Introducer-assisted endoscopic transpapillary gallbladder biopsy for indeterminate gallbladder fundal wall thickness

Endoscopic transpapillary gallbladder biopsy (ET-GBBx) remains challenging; therefore, there is no recommendation for the histological examination of patients with resectable gallbladder cancer [1] [2]. Endoscopic introducer-assisted procedures recently emerged for pancreatico-biliary interventions [3]. This article describes the use of introducer-assisted ET-GBBx for indeterminate gallbladder fundal wall thickening.

A 69-year-old man was referred to our department with gradual deterioration of gallbladder fundal wall thickness ([Fig. 1]) and an increased serum carbohydrate antigen 19–9 level of 88 U/mL. Abdominal ultrasonography after a perflubutane injection revealed early contrast-enhanced fundal wall thickening of the gallbladder and liver parenchyma. Delayed contrast-attenuated liver parenchyma on the gallbladder fossa indicated direct liver invasion ([Fig. 2]). The patient requested a definitive pathological diagnosis, and ET-GBBx was performed after a multidisciplinary discussion.

Fig. 1 Contrast-enhanced abdominal computed tomography performed at admission revealed contrast-enhanced gallbladder fundal wall thickness with an obscure demarcation line of the liver parenchyma and gallbladder fossa (red arrows).

Fig. 2 Contrast-enhanced abdominal ultrasonography. a Contrast-enhanced gallbladder fundal wall thickness with liver parenchyma in the early phase (yellow arrows). The image on the left is the reference image. b Direct liver invasion was suggested by the contrast-attenuated liver parenchyma on the gallbladder fossa in the delayed phase (red arrows). The image on the left is the reference image.

After guidewire coiling of the gallbladder, ET-GBBx using peroral cholangioscopy (POCS – SpyGlass DS System; Boston Scientific, Marlborough, Massachusetts, USA) [4] was attempted; however, an obstruction was noted at the cystic duct despite dilation using a drill dilator. Next, we attempted fluoroscopy-guided ET-GBBx using biopsy forceps (Radial Jaw 4P; Boston Scientific) through the outer sheath of the endoscopic introducer (EndoSheather; Piolax, Yokohama, Japan) without complications ([Fig. 3], [Video 1]). Histologically, all three specimens were adenocarcinoma ([Fig. 4]); thus, an extended radical cholecystectomy was performed.

Fig. 3 Endoscopic transpapillary gallbladder biopsy using biopsy forceps under fluoroscopic guidance. Biopsy forceps were passed through the outer sheath of the endoscopic introducer to the gallbladder fundus.

Video 1 Introducer-assisted endoscopic transpapillary gallbladder biopsy for indeterminate gallbladder fundal wall thickness.

Fig. 4 Microscopic findings of a specimen obtained from the gallbladder fundus. Severe atypical columnar cells with loss of polarity, nuclear enlargement, and stratification indicated a tubulo-papillary growth pattern. Histologically, the diagnosis was adenocarcinoma. Hematoxylin and eosin staining.

The potential of ET-GBBx using small biopsy forceps has been reported [5]; however, that study carried the risk of sampling errors due to its small sample size. This endoscopic introducer functions as a dilator and a delivery sheath for instruments, including large biopsy forceps up to 1.9 mm (5.7 Fr) in diameter. However, dedicated devices such as rotatable and bendable biopsy forceps are warranted for whole-gallbladder biopsy. These findings indicate that ET-GBBX is feasible for gallbladder fundus lesions unless an ultra-slim POCS is developed and advanced through the spiral valve of Heister.

Endoscopy_UCTN_Code_TTT_1AR_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Nagino M, Hirano S, Yoshitomi H. et al. Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition. J Hepatobiliary Pancreat Sci 2021; 28: 26-54
• 2 Pouw RE, Barret M, Biermann K. et al. Endoscopic tissue sampling – Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 1174-1188
• 3 Kito Y, Kato A, Yoshida M. et al. Facile and secure deployment of plastic stent through an endoscopic tapered sheath for endoscopic ultrasound-guided drainage. Endoscopy 2022; 54: E674-E675
• 4 Kamada H, Kobara H, Yamana H. et al. Endoscopic direct visualization of gallbladder polypoid lesion using peroral digital single-operator cholangioscopy. Endoscopy 2021; 53: E263-E264
• 5 Fujiwara S, Kobayashi M, Ohtsuka K. et al. The Double-Max method: a novel method for gallbladder epithelial biopsy. VideoGIE 2022; 7: 334-336

Publikationsverlauf

Artikel online veröffentlicht:
31. Januar 2023