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Biliary Tree Diagnostics: Advances in Endoscopic Imaging and Tissue Sampling. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010135. [PMID: 35056443 PMCID: PMC8781810 DOI: 10.3390/medicina58010135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 12/12/2022]
Abstract
The diagnostic approach to the biliary tree disorders can be challenging, especially for biliary strictures. Albeit the great diagnostic impact of endoscopic retrograde cholangiopancreatography (ERCP) which allows one to obtain fluoroscopic imaging and tissue sampling through brush cytology and/or forceps biopsy, a considerable proportion of cases remain indeterminate, leading to the risk of under/over treated patients. In the last two decades, several endoscopic techniques have been introduced in clinical practice, shrinking cases of uncertainties and improving diagnostic accuracy. The aim of this review is to discuss recent advances and emerging technologies applied to the management of biliary tree disorders through peroral endoscopy procedures.
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Mukewar S, Carr-Locke D. Advances in Endoscopic Imaging of the Biliary Tree. Gastrointest Endosc Clin N Am 2019; 29:187-204. [PMID: 30846148 DOI: 10.1016/j.giec.2018.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Direct endoscopic imaging of the biliary tree is increasingly performed by endoscopists since the introduction of digital single-operator cholangioscopy. In parallel, there have been several advances to overcome the challenges associated with direct peroral cholangioscopy with development of multibending cholangioscopes and new devices to enable direct placement of an endoscope into the biliary tree without a supporting duodenoscope. The indications for cholangioscopy are also evolving with newer indications, such as intraductal lithotripsy, foreign body (mostly stent) removal, guide wire cannulation of specific ducts, photodynamic therapy for cholangiocarcinoma, and performance of fluoroscopy-free cholangiography. There has also been progress in image enhancement during cholangioscopy and additional imaging techniques, such as intraductal ultrasound, confocal laser endomicroscopy, and optical coherence tomography.
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Affiliation(s)
- Saurabh Mukewar
- David H. Koch Medical Center, Department of Gastroenterology, Joan & Sanford I. Weill Medical, College of Cornell University, New York Presbyterian Hospital, 1278 York Avenue, 9th Floor, New York, NY 10065, USA.
| | - David Carr-Locke
- David H. Koch Medical Center, Department of Gastroenterology, Joan & Sanford I. Weill Medical, College of Cornell University, New York Presbyterian Hospital, 1278 York Avenue, 9th Floor, New York, NY 10065, USA
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Sarkisian AM, Sharaiha RZ. Malignant Biliary Obstruction of the Hilum and Proximal Bile Ducts. ERCP 2019:385-393.e3. [DOI: 10.1016/b978-0-323-48109-0.00040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Lee YN, Moon JH, Choi HJ. Role of Image-Enhanced Endoscopy in Pancreatobiliary Diseases. Clin Endosc 2018; 51:541-546. [PMID: 30508879 PMCID: PMC6283762 DOI: 10.5946/ce.2018.203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 11/16/2018] [Indexed: 12/13/2022] Open
Abstract
Recent advances in cholangiopancreatoscopy technology permit image-enhanced endoscopy (IEE) for pancreatobiliary diseases. There are limitations in endoscopy performance and in the study of the clinical role of IEE in bile duct or pancreatic duct diseases. However, currently available IEEs during cholangiopancreatoscopy including traditional dye-aided chromoendoscopy, autofluorescence imaging, narrow-band imaging, and i-Scan have been evaluated and reported previously. Although the clinical role of IEE in pancreatobiliary diseases should be verified in future studies, IEE is a useful promising tool in the evaluation of bile duct or pancreatic duct mucosal lesions.
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Affiliation(s)
- Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyun Jong Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
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Papafragkakis C, Lee J. Comprehensive management of cholangiocarcinoma: Part I. Diagnosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii1500341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Charilaos Papafragkakis
- epartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Lee
- epartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Peroral cholangioscopy has become an important tool in the diagnosis and treatment of a variety of biliary diseases, ranging from indeterminate biliary strictures to bile duct stones. Although the first cholangioscopy was performed in the 1970s, recent technological advances have provided us with cholangioscopes that yield high-resolution images, possess single-operator capability, and have ultrathin design to allow easier maneuverability and detailed imaging of the biliary tract. We review here the currently available devices for peroral cholangioscopy, their clinical applications, limitations, and complications.
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Affiliation(s)
- Ming-Ming Xu
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Cornell University, New York, NY, USA
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Ishida Y, Itoi T, Okabe Y. Can image-enhanced cholangioscopy distinguish benign from malignant lesions in the biliary duct? Best Pract Res Clin Gastroenterol 2015; 29:611-25. [PMID: 26381306 DOI: 10.1016/j.bpg.2015.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/17/2015] [Accepted: 05/21/2015] [Indexed: 01/31/2023]
Abstract
A new video peroral cholangioscopy (POCS) has been developed with high-quality digital imaging, and its clinical use has been reported. Additionally, direct peroral cholangioscopy (D-POCS) using an ultraslim endoscope has been proposed recently. To improve the diagnostic yield of POCS or D-POCS, image-enhanced endoscopy has been used in combination. Chromoendoscopy with methylene blue staining (ME), autofluorescence imaging (AFI), and narrow-band imaging (NBI) has been evaluated in biliary tract diseases. Observation of the mucosal structure and vessels is reportedly important for distinguishing non-neoplasms from neoplasms. Therefore, NBI is the most promising tool among image-enhanced endoscopies as it can enhance visualization of the mucosal structure and vessels simultaneously. There are currently few reports that have evaluated the utility of POCS or D-POCS based on pathological findings. Thus, endoscopic findings of the bile duct mucosa have not yet been fully established. At present, POCS-guided biopsy should be carried out.
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Affiliation(s)
- Yusuke Ishida
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan.
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
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Abstract
PURPOSE OF REVIEW Endoscopists have long awaited advances in the equipment and techniques for cholangiopancreatoscopy. Since the turn of the millennium, endoscopists have witnessed an explosion in the development and refinement of the capabilities of cholangioscopes as they move from being almost exclusive to tertiary care academic settings to a wider range of practices. RECENT FINDINGS Studies have tested and constructively critiqued the procedure, hoping to increase the success rate of diagnostic and therapeutic interventions. Many have found significant improvement upon the limitations of radiographic imaging in diagnosing diseases and achieving full clearance of biliary stones. Image quality has improved with a range of features. However, most of these still need to be studied further. The addition of balloon catheters and overtubes has improved stability and access to the biliary ducts, but comes with complications that need to be studied further. SUMMARY Although we still have improvements to yearn for, the future looks bright. As endoscopists continue their commitment to the promise of direct visualization of the biliary trees and the complementary tools for diagnosis and treatment, we are continuing to raise quality of care for patients with complicated biliary diseases.
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Abstract
The causes of obstructive jaundice are varied, and timely, accurate methods of investigation are essential to avoid the development of complications. Imaging, invasive or non-invasive, should be carefully selected depending on the suspected underlying pathology in order to determine the degree and level of obstruction along with tissue acquisition and staging where relevant. Several imaging techniques will also allow subsequent therapeutic interventions to be carried out. This article reviews advances in the investigation of obstructive jaundice, highlighting recent developments, many of which at present remain restricted to large centres of expertise, but are likely to become more widespread in use as research progresses and local experience continues to improve.
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Affiliation(s)
- J Addley
- Department of Gastroenterology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK.
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Sethi A. Endoscopic retrograde cholangioscopy and advanced biliary imaging. Gastrointest Endosc Clin N Am 2012; 22:451-60. [PMID: 22748242 DOI: 10.1016/j.giec.2012.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Developments in endoscopic retrograde cholangioscopy provide multiple new advanced methods of biliary imaging. Cholangioscopy provides direct visualization of epithelium with white light as well as advanced modalities, such as narrow band imaging and autofluorescence. In vivo histologic images can be achieved with confocal endomicroscopy. Cross-sectional imaging is also possible with intraductal ultrasonography and optical coherence tomography. This article describes these advanced imaging techniques, which can be used together to assist in the diagnosis of biliary strictures and lesions.
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Affiliation(s)
- Amrita Sethi
- Division of Gastroenterology and Hepatology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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Chin MW, Byrne MF. Update of cholangioscopy and biliary strictures. World J Gastroenterol 2011; 17:3864-9. [PMID: 22025874 PMCID: PMC3198015 DOI: 10.3748/wjg.v17.i34.3864] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 01/15/2011] [Accepted: 01/22/2011] [Indexed: 02/06/2023] Open
Abstract
Cholangioscopy remains another modality in the investigation of biliary strictures. At cholangioscopy, the “tumour vessel” sign is considered a specific sign for malignancy. Through its ability to not only visualise mucosa, but to take targeted biopsies, it has a greater accuracy, sensitivity and specificity for malignant strictures than endoscopic retrograde cholangiopancreatography guided cytopathological acquisition. Cholangioscopy however, is time consuming and costly, requires greater technical expertise, and should be reserved for the investigation of undifferentiated strictures after standard investigations have failed.
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Tamada K, Ushio J, Sugano K. Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations. World J Clin Oncol 2011; 2:203-16. [PMID: 21611097 PMCID: PMC3100496 DOI: 10.5306/wjco.v2.i5.203] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/16/2010] [Accepted: 09/23/2010] [Indexed: 02/06/2023] Open
Abstract
The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.
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Affiliation(s)
- Kiichi Tamada
- Kiichi Tamada, Jun Ushio, Kentaro Sugano, Department of Gastroenterology and Hepatology, Jichi Medical University, Yakushiji, Tochigi 329-0498, Japan
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13
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Abstract
In the evaluation of biliary diseases, cholangioscopy is considered as complementary procedure to radiographic imaging. Direct visualization of the bile duct is the premier advantage of cholangioscopy over indirect imaging techniques. However, cholangioscopy has not gained wide acceptance because of several technical limitations such as scope fragility, impaired steerability, limited irrigation, and suction capabilities, as well as the need for two experienced endoscopists. Recent innovations such as the implementation of electronic video cholangioscopes and the development of single-operator systems facilitate the procedure, and promise to increase the diagnostic and therapeutic yield of cholangioscopy.
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Affiliation(s)
- Grischa Terheggen
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217 Düsseldorf, Germany.
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Itoi T, Osanai M, Igarashi Y, Tanaka K, Kida M, Maguchi H, Yasuda K, Okano N, Imaizumi H, Yokoyama T, Itokawa F. Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions. Clin Gastroenterol Hepatol 2010; 8:934-8. [PMID: 20655394 DOI: 10.1016/j.cgh.2010.06.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 06/25/2010] [Accepted: 06/30/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We evaluated the diagnostic ability of a newly developed peroral video cholangioscopy (PVCS) in patients with pancreaticobiliary disorders. METHODS We retrospectively evaluated data from 144 patients with pancreaticobiliary disorders, collected from 5 tertiary referral centers. Endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) was performed before PVCS. We performed 2 types of PVCS, using a conventional therapeutic duodenoscope. If tissue samples were needed, cholangioscopy-assisted biopsy or fluoroscopy-guided biopsy was performed. RESULTS PVCS was advanced into the bile duct in all cases after patients received EST (n = 134 cases), EPBD (n = 2), a combination of EST and EPBD (n = 1), or without treatment of the major papilla (n = 7). Biopsy samples were collected successfully from 112 of 120 cases in which endoscopists considered tissue sampling necessary. Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy correctly identified 83 of 96 malignant lesions and 19 of 24 benign lesions (accuracy = 85.0%; sensitivity = 86.5%; specificity = 79.2%; positive predictive value = 94.3%; negative predictive value = 59.4%). Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy plus PVCS correctly identified 95 of 96 malignant lesions and 23 of 24 benign lesions (accuracy = 98.3%; sensitivity = 99.0%; specificity = 95.8%; positive predictive value = 99.0%; negative predictive value = 95.8%). Procedure-related complications included pancreatitis (4 cases, 2.8%) and cholangitis (6 cases, 4.3%). CONCLUSIONS PVCS is an accurate diagnostic tool for patients with pancreaticobiliary disorders; resolution was well-defined when combined with biopsy analysis. Prospective multicenter clinical trials should evaluate the clinical utility of PVCS in diagnosis of biliary tract diseases.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan.
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Itoi T, Neuhaus H, Chen YK. Diagnostic value of image-enhanced video cholangiopancreatoscopy. Gastrointest Endosc Clin N Am 2009; 19:557-66. [PMID: 19917461 DOI: 10.1016/j.giec.2009.06.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We summarized past and present results concerning the observation capability of cholangiopancratoscopy using chromoendoscopy, autofluorescence imaging (AFI), and narrow-band imaging (NBI). New generation peroral and percutaneous transhepatic video cholangiopancreatoscopes provide superior quality images. Pilot studies suggest that chromoendocholangioscopy using methylene blue or cholangioscopy using AFI can distinguish benign from malignant bile duct lesions. On the other hand, the NBI system enhances the imaging of certain features such as mucosal structures and microvessels in pancreatobiliary lesions. In patients with main-duct-type intraductal papillary mucinous neoplasm, peroral pancreatoscopy can be used to determine extent of tumor involvement. Although many technical hurdles still need to be overcome, image-enhanced cholangiopancratoscopy appears to be a promising modality to improve diagnostic accuracy of pancreatobiliary diseases, particularly in distinguishing benign from malignant lesions.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Nishishinjuku 6-7-1, Shinjuku-ku, Tokyo 160-0023, Japan.
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Itoi T, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T. Evaluation of peroral videocholangioscopy using narrow-band imaging for diagnosis of intraductal papillary neoplasm of the bile duct. Dig Endosc 2009; 21 Suppl 1:S103-7. [PMID: 19691722 DOI: 10.1111/j.1443-1661.2009.00849.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND It is very important for intraductal papillary neoplasm of the bile duct (IPNB) to determine the extension of the neoplasms because of substantial differences in the approach to treatment strategy. Peroral videocholangioscopy (PVCS) has been developed as a new diagnostic tool for high resolution imaging of biliary disorders. Recently, narrow-band imaging (NBI) has made it possible to emphasize the imaging of certain features, such as mucosal structures and capillary vessels. The aim of this study is to evaluate the clinical usefulness of PVCS using NBI for the diagnosis of IPNB. PATIENTS AND METHODS Four patients (3 men and 1 woman) were eligible for this study as they were scheduled for PVCS for evaluation of IPNB between August 2005 and September 2008 at Tokyo Medical University Hospital. We evaluated endoscopic imaging of white light imaging (WLI) and NBI for IPNB lesions, and ability of removing mucin in the bile duct by PVCS. The quality of the visualization was evaluated. : (i) poor, (ii) fair, and (iii) excellent, compared to WLI and the feasibility of irrigation: (i) poor, (ii) fair, and (iii) excellent, compared to those in patients with non-mucin-producing biliary tract diseases. RESULTS After sufficient removal of mucin by balloon catheter, conventional cholangioscopy could detect the papillary lesion, and revealed the range of tumor spread in all cases. Interestingly, another papillary lesion far from the main tumor was detected only by PVCS. In the ability to detect the fine mucosal structure, NBI was predisposed to be better than conventional imaging while only one case was "poor" by NBI observation because we could not eliminate the influence of bile. CONCLUSION Our results presented here suggest that the depiction ability of the margin of lesions by NBI observation is superior to conventional observation if abundant mucin can be removed sufficiently. Although further cases should be accumulated, choledochoscopy using NBI may be helpful for the observation of fine mucosal structures, resulting in diagnosis of tumor spread in patients with IPNB.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan.
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SATO M, INOUE H, OGAWA S, OHASHI S, MAETANP I, IGARASHI Y, SAKAI Y. Differences in Fine Mucosal Structure between Superficial Spreading Carcinoma and Non‐neoplastic Bile Duct Mucosa Detected by Percutaneous Transhepatic Cholangioscopy. Dig Endosc 1997. [DOI: 10.1111/j.1443-1661.1997.tb00459.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Masahiro SATO
- Third Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Hirokazu INOUE
- Third Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | | | - Shigeki OHASHI
- Third Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Iruru MAETANP
- Third Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Yoshinori IGARASHI
- Third Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Yoshihiro SAKAI
- Division of Digestive Endoscopy, Ohashi Hospital, Toho University School of Medicine, Tokyo, Japan
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