Post written by Il Sang Shin, MD Jong Ho Moon, MD, PhD Yun Nah Lee, MD, PhD, from the Digestive Disease Center and Research Institute, Departments of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea.   

Although cholangiocarcinoma (CCA) has very high mortality rates due to its late detection, satisfactory screening methods of CCA have not been established. The focus of our study was to identify the role of peroral cholangioscopy (POC) as a screening tool for neoplastic bile duct lesions including CCA in the bile duct.

Recent remarkable advances in POC made it possible to diagnose neoplastic bile duct lesions via direct endoscopic evaluation of the bile duct. However, there was no report presenting a possible role for POC in terms of screening for neoplastic bile duct lesions in patients at greater risk of CCA than the general population. We believed that this study could provide a milestone for the future role of POC and contribute to improving the prognosis of CCA. We conducted this study to evaluate the usefulness of direct POC to screen for neoplastic bile duct lesions in patients with bile duct stones (a possible risk factor for CCA).

In 207 patients who underwent direct POC after extraction of bile duct stones, 31 (15.6%) exhibited abnormal intraductal mucosal lesions. Among them, CCAs (n = 4), intraductal papillary neoplasms of the bile duct (IPN-B) (n = 2), and adenoma with dysplasia (n = 1) were diagnosed after POC-guided forceps biopsy. Curative surgical resection was performed in 4 patients with CCAs and 1 with an IPN-B. The incidence of neoplastic bile duct lesions in this study was 3.5%, and the number needed to screen (smallest number of patients who would need to be screened to detect 1 neoplastic lesion) was 29.6 (95% CI 17.1-108.8). Routine direct POC after bile duct stone removal led to surgical interventions in 5 patients, which increased the likelihood of cure. Considering the poor prognosis of CCA, screening and surveillance using POC in patients at risk of CCA will help to detect early neoplastic bile duct lesions, similar to regular EGD and colonoscopy in patients with gastrointestinal mucosal tumors.

Despite the evidence that direct POC is suitable for the screening of neoplastic bile duct lesions in this study, it has not yet been used in the world as a common practice. We need further studies to show that another type of single-operator cholangioscopy, SpyGlass® Direct Visualization System, can be useful for the same purpose. If a clear consensus on the high-risk group of CCA and the survival benefits of screening via POC are established, POC will be recognized as a valuable tool for screening neoplastic bile duct lesions.

Figure 1. Patient flowchart. POC, Peroral cholangioscopy; POC-FB, peroral cholangioscopy-guided forceps biopsy sampling.

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