Endoscopic ultrasound-guided gastroenterostomy: an international consensus on current and expanding indications, techniques, periprocedural care, and institutional requirements

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.