A guidewire-assisted biopsy technique to assist advancement through a biliary stricture to perform selective mapping biopsy.

An endoscopic transpapillary mapping biopsy is useful for evaluating intraepithelial tumor spread in bile duct cancers [1,2]; however, it is occasionally technically difficult to advance the biopsy forceps through a biliary stricture. Here, we describe the case of a patient with a hilar biliary stricture who underwent a selective mapping biopsy. The biopsy technique described is suitable where the bile duct is inaccessible when introducing conventional biopsy forceps. A 69-year-old woman presented with obstructive jaundice. Magnetic resonance cholangiography indicated a hilar biliary stricture (●" Fig.1). We attempted a transpapillary intraductal biopsy of the biliary stricture and a mapping biopsy using conventional biopsy forceps to confirm the definitive diagnosis and look for proximal intraepithelial tumor spread; however, the forceps could not be passed through the stricture. Therefore, we attempted a guidewire-assisted intraductal biopsy. First, a 0.025-inch guidewire (VisiGlide 2TM; Olympus Medical Systems, Tokyo, Japan) was placed at the left intrahepatic bile duct. The guidewire was gripped by the biopsy forceps (Radial JawTM 4P; Boston Scientific Japan, Tokyo, Japan) outside the papilla (●" Fig.2). Thereafter, the biopsy forceps, which were still securely gripping the guidewire, were slid into the bile duct and advanced through the hilar biliary stricture under fluoroscopic guidance (●" Fig.3,●" Video 1). Finally, a successful biopsywas performed from the B4 confluencewithout any complications occurring. Intraductal biopsy specimens of biliary strictures can be obtained under fluoroscopic guidance using conventional biopsy forceps, biliary introducers [3], or ropeFig.3 Fluoroscopic image showing the biopsy forceps gripping the guidewire, while being advanced through the biliary stricture. Fig.2 Endoscopic image showing the jaw configuration biopsy forceps: a open and positioned just outside the papilla; b gripping the guidewire outside the papilla. Fig.1 Magnetic resonance cholangiography image in a 69-year-old woman with obstructive jaundice showing a hilar biliary stricture.