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Comparative Diagnostic Accuracy of Cholangioscopy-Based Modalities for Indeterminate Biliary Strictures: A Systematic
Abdul Subhan Talpur1, Kainat Urooj2, Fawad Talat3
1UHS Wilson Medical Center, Johnson City, NY, USA. abdul_subhan17t@hotmail.com.
Digestive Diseases and Sciences
|July 11, 2026
Summary
Single-operator cholangioscopy (SOC) offers the highest sensitivity for diagnosing indeterminate biliary strictures, but combined fluorescence in situ hybridization (FISH) with brush cytology is a viable alternative with lower morbidity.
Area of Science:
- Gastroenterology and Hepatology
- Diagnostic Imaging
- Oncology
Background:
- Indeterminate biliary strictures pose diagnostic challenges, with differentials including benign conditions and cholangiocarcinoma.
- Endoscopic retrograde cholangiopancreatography (ERCP)-guided brush cytology has limited sensitivity for malignancy detection.
- Emerging techniques like fluorescence in situ hybridization (FISH), intraductal biopsy (IDB), and single-operator cholangioscopy (SOC) aim to improve diagnostic accuracy.
Purpose of the Study:
- To conduct a network meta-analysis (NMA) comparing the diagnostic performance of five strategies for indeterminate biliary strictures.
- To rank these modalities based on sensitivity, specificity, and overall accuracy.
- To provide evidence-based guidance for selecting the optimal diagnostic approach.
Main Methods:
- A systematic literature search was performed across major databases (PubMed, EMBASE, Cochrane, Scopus) up to December 2024.
- Eligible studies included adult patients with indeterminate biliary strictures, comparing diagnostic modalities against a reference standard.
- A Bayesian hierarchical random-effects model was used to pool diagnostic accuracy data, assessing sensitivity, specificity, and adverse events.
Main Results:
- Thirty-eight studies (4,912 patients) evaluated brush cytology, FISH, IDB, SOC (SpyGlass DS), and combined FISH + brush cytology.
- SOC demonstrated the highest pooled sensitivity (82%), while brush cytology had the lowest (45%).
- Brush cytology showed the highest specificity (97%), whereas SOC had the lowest (89%). SOC ranked first in overall diagnostic accuracy (SUCRA 88%).
Conclusions:
- Single-operator cholangioscopy (SOC) offers superior sensitivity for indeterminate biliary strictures but has lower specificity and higher adverse event rates.
- Combined FISH + brush cytology is a high-value, lower-morbidity alternative, with non-statistically significant sensitivity differences compared to SOC.
- The choice of modality should balance diagnostic capacity, pretest probability, and the clinical implications of false-negative and false-positive results.
