Geraci G, Pisello F, Arnone E, Modica G, Sciumè C
University of Palermo, Section of General and Thoracic Surgery, Service of Diagnostic and Operative Digestive Endoscopy, Palermo.
G Chir. 2008 Oct;29(10):403-6.
The differential diagnosis between malignant and benign biliary strictures is the cornerstone of the management of jaundiced patients. The aim of our study is to define the role of cytology of the bile withdrawn during endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of the nature of biliary stricture.
This retrospective study was conducted on 67 consecutive patients affected of ingravescent obstructive jaundice who underwent ERCP+/-PTE (percutaneous transhepatic endoscopic)+bile withdrawn+stenting. We founded hilar stricture in 21 patients (31.3%), middle third the common duct stricture in 17 (25.3%), and lower third stricture in 28 patients (41.4%). In one patient (2%) the cholangiography did not show any stricture, but we continued with the withdrawn of bile after positioning a naso-biliary drainage.
Diagnosis was made in only 40 of 65 patients (61.5%) and no epithelial lining cells of the biliary tree was found in the remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams (62.5%). During follow-up only 7 of these 25 patients resulted in having a benign disease (true negatives 28%) while the remaining 18 cases were diagnosed with malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma (65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25 non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The statistical analysis by chi-square test allowed us to conclude that bile cytology, if diagnostic, is significantly valid in identifying carcinoma of the pancreato-biliary tract (p<0.05) instead, considering the high rate of non diagnostic samples, its meaning is limited (p=0.09).
Exfoliative cytology of bile samples obtained during ERCP is easier and less invasive method to determine the diagnosis of biliary strictures, but due to its low sensibility, varying from 6 to 63%, it doesn't appear accurate to establish a definite diagnosis; the stricture dilatation before the withdrawal increases the diagnostic sensibility and accuracy of the cytological exam.
Bile withdrawn for cytology during ERCP is a safe method with no increasing in patient's morbidity. It allows a diagnostic orientation in 75% of the patients. Bile withdrawn after dilatation of stricture allows improves sensibility and accuracy. Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (positive predictive value 100%).
恶性与良性胆管狭窄的鉴别诊断是黄疸患者治疗的基石。我们研究的目的是确定在经内镜逆行胰胆管造影术（ERCP）期间抽取的胆汁细胞学检查在明确胆管狭窄性质诊断中的作用。
本回顾性研究对67例连续性进行性梗阻性黄疸患者进行，这些患者接受了ERCP+/-经皮经肝胆道内镜检查（PTE）、胆汁抽取及支架置入。我们发现21例患者（31.3%）存在肝门部狭窄，17例（25.3%）存在胆总管中段狭窄，28例（41.4%）存在胆总管下段狭窄。1例患者（2%）胆管造影未显示任何狭窄，但在放置鼻胆管引流后我们继续抽取胆汁。
65例患者中仅40例（61.5%）做出诊断，其余25例患者（38.5%）未发现胆管树的上皮衬里细胞。40例诊断性检查中的25例（62.5%）排除了胰胆管系统存在肿瘤（无恶性细胞）。在随访期间，这25例患者中仅7例最终诊断为良性疾病（真阴性28%），其余18例被诊断为胰胆管系统恶性肿瘤（假阴性72%）。14例细胞学检查呈癌阳性的患者中，9例（65%）被诊断为胆管癌，4例（28%）为胰腺癌，1例为壶腹癌。25例非诊断性样本中，5例（20%）结果为良性，20例（80%）为恶性。通过卡方检验进行的统计分析使我们得出结论，胆汁细胞学检查如果具有诊断性，则在识别胰胆管系统癌方面具有显著有效性（p<0.05）；相反，考虑到非诊断性样本的高比例，其意义有限（p=0.09）。
ERCP期间获取的胆汁样本的脱落细胞学检查是确定胆管狭窄诊断的更简便且侵入性较小的方法，但由于其敏感性较低，在6%至63%之间变化，似乎无法准确做出明确诊断；在抽取胆汁前进行狭窄扩张可提高细胞学检查的诊断敏感性和准确性。
ERCP期间抽取胆汁进行细胞学检查是一种安全的方法，不会增加患者的发病率。它能为75%的患者提供诊断方向。在狭窄扩张后抽取胆汁可提高敏感性和准确性。然而，阴性结果不能排除恶性疾病，但如果为阳性，则被视为具有诊断性（阳性预测值100%）。
