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There are several methods for obtaining tissue samples from the pancreaticobiliary tract during endoscopic retrograde cholangiopancreatography. Confirmation of histology is often necessary to guide subsequent therapy. In this review, several techniques are described, including exfoliative cytology, brush cytology, endobiliary forceps biopsy, and endobiliary fine-needle aspiration. In addition, digital image analysis and molecular genetic analysis are discussed. This review of all the above tissue sampling and analysis techniques also provides practical advice, and high-lights more recent studies, which suggest that the diagnostic yield from tissue obtained at endoscopic retrograde cholangiopancreatography is increased with multimodal tissue sampling.

A 58-year-old woman underwent outpatient colonoscopy with multiple cold forceps biopsy for evaluation of a presumptive diagnosis of ulcerative colitis. Six hours following the procedure, she developed subcutaneous crepitus and presented to the emergency department, where chest X-ray revealed pneumomediastinum and subcutaneous emphysema. Our case discusses this unusual complication of colonoscopy and its diagnosis and management.

It is important to determine the benign or malignant nature of a biliary stricture, and a tissue diagnosis is usually desirable. This article discusses methods for diagnosis of malignant biliary strictures, including bile cytology, biliary brush cytology, intraductal forceps biopsy, needle aspiration, scraping devices, and endoscopic ultrasound-guided aspiration. Ki-ras analysis and the use of flow cytometry are also reviewed. In most cases a combination of tissue sampling techniques will result in the highest diagnostic yield.

Sarcomatoid carcinomas (SARCs) of lung are a group of rare but aggressive tumors. They usually present as large peripheral masses on chest roentgenograms, and less present as endobronchial tumors. Although surgical exploration can be proceeded in endobronchial tumors without a definite diagnosis, some special occasions preclude this option. Until now, preoperative diagnosis of SARC when it is endobronchial has been scarcely reported. Herein, we describe a case of endobronchial SARC diagnosed by cryoprobe plus forceps biopsy preoperatively, followed by a timely surgical treatment and a good result.

To investigate the usefulness of chromoendoscopy, using an acetic acid indigocarmine mixture (AIM), for gastric adenoma diagnosed by forceps biopsy.A total of 54 lesions in 45 patients diagnosed as gastric adenoma by forceps biopsy were prospectively enrolled in this study and treated by endoscopic submucosal dissection (ESD) between January 2011 and January 2012. AIM-chromoendoscopy (AIM-CE) was performed followed by ESD. AIM solution was sprinkled and images were recorded every 30 s for 3 min. Clinical characteristics such as tumor size (2 cm, ≥ 2 cm), surface color in white light endoscopy (WLE) (whitish, normochromic or reddish), macroscopic appearance (flat or elevated, depressed), and reddish change in AIM-CE were selected as valuables.En bloc resection was achieved in all 54 cases, with curative resection of fifty two lesions (96.3%). Twenty three lesions (42.6%) were diagnosed as well-differentiated adenocarcinoma and the remaining 31 lesions (57.4%) were gastric adenoma. All adenocarcinoma lesions were well-differentiated tubular adenocarcinomas and were restricted within the mucosal layer. The sensitivity of reddish color change in AIM-CE is significantly higher than that in WLE (vs tumor size ≥ 2 cm, P = 0.016, vs normochromic or reddish surface color, P = 0.046, vs depressed macroscopic type, P = 0.0030). On the other hand, no significant differences were found in the specificity and accuracy. In univariate analysis, normochromic or reddish surface color in WLE (OR = 3.7, 95%CI: 1.2-12, P = 0.022) and reddish change in AIM-CE (OR = 14, 95%CI: 3.8-70, P0.001) were significantly related to diagnosis of early gastric cancer (EGC). In multivariate analysis, only reddish change in AIM-CE (OR = 11, 95%CI: 2.3-66, P = 0.0022) was a significant factor associated with diagnosis of EGC.AIM-CE may have potential for screening EGC in patients initially diagnosed as gastric adenoma by forceps biopsy.

To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction.Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up.Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred.Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Peripheral lung lesions are sometimes difficult to reach even with endobronchial ultrasound (EBUS) and insufficient material is often obtained by transbronchial forceps biopsy. Cryoprobes can be used for performing tissue biopsies. We evaluated the safety and feasibility of the cryoprobe in combination with EBUS for the diagnosis of peripheral lung lesion. Patients with peripheral lung lesions of up to 4 cm were enrolled. After identifying the lung lesion by radial EBUS, forceps biopsies and cryobiopsies were performed in a randomised order. We evaluated safety and feasibility,, and compared diagnostic yield and sample size. 39 patients were randomised and the peripheral lung lesion was reached in 31. The overall diagnostic yield was 60.5% and, in the lesions reached by EBUS, it was 74.2%. In 19 cases, the diagnosis was made with forceps as well as cryobiopsy and, in four cases, only with cryobiopsy. Cryobiopsies were significantly larger than forceps biopsies (11.17 mm(2) versus 4.69 mm(2), p

Larger biopsy specimens or increasing the number of biopsies may improve the diagnostic accuracy of gastric epithelial neoplasia (GEN). The aims of this study was to compare the diagnostic accuracies between conventional and jumbo forceps biopsy of GEN before endoscopic submucosal dissection (ESD) and to confirm that increasing the number of biopsies is useful for the diagnosis of GEN. The concordance rate between EFB and ESD specimens was not significantly different between the two groups [83.1 % (54/65) in JG vs. 79.1 % (53/67) in CG]. On multivariate analyses, two or four EFBs significantly increased the cumulating concordance rate [coefficients; twice: 5.1 (P = 0.01), four times: 5.9 (P = 0.02)]. But, the concordance rate was decreased in high grade dysplasia (coefficient −40.32, P = 0.006). One hundred and sixty GENs from 148 patients were randomized into two groups and finally 67 GENs in 61 patients and 65 GENs in 63 patients were allocated to the conventional group (CG) or jumbo group (JG), respectively. Four endoscopic forceps biopsy (EFB) specimens were obtained from each lesion with conventional (6.8 mm) forceps or jumbo (8 mm) forceps. The histological concordance rate between 4 EFB specimens and ESD specimens was investigated in the two groups. Before ESD, the diagnostic accuracy of GENs was significantly increased not by the use of jumbo forceps biopsy but by increasing the number of biopsies.

Background/Aims There are several methods for obtaining tissue samples to diagnose malignant biliary strictures during endoscopic retrograde cholangiopancreatography (ERCP). However, each method has only limited sensitivity. This study aimed to evaluate the diagnostic accuracy of a combined triple-tissue sampling (TTS) method (on-site bile aspiration cytology, brush cytology, and forceps biopsy). Methods We retrospectively reviewed 168 patients with suspicious malignant biliary strictures who underwent double-tissue sampling (DTS; n=121) or TTS (n=47) via ERCP at our institution from 2004 to 2011. Results Among the 168 patients reviewed, 117 patients (69.6%) were eventually diagnosed with malignancies. The diagnostic sensitivity for cancer was significantly higher in the TTS group than the DTS group (85.0% vs 64.9%, respectively; p=0.022). Furthermore, the combination of brush cytology and forceps biopsy was superior to the other method combinations in the DTS group. With respect to cancer type (cholangiocarcinoma vs noncholangiocarcinoma), interestingly, the diagnostic sensitivity was higher for cholangiocarcinoma in the TTS group than the DTS group (100% vs 69.4%, respectively; p

The diagnosis of Kümmell’s disease mainly depends on clinical and radiologic findings. However, these are not the gold standards for diagnosing this disease; bone biopsy is required. The authors performed modified bone biopsy and cement-filling techniques during kyphoplasty and investigated the feasibility and efficacy of kyphoplasty for the treatment of Kümmell’s disease. This study included 28 patients (9 men and 19 women; average age, 71.9 years) with Kümmell’s disease. All patients underwent the modified biopsy procedure and kyphoplasty with the modified cement-filling technique. Treatment efficacy was evaluated using visual analog scale pain scores, Oswestry Disability Index scores, vertebral height, and Cobb angles pre- and postoperatively and at final follow-up. All patients tolerated the procedure well and had immediate back pain relief after kyphoplasty. Biopsy examination revealed necrotic bone in 24 patients and sparse cancellous bone in 2; it was unsuccessful in 2 patients. No severe complication occurred in any patient. Two patients had cement leakage but no clinical symptoms. All efficacy measures were significantly better at the postoperative assessments than the preoperative assessments ( P Kyphoplasty is a relatively effective and safe method for treating Kümmell's disease when modified techniques are performed to prevent cement leakage, and forceps biopsy can be used in the differential diagnosis of this condition.

Histologic discrepancies among specimens obtained by forceps biopsy and endoscopic resection (ER) between the differentiated and undifferentiated types often occur in early gastric cancer (EGC). This study aimed to evaluate the predictive clinicopathologic characteristics and clinical implications of histologic discrepancies in EGC.From August 2005 to March 2012, 596 lesions from 579 patients underwent ER for EGC. The lesions studied were diagnosed as the differentiated histologic type from forceps biopsy specimens. The lesions were grouped according to the occurrence of histologic discrepancy between the differentiated and undifferentiated types in specimens obtained by ER as concordant (n = 570) or discordant (n = 26). The main outcome measures were en bloc resection, complete resection, and curative resection rates.The histologic discrepancy rate was 4.4% among the studied lesions. Larger size, lesion location in the mid third of the stomach, easy friability, exudates, and submucosal invasion shown on endoscopic ultrasound were significantly related to histologic discrepancy in the univariate analysis. In the multivariate analysis, lesion location in the mid third of the stomach [odds ratio (OR) 5.34, 95% confidence interval (CI) 1.59-19.13] and easy friability (OR 29.26, 95% CI 2.30 to999.9) were significant factors associated with histologic discrepancy. The complete resection and curative resection rates were significantly lower and the additional operation rates after ER were significantly higher in the discordant group.The EGCs with histologic discrepancy between the differentiated and undifferentiated types changed the therapeutic outcomes of ER. Easily friable lesions located in the mid third of the stomach carry a significant risk for histologic discrepancy in undifferentiated histology when ER of EGCs is performed.

The purpose of this study was to evaluate the diagnostic yield of endobronchial ultrasound with real-time-guided transbronchial needle aspiration (EBUS-TBNA), endobronchial forceps biopsy (EBBx), and 2D fluoroscopic-guided transbronchial forceps biopsy (TBLBx) for centrally located peribronchial lung lesions.A retrospective chart review of consecutive patients who underwent EBUS-TBNA of centrally located peribronchial lesions, that is, medial margin of the mass within inner third of hemithorax by computerized tomography scan. Patients who underwent EBUS-TBNA for lymph node sampling were excluded.Thirty-two cases met the inclusion criteria. The mean age was 69±12 years. Sixteen (50%) were male patients. Of the 32 EBUS-TBNA cases, 13 underwent concomitant TBLBx (group 1), 8 had concomitant EBBx (group 2), and 11 had EBUS-TBNA alone (group 3). In group 1, the diagnostic yield of EBUS-TBNA was 95% (n=12/13), whereas the yield of TBLBx was 61% (n=8/13). In group 2, the diagnostic yield of EBUS-TBNA was 100% (n=8/8), whereas EBBx was positive in 75% (n=6/8). In group 3, the diagnostic yield of EBUS-TBNA was 91% (n=10/11). Overall diagnostic yield of EBUS-TBNA of centrally located peribronchial lung lesions was 94% (n=30/32).Where available, EBUS-TBNA of centrally located peribronchial lung lesions should be given a strong consideration given its high diagnostic yield.

Endoscopic forceps biopsy (EFB) is a major diagnostic procedure for gastric epithelial neoplasia (GEN). However, discrepancy between the result of EFB and endoscopic resection (ER) is not uncommon. Thus, there is controversy over whether specimens obtained by EFB are optimal for diagnosis of GEN. We investigated the discrepancy between EFB and ER in the diagnosis of GEN.A total of 1,850 GEN cases were histologically diagnosed with EFB, including 954 low-grade dysplasias (LGDs), 315 high-grade dysplasias (HGDs), and 581 carcinomas. Following diagnosis with EFB, all patients were treated with ER. We retrospectively reviewed the pathologic findings and patient characteristics and analyzed predictors for the discrepancy between the two procedures (largest diameter, number of biopsy fragments, number of biopsy fragments/largest diameter, location, macroscopic type, color, surface unevenness, and erosion).The overall discrepancy rate between EFB and ER was 31.7 % (587/1,850). Among the discordant group, 440 (23.9 %) cases showed a higher grade of disease after ER; 229 of the 954 LGDs (24.0 %) were diagnosed as HGD or carcinoma, 166 of the 315 HGDs (52.7 %) as carcinoma, and 45 of the 581 differentiated carcinomas (7.7 %) as undifferentiated carcinoma. In the LGD group with EFB, the largest diameter (≥1.8 cm; P0.001), surface unevenness (P = 0.014), and depressed macroscopic type (P0.001) were factors associated with discrepancy. In the carcinoma group with EFB, flat macroscopic type (P = 0.043) was the only significant factor. In the HGD group with EFB, there were no significant factors for discrepancy.EFB can be insufficient for diagnosing GENs, and ER can be considered not only as treatment but also as a diagnostic modality in GEN. It is especially pertinent to all cases of HGD regardless of their endoscopic features and to cases of LGDs with the largest lesion diameter ≥1.8 cm, surface unevenness, or a depressed macroscopic type.

A 75-year-old male was admitted to our hospital with epigastric ain and serum liver enzyme abnormalities. Contrast-enhanced CT howed irregular thickening of the wall of the middle bile duct. RCP disclosed wall irregularities in the middle bile duct with a ranular filling defect, and peroral video cholangioscopy (PVCS) emonstrated many polypoid lesions extending from the bifurcaion of the cystic duct branch to the distal bile duct (Fig. 1 white ight (a), NBI (b)). A forceps biopsy of the lesions showed lymphoid ollicles without any evidence of malignancy histopathologically. owever, the patient underwent pancreaticoduodenectomy with xtrahepatic bile duct resection under suspicion of cholangiocarcioma.

Endobronchial ultrasound (EBUS) has contributed substantially to the diagnosis of centrally located lesions within the thorax. More recently, this technology has been applied to the diagnosis of peripheral pulmonary lesions. One accepted technique for visualizing peripheral pulmonary lesions using radial EBUS involves use of a guide sheath placed within or adjacent to the lesion after localization using a radial EBUS probe. A diagnostic yield of >70% has been reported using this method, though direct visual feedback of needle aspiration within the mass is still lacking. Under continuous ultrasound guidance, the diagnostic yield of linear array EBUS is higher than 90%. In this case series, we present 3 cases in which transbronchial needle aspiration and forceps biopsy of peripheral pulmonary lesions were performed under continuous radial EBUS guidance using a modified "double-barrel" bronchoscope.

The term “conventional biopsy techniques” implies all those traditional sampling techniques that can be used without adopting the latest technology. Even if the diagnostic possibilities and sensitivity of bronchoscopy have greatly increased by the recent advent of new technological tools, the use of conventional biopsy techniques remains relevantly unchanged and allows the pulmonologist to successfully approach a high percentage of endobronchial, pulmonary and mediastinal lesions for diagnostic purposes.

Background Measurements of CFTR function in rectal biopsies ex vivo have been used for diagnosis and prognosis of Cystic Fibrosis (CF) disease. Here, we aimed to evaluate this procedure regarding: i) viability of the rectal specimens obtained by biopsy forceps for ex vivo bioelectrical and biochemical laboratory analyses; and ii) overall assessment (comfort, invasiveness, pain, sedation requirement, etc.) of the rectal forceps biopsy procedure from the patients perspective to assess its feasibility as an outcome measure in clinical trials. Methods We compared three bowel preparation solutions (NaCl 0.9%, glycerol 12%, mannitol), and two biopsy forceps (standard and jumbo) in 580 rectal specimens from 132 individuals (CF and non-CF). Assessment of the overall rectal biopsy procedure (obtained by biopsy forceps) by patients was carried out by telephone surveys to 75 individuals who underwent the sigmoidoscopy procedure. Results Integrity and friability of the tissue specimens correlate with their transepithelial resistance (r = −0.438 and −0.305, respectively) and are influenced by the bowel preparation solution and biopsy forceps used, being NaCl and jumbo forceps the most compatible methods with the electrophysiological analysis. The great majority of the individuals (76%) did not report major discomfort due to the short procedure time (max 15 min) and considered it relatively painless (79%). Importantly, most (88%) accept repeating it at least for one more time and 53% for more than 4 times. Conclusions Obtaining rectal biopsies with a flexible endoscope and jumbo forceps after bowel preparation with NaCl solution is a safe procedure that can be adopted for both adults and children of any age, yielding viable specimens for CFTR bioelectrical/biochemical analyses. The procedure is well tolerated by patients, demonstrating its feasibility as an outcome measure in clinical trials.

The diagnostic yield of flexible bronchoscopy with direct standard forceps biopsy ranges from 72% to 82% in large (>200 patients) case series of patients with endobronchial visible tumours presenting as an exophytic mass or submucosal lesion [1]. At least three endobronchial forceps biopsy samples are recommended at the risk of mild self-limiting (10%) or severe life-threatening ( 90% [3, 4]. A flexible cryoprobe (ERBE USA, Inc., Marietta, GA, USA) for use within a flexible bronchoscope was introduced in 1994. Shortly thereafter, Mathur et al. [5] and Vergnon et al . [6] described its application in the treatment of malignant airway obstruction (palliation) and radio-occult early-stage lung cancer (cure) applying multiple …

To assess the accuracy of cytological sampling and forceps biopsy in obstructing biliary lesions and to identify factors predictive of success.Consecutive patients (n = 119) with suspected malignant inoperable obstructive jaundice treated with percutaneous transhepatic biliary drainage during 7 years were included (60 male; mean age 72.5 years). All patients underwent forceps biopsy plus cytological sampling by washing the forceps device in cytological solution. Patient history, procedural and pathological records, and clinical follow-up were reviewed. Statistical analysis included chi-square test and multivariate regression analysis.Histological diagnosis after forceps biopsy was more successful than cytology: Sensitivity was 78 versus 61%, and negative predictive value was 30 versus 19%. Cytology results were never positive when the forceps biopsy was negative. The cytological sample was negative and forceps sample positive in 2 cases of cholangiocarcinoma, 16 cases of pancreatic carcinoma, and 1 case of benign disease. Diagnostic accuracy was predicted by low bilirubin (p0.001), aspartate transaminase (p0.05), and white cell count (p ≤ 0.05).This technique is safe and effective and is recommended for histological diagnosis during PTBD in patients with inoperable malignant biliary strictures. Diagnostic yield is greater when bilirubin levels are low and there is no sepsis; histological diagnosis by way of forceps biopsy renders cytological sampling unnecessary.

PURPOSE: To clarify the natural history of fundic gland polyposis (FGP) without familial adenomatosis coli (FAC). MATERIALS AND METHODS: Thirty-one FGP patients without FAC (six men and 25 women) were followed up with radiography and endoscopy for 1-13 years (mean, 4.3 years). RESULTS: In eight of 11 patients who initially had a single polyp, the polyp disappeared, probably due to endoscopic forceps biopsy. Of 20 patients with multiple polyps, seven (one man and six women with a mean age of 40.6 years at initial diagnosis) had obvious changes in the number of polyps, including complete disappearance in three patients, a decrease in one, transient disappearance followed by recurrence in two, and an increase in one. These patients were younger and had a greater number of polyps at initial diagnosis than the remaining 16 patients without any remarkable change. CONCLUSION: FGP without FAC is characterized by spontaneous decrease or increase in the number of polyps, especially in middle-aged female patients wi...

The high diagnostic yield and favorable safety profile of endobronchial ultrasound-guided transbronchial forceps biopsy of the mediastinal lymph nodes have been recently demonstrated. We report an unusual technical problem during endobronchial ultrasound-guided transbronchial forceps biopsy that could be a prerequisite for severe complications. A rupture of the steering band precluded closure of the forceps jaws opened in the subcarinal lymph node. A solution to the problem is presented, together with other procedure-related complications reported in the literature. The report emphasizes that a dysfunction of the forceps steering band can result in severe complications when it occurs during transbronchial sampling of mediastinal lesions.

Since the introduction of the flexible fibreoptic bronchoscope in the late 1960s there have been relatively few technological advances for three decades, aside from the development of a white light video bronchoscope with a miniature charge-coupled device built in its tip replacing the fibreoptics. White light flexible videobronchoscopy with its ancillary devices (forceps biopsy, bronchial brushing, bronchoalveolar lavage, bronchial washings and transbronchial needle aspiration) has long been the only established diagnostic bronchoscopic technique. With the advances in microtechnology over the past two decades, recent technical developments such as autofluorescence bronchoscopy and endoscopic ultrasound allow better evaluation of endobronchial, mediastinal and parenchymal lesions. © ERS 2010., SCOPUS: re.j, info:eu-repo/semantics/published

Background and objective: In order to obtain information on the clinical application of bronchoscopy in Japan, the Japan Society for Respiratory Endoscopy (JSRE) conducted a postal survey. Methods: A questionnaire was sent to 526 authorized institutes of the JSRE. The subject was bronchoscopy procedures performed during 2006. Results: The response rate was 71.3%. The total number of bronchoscopies performed was 74 770. Of these, 74 412 were flexible bronchoscopies and 358 were rigid bronchoscopies. At least one JSRE-authorized specialist had worked with 97% of respondents. Eighty-five per cent of respondents performed bronchoscopy under topical anaesthesia for almost all patients. Seventy-five per cent of respondents routinely used the oral route. The reported numbers of diagnostic bronchoscopies was 12 509 for simple bronchoscopy, 25 971 for forceps biopsy, 26 289 for brush biopsy, 25 659 for bronchial washing, 1387 for transbronchial needle aspiration and 6716 for BAL. Three deaths were caused by forceps biopsy (0.012%). The morbidity rates for these diagnostic procedures ranged from 0.14% to 2.5%. The reported numbers of therapeutic bronchoscopies was 476 for tracheobronchial stent, 164 for neodymium (Nd): yttrium-aluminium garnet (YAG) laser photoresection (LPR), 40 for photodynamic therapy, 81 for balloon dilatation, 145 for endobronchial electrocautery, 120 for argon plasma coagulation, 109 for microwave coagulation (MWC), 116 for ethanol injection, 110 for foreign body removal and 89 for bronchial occlusion. Deaths occurred only as a consequence of Nd : YAG LPR (0.61%). The morbidity rates for these therapeutic procedures ranged from 0% to 5%. Conclusions: The preparation for, and practice of, bronchoscopy varied greatly between respondents. Diagnostic bronchoscopy was well tolerated and safe. Therapeutic procedures did not appear to be practised widely or frequently.

32 forceps biopsies were performed in 30 patients with obstructive jaundice during percutaneous transhepatic biliary drainage procedures. In one patient an adequate specimen could not be obtained. In 25 of the remaining 31 cases diagnosis was confirmed histologically (malignant tumours: n = 22, benign stricture: n = 3). In 6 patients false-negative results were obtained. Transluminal biopsy is an easily performed adjunct to percutaneous transhepatic diagnostic interventions with minimal additional discomfort for the patient. In many cases percutaneous needle biopsy can be avoided. Forceps biopsy enables nonoperative histological diagnosis of small carcinomas of the bile ducts.

Background The "mother–baby" endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon–assisted endoscopy, for direct POC. Objective To evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access. Setting A single center. Design Case series. Patients Twelve patients with biliary disease. Interventions Direct POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures. Main Outcome Measurements Success rate of this technique, diagnostic or therapeutic feasibility, and complications. Results Overtube-balloon–assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred. Limitations A small number of patients and no comparison with conventional cholangioscopy. Conclusions The overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC.

At first glance, the variability in the histological differential diagnosis of early epithelial neoplasia of the stomach, first reported by Schlemper et al. [1] and subsequently confirmed in further reports [2]–[4], is alarming. This variability then gave rise to critical comments [5]. One gastroenterologist was even moved to give his comments the title “Japanese Fairy Tales,” [6] and concluded “The high prevalence of early gastric carcinoma in Japan and the successes in combating carcinoma of the stomach are possibly nothing but an artefact.” This commentator, however, overlooked the fact that one of the Western pathologists established exactly the same diagnoses, as did the four Japanese pathologists. He also failed to note that, in contrast to this group of four Japanese and one Western pathologist, the diagnoses made by the three other Western pathologists in forceps biopsy material differed considerably from their own diagnoses in the mucosectomy specimens from the same patients. Similar variable results in identical specimens were also revealed by the slide seminar that led to the compromise Vienna classification of gastrointestinal epithelial neoplasia [7], so that we might be justified in claiming that, in this area the term “Western deficiency” might be a more accurate comment than “Japanese fairy tales.”[8]

AIM: To increase the diagnostic potential of endoscopic biliary tract brushing, we devised an approach alternative to cytological smearing, leading to the preoperative histological examination of the collected material. METHODS: One hundred twelve consecutive biliary brush specimens were included. All patients presented a stricture of the biliary tract, leading to a diagnostic procedure by brushing. Immediately following brushing, the endoscopist immersed the brush into methanol and sent it to the pathology laboratory. The brush was introduced into a cassette for paraffin embedding and sections parallel to the long axis of brush were cut until the metal wire was almost reached, then the block was rotated and new sections were obtained from the opposite side. Samples of the mucosa, inflammatory cell aggregates, small fragments of carcinomas, or isolated cells were observed, and displayed an optimal fixation, allowing a definite diagnosis that proved mandatory for therapy in the vast majority of cases (99.1%). RESULTS: The results obtained in 112 consecutive cases using such technique compared with final histological diagnosis proved: 91% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 87% negative predictive value (NPV) (P < 0.001). In nonoperated patients, the clinical diagnosis after at least 6 months of follow-up showed: 95.5% sensitivity, 100% specificity, 100% PPV, and 88.2% NPV (P < 0.001). CONCLUSION: Such novel approach to the preoperative diagnosis of biliary tract lesions proved to be highly sensitive and specific, limiting the inadequate preoperative diagnoses to less than 1%.

The role of laparoscopy in the diagnosis of gallbladder cancer was evaluated. Fifteen patients who were suspected of having gallbladder cancer, following physical examination, laboratory tests, and imaging techniques, received laparoscopy at our clinic, and the laparoscopic findings and histologies were analyzed. Five patients in whom the gallbladder was observed were laparoscopically confirmed as having gallbladder cancer, and in 2 of these cases metastases to the liver were observed. Among the 10 patients in whom the gallbladder could not be observed, metastases to the liver and the peritoneum were observed in 6 and 4 cases, respectively. In 3 cases neither the gallbladder nor metastases to other visceral organs could be observed. Thus, the qualitative rate of laparoscopic diagnosis was 80% (12/15 cases). Five cases (42%) among the 12 cases in which laparoscopy suggested gallbladder cancer, were histologically confirmed after biopsy specimens were obtained. Only one of these cases was diagnosed by direct forceps biopsy of the gallbladder wall.