Evaluation of Different Modalities (Surgery and Endoscopy) in Management of Indeterminate Lower Common Bile Duct Stricture

Background: Biliary stricture examination with different methods help to discover its extent, nature and origin of obstruction to reach proper diagnosis and proper treatment.Methods: This prospective study was done on 100 patients who had distal CBD stricture, which was confirmed by MRCP, ERCP, brush cytology, forceps biopsy and conventional cytology.Results: The study included 100 patients with indeterminate distal CBD stricture, Age 15.92±50.6, Female 60%, smokers 29%, jaundice 89 %, tumor markers +ve in 23%. MRCP with ERCP had the upper hand in diagnosing the stricture, tissue sampling only done in case of visible ampullary or distal CBD lesion (25 patients) proved malignancy in 2 patients, Brush cytology sensitivity 20.6% and 60% accuracy, DIA only done for 21 patients with 57.1% sensitivity and 81%accuracy. EUS done for 5% of cases. As regard definitive diagnosis and management 69(69%) proved benign and 31 cases (31%) proved malignant. The benign group included 50 patients responded to ERCP dilatation and stenting, 3 patients had prominent ampullary swelling excised by ERCP (ampullectomy with stenting), 16 patients did not respond to frequent ERCP dilatation or incompliant to frequent endoscopy underwent surgery. The malignant group included 14 patients were inoperable due to encasing of major vessels or developing metastasis and managed by palliative ERCP and stenting, 9 patients refused operation or were unfit due to multiple co-morbidities managed by palliative ERCP and stenting or PTDs.Conclusions: Diagnosing indeterminate CBD strictures requires a combination of noninvasive imaging, endoscopic techniques, and tissue sampling, DIA, MRCP and ERCP and EUS. After all indeterminate distal CBD stricture may still questionable and need long term follow up. Multidisciplinary team is mandatory.