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Background and Aims: Cholangiopancreatoscopy for evaluating pancreaticobiliary pathology is currently limited by suboptimal optics. The aim of this study was to characterize the operating characteristics of per-oral video cholangiopancreatoscopy with narrow-band imaging (POVCP) findings in indeterminate pancreaticobiliary disease and to describe their association with neoplasia., Methods: Data from consecutive patients undergoing POVCP for the evaluation of indeterminate pancreaticobiliary disease at a single tertiary care center were analyzed. Two experienced investigators had previously agreed on POVCP findings and terminology that were documented in endoscopy reports. Endoscopic procedural data from POVCPs performed between January 2006 and April 2015 and clinical data were abstracted from the endoscopic database and electronic medical records. Study endpoints included tissue-proven neoplasia or benign disease with ≥1 year of follow-up., Results: A total of 109 patients were identified; 13 were excluded because of the presence of stone disease, known pancreaticobiliary malignancy, or presumed benign disease with ≤1 year of follow-up. Most patients (85%) underwent POVCP for biliary disease and 15% underwent POVCP for a pancreatic cause. Tortuous and dilated vessels (P < .001), infiltrative stricture (P < .001), polypoid mass (P = .003), and the presence of fish-egg lesions (P = .04) were found to be significantly associated with neoplasia. The overall POVCP impression had a high sensitivity (85%) and negative predictive value (89%) in assessing for the presence of neoplasia., Conclusions: Per-oral video cholangiopancreatoscopy is effective in the evaluation of indeterminate pancreaticobiliary disease. Tortuous and dilated vessels, infiltrative stricture, polypoid mass, and the presence of fish-egg lesions are significantly associated with neoplasia., (Copyright © 2017. Published by Elsevier Inc.)

Background: The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated., Objective: To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions., Design: Prospective, long-term follow-up, paired design cohort study., Setting: Tertiary center., Patients: Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions., Interventions: Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps., Main Outcome Measurements: Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer)., Results: A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing (P < .0001) and standard forceps biopsy (P = .0215)., Limitations: Potential for selection bias., Conclusions: Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. (, Clinical Trial Registration Number: NCT01227382.)., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: MRCP is rapidly replacing diagnostic ERCP in various pancreaticobiliary diseases. This study was designed to evaluate the accuracy of MRCP in detecting and determining the extent of choledochal cysts, as well as associated ductal anomalies or lesions., Methods: The study design was an 8-year retrospective survey conducted at a tertiary referral center, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). There were 72 patients with choledochal cysts. All patients underwent both MRCP and ERCP. MRCP findings were compared with those of ERCP as the criterion standard., Results: The overall detection rate of MRCP for choledochal cysts was 96% (69/72). The sensitivity, the specificity, the positive predictive value, and the negative predictive value of MRCP for classifying choledochal cysts according to Todani's classification were 81%, 90%, 86%, and 86% in type I, respectively; 73%, 100%, 100, and 95% in type III, respectively; 83%, 90%, 80%, and 91% in type IVa, respectively; 100%, 100%, 100%, and 100% in type IVb, respectively; and 100%, 100%, 100%, and 100% in type V, respectively. The sensitivity, the specificity, and the accuracy of MRCP for detecting ductal anomalies were 83%, 90%, and 86%, respectively. The detection rate of MRCP for concurrent cholangiocarcinoma and choledocholithiasis was 87% (13/15) and 100% (8/8), respectively., Conclusions: MRCP showed overall good accuracy in the detection and the classification of choledochal cysts and revealed associated cholangiocarcinoma and choledocholithiasis with excellent accuracy. MRCP, therefore, may supersede the diagnostic role of ERCP for the patients with choledochal cysts. However, MRCP showed limited capacity to detect minor ductal anomalies or small choledochocele.

Background: Sclerosing cholangitis with autoimmune pancreatitis has a cholangiographic appearance that is similar to that of primary sclerosing cholangitis, but only the former responds well to corticosteroid therapy. It, therefore, is necessary to distinguish between these two diseases. Cholangiography is the reference standard for the diagnosis of primary sclerosing cholangitis. The present study compared the characteristic findings for these two types of sclerosing cholangitis., Methods: Cholangiograms from patients with primary sclerosing cholangitis (n = 29) and sclerosing cholangitis with autoimmune pancreatitis (n = 26) were studied with regard to length and region of stricture formation, and other characteristic findings., Results: Band-like stricture, beaded or pruned-tree appearance, and diverticulum-like formation were significantly more frequent in primary sclerosing cholangitis. In contrast, segmental stricture, long stricture with prestenotic dilatation and stricture of the distal common bile duct were significantly more common in sclerosing cholangitis with autoimmune pancreatitis. Discriminant analysis based on these findings correctly identified 27 of 28 patients with primary sclerosing cholangitis and 25 of 26 patients with sclerosing cholangitis with autoimmune pancreatitis. It also identified a patient with an incorrect diagnosis of primary sclerosing cholangitis who proved, on review of a surgical specimen, to have findings consistent with lymphoplasmacytic sclerosing cholangitis., Conclusions: Characteristic cholangiographic features allow discrimination of sclerosing cholangitis with autoimmune pancreatitis and lymphoplasmacytic sclerosing cholangitis without pancreatitis from primary sclerosing cholangitis.

Background: Choledochoceles (type III biliary cysts) are cystic dilations of the terminal common bile duct or common pancreatobiliary channel. Although no size criteria have been defined, it is generally assumed these must be large. However, we describe patients who do not meet the perceived size criteria for choledochoceles, but who nonetheless have a dilated common pancreatobiliary channel., Methods: We reviewed the presenting symptoms, endoscopic and radiographic findings, and response to endoscopic therapy of patients meeting our criteria for the dilated common channel syndrome., Results: Of 2847 patients undergoing ERCP, 100 (3.5%) had the dilated common channel syndrome. Common presenting symptoms and signs included abdominal pain in 97%, abnormal liver function test(s) in 66%, and a history of acute or recurrent pancreatitis in 46%. A bulge was visible above the papilla in 88%, with a dilated common bile duct in 54% and a dilated pancreatic duct in 28%. After endoscopic unroofing of the common channel, 77% had complete and long-lasting resolution of symptoms, 18% had partial or transient improvement, and 5% had no change., Conclusions: Although classic choledochoceles are rare, a lesser degree of dilation of the common channel is more frequent than generally appreciated. We postulate that this finding represents an "incomplete," acquired form of choledochocele, possibly caused by underlying papillary stenosis. Whatever the etiology and appropriate term, the presence of a dilated common channel predicts a high rate of clinical response to endoscopic therapy.