{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 28, Ep 3 of 7: The Obstructed and Indeterminate Biliary Tree","html":"","width":"100%","height":180,"duration":1004,"description":"Episode three centers on the stricture you cannot name: painless jaundice, a tight narrowing, and imaging that says cancer without proving it. Tissue acquisition is the whole game, and every step up the diagnostic cascade works by getting closer to the tumor, from a shallow brush that misses submucosal cholangiocarcinoma to intraductal biopsy and FISH to cholangioscopy to an EUS needle in the mass itself. The transplant candidate inverts that hierarchy, because a needle in the hilar primary can seed the peritoneum and disqualify the cure. Then durable drainage follows anatomy: covered metal distally to block ingrowth, uncovered metal at the hilum to preserve side branches, and always enough viable liver drained to clear the bilirubin.\n \nTopics covered\n\nBrush cytology and why it misses cholangiocarcinoma\nIntraductal biopsy, FISH, and cholangioscopy\nEUS fine needle biopsy of a pancreatic head mass\nTransplant candidate and needle-tract seeding\nEndoscopic ampullectomy versus Whipple\nDistal covered metal stents\nHilar uncovered metal stents and side branches\nDraining fifty percent of viable liver\n \n \nKey decisions\n\nDo not trust a negative brush cytology in a malignant-looking stricture; stack intraductal forceps biopsy and FISH for polysomy, then cholangioscopy with targeted biopsy, because each step samples deeper than superficial shed cells.\nFor a pancreatic head mass needing tissue before neoadjuvant chemotherapy, use EUS-guided fine needle biopsy of the mass itself, favoring a biopsy needle over aspiration when you need core architecture and immunohistochemistry.\nIn a transplant candidate never needle the hilar primary by EUS or percutaneous route; stay inside the duct with brush and intraductal biopsy, and biopsy suspicious regional nodes only as a transplant-eligibility test.\nResect an ampullary adenoma en bloc for lesions up to two to three centimeters after EUS excludes intraductal extension, accepting a ten to fifteen percent pancreatitis rate to spare the...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}