Updated Classification of EUS-Guided Gastroenterostomy Misdeployment

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used for the management of malignant and benign gastric outlet obstruction because of its safety and efficacy. Although lumen-apposing metal stents (LAMS) have improved technical success, misdeployment remains the most common adverse event and has traditionally been associated with the need for surgery. Misdeployment during EUS-GE is classified into four types (Types I-IV) based on stent position and associated defects. Emerging evidence from expert centers suggests that most misdeployments can be recognized early and are amenable for endoscopic salvage using contemporary rescue techniques, including defect closure, bridging stent placement, and natural orifice transluminal endoscopic surgery (NOTES) based approaches. In light of evolving procedural experience and expanding therapeutic options, we propose an updated, strategy-oriented classification of EUS-GE misdeployment. This includes subclassification of Type II and Type III based on guidewire access in the jejunal loop as well as the addition of Type V (complete intraperitoneal) and Type T (through-and-through) misdeployment. This review provides a comprehensive framework integrating misdeployment patterns with practical management strategies with focus on endoscopic rescue procedures. A structured, decision-oriented approach to misdeployment may reduce the need for surgical intervention and improve the safety and outcomes of EUS-GE.