I suppose that we are considering extra-hepatic bile stricture.

I think that a preoperative cytological confirmation is not necessary. The incidence of benign biliary stricture in absence of previous surgery or calculi is less than 10%. The chance to have preoperative positive cytology is about 50%. In case of a report "negative for tumor cells" are we so confident in suggesting follow-up or stenting? We have to clearly inform the patient, what about: you have a 90% chance to have a malignant stricture.

It's extremely important to have a well done pre-op work up and than we can offer surgery without hesitations

Actually we never used cytology as a treatment planning guide in case of extrahepatic BD stricture. However we always refer those patients to gastroenterologists for stenting in order to gain time interval for more extensive imaging studies and preoperative preparation of the patient. It is justified to do that and to spend some time and efforts in order to improve nutritional status and liver function, as these patients usually need major HPB surgery. Primary exploratory surgery was not regarded as a good idea by our team.

Of course none of us is used to explore a patient without a correct full preoperative imaging. My original question only regarded an histopathologic confirmation

Yes of course it is needed. But sometimes if there is no malignancy and stricture is due to inflammatory process, even then surgery is done to relief the symptoms.

so if biopsy is negative for malignancy even then surgery will be done. But this doesn't mean that biopsy is not required. Ur investigations should include a preop biopsy.

Citology/histology may have sense only when there is still doubt whether it is a cancer or IgG4-related disease in a patient with clinical suspicion but normal serum values of IgG4 as we need to spare patient from unnecessary major resection, or from neoadjuvant chemoradiation of benign condition. Honestly I have limited experience with 5 patients with autoimmune cholangitis/pancreatitis (IgG4-related) presenting with obstructive jaundice and none of them was correctly diagnosed preoperatively.

The chance to have a preoperative cytology is so low that it's not necessary, obviously this doesn't mean that we don't have to use brushing but the problem is when it' s negative and this occurs in about 50% of cases. Moreover we have to keep in mind that stents are a problem to have a good staging expecially for excluding vascular incasement. Concerning autoimmune pancreatitis in our series (of about 1900 pts in total) we don't have cases with biliary stricture but only cases with pancreas enlargement that causes biliary obstruction (our incidence of autoimmune pancreatitis Is of 6%)

As an alternative, you could perform an intraoperative cytologic analysis and frozen section examination of suspect areas in collaboration with experienced pathologists .

Konradin Metze, UNICAMP

Unfortunately, It is very hard (and dangerous) to obtain pathologic material suitable for frozen analysis during surgery for suspect biliary malignancies.

Together with my residents, I myself have signed-out repeatedly frozen section diagnoses of biopsies from the biliary system or hepatic hilus . If technically well-performed , frozen sections from these areas usually reveal good histological images and thus permit rather secure diagnoses. I am unaware of complications due to these biopsies.

Konradin Metze, UNICAMP

I agree it is possible in advanced case, rather than in the case of an intraductal small lesion. However, I wonder if an intraoperative negative result could avoid further intervention in the case of MRI-suspected biliary stricture.

The diagnostic gold standard is still ( and will be in future ) a histological diagnosis, if the biopsy is representative MRI images n e v e r can achieve this level !

Therefore the definite diagnosis always comes from the surgical pathologist

Konradin Metze, UNICAMP.

I agree that intra-operative diagnosis can be obtained with frozen section. Once more this confirm that we have to operate patient with biliary stenosis in absence of stones or previous "biliary" surgery

Clinical context is the first priority. Sometimes these patients must under go radical surgery without an histopathological diagnosis of malignancy, which is not easy to obtain, even with an intraoperative consultation. This is one of those situaciones in which such an aggressive surgical procedure is needed, despite the etiology of disease. Patients must understand it, and surgeons thanked for it.

Yes a histopathologic or cytologic procedure is advisable, before the surgery , in the treatment of biliary strictures without calculi. But a MR imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice. Although ERCP with tissue biopsy or frozen section, during the surgery, is needed for the definitive diagnosis of many of these strictures, some of these conditions may show characteristic findings at MR imaging-MR cholangiopancreatography that help in making a definitive diagnosis.

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Yes, pre-operative cytologic or, preferably, histologic confirmation is the ideal, and new biopsy devices may help - but still are a little too far from being reliable. Unfortunately, not always we can obtain that information and, if those procedures results are negative for malignancy, we have to rely on the clinical presentation and, to some extent, abdominal MRI-MRI cholangiopancreatography. Nevertheless, when in doubt, I think it is in the best interest of the patient to propose a surgical approach so an opportunity for a cure not be missed (albeit all the negativity of cytology or biopsy).