Fluoroscopy-guided, sheath-assisted biopsy for indeterminate intraductal biliary masses

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary biopsy is an established diagnostic method for cholangiocarcinoma; however, its sensitivity remains relatively low, ranging between 40 and 60% with forceps biopsies [1]. In contrast, peroral cholangioscopy with cholangioscopy-directed biopsies demonstrates higher diagnostic performance, with a pooled sensitivity of 71.9% and a specificity of 99.1% [2]. Nevertheless, due to high costs and variability in reimbursement across countries, access to cholangioscopy may be limited. In such cases, fluoroscopy-guided, sheath-supported biopsy can serve as a useful alternative.

We applied this technique in three patients with intraductal masses located in the hilar, mid, and distal bile duct, all of whom had previously undergone negative biopsies (brush cytology, blind biopsy forceps, and bile cytology). During ERCP, fluoroscopy-guided and sheet-supported biopsies were performed. The key procedural step was to localize the level of the mass on cholangiographic images ([Fig. 1]). A stent introduction system, without a preloaded stent, was advanced over the guidewire beyond the level of the mass ([Fig. 2]). After removing the wire, pediatric forceps were introduced through the sheath and advanced slightly beyond the introducer and opened. The entire system was then gently withdrawn under fluoroscopic guidance to target the lesion, allowing multiple biopsies to be obtained ([Fig. 3]). Throughout the entire procedure, the introducer sheet was kept in the bile duct, providing a stable position and desired access. In the conclusion of each procedure, plastic stents were placed via the same introducer ([Video 1]). All procedures were uneventful.

Fig. 1 A fluoroscopic image: The mass in the hilum was visualized.

Fig. 2 A stent introducer sheath was advanced over the wire just above the level of a mass.

Fig. 3 Pediatric biopsy forceps were advanced through the stent introducer, opened and pulled back to the level of mass. Multiple biopsies were obtained. The plastic stent was placed over the same introducer.

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Fluoroscopy-guided, sheet-supported biopsy of non-diagnosed intraductal biliary masses.Video 1

Histopathological examination revealed intraductal papillary neoplasm of the bile ducts with low- and high-grade dysplasia in one case and adenocarcinoma in two cases.

Fluoroscopy-guided, sheath-assisted biopsy represents a simple and accessible diagnostic option for intraductal biliary masses, particularly in settings where cholangioscopy is unavailable, providing diagnostic support when other modalities prove insufficient.

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Contributorsʼ Statement

Katarzyna M. Pawlak: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Jakub Juźwiak: Methodology. Marek Brzosko: Project administration, Writing – review & editing. Jacek Piątkowski: Methodology, Writing – review & editing. Marek Jackowski: Project administration, Writing – original draft, Writing – review & editing. Mateusz Jagielski: Conceptualization, Data curation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Kamp EJCA, Dinjens WNM, Doukas M. et al. Optimal tissue sampling during ERCP and emerging molecular techniques for the differentiation of benign and malignant biliary strictures. Therap Adv Gastroenterol 2021; 14: 17562848211002023
• 2 BadshahMBVanar V, Kandula M. et al. Peroral cholangioscopy with cholangioscopy-directed biopsies in the diagnosis of biliary malignancies: a systemic review and meta-analysis. Eur J Gastroenterol Hepatol 2019; 31: 935-940

Publication History

Article published online:
28 January 2026