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Updated: Jun 2, 2026
Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
Effectiveness and safety of ERCP using the European Society of Gastrointestinal Endoscopy algorithm for biliary
Livia Archibugi1,2, Elton Dajti3, Federico Iacopini4
1Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, Pancreato-Biliary Endoscopy and Endosonography Division, Italy, Milan.
Background:
Biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) remains a critical yet challenging step, particularly in patients with a naïve papilla. The European Society of Gastrointestinal Endoscopy (ESGE) proposed a stepwise algorithm to guide cannulation strategies, but its real-world applicability and outcomes have not been systematically evaluated. This study aimed to assess the effectiveness and safety of ESGE algorithm-guided biliary cannulation during ERCP in a multicenter Italian cohort.
Methods:
This was a prospective observational study conducted across 11 Italian centers. Consecutive patients undergoing ERCP with naïve papilla were enrolled. Cannulation strategies were categorized based on adherence to the ESGE algorithm.
Results:
A total of 1435 patients were included and 1086 (75.7%) procedures adhered to the ESGE algorithm. Compared with nonadherence, adherence to the ESGE algorithm resulted in significantly higher biliary cannulation success (98.6% vs. 78.8%; P < 0.001) and shorter procedure duration (median 21 vs. 35 minutes; P < 0.001). Among difficult cannulation cases, success remained higher in the ESGE adherence group (93.1% vs. 78.8%; P < 0.001). At multivariable analyses, factors significantly associated with successful cannulation were adherence to the ESGE algorithm, prone position, degree of ERCP difficulty, and use of short guidewire. Rates of post-ERCP pancreatitis were comparable overall, but moderate-to-severe pancreatitis and perforation were less frequent in the ESGE adherence group.
Conclusions:
Adherence to the ESGE cannulation algorithm was feasible and was associated with higher cannulation success during ERCP.
