Kordeni K, Vezakis A, Voulgaris T, Sotirianakou A, Politi E, Gazouli M. Methods improving endoscopic retrograde cholangiopancreatography brush cytology in malignant biliary strictures. World J Gastroenterol 2026; 32(21): 117828 [DOI: 10.3748/wjg.v32.i21.117828]
Corresponding Author of This Article
Maria Gazouli, MD, PhD, Doctor, Professor, Department of Basic Medical Sciences, Medical School, National and Kapodistrian University of Athens, No. 176 Michalakopoulou, Athens 11527, Greece. mgazouli@med.uoa.gr
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
review-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Kleoniki Kordeni, Athina Sotirianakou, Second Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens 11527, Greece
Antonios Vezakis, Theodoros Voulgaris, Department of Endoscopy, Second Academic Surgical Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens 11528, Greece
Ekaterini Politi, Department of Cytopathology, Areteion Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
Maria Gazouli, Department of Basic Medical Sciences, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
Author contributions: Kordeni K conceived the study and drafted the manuscript; Vezakis A and Voulgaris T contributed to study design and critical revision; Sotirianakou A and Politi E contributed to data interpretation and manuscript preparation; Gazouli M supervised the study and critically revised the manuscript; All authors read and approved the final manuscript.
AI contribution statement: The author used ChatGPT as an AI tool to check the grammar and language accuracy, and to rephrase the text.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Corresponding author: Maria Gazouli, MD, PhD, Doctor, Professor, Department of Basic Medical Sciences, Medical School, National and Kapodistrian University of Athens, No. 176 Michalakopoulou, Athens 11527, Greece. mgazouli@med.uoa.gr
Received: December 23, 2025 Revised: February 16, 2026 Accepted: March 9, 2026 Published online: June 7, 2026 Processing time: 160 Days and 19.3 Hours
Abstract
Accurate diagnosis of biliary strictures is crucial as malignant causes are associated with high morbidity and mortality, and unnecessary surgery for benign disease carries substantial risk. Endoscopic retrograde cholangiopancreatography with brush cytology remains the most widely used tissue sampling technique, but its sensitivity in distinguishing benign from malignant strictures is limited. This review summarized current and emerging strategies aimed at improving the diagnostic yield of endoscopic retrograde cholangiopancreatography brush cytology. Technical refinements such as rapid on-site evaluation, sheath-rinse collection, and increased brushing passes have shown incremental improvements. Combining brushing with bile aspiration or intraductal biopsy further enhances sensitivity. In parallel, molecular approaches including fluorescence in situ hybridization, next-generation sequencing, and microRNA profiling offer promising advances in early and accurate detection. A multimodal approach that integrates optimized cytological sampling with molecular diagnostics appears most effective in improving accuracy. Standardization and validation of these combined methods in prospective studies are needed to establish their role in clinical practice and to improve outcomes for patients with indeterminate biliary strictures.
Core Tip: Endoscopic retrograde cholangiopancreatography brush cytology remains a first-line sampling technique for indeterminate biliary strictures but suffers from limited sensitivity despite high specificity. Technical refinements including increased brushing passes, rapid on-site cytopathology evaluation, sheath-rinse techniques, and combined bile aspiration or fluoroscopic-guided biopsy improve cellular yield and diagnostic accuracy. Integration of advanced molecular diagnostics such as fluorescence in situ hybridization, next-generation sequencing, and microRNA profiling further enhances detection rates and enables identification of actionable genomic alterations. A multimodal diagnostic strategy combining optimized sampling techniques with molecular analysis represents the most effective current approach for improving early diagnosis and clinical decision making in malignant biliary strictures.
