A novel technique for biliary biopsy using the sheath of a plastic stent and a non-return valve.

Endoscopic transpapillary biopsy has been widely performed for the diagnosis of biliary disease. Direct-vision biliary biopsy using peroral cholangioscopy has been reported to be very useful [1–4]. At centers where peroral cholangioscopy is unavailable, biliary biopsy can be performed under fluoroscopic guidance. It is however sometimes difficult to obtain adequate biopsy specimens owing to issues with guidance of the biopsy forceps. Hijioka et al. reported a useful technique for biliary biopsy using miniforceps with a biliary dilator [5]. Herein, we report a useful modification of their procedure. A 70-year-old man with obstructive jaundice due to gallbladder cancer (▶Fig. 1) was referred to our hospital for right-sided hemihepatectomy. Biopsy specimens from the left biliary duct were needed to determine the extent of liver resection required. The system of a 7-Fr biliary plastic stent (Flexima; Boston Scientific, Marlborough, Massachusetts, USA) with the stent removed was used to perform the biopsy (▶Fig. 2 a). Without a sphincterotomy having been performed, the system was inserted into the biliary duct over a guidewire. The guidewire allowed the system to be advanced to the biopsy site, and the inner sheath assisted passage through the stenotic area. At the biopsy site, the inner sheath was removed and a mini-forceps (SpyByte; Boston Scientific) was introduced into the outer sheath, which remained on the guidewire. The tip of the outer sheath had a radiopaque marker to allow identification of the exact exit point of the forceps fluoroscopically (▶Fig. 2b). Furthermore, attachment of a non-return valve (Terumo, Tokyo, Japan) to the end of the sheath (▶Fig. 2 c) allowed contrast medium to be injected into the biliary duct to recognize the exact biopsy site, without removal of the forceps, and a biopsy was successfully taken (▶Fig. 3; ▶Video 1). Finally, the plastic stent was re-mounted on the system and placed at the biliary stenosis. We believe that this technique would be useful at centers where peroral cholangioscopy is unavailable.