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 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.