Post written by Carlos Robles-Medranda, MD, from the Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador.

Accurately diagnosing indeterminate biliary lesions on clinical practice is a challenging task. Endoscopists may use Digital single operator cholangioscopy (DSOC) to evaluate those lesions, acquire histologic specimens, and to guide clinical management. Various DSOC classification systems and optical criteria have been proposed to predict malignancy in biliary lesions; nevertheless, previous classification systems and proposed optical criteria are associated with moderate to fair agreement among observers.

Currently there are various optical criteria proposed to predict malignancy in indeterminate biliary lesions; however, any single criterion has proven to be sufficient to predict the presence of neoplasia. Furthermore, proposing a single, validated and reliable visual criterion to distinguish neoplastic from non-neoplastic bile duct lesions during DSOC may overcome variability between observers, guide biopsy sampling, and prevent repeated DSOC evaluations and delays in clinical management of patients with indeterminate biliary lesions.

In this retrospective study, we evaluated biliary lesions via DSOC in 95 patients. In those patients with histological and 6-month clinical follow-up confirmed neoplasia, the presence of irregular, tortuous vessels was observed in 94.2% of patients. The use of this single criterion of neovasculature accurately predicted neoplasia with a sensitivity of 94%, a negative predictive value of 90%, and a positive likelihood ratio of 2.53. In addition, the interobserver and intraobserver agreement was excellent (k > 80; P < .001) between expert endoscopists and nonexpert physicians.

Our study suggests that the presence of irregular or spider vascularity is a validated and reliable visual criterion of biliary neoplastic lesions. Prospective multicenter trials are needed to evaluate neovasculature as a single factor for predicting neoplasia.  

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