Reply to Ustundag et al.

We thank Dr. Ustundag and colleagues for their interest in our article [1].

There may be cases in which it is difficult to open the forceps due to the form of the tumor, such as those in which the entire bile duct is strictured. In this study, we did not encounter such a case and thus found no difficulty using the method. However, we took care to open the forceps cup in the duct sufficiently before the stricture. Two cases were diagnosed based on clinical course without histology in this study. One of the cases investigated was a recurrence of lymphadenopathy in a 43-year-old male after gastric cancer resection. A definitive diagnosis of the gastric cancer was established by surgery. We could not obtain the tissue but diagnosed it as a recurrent lymphadenopathy based on image observations and the clinical course. Another case was a 69-year-old female patient with pancreatic cancer diagnosed by computed tomography to have locally advanced pancreatic head cancer invading the common bile duct, the portal vein, and the superior mesenteric artery. Placement of a biliary stent and chemotherapy were performed, and the patient died 8 months later due to progression of the pancreatic cancer, which was diagnosed based on the image observations and the clinical course.

An equal number of standard and large-capacity forceps were chosen as the first biopsy forceps by the envelope method. Wire-guided forceps are easy to insert [2] [3], but the cups of the biliary introducer are too small to obtain satisfactory samples. We use them in those cases where we need to determine superficial lateral spreading of biliary cancer.

The MTW forceps have large-sized cups, are controllable forceps, and are thus likely to be effective. However, they have a drawback of much higher cost than the Radial jaw. The high diagnostic rate even in cases of secondary cancers shows that the forceps collected deep tissues. This is a very significant advantage of large-capacity forceps. As highlighted in our study, the fact that the pathologists' diagnoses were not made in a blind manner is a limitation of this study.

References

• 1 Ikeda M, Maetani I, Terada K et al. Usefulness of endoscopic retrograde biliary biopsy using large-capacity forceps for extrahepatic biliary strictures: a prospective randomized study.  Endoscopy. 2010;  42 837-841
• 2 Howell D A, Parsons W G, Jones M A et al. Complete tissue sampling of biliary strictures at ERCP using a new device.  Gastrointest Endosc. 1996;  43 498-502
• 3 Farrell R J, Jain A K, Brandwein S L et al. The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures.  Gastrointest Endosc. 2001;  54 587-940