title: Efficacy of SpyGlass(TM)-directed biopsy compared to brush cytology in obtaining adequate tissue for diagnosis in patients with biliary strictures.
abstract: OBJECTIVE
  To evaluate the diagnostic yield (inflammatory activity) and efficiency (size of the biopsy specimen) of SpyGlass(TM)-guided biopsy vs standard brush cytology in patients with and without primary sclerosing cholangitis (PSC).
  
  
  METHODS
  At the University Medical Center Mainz, Germany, 35 consecutive patients with unclear biliary lesions (16 patients) or long-standing PSC (19 patients) were screened for the study. All patients underwent a physical examination, lab analyses, and abdominal ultrasound. Thirty-one patients with non-PSC strictures or with PSC were scheduled to undergo endoscopic retrograde cholangiography (ERC) and subsequent peroral cholangioscopy (POC). Standard ERC was initially performed, and any lesions or strictures were localized. POC was performed later during the same session. The Boston Scientific SpyGlass System(TM) (Natick, MA, United States) was used for choledochoscopy. The biliary tree was visualized, and suspected lesions or strictures were biopsied, followed by brush cytology of the same area. The study endpoints (for both techniques) were the degree of inflammation, tissue specimen size, and the patient populations (PSC vs non-PSC). Inflammatory changes were divided into three categories: none, low activity, and high activity. The specimen quantity was rated as low, moderate, or sufficient.
  
  
  RESULTS
  SpyGlass(TM) imaging and brush cytology with material retrieval were performed in 29 of 31 (93.5%) patients (23 of the 29 patients were male). The median patient age was 45 years (min, 20 years; max, 76 years). Nineteen patients had known PSC, and 10 showed non-PSC strictures. No procedure-related complications were encountered. However, for both methods, tissues could only be retrieved from 29 patients. In cases of inflammation of the biliary tract, the diagnostic yield of the SpyGlass(TM)-directed biopsies was greater than that using brush cytology. More tissue material was obtained for the biopsy method than for the brush cytology method (P = 0.021). The biopsies showed significantly more inflammatory characteristics and greater inflammatory activity compared to the cytological investigation (P = 0.014). The greater quantity of tissue samples proved useful for both PSC and non-PSC patients.
  
  
  CONCLUSIONS
  SpyGlass(TM) imaging can be recommended for proper inflammatory diagnosis in PSC patients. However, its value in diagnosing dysplasia was not addressed in this study and requires further investigation.
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Johannes Wilhelm
authors.initials: JW
authors.lastname: Rey
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Torsten
authors.initials: T
authors.lastname: Hansen
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Dümcke
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Achim
authors.initials: A
authors.lastname: Tresch
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Katja
authors.initials: K
authors.lastname: Kramer
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Peter Robert
authors.initials: PR
authors.lastname: Galle
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Goetz
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Marcus
authors.initials: M
authors.lastname: Schuchmann
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Ralf
authors.initials: R
authors.lastname: Kiesslich
authors.affiliation: Johannes Wilhelm Rey, Katja Kramer, Peter Robert Galle, Martin Goetz, Marcus Schuchmann, Ralf Kiesslich, Arthur Hoffman, Department of Internal Medicine I, University Medical Center, 55131 Mainz, Germany.
authors.forename: Arthur
authors.initials: A
authors.lastname: Hoffman
keywords: Biopsy; Brush cytology; Cholangioscopy; Endoscopic retrograde cholangiopancreatography; Primary sclerosing cholangitis
references.citation: Gastrointest Endosc. 2005 Sep;62(3):374-82
references.pmid: 16111955
references.citation: Gastrointest Endosc. 2007 May;65(6):832-41
references.pmid: 17466202
references.citation: Gastrointest Endosc. 2008 Apr;67(5):AB57-349
references.pmid: 18578045
references.citation: Gastrointest Endosc. 2011 Oct;74(4):805-14
references.pmid: 21762903
references.citation: Clin Gastroenterol Hepatol. 2012 Sep;10(9):1042-6
references.pmid: 22677575
references.citation: World J Gastroenterol. 2009 Mar 21;15(11):1353-8
references.pmid: 19294765
references.citation: Surg Endosc. 2013 May;27(5):1569-72
references.pmid: 23233008
references.citation: Gastrointest Endosc. 2000 Nov;52(5):635-8
references.pmid: 11060188
references.citation: Indian J Pathol Microbiol. 2003 Apr;46(2):197-200
references.pmid: 15022908
references.citation: Cytopathology. 2004 Apr;15(2):74-9
references.pmid: 15056166
references.citation: Diagn Cytopathol. 2002 May;26(5):273-7
references.pmid: 11992366
references.citation: Endoscopy. 2013 Aug;45(8):635-42
references.pmid: 23807803
references.citation: Liver Transpl. 2013 Feb;19(2):199-206
references.pmid: 23404861
references.citation: J Hepatobiliary Pancreat Sci. 2014 Jun;21(6):410-7
references.pmid: 24123930
references.citation: Endoscopy. 2009 Nov;41(11):959-64
references.pmid: 19802775
references.citation: Endoscopy. 1977 Mar;9(1):27-30
references.pmid: 862583
references.citation: Gastrointest Endosc. 2002 Dec;56(6):803-9
references.pmid: 12447289
references.citation: Clin Gastroenterol Hepatol. 2012 May;10(5):466-71; quiz e48
references.pmid: 22178463
references.citation: Eur J Gastroenterol Hepatol. 2012 Jun;24(6):656-64
references.pmid: 22433791
references.citation: Gastrointest Endosc. 1995 Dec;42(6):584-5
references.pmid: 8674932
references.citation: Endoscopy. 2006 Jul;38(7):665-9
references.pmid: 16673310
references.citation: Asian Pac J Cancer Prev. 2011;12(10):2793-6
references.pmid: 22320994
references.citation: Gut. 1997 May;40(5):671-7
references.pmid: 9203949
references.citation: Gastrointest Endosc. 2007 Feb;65(2):303-11
references.pmid: 17258991
references.citation: Gastrointest Endosc. 2011 Jan;73(1):71-8
references.pmid: 21067747
references.citation: Curr Opin Gastroenterol. 2008 Sep;24(5):627-30
references.pmid: 19122506
references.citation: HPB (Oxford). 2012 Jul;14(7):425-34
references.pmid: 22672543
references.citation: Gastrointest Endosc. 1999 Jul;50(1):67-73
references.pmid: 10385725
references.citation: Dig Dis. 2013;31(1):118-25
references.pmid: 23797133
references.citation: J Interv Gastroenterol. 2011 Apr;1(2):70-77
references.pmid: 21776429
references.citation: Gastroenterology. 2006 Oct;131(4):1064-72
references.pmid: 17030177