Endoscopic ultrasound-guided gastroenterostomy: an international consensus on current and expanding indications,...

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and related EUS-guided anastomoses are increasingly used for gastric outlet obstruction (GOO) and other complex gastrointestinal scenarios, but the indications, technical standards, and periprocedural care remain heterogeneous.

An international panel of 66 experts (i-EUS) developed statements using a structured modified Delphi process. Literature searches were performed up to 30 April 2025. Comparative PICO-framed questions with extractable evidence underwent structured evidence synthesis and GRADE assessment, whereas procedural, technical, and organizational statements were classified as consensus based. Consensus was predefined as ≥ 85 % agreement.

Of 25 draft statements, 20 reached consensus and five did not. Six endorsed statements were GRADE based and 14 were consensus based. For malignant GOO, EUS-GE was recommended over duodenal stenting because of greater durability and fewer reinterventions, and suggested over surgical bypass because of comparable efficacy and fewer overall adverse events. Consensus-based statements addressed expert-center requirements, supervised training, catheter-based target-loop distension, freehand lumen-apposing metal stent (LAMS) deployment, fluoroscopy availability, antithrombotic management, refeeding, postprocedural imaging, recurrent obstruction, and misdeployment. Conditional recommendations addressed LAMS-diameter selection, selected benign GOO, EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE)/EUS-directed transgastric interventions (EDGI) in Roux-en-Y gastric bypass (RYGB), and malignant afferent limb syndrome. No formal recommendation was issued for peritoneal carcinomatosis, routine tracheal intubation, antibiotic prophylaxis, EUS-directed entero-enterostomy (EDEE) in non-RYGB anatomy, or EUS-guided coloenterostomy.

These i-EUS recommendations provide a practical framework for EUS-GE and related anastomoses in expert settings. The evidence base remains limited, and prospective comparative studies are needed to refine patient selection, training requirements, and long-term outcomes.