Histology was positive for cholangiocarcinoma and hepatic resection was scheduled.

Fig. 2 Fluoroscopic image of an 11.5-Fr biliary dilation catheter advanced, after cutting the tapered tip, over a 6-Fr catheter and a 0.035-inch guidewire

Fig. 3 The tunnel technique: fluoroscopic image of 7-Fr biopsy forceps advanced inside an 11.5-Fr biliary dilation catheter after cutting the tapered tip.

Fig. 4 Biopsy specimen for histopathological analysis obtained with 7-Fr biopsy forceps with 7-mm-wide cups.

Video 1 Application of the tunnel technique for endoscopic transpapillary biopsy of a stenosis in the left intrahepatic duct.

The tunnel technique for transpapillary biopsies appears to be a non-expensive, safe method, associated with a low risk of biliary injuries likely as a result of advancing the forceps inside a protective tunnel. By using standard forceps, adequate tissue sampling might be obtained during fluoroscopy-assisted biopsies. Further studies are needed to validate this method for biliary stenoses.

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• References

• 1 Chen WM, Wei KL, Chen YS. et al. Transpapillary biliary biopsy for malignant biliary strictures: comparison between cholangiocarcinoma and pancreatic cancer. World J Surg Oncol 2016; 14: 140
• 2 Pereira P, Vilas-Boas F, Peixoto A. How SpyGlass™ May Impact Endoscopic Retrograde Cholangiopancreatography Practice and Patient Management. GE Port J Gastroenterol 2018; 25: 132-137