Does Biliary Stricture Brushing During Endoscopic Retrograde Cholangio-Pancreatography Lead to Increased Risk of Post-ERCP Pancreatitis? If So, Is It Worth It?

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Introduction: Pancreatitis is one of the most common and serious complications of endoscopic retrograde cholangiopancreatography (ERCP). Patient related, provider related and many procedure related risk factors have been identified and studied. Brush cytology of biliary, pancreatic or hepatic duct strictures obtained during ERCP can differentiate benign vs. malignant strictures. Although the specificity of brush cytology is very high, the sensitivity is highly variable, ranging from 23-56%. The influence of obtaining biliary brush cytology on the development of post-ERCP pancreatitis (PEP) has not been established, due to a paucity of evidence. Our project examined whether brush cytology was associated with an increased incidence of PEP and if so, did the benefit outweigh the risk. Methods: A retrospective chart review identified 1342 patients undergoing ERCP at our institution from January 1st 2012 to December 31st 2017. We excluded all patients under 18 years old and those undergoing follow-up ERCP for stent removal. The primary outcome was incidence of PEP, defined as the presence of abdominal pain and serum lipase over 3 times the upper limit of normal. We identified all patients with and without stricture brushing performed during ERCP, compared their incidence of PEP and used multivariate logistic regression to assess the association between the two. We also described the proportion of pathology sample results obtained during stricture brushing which were confirmed upon further testing. Results: 116 patients who had stricture brushing during the study period and 14 (12%) patients developed PEP. 1226 patients without brushing and 61 patients (5%) developed PEP (p <0.01). Multivariate logstic regression showed a significant association between stricture brushing and the development of PEP (odds ratio 2.73, 95% CI: 1.35 to 5.4). Significant covariates in the development of PEP included the patient's BMI (odds ratio 1.04, 95% CI: 1.01 to 1.08) and multiple cannulation attempts (≥2)(odds ratio 1.99, 95% CI: 1.00 to 3.96, p<0.05). Of the 116 patients who had brushing performed, 17(14.7%) had a positive cytology, 23 (19.8%) had atypical cells, and, 76(65.5%) had a negative result. Conclusion: Biliary stricture brushing was found to be significantly associated with increased risk of development of PEP in patients undergoing ERCP. The high rate of false negative pathology might indicate that the risk associated with stricture brushing may outweigh the diagnostic benefit.761_A Figure 1. Baseline Characteristics of Patients with and without Structure Brushing761_B Figure 2. Rates of Pancreatitis in Patients with and without Stricture Brushing761_C Figure 3. Odds Ratio Estimates for Multivariable Model Covariates

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