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.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to the biliary tree. Over the past two decades, device-assisted enteroscopy (DAE), including single-balloon, double-balloon, and motorized spiral enteroscopy, has expanded the feasibility of ERCP in this population, with overall technical success rates generally reported between 70% and 90%. Nevertheless, these techniques are technically demanding, time-consuming, and frequently affected by limited reach and unstable positioning. More recently, interventional endoscopic ultrasound (EUS)-guided procedures have emerged as highly effective alternatives, significantly improving clinical outcomes in selected patients, particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective. Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail, though it is associated with a greater burden of reinterventions and adverse events. This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy, focusing on technical considerations, efficacy, and safety profiles of DAE-assisted ERCP, EUS-guided interventions, and motorized systems. The evolving landscape of biliary drainage in this setting highlights the need for tailored treatment strategies, multidisciplinary collaboration, referral to high-volume centers, and further prospective studies to refine patient selection and optimize clinical outcomes.

Background: Although the incidence of H. pylori infection is decreasing globally, it is not completely negligible. Because H. pylori infection is associated with various pathologies, ranging from peptic ulcer disease to neoplastic lesions, research into and treatment of H. pylori infections remain important. Objectives: We aimed to assess the diagnostic performance of gastric juice analysis (Endofaster®) for the detection of H. pylori in patients undergoing esophagogastroduodenoscopy (EGDS), using conventional histology as the reference standard. Our secondary objectives were to identify the optimal ammonium concentration thresholds for defining positive and negative results and to propose a clinical flowchart to support patient management. Methods: The diagnostic accuracy of Endofaster was first analyzed using an unmatched training cohort comprising an equal number of H. pylori-positive patients (n = 30) and negative controls (n = 30) who underwent EGDS. The derived thresholds were subsequently evaluated in an independent validation cohort of patients who underwent EGDS with Endofaster. Histological examination is the gold standard for H. pylori diagnosis. Results: In the training cohort, an ammonium concentration cut-off of 62 ppm/mL yielded a sensitivity of 90% (95% CI: 74–97%) for ruling out H. pylori infection. For confirming infection, the optimal cut-off was 100 ppm/mL, corresponding to a specificity of 95% (95% CI: 83–99%). Ammonium values > 62 and <100 ppm/mL were considered indeterminate, suggesting gastric biopsy was required for confirmation. The validation cohort included 196 patients (mean age: 59.9 ± 12.7 years), with a histology-based H. pylori prevalence of 19%. In this cohort, Endofaster® demonstrated a sensitivity of 70% (95% CI: 51–85%) and a specificity of 93% (95% CI: 88–97%). Indeterminate results were observed for 29 patients (15%). Conclusions: Endofaster® provides a largely reliable diagnosis of H. pylori infection during EGDS when a decision-making approach is applied, allowing gastric biopsies to be reserved for indeterminate cases only.

Background and study aims:There is no consensus regarding optimal selection of self-expandable stents (SEMS) for biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP). This study compared stent dysfunction, patient survival, and adverse events in patients with unresectable malignant distal biliary strictures (DBS) treated with ERCP, randomized to partially covered (PC-SEMS) or uncovered (U-SEMS) stents. Patients and methods:A prospective, multicenter, randomized controlled trial was performed in adult patients with DBS (March 2021-February 2023) with 12-month follow-up. Analyses were conducted according to intention-to-treat (ITT) and per-protocol (PP) principles. Procedural and post-procedural outcomes were evaluated using PP analyses and stent patency was evaluated with Kaplan-Meier analysis. Results:Among 261 patients, 130 were randomized to PC-SEMS and 131 to U-SEMS. Baseline features were similar between groups (mean age 73 ± 11 years; 51% male). Most strictures were due to pancreatic adenocarcinoma (75%), and 49% of patients had metastatic disease. Overall, stent dysfunction was comparable (11% vs 14%; P = 0.70). No significant differences were observed in patient survival (108 vs 100 days). A trend toward higher procedure-related complications was noted with PC-SEMS (2% vs 7%; not significant). Conclusions:PC-SEMS and U-SEMS in unresectable DBS showed comparable patency, survival, and stent dysfunction rates, with tumor ingrowth rarely observed and a trend toward more procedure-related complications in PC-SEMS. In this group with limited survival, there was no observed patency advantage with PC-SEMS. Potential benefit of PC-SEMS in populations with longer prognosis warrants further study.