Giuseppe Vanella, Albrecht Neesse, Cecilia Binda, Jeanin E van Hooft, Antonio Facciorusso, Manuel Perez-Miranda, Giovanni Marchegiani, Michiel Bronswijk, Marco Spadaccini, Alexander Arlt, Lucio Carrozza, Pedro Moutinho-Ribeiro, Chiara Coluccio, Tajana Pavic, Fausto Catena, Enrique Perez-Cuadrado-Robles, Maria Cristina Conti Bellocchi, Roy L J van Wanrooij, Edoardo Forti, Andrada Seicean, Andrea Lisotti, Marcello Maida, Aurelio Mauro, Schalk Willem Van der Merwe, Stefano Mazza, Margherita Pizzicannella, Giacomo Emanuele Maria Rizzo, Gianfranco Donatelli, Daniela Scimeca, Serena Stigliano, Edoardo Troncone, Andrea Anderloni, Carlo Fabbri, Ilaria Tarantino, Joan B Gornals, Lorenzo Fuccio
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.
BACKGROUND: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and related EUS-guided anastomoses are increasingly used for gastric outlet obstruction and other complex gastrointestinal scenarios, but indications, technical standards, and peri-procedural 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 5 did not. Six endorsed statements were GRADE-based and 14 were consensus-based. For malignant gastric outlet obstruction, 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-centre requirements, supervised training, catheter-based target-loop distension, freehand LAMS deployment, fluoroscopy availability, antithrombotic management, refeeding, post-procedural imaging, recurrent obstruction, and misdeployment. Conditional recommendations addressed LAMS diameter selection, selected benign gastric outlet obstruction, EDGE/EDGI in Roux-en-Y gastric bypass, and malignant afferent limb syndrome. No formal recommendation was issued for peritoneal carcinomatosis, routine tracheal intubation, antibiotic prophylaxis, EDEE in non-RYGB anatomy, or EUS-guided colo-enterostomy.
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.