Eus-Guided Fna And Ercp In One Session In Presumed Malignant Biliary Obstruction

Objective: To determine the efficacy of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) and endoscopic retrograde cholangiopancreatography (ERCP) in the same session in patients with presumed malignant biliary obstruction. Methods: The data were collected retrospectively and prospectively at MD Anderson Cancer Center from July 1, 2001 to October 31, 2004. Patients who underwent EUS and ERCP in the same session for presumed malignant biliary obstruction were included. A comparison was made of the sensitivities and specificities of tissue diagnosis by various endoscopic methods. Procedural details and complications were evaluated. Results: A total of 114 patients underwent 118 combined EUS/ERCP procedures under total intravenous anesthesia. In 118 procedures, 90 FNAs were performed. Of the 90 FNAs, 56 were positive for malignancy (54 adenoca, 1 adenosquamousca, 1 endocrine ca), 3 suspicious for carcinomas and 31 negative. At surgery, 1 of the 56 was a false positive. The 3 suspicious and 8/31 negatives were carcinomas. Excluding the 3 suspicious, EUS-FNA had a sensitivity of 87.3% (55/63), specificity 95.8% (23/24), positive predictive value (PPV) 98.2% (55/56), and negative predictive value (NPV) 74.2% (23/31). In more than 30 cases, final FNA results by PAP staining, immediately read by a cytologist, became available during ERCP obviating the need for further sampling effort by brushing and biopsy. A total of 57 brushings and 15 biopsies of the bile ducts were performed. Excluding 4 suspicious results, brushing had a sensitivity of 13.8% (4/29), specificity 100% (24/24), PPV 100% (4/4), NPV 49% (24/49). Excluding 1 suspicious result, biopsy had a sensitivity of 50% (3/6), specificity 100% (8/8), PPV 100% (3/3), NPV 73% (8/11). The average total procedure time was 73.6 min. Major complications occurred in 12: pancreatitis (6), cholangitis (2), hemobilia (1), bacteremia (1), fever (1) and abdominal pain (1) prompting hospital observation. There was no procedure-related mortality. Conclusions: Contrary to traditional practice, our study shows that performing EUS with FNA and ERCP in the same session is useful in providing tissue diagnosis and biliary drainage at the same time in patients with possible malignant biliary obstruction. This combined approach frequently eliminates additional endoscopies for either biliary drainage or tissue sampling, thus resulting in cost-effectiveness and convenience without compromising patient safety.