Post written by Jan Peveling-Oberhag, MD, from the Department of Gastroenterology, Klinikum Stuttgart, Stuttgart, Germany.

The cryobiopsy technique is a new method for tissue extraction that allows for extraction of high tissue amounts with a minimal diameter endoscopic instrument. Forceps biopsies through the very small working channel of a cholangioscope are oftentimes unrepresentative.

In this case report, cryobiopsy led to a successful clinical outcome with excellent tissues samples that enabled histology-based diagnosis of a critical bile duct stricture. We did not observe adverse events or safety signals.

Indeterminate biliary strictures still pose a major challenge in endoscopic diagnostics today. Cholangioscopy allows for high-quality visualization. However, endoscopists around the world are frustrated with the low sensitivity of cholangioscopic forceps biopsies.

Cryobiopsy in the biliary system is a promising new technique that has the potential to overcome this disadvantage. It might thereby improve the diagnostic work-up of indetermined biliary strictures in the future.

Direct visualization of indeterminate biliary strictures by cholangioscopy and targeted biopsies of the area of interest should intuitively provide the best possible diagnostic accuracy. However, sensitivity remains low and comparable with “blind” fluoroscopic-guided biopsies with a standard biopsy forceps.

This discrepancy can be explained by the small opening diameter of the cholangioscopic forceps, which leads to smaller specimen. In addition, the small cholangioscopic forceps has difficulties penetrating the dense epithelium of the bile duct, even when “bite-on-bite” biopsy strategy is used.

Cholangioscopy-guided cryobiopsy has the potential to overcome these shortcomings, providing large and representative specimen in this setting.

A, Cryo device with cart. B, Cryo device and instrument setting (effect 1, probe length 1150 mm). C, Cryoprobe tip (diameter 1.1 mm).

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