Since biliary drainage has advanced with the development of percutaneous transhepatic cholangiography (PTC), a two-step method was introduced; initially PTC was performed by a 20- or 21-gauge needle and, if necessary, a second puncture was performed using the same gauge needle covered by a polyethylene tube.¹⁾ Lately, the direct-approach under fluoroscopic control was used where the needle advanced parallel to the X-ray beam and its direction was regulated more accurately. Moreover, the difficulty in puncturing the bile duct selectively was overcome by the advent of ultrasonic guidance.²⁾ Percutaneous biliary drainage (PTBD) is widely accepted for palliation of malignant obstruction, with lower morbidity and mortality.³⁾ In addition to the symptomatic relief and control of metabolic alterations associated with obstructive jaundice, the technique provides diangostic information, including the character, level and extent of obstruction. Also, biliary catheterization provides access for brush biopsy so that a specific cytologic diagnosis can be made.⁴⁾ The introduced catheter could be used to approach the obstructive lesion. Thus, we thought that it would be possible to obtain enough specimen for histopathologic findings. So we tried to perform a biopsy with the gastrofiberscopic biopsy forceps through the biliary stent catheter under fluoroscopic control. We report the first two cases of percutaneous transcatheteral biliary biopsy (PTBB) during PTBD and the successful results.

A tissue-confirmed diagnosis of neoplasm is desirable in the management of patients with tumor-caused obstructions of the biliary ducts. Even though the diagnosis is suggested by cholangiography, histologic diagnosis is very important and has a major role in prognosis. In fact, most histologic diangoses are often established only after operative biopsy, and are sometimes confirmed at necropsy. So cholangiography alone is not definitive for malignancy, and other possible causes of bile duct stricture, such as sclerosing cholangitis, can not be well discriminated.

For the tissue confirmation of a malignant neoplasm, a cytologic examination of the bile via radiologically placed drainage catheters has been reported.⁶⁾ While the detection rate of 34% was low, bile cytology was recommended as essentially a simple, noninvasive method for confirmation of a clinical and cholangiographic diagnosis.⁴⁾ On the other hand, the brush biopsy of biliary ducts via percutaneous transhepatic catheterization has been tried and a successful result was reported by Elyaderani and Gabrielle.⁷⁾ In their one case, although a forceps biopsy was performed, the result was negative. They thought that the negative result from the forceps biopsy was probably due to the long-standing percutaneous catheterization and the chronic inflammation or the inappropriate position of the forceps, and suggested that a brush or forceps biopsy should be performed as soon as possible following catheterization. To make a precise histopathologic diagnosis in malignant biliary stricture, a forceps biopsy seems to be a most desirable method. In addition, a higher accuracy is expected. So it is possible to transcatheterally approach the site of the obstruction of the biliary tract with the long biopsy forceps. We performed PTBB in two cases. Biopsy specimens were successfully obtained and a histopathologic diagnosis was correctly made. But in the first case, the shock stage developed immediately after the procedure due to hemorrhage, and gradually bile pertonitis also arose. On examination of the cholangiogram, we considered that the hemorrhage and the bile leakage did not occur at the site of the biopsy, but rather previously occurred at the site of the traumatic perforation by the guide wire. In the second case, no specific complication followed the procedure of PTBB. The method of PTBB is possible for biopsy of intra-and extrahepatic biliary obstructions. But the biopsy of the intrahepatic biliary obstruction is safer than that of the extrahepatic obstruction because the intrahepatic hemorrhage and bile leakage is limited by the parenchyma of the liver. But even in an extra-hepatic obstruction, the biopsy forceps are easily directed to approach the mass of the obstructive site and complications are rarely expected. Our first patient had extrahepatic obstructions accompanied by complications after the procedure. But in this case, the complications seemed to have no relation to the anatomical site of obstruction. Percutaneous transhepatic cholangioscopy^5,8) and transcatheteral cholangioscopy are other methods for establishing a histopathological diagnosis, when the cholangioscope is so equipped. But in order to perform percutaneous transhepatic cholangioscopy, after intrahepatic dilatation to a larger diameter using a fibrous tract dilatator, it take 3 weeks to insert a flexible fiberoptic choledochoscope thrugh the solid intrahepatic fibrous tract. Also, in transcatheteral cholangioscopy, catheters of a larger diameter and more extensive dilatation are needed for the passage of the cholangioscope through the catheter, which can give rise to more complications. We considered that PTBB was a safe and simple method of biliary biopsy during PTBD without special instruments. Additional studies and observations are needed to evaluate the results of PTBB, and it is thought that the method as well as the instrument should be further improved.