Digestive Diseases and Sciences

, Volume 56, Issue 2, pp 596–601 | Cite as

A Novel Method of Forceps Biopsy Improves the Diagnosis of Proximal Biliary Malignancies

  • Hasan KulaksizEmail author
  • Pavel Strnad
  • Achim Römpp
  • Guido von Figura
  • Thomas Barth
  • Irene Esposito
  • Peter Schirmacher
  • Doris Henne-Bruns
  • Guido Adler
  • Adolf Stiehl
Original Article


Background and Aims

Tissue specimen collection represents a cornerstone in diagnosis of proximal biliary tract malignancies offering great specificity, but only limited sensitivity. To improve the tumor detection rate, we developed a new method of forceps biopsy and compared it prospectively with endoscopic transpapillary brush cytology.

Patients and Methods

43 patients with proximal biliary stenoses, which were suspect for malignancy, undergoing endoscopic retrograde cholangiography were prospectively recruited and subjected to both biopsy [using a double-balloon enteroscopy (DBE) forceps under a guidance of a pusher and guiding catheter with guidewire] and transpapillary brush cytology. The cytological/histological findings were compared with the final clinical diagnosis.


35 out of 43 patients had a malignant disease (33 cholangiocarcinomas, 1 hepatocellular carcinoma, 1 gallbladder carcinoma). The sensitivity of cytology and biopsy in these patients was 49 and 69%, respectively. The method with DBE forceps allowed a pinpoint biopsy of the biliary stenoses. Both methods had 100% specificity, and, when combined, 80% of malignant processes were detected. All patients with non-malignant conditions were correctly assigned by both methods. No clinically relevant complications were observed.


The combination of forceps biopsy and transpapillary brush cytology is safe and offers superior detection rates compared to both methods alone, and therefore represents a promising approach in evaluation of proximal biliary tract processes.


Cholangiocarcinoma Double-balloon enteroscopy Endoscopic retrograde cholangiography 

List of Abbreviations




Double-balloon enteroscopy


Endoscopic retrograde cholangiography


Endoscopic ultrasonography-guided fine-needle aspiration


Hepatocellular carcinoma


Hematoxylin and eosin


Periodic Acid Schiff


Primary sclerosing cholangitis



We would like to thank all the participating patients for making this study possible. Our work was supported by German Research Foundation grants KU 1253/5-3 (H.K.) and STR 1095/2-1 (P.Str.). The technical assistance of Annemarie Schmid is greatly acknowledged.

Conflict of interest

The authors declare that they do not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.


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Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Hasan Kulaksiz
    • 1
    Email author
  • Pavel Strnad
    • 1
  • Achim Römpp
    • 1
  • Guido von Figura
    • 1
  • Thomas Barth
    • 2
  • Irene Esposito
    • 3
    • 4
  • Peter Schirmacher
    • 4
  • Doris Henne-Bruns
    • 5
  • Guido Adler
    • 1
  • Adolf Stiehl
    • 6
  1. 1.Department of Internal Medicine I, Center for Internal MedicineUniversity Medical Center UlmUlmGermany
  2. 2.Department of PathologyUniversity Medical Center UlmUlmGermany
  3. 3.Institute of PathologyTechnische Universität MünchenMunichGermany
  4. 4.Institute of PathologyUniversity Medical Center UlmUlmGermany
  5. 5.Department of SurgeryUniversity Medical Center UlmUlmGermany
  6. 6.Department of Internal Medicine, Division of GastroenterologyUniversity Medical Center HeidelbergHeidelbergGermany

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