Direct visualization of indeterminate pancreaticobiliary strictures with probe-based confocal laser endomicroscopy: a multicenter experience

• Published in: Gastrointestinal endoscopy Vol. 74; no. 5; pp. 961 - 968
• Main Authors: Meining, Alexander, MD, Chen, Yang K., MD, Pleskow, Douglas, MD, Stevens, Peter, MD, Shah, Raj J., MD, Chuttani, Ram, MD, Michalek, Joel, PhD, Slivka, Adam, MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.11.2011
• Subjects: Aged; Biliary Tract Neoplasms - complications; Biliary Tract Neoplasms - diagnosis; Biliary Tract Neoplasms - pathology; Biopsy; Cholangiopancreatography, Endoscopic Retrograde; Constriction, Pathologic - diagnosis; Constriction, Pathologic - etiology; Constriction, Pathologic - pathology; False Negative Reactions; False Positive Reactions; Female; Gastroenterology and Hepatology; Humans; Learning Curve; Male; Microscopy, Confocal; Middle Aged; Pancreatic Neoplasms - complications; Pancreatic Neoplasms - diagnosis; Pancreatic Neoplasms - pathology; Predictive Value of Tests; Prospective Studies; probe-based confocal laser endomicroscopy; positive-predictive value; NPV; PPV; confocal laser endomicroscopy; CLE; negative-predictive value; pCLE
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2011.05.009

Background Because of the low sensitivity of current ERCP-guided tissue sampling methods, management of patients with indeterminate pancreaticobiliary strictures is a challenge. Probe-based confocal laser endomicroscopy (pCLE) enables real-time microscopic visualization of strictures during an ongoing ERCP. Objective To document the utility, performance, and accuracy of real-time pCLE diagnosis compared with histopathology. Design Prospective observational study within the framework of a multicenter registry. Setting Five academic centers. Patients This study involved 102 patients with indeterminate pancreaticobiliary strictures. Intervention Clinical information, ERCP findings, tissue sampling results, and pCLE videos were collected prospectively. Investigators were asked to provide a presumptive diagnosis based on pCLE during the procedure before pathology results were available. All patients received at least 30 days of follow-up until definitive diagnosis of malignancy was established or 1-year follow-up if index tissue sampling was benign. Main Outcome Measurements Diagnostic accuracy, sensitivity, specificity of ERCP-guided pCLE compared with ERCP with tissue acquisition. Results There were no pCLE-related adverse events in the study. We were able to evaluate 89 patients, of whom 40 were proven to have cancer. The sensitivity, specificity, positive-predictive value, and negative-predictive value of pCLE for detecting cancerous strictures were 98%, 67%, 71%, and 97%, respectively, compared with 45%, 100%, 100%, and 69% for index pathology. This resulted in an overall accuracy of 81% for pCLE compared with 75% for index pathology. Accuracy for combination of ERCP and pCLE was significantly higher compared with ERCP with tissue acquisition (90% vs 73%; P = .001). Limitations Investigators had access to all relevant clinical information, which may have biased the predictive characteristics of pCLE. Conclusion Probe-based CLE provides reliable microscopic examination and has excellent sensitivity and negative predictive value. The significantly higher accuracy of ERCP and pCLE compared with ERCP with tissue acquisition may support supplementing ERCP with pCLE.